Medical Humanities Blog

On the Integration of Mental Health & Primary Care

The disconnect between care and reimbursement for mental health services and other kinds of clinical services suggests just how deeply mind-body dualism pervades Western and American culture, despite the best efforts of many champions over many, many decades.  The beast lives, as I put it in my dissertation.  Thus, the news of a WHO Report on the need to integrate mental health care into primary care is welcome, though I admit it seems almost ridiculous to me that justification is needed for the notion that caring for those suffering from mental and emotional illnesses  is crucial to improving population health, let alone being important to lessening stigma, centering marginalized populations, and caring for persons with disabilities.

Here are some of the details of the Report, which may be downloaded as a PDF here:

Integrating mental health into primary care
A global perspective

Michelle Funk, Department of Mental Health and Substance Abuse, World Health Organization
Gabriel Ivbijaro, Wonca Working Party on Mental Health, London UK
World Health Organization and World Organization of Family Doctors (Wonca) 2008

Available online PDF file [224p] at:
http://www.who.int/mental_health/policy/Mental%20health%20+%20primary%20care-%20final%20low-res%20140908.pdf

“….This report presents the justification and advantages of providing mental health services in primary care. At the same time, it provides advice on how to implement and scale-up primary care for mental health, and describes how a range of health systems have successfully undertaken this transformation.

Mental disorders affect hundreds of millions of people and, if left untreated, create an enormous toll of suffering, disability and economic loss. Yet despite the potential to successfully treat mental disorders, only a small minority of those in need receive even the most basic treatment.

Integrating mental health services into primary care is the most viable way of closing the treatment gap and ensuring that people get the mental health care they need. Primary care for mental health is affordable, and investments can bring important benefits.

Key Messages:
1. Mental disorders affect hundreds of millions of people and, if left untreated, create an enormous toll of suffering, disability and economic loss.
2. Despite the potential to successfully treat mental disorders, only a small minority of those in need receive even the most basic treatment.
3. Integrating mental health services into primary care is the most viable way of closing the treatment gap and ensuring that people get the mental health care they need.
4. Primary care for mental health is affordable, and investments can bring important benefits.
5. Certain skills and competencies are required to effectively assess, diagnose, treat, support and refer people with mental disorders; it is essential that primary care workers are adequately prepared and supported in their mental health work.
6. There is no single best practice model that can be followed by all countries. Rather, successes have been achieved through sensible local application of broad principles.
7. Integration is most successful when mental health is incorporated into health policy and legislative frameworks and supported by senior leadership, adequate resources, and ongoing governance.
8. To be fully effective and efficient, primary care for mental health must be coordinated with a network of services at different levels of care and complemented by broader health system development.
9. Numerous low- and middle-income countries have successfully made the transition to integrated primary care for mental health.
10. Mental health is central to the values and principles of the Alma Ata Declaration; holistic care will never be achieved until mental health is integrated into primary care….”

Content:

Executive summary
Introduction

PART 1: Primary care for mental health in context
Chapter 1: Primary care for mental health withina pyramid of health care
Chapter 2: Seven good reasons for integrating mental health into primary care

PART 2: Primary care for mental health in practice
10 principles for integrating mental health into primary care
Argentina: Physician-led primary care for mental health in Neuquén province, Patagonia region
Australia: Integrated mental health care for older people in general practices of inner-city Sydney
Belize: Nationwide district-based mental health care.
Brazil: Integrated primary care for mental health in the city of Sobral
Chile: Integrated primary care for mental health in the Macul district of Santiago.
India: Integrated primary care for mental health in the Thiruvananthapuram District, Kerala State.
Islamic Republic of Iran: Nationwide integration of mental health into primary care
Saudi Arabia: Integrated primary care for mental health in the Eastern Province
South Africa: Integrated primary care services and a partnership for mental health primary care – Ehlanzeni District, Mpumalanga Province, and Moorreesburg District, Western Cape Province.
Uganda: Integrated primary care for mental health in the Sembabule District
United Kingdom of Great Britain and Northern Ireland: Primary care for mental health for disadvantaged communities in London

Report conclusions
Annex 1: Improving the practice of primary care for mental health

(h/t EQUIDAD listserv)

Call for Papers: The European Association for the History of Medicine and Health 2009 Conference

Call for Papers, EAHMH Conference 2009

Theme:
"Global Developments and Local Specificities in the History of Medicine and Health"

The European Association for the History of Medicine and Health (EAHMH) invites submissions for its bi-annual meeting, to be held in Heidelberg (Germany), 3-6 September 2009. The association welcomes submissions on the general theme:

"Global Developments and Local Specificities in the History of Medicine and Health".

