Primary prevention in psychiatry in general hospitals in South Asia.

The focus of primary prevention is on reducing the disease incidence. Primary prevention in mental health has been given minimal priority in low-resource settings with no significant investments. General hospitals are one of the main providers of mental health services in South Asia. This paper focuses on primary prevention activities, which can be undertaken in a general hospital in South Asia with abysmally low-mental health resources. For implementing primary prevention in psychiatry, a general hospital may be conceptualized as a population unit, located in a well-populated area with easy accessibility where different kinds of communities, for example, students and resident doctors, consultants, patients and their caregivers, and paramedical, nursing, administrative and other supportive staff, coexist and have varied functions. All the functional components of the general hospital psychiatric units (GHPUs) offer scope for introducing primary preventive psychiatry services. Psychiatrists in GHPUs can lead efforts for primary prevention in mental health in the hospital by employing strategies in the framework of universal, selective, and indicated prevention. The preventive strategies could be targeted at the patients visiting the hospital for various health services and their caregivers, employees, and the trainees. Similar principles can be employed in teaching and training.

INTRODUCTION

Prevention of mental disorders is an important public health concept contributing to overall reduction in morbidity due to mental ill health. Primary prevention, though conceptually focuses on decreasing the disease incidence by reducing risk factors and enhancing protective factors, is presumed to function at universal, selective, and indicated levels in mental health, with the universal strategies focused at the general population, selective ones targeted on the at-risk groups and the indicated ones acting on the high-risk persons with minimal but detectable signs or symptoms of mental disorder.[1] An effective primary prevention program in psychiatry can work at macro level aimed at changing the society and the culture and at microlevels aimed at individuals, small groups or social networks.[2] Effective prevention can help in reducing stigma, discrimination, and human rights violations associated with mental disorders. However, primary prevention has not been recognized as a responsibility by the mental health professionals.[23]

Most of the primary prevention efforts have been made in high-income (HI) countries. Hence, the published literature is also dominated by the studies from HI countries.[4] These findings are difficult to replicate in the low-mental health resource settings of South Asia due to vast differences in quantity and quality of mental health resources [Table 1].[56] For example, as per Mental Health Atlas 2011[5] and 2014[6], the United Kingdom as a representative of HI countries has 49 times more psychiatrists, 565 times more nurses, 183 times more clinical psychologists, and 28 times more social workers per 10,000 of population than in India, a representative of low- and middle-income countries [Table 1]. The global burden of mental illness has also been underestimated. As per recent estimates, it accounts for 32·4% of years lived with disability (YLDs) and 13·0% of disability-adjusted life-years (DALYs) instead of the earlier estimates suggesting 21·2% of YLDs and 7·1% of DALYs.[7] All the countries in South Asia, where one-fourth of humanity lives, have very meager mental health resources, which are spent mostly in bridging huge treatment gap. Unfortunately, prevention in mental health, especially the primary prevention has been given minimal priority in South Asia with no significant investments.[8]

Table 1

Mental health resources in South Asia (source: Mental Health Atlas, 2011, 2014)

In South Asia, mental health services are generally offered across multiple settings including general hospital psychiatric units (GHPUs), psychiatric hospitals, community mental health services, and office-based practices.[910] In South Asia, GHPUs are the main providers of mental health services[11] and provide a comprehensive range of services and also contribute significantly to research surpassing the mental hospitals.[12] GHPUs attached to the medical schools play an important role in teaching and training of undergraduate and postgraduate students in medicine and nursing. Currently, in South Asia, there are about 680 medical schools[131415161718] [Table 1]. In Sri Lanka and Nepal, there is also an examination for psychiatry for medical undergraduates. GHPUs offer scope for introducing primary preventive psychiatry services in a general hospital.

This paper focuses on primary prevention activities, which can be undertaken in a general hospital (utilizing the available resources) in South Asia. Many of these are already in use in some of the GHPUs across South Asia including at the authors’ institutions.

