“Reason for referral: anxious depressive syndrome” was the only information I had about Alan (name changed for anonymity), my last patient in the clinic that afternoon.

He was sent by his family doctor to the mental health team that supported primary care providers, where I worked as a mental health nurse. Alan nervously sat in my office and disclosed how his two oldest sons, kidnapped while visiting their home country, endured a horrific traumatic experience.

When I informed the program psychiatrist of Alan’s story, he agreed to visit him immediately. Alan left our office that day with the correct diagnosis, appropriate trauma-informed treatment, and a referral to the clinical psychologist.

Receiving adequate and timely diagnosis can be an uphill battle for those with mental health issues, leading to delays in treatment. This is why primary care is so crucial, since it is usually the gateway to the healthcare system, and it plays a central role in early detection and management of mental health problems and addictions.

However, primary care professionals struggle to find the time, support, or resources they may need to properly diagnose and treat patients with mental illness. This process is further complicated when people fall in the gap between primary care and secondary care, such as those with complex mental health problems, trauma-related disorders, patients with persistent physical complaints, people with uncontrolled chronic conditions and comorbidities, chronic pain or people with problems related to autism spectrum disorder.

One way to support primary care professionals in attending to people suffering from mental health problems is by promoting mental health-primary care collaborative initiatives.

A 2020 article reported that these types of programs can help people with mental health issues access the right resources while improving wait times that otherwise tend to be long. Additionally, collaborative initiatives optimize the use of the available resources, reducing costs and increasing the efficiency of the healthcare system.

Further, the British Psychological Society highlights some of the benefits of incorporating clinical psychologists to