The general theme encompasses a number of issues, including:

-          the impact of globalisation processes (political, economic,
means of communication etc.) on local ideas and practices in medicine

-          the spread of local medical ideas, practices, as well as
materials (remedies, instruments, etc.) to broader national and international contexts (*travelling knowledge*)

-          processes such as the hybridisation of "local" and "global"
(or more hegemonic) concepts or practices

-          the invention of (supposed) local traditions and their
relations to previously transferred / migrated knowledge or practices (e.g. newly emerging "traditional medicine" in South America modelled on "alternative medicine" in Europe, or on Asian "medical systems")

-          the interrelations between colonial powers and colonies, or
former colonial powers and former colonies in the realms of medicine and public health

-          linguistic and cultural translations/adaptations of *foreign*
medical concepts and practices

-          the shifting perceptions about what constitutes the centre
and what the periphery of certain developments, like "innovations"

-          physicians as (global) travellers.

Submissions from all eras and regions of the world are welcome. In addition to single-paper proposals, the Scientific Board accepts proposals for sessions including at least three papers, as well as suggestions for suitable chairpersons and/or discussants.

Abstracts should not exceed one page and should include information concerning the scientific question examined, the sources used and preliminary results. Be sure to include the title of the paper and the essential information concerning the author (name, university,
e-mail-address) on the abstract. Proposals for sessions should contain the collected abstracts for the session and may also list proposals for chairperson and discussant. The Scientific Board of the EAHMH reserves the right to add papers to proposed sessions after consultation with the original proposer. International panels are encouraged. Normally one person should not appear more than once in a capacity (as paper giver, chairperson or discussant). All papers will be judged on their own merits and must represent original work not already published or in press. The presentation of each paper will be limited to 20 minutes.

Please submit all proposals for sessions or for individual papers to marie.c.nelson@liu.se with a copy to volker.roelcke@histor.med.uni-giessen.de no later than January 31, 2009.

Further details available shortly at www.eahmh.net( http://www.eahmh.net/) .
Dr Alex Mold
Lecturer in History
Centre for History in Public Health
Department of Public Health and Policy
London School of Hygiene & Tropical Medicine Keppel Street London WC1E 7HT Tel. + 44 (0)20 7927 2166 www.lshtm.ac.uk/history

(h/t H-SCI-MED-TECH listserv)

Slow Blogging

I have quite a few posts in the hopper, but will be traveling for the next two weeks, so blogging may be slow until the new year.

On Research in Developing Countries

Despite my total lack of surprise, I am still outraged at some of the news coming out regarding the practices of clinical research in India.  Ed Silverman, at the indispensable Pharmalot, notes:

The race to test drugs in India, where costs are lower and patients are plentiful, is creating a vast cottage industry of doctors and contract research operators, but a dearth of oversight and ethical standards [. . . ]

Silverman references a series of articles on the subject written in the St. Petersburg Times.  Some highlights from the main Times article:

In the past three years, the FDA has inspected just eight of the thousands of trial sites in India.

In the burgeoning clinical trial business, says Amar Jesani, a doctor and medical ethicist in Mumbai, every layer of oversight is compromised by cash, and independent monitoring is nonexistent. He has resigned from supposedly independent ethics committees that rubber-stamp drug companies' proposals and overrule any objections.

Dr. S.P. Kalantri has conducted trials for global pharma at the government hospital in Sevagram, a small town in central India. But he said he has pulled back from doing the studies.