CONCEPTUALIZING PRIMARY PREVENTION IN A GENERAL HOSPITAL

For the purpose of planning primary prevention in psychiatry, the general hospital can be conceptualized as a population unit, located in community with easy accessibility, visited by different kinds of people with varied roles, for example, students and resident doctors, consultants, patients and their caregivers, and paramedical, nursing, administrative, and other supportive staff. At many places, there is also a residential campus for the families of the hospital doctors and staff. These communities perform different kinds of activities such as studying and learning, clinical care, teaching, research and other activities in the general hospital as their workplace. Psychiatrists in a general hospital can lead efforts for primary prevention in mental health in the hospital by employing strategies in the framework of universal, selective, and indicated prevention for different communities in the hospital including the patients visiting the hospital for various health services and their caregivers, employees, and the trainees. Roadmap to primary prevention in psychiatry in general hospitals is elaborated in Table 2.

Table 2

Roadmap to primary prevention in mental health in a general hospital

Specific strategies targeted at different groups are discussed in the following paragraphs.

Primary preventive psychiatry services for the patients and their caregivers visiting the hospital for various health services

Universal prevention strategies can be implemented by improving inpatient and outpatient facilities such as creating comfortable waiting area with basic facilities, clear signage, drinking water, and cafeteria facility and display of health messages.

Selective prevention would include interventions by the consultation-liaison (CL) psychiatric service team at liaising with various other clinical departments, especially neurology, endocrinology, oncology, Intensive Care Units (ICUs), and other such services, where patients have higher chances of having mental health problems. CL team can also conduct workshops for the health professionals from these disciplines aimed at identifying anxiety, depressive, or other psychiatric symptoms, introduce stress reduction techniques, anxiety management, and when to seek help from CL team.

Indicated prevention can be practised by employing preventive measures in patients at high risk to develop mental health problems, for example, preventing delirium in postoperative patients or those admitted to the ICU. Regular workshops on nonpharmacological measures to prevent ICU delirium can be conducted for the staff manning ICU by CL psychiatry teams.[19]

Primary preventive psychiatry services for the patients and their caregivers visiting psychiatry services

Primary prevention strategies can also be employed for the patients visiting psychiatric services and also for their caregivers.

Universal primary prevention strategies can be introduced by improving the general outpatient and inpatient facilities and display of mental health education material at prominent places. In South Asia, the caregivers accompany most of the patients with mental illness for hospital visit. Psychoeducational interventions can also be introduced, especially for the caregivers with focus on their ward's illness, their concerns of caregiving, strengthening problem-solving, and preventing stress and burden.[19]

Caregiver self-help and support groups can be formed for tackling stigma and promoting advocacy. Such groups can also help in sharing information regarding management of illness and newer treatments. The strategy has a potential of sharing information across different stakeholders on how to negotiate through various mental health systems and facts about the legislations and benefits.

Selective preventive strategies for patients would include lifestyle modifications comprising of emphasis on adequate sleep, nutrition, moderate physical exercise, and meditative techniques for certain specific disorders and smoking cessation, emphasis on acquiring/maintaining age-appropriate social and vocational skills resuming role functioning, recreation and socialization, imparting knowledge about contraception to patients in reproductive age group and need for planned pregnancy, and resolving alcohol/substance use-related issues, if any.

Indicated prevention would include monitoring of physical health and metabolic syndrome. Most caregivers experience anxiety and stress in their caregiving role and may experience subsyndromal symptoms, especially if the patient has chronic illness and need to be screened for such symptoms and managed accordingly.[20] Indicated prevention can also be useful for identifying persons at risk of developing mental illness among the relatives of patients with severe mental illnesses such as schizophrenia and bipolar disorders as the genetic risk for developing an illness is directly proportional to the genetic loading. In patients with severe mental illness having positive family history of mental illness, screening can be done in the nonaffected relatives to identify at-risk individuals.

Primary preventive psychiatry services for the employees in the hospital

Preventive services for the employees could include providing positive mental health messages, mental health awareness, and stress management programs at the time of entry and also at periodic intervals. Certain other employee friendly facilities such as a comfortable working environment and childcare facilities for the working mothers are some other primary prevention strategies reducing work stress and preventing mental health problems. The senior-level administrators can also be sensitized at identifying mental health issues in their subordinates, who are not performing well and steps to be taken to handle such issues. Such principles of primary prevention can be applied in any workplace. In fact, some of the workplaces in corporate world employ such strategies to reduce stress in their employees.

