Journal of Health Care Communications Open Access

According to the World Health Organization’s (WHO), mental illness is becoming the number one cause of years lived with disability worldwide [1-3], with a high economic cost to society [4]. Depression, one of the most prevalent and costly conditions in our society, affects over 400 million people globally [5,6]. When mental illness is concurrent with other conditions like addictions or physical illnesses, there is higher morbidity and cost to the healthcare system [7]. A recent study conducted by May and colleagues found that a depression diagnosis at any time following coronary artery disease increases the risk of death 2-fold [8]. These facts underscore the need for effective, feasible and sustainable programs, which promote early recognition and evidence-based treatment strategies [9,10].

In recent years, integration of mental health in primary care has become an area of focus when redesigning mental healthcare service delivery. Primary care is often the first point of contact [11-13], the vast majority of common mental health problems can be handled early and effectively in this setting [14,15], and many patients preferred to be treated by their physician. There is an established trust as such they are more comfortable, likely, and feel less stigmatized sharing problems [16-18]. However, even when the diagnosis is made, a large majority of patients do not receive adequate treatment [19]. For example, depression and anxiety disorder studies show that in mild to moderate cases, most patients receive antidepressants [20-22] but antidepressants in this group are not necessarily associated with improved long-term clinical outcomes [23,24]. The majority of patients prefer non-drug options [25], and although we agree that antidepressants are necessary in many cases, when clinically acceptable, patient choice of evidence-based treatment options improves outcomes [26]. So, what are we missing, what is needed to fill this gap? We hear time and again that physician knowledge gaps contribute to unrecognized and undertreated mental illness in primary care, but the extent to which training programs effectively translate knowledge and skills into improved clinical outcomes remain questionable [27-30].

The truth is that it is not that simple. Although training is a first step, there is interplay of factors to consider if efforts of providing adequate mental healthcare are to be successful. The following is by no means an exhaustive list, but it gives us the big picture of this multifaceted problem. First, we need to recognize that primary care physician factors contributing to this gap expand well beyond training. Physicians extend care to a large number of domains resulting in competing training demands. If physicians feel unprepared, there can be associated anxiety in managing mental illness, especially if specialty back up proves to be difficult or non-existent. Then there are time factors. Mental health is intertwined with physical health, therefore not only confuses symptoms, but mental illness can be overlooked when physicians have to deal with on average 2-5 problems within one visit of 10-15 minutes. Additionally, primary care physicians’ burden of managing mental illness compared to other medical conditions is higher [31]. When the burden is intensified by a lack of systems support for chronic disease management such as lack of resources, reimbursement, legislation, collaborative teams, government funded psychotherapy or evidence-based allied health professional services for patients with financial restraints, one begins to understand how not taking these factors into account only serves to perpetuate the problem. Patient factors also are significant in the equation. For example, the lack of knowledge or awareness between common symptoms and mental illness which delays treatment. Reluctance to seek help due to stigma [32-37], or non-adherence to treatment for various reasons including financial restraints. Time factors are also prevalent when patients are unable or unwilling to attend frequent doctor/professional visits only to resurface in primary care at which time are in crisis or the condition is much harder to treat [38-41].

In other words, although training is central to help improve clinical outcomes, a comprehensive program, which incorporates as much as possible these contributing factors, should be considered in order to create a paradigm shift in primary mental health care. Both top-down government systems supports and bottom-up approaches are required [42-56]. Without these components in place, this not only affects the feasibility to effectively integrate training programs in primary care, but also efforts by policy and decision-makers in restructuring services to deliver comprehensive, cost-effective, and patient-centered care could prove fruitless.

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