"It's difficult to explain the complexities of trials to study participants,'' Kalantri said of the hospital's mostly poor, illiterate patients. "I think many investigators tend to take their patients for a ride. And there's an abysmal lack of know-how about clinical research among investigators."

• • •

On the ground in India, it is impossible to find anyone running, monitoring or auditing clinical trials who is not on the payroll of the drug makers.

Doctors are paid according to the number of patients they enroll. Local ethics boards, set up to ensure patient safety, are often comprised of colleagues who approve each others' projects and blackball naysayers.

C.J. Shishoo, former dean of India's oldest pharmacy college, runs an independent ethics committee in Ahmedabad. He lost the business of two big clients when he objected to how they were running their studies.

"They just went elsewhere,'' Shishoo said of the drug companies he alienated. "I'm very much concerned. Life here is a little cheap."

I think academic detachment is not the appropriate response to this kind of information.  In part, my outrage, which again, I feel despite a total lack of surprise at these findings, is borne in part out of a concern for the social, cultural, and health related ills that flow from structural inequities and practices, past and present, that represent political and economic choices made by Western countries, communities, and institutions.

That is an intentionally provocative statement, but it builds on a great deal of work (mine and others) regarding the idea that problems of justice and population health, globally and locally, are largely traceable to social and economic conditions that are in turn the products of choices made and not made by any given community and society.  On the global level, I find Amartya Sen's work on this most eloquent and persuasive, though Paul Farmer's writings are also instructive.  And in the recent talk given by Sir Michael Marmot, he states that part of the point of the WHO CSDOH Report is that these conditions are in fact the product of political choices made.

The ethical aspects of many of these choices are highly contestable -- indeed, a fundamental characteristic of public health policy in general is that it is virtually always contested (Stone 2002).  The ethically optimal choices are rarely facile and obvious; ethics is hard.  But what outrages me about what is going on in India is that the ethics do not seem quite so difficult, especially given the terrible history of colonialism on the subcontinent.

(If you are not aware of what happened in Bhopal, India, please read, as it is relevant, IMO).

Thoughts? 

On Graphic Medicine

Ian Williams was kind enough to alert me to the existence of a new project he is working on, entitled "Graphic Medicine."  I liked his description and rationale so much, I requested and received permission to post verbatim his discussion:

"It has long been known that comics are “not just for kids”. Over the past decade this underrated  medium has begun to receive recognition and acclaim from literary critics, academics, and broadsheet reviewers. This renaissance is partly due to the rise in popularity of the graphic novel. In contrast to production line, genre based, mainstream comics, graphic novels are full length, square bound “serious” comic books, aimed at adults, usually written and illustrated by one person, thus encapsulating the style, narrative and subjective worldview of an individual. Often drawing on direct experience, the author builds a world into which the reader is drawn. Amongst the growing number of autobiographical works, titles dealing directly with the patient experience of illness or caring for others with an illness are to be found.

Thanks in part to the medical humanities movement many medical schools will now have tutors suggesting students read classic literature or modern novels to gain insight into the human condition.  I think is high time that graphic fiction was taken as seriously: comics and graphic novels could be used as a resource for health professionals, playing a valuable role in: Reflecting or changing cultural perceptions of medicine; Relating the patient/carer/provider experience; Enabling discussion of difficult subjects; Helping other sufferers or carers.  To this end I have set up a website:

www.graphicmedicine.org

which aims to introduce the interested reader to some key works in the comics medium. I have reviewed and rated all the graphic novels and comics I have found to contain stories that could be of relevance (the trouble is, because I am of the opinion that everything is of relevance to healthcare professionals, I keep finding more!). The site aims to promote discussion and critical appraisal of the medium, it is not just a fan site. I have included a site user comments section after every review and a general discussion page. I hope that many people will register with the site and a community will develop.