Primary preventive services for the students and trainees

Students and trainees is another important population group offering scope of primary prevention in psychiatry. This population includes late adolescents and young adults, who are at a high risk of developing mental health problems. Medical students have high prevalence of depression, anxiety, and psychological distress, higher than that in the than age-matched general population and other student groups.[2122]

Universal intervention strategies for the students and trainees include screening for mental health problems at entry level and on periodic basis, mentorship programs, periodic programs at inculcating interpersonal and communication skills, stress management, sensitization against substance use, lifestyle promotion, and problem-solving skills, and improving basic facilities such as hostels.

Selective interventions may include the identification of students who are irregular in their attendance in the classes or are not performing well, looking into the reasons and taking remedial measures.

Indicated prevention strategies can be employed for students identified to have or likely to have mental health issues during screening. Interventions would include addressing the mental health issues and introducing suitable therapeutic interventions.

Primary prevention in teaching curriculum

At present, there is a little focus on primary prevention in mental health in the undergraduate and postgraduate curriculum in medicine and nursing. Primary preventive strategies in mental health need to be included in these curricula. In South Asia and many other low-resource countries, the families and their networks are one of main support systems for any person in distress. Health services in general are not well equipped, and there is a gross deficiency of manpower. Similarly, there is a dearth of paramedical health professionals such as health workers, nurses, social workers, and psychologists. In this background, it is important to integrate evidence-based preventive and promotive strategies for improving health/mental health in the undergraduate as well as the postgraduate curriculum so that the trainees develop knowledge, attitude, and skills to implement these in routine clinical practice. The training should start from the beginning in form of a foundation course incorporating communication skills, mentorship program, and introduction to public mental health. This can be further strengthened when the student comes for clinical postings in the later years of training. An integrated training can also be conducted in collaboration with the discipline of community medicine.[2324]

This model of primary prevention as a whole or some of its components can also be applied to the universities and schools. It is important to add here that such an approach can be used in other educational institutions also.

Collaborations with other institutions

The general hospitals can also develop linkages with the community and other institutions, depending on the resources available. The linkages could be made with educational institutions such as schools and colleges, the voluntary agencies and the corporate sector. Mental health professionals working in the general hospitals can conduct public health awareness lectures in the educational institutions and work places on mental health, positive mental health, and stress management. Specific programs can also be undertaken for the school and college teachers to sensitize them so that they can identify mental health issues in their students at the earliest. Similarly, such programs tailored at the senior management in the corporate sector can be helpful in promoting mental health. A focus on alcohol and substance use also needs to be kept in such programs. Linkages can also be developed with the voluntary sector to conduct such programs.

Many of these preventive strategies have been carried out at individual level in different institutions in the country including the All India Institute of Medical sciences, New Delhi, though evaluation of their effectiveness has not been carried out. However, the primary preventive strategies, especially for students and trainees have been helpful in sensitizing the students, trainees, teachers, and administrators about these issues (Personal communication with Prof. Pratap Sharan, Incharge of student welfare at All India Institute of Medical Sciences, New Delhi).

There are many barriers to implement preventive aspects in psychiatry; many of these are important barriers to primary prevention as well. One of the most important barriers is the long time taken to show the impact of preventive efforts. This results in availability of limited funds and resources for research and implementation of these strategies. Moreover, it is difficult to generalize the research findings for different settings due to various limitations such as small sample size, lack of long duration of follow-up, lack of multisite or multicountry studies, use of varied instruments across the studies, effect of cultural factors, and lack of economic evaluation studies. Preventive psychiatry has also been ignored in the curriculum of various medical and paramedical courses where there is more focus on biomedical model. Therefore, the clinicians, thus trained, see their role mostly in the curative aspects of diseases.[25262728]

CONCLUSION

It is possible to introduce primary prevention strategies in general hospitals in South Asia utilizing the concept of universal, selective, and indicated prevention. The strategies could be targeted at the patients visiting the hospital for various health services and their caregivers, employees, and the trainees. There is further scope at utilizing the similar kind of strategies in the university setups and similar institutions. There is also a need for building up knowledge regarding how to practice primary prevention in clinical care, teaching, and research and generating evidence for the same in hospital settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.