Of course stories, whether written or drawn are not real life; even autobiographies are carefully constructed representations. Written stories tend to have a structure, with some sort of ultimate resolution or message (as well as a beginning and middle). Stories of illness that are written down or drawn by skilled, articulate authors, published by a commercial company and bought by enough people to warrant reprinting, are a highly selected marginal subgroup of the total that are "out there", passed on by word of mouth, unwritten. Many of these "other" stories will be incoherent, too painful to relate, too distressing to hear, and so utterly bleak, miserable or banal that no commercial press is ever likely to publish them. There are other arguments against taking literature or comics as representative of real experience. I am exploring these issues in my MA dissertation (working title: “Comics as medical narrative: a resource for health professionals?”) which I aim to finish this spring.

Ian Williams, General Practitioner and Trainer, North Wales UK"

_____________________

Recommended!

Workshop on Neurocultures

Neurocultures Workshop
at Max Planck Institute for the History of Science, Berlin
20-22 February 2009.

From 20-22 February 2009, the workshop "Neurocultures," co-organized by the Max Planck Institute for the History of Science and the  Brain, Self and Society project at the BIOS Centre of the London School of Economics, will take place in Berlin. It will focus on the emergence of "neurodisciplines" such as neuroethics, neuropsychoanalysis, neuroeconomics, and related practices in contemporary culture. For more information, please see http://www.brainhood.net/news/neurocultures.html.

Due to severe spatial restraints we can only accommodate about 30 attendants apart from the speakers. If you are interested in joining us, please contact  Nicolas Langlitz   – places will be distributed on a first-come first-served basis.

(h/t NEURO-L listserv)    
 

On the Social Determinants of Health, the NIH, and Translation

Translation is a hot-button word in public health and research policy these days.  This is welcome, because one of the principal themes of this blog has been that even if we ceased all technical innovation in health, we have all the evidence and interventions we need to make our (U.S. and global) population substantially healthier than it is.  This is not to endorse the cessation of innovation, but to note that the link between improved population health and translation of the evidence we already possess, in my opinion, rests on much firmer footing than does the link between population health and increased innovation.

Thus, as always, the policy arguments I suggest are focused on notions of relative priority.  One of the primary criticisms of research and scholarship on the social determinants of health is that much of the evidence is just that, and that SDOH scholars and stakeholders often are focused on documenting the evidence rather than working to translate that evidence into policy and practice.  (As an aside, one can also see the specter of the naturalistic fallacy lurking here, in which too many stakeholders simply presume that the evidence itself justifies normative commitments, which is dubious).  To that end, I was pleased to watch the live Videocast of a talk given by Sir Michael Marmot, one of the most important social epidemiologists in the world and the Chair of the WHO Commission on the Social Determinants of Health.  The talk is (aptly) entitled, "Social Determinants of Health: From Research to Action."

He is a gifted speaker, and both his passion and his erudition shine through in the talk.  He had been invited to speak to the NIH Directors in a closed-door meeting held yesterday, Dec.11, 2008, followed by the public talk.  The NIH Videocast service, which is a wonderful resource, has quickly archived Marmot's talk, which you can access here (RealPlayer required).

There is simply too much incredible information from the talk to encapsulate here in a blog post, but one thing I was struck by is Marmot's insistence on and commitment to strategies and means of implementing the robust SDOH evidence base.  At various times in the talk, Marmot evinces both great pessimism and sunny optimism as to the state of the political will needed to incorporate the SDOH into public health policy.  In my mind, what is most needed is a fundamental reconceptualization of what we deem to be public health policy, such that social policies like housing, occupation, and environment are all expressly and directly deemed to be public health policy, and are implemented as such.

Sadly, for many reasons, I do not share some of Marmot's optimism, especially not in the U.S.  But, as the humanists themselves epitomized, there are some fights worth fighting even if you know you are going to lose.

Thoughts?

On Zimbabwe, Cholera, and the Pump

The ever-fascinating Stuart Rennie at Global Bioethics Blog observes regarding the Zimbabwe cholera epidemic:

If you were ever wondering if politics is a 'social determinant of health', well, just take a hard look at Zimbabwe. A few decades ago, the country was the breadbasket of the sub-Saharan region, and it is now heavily dependent on food aid and imports, with an economy crippled by massive debt and astronomical levels of inflation. In fact, its chief export in the coming months, besides Zimbabweans, could be infectious disease.

Of course, anyone remotely familiar with Sen and Farmer's work, to name only two, understands that political structures are the chief determinants of health.

In a particularly nice metaphor, Rennie notes that

Epidemiologist John Snow is said to have removed the handle on the water pump on Broad Street in London in 1854, once he discovered that contaminated water from the pump was responsible for the city's deadly cholera epidemic. The outbreak dissipated soon afterward. In Zimbabwe, Mugabe is the pump handle.

Well-said. 

Call for Papers: "New Directions in American Health Care: Innovations From Home and Abroad."

Hofstra University will host a two-day conference on Thursday and Friday, March 11-12, 2010: "New Directions in American Health Care: Innovations From Home and Abroad."

The goal of the conference is twofold: 1) to facilitate discussion from an interdisciplinary perspective, a year into the new presidential administration, around transferable, just solutions to America's health coverage crisis; and 2) to help set a research and policy agenda to broaden social justice by ameliorating critical dilemmas in coverage, cost and quality of health care.

Researchers and scholars from a variety of disciplines (including law, ethics, anthropology, political science, public health, health policy, history, economics, sociology, health services research and health systems research) are invited to submit 400-600 word summaries of their papers for consideration for presentation at one of the following sessions:

• Lessons from the states and localities
• Lessons from abroad Historical perspectives on U.S. reform efforts
• Legal and ethical issues in American health insurance
• Quality of care and health coverage innovation
• Socioeconomic disparities and health coverage innovation
• Special issues in suburban health care and coverage
• Meeting the challenges of an aging population

Applicants should submit summaries as attachments via email to hofculctr@hofstra.edu by Feb. 27, 2009. Applicants should indicate in the covering e-mail the session for which they believe the submission is appropriate. Submissions will be evaluated by peer reviewers on the basis of quality and appropriateness of subject matter. Notification of acceptance will be sent by June 20, 2009.

The conference has already enlisted two keynote speakers:

Vicente Navarro, M.D., Ph.D., Dr.P.H.
Professor of Public Policy, Sociology and Public Studies, Johns Hopkins University's Bloomberg School of Public Health, Baltimore, Md.

Peter Zweifel, Ph.D. Professor of Economics, University of Zurich, Switzerland.

Conference Co-Directors:
Janet Dolgin, Ph.D., J.D. Jack and Freda Dicker Distinguished Prof. of Health Care Law (Janet.L.Dolgin@hofstra.edu)
Rachel Kreier, Ph.D. Assistant Professor of Economics (Rachel.E.Kreier@hofstra.edu)
Corinee Kyriacou, Ph.D. Assistant Professor of Community Health (Corinne M.Kyriacou@hofstra.edu)

For more information, visit the conference website: hofstra.edu/Community/culctr/culctr_events_americanhealthcare

(h/t Spirit of1848 Listserv)

On Screening for Traumatic Brain Injury in U.S. Soldiers

The Institute of Medicine has released several fascinating reports in the last week.  The first addressed work hours for medical residents and trainees, a subject I have addressed in the past.  The second, released today, addresses traumatic brain injury among U.S. soldiers.  The report is the latest in a series addressing the "Gulf War and Health," which included a report on Gulf War Syndrome, which I mentioned here.

In a curious parallel to some of the themes of visibility and pathology I mentioned in connection with contested illnesses, the N.Y. Times article covering the latest report (entitled "Long-Term Consequences of Traumatic Brain Injury") notes that

For years, veterans’ advocates and researchers have called for more careful investigation of head injuries — not just severe wounds but also “closed head” injuries, which do not produce visible damage and do not show up on CT scans.

Indeed, one of the most serious problems with so-called mild traumatic brain injury ("mTBI") is that the neuropathological sequelae may be protracted, that is, they may take awhile to show up.  (Full disclosure: I have a forthcoming article on concussions in professional American football, so this is an area of interest for me).  Thus a person may suffer some kind of mTBI and by all accounts appear just fine for days on end, with no visible damage.  Again, the importance of the visible in biomedical culture can, IMO, not be overestimated.

In any case, the full report is available for purchase here through IOM, and the executive summary may be downloaded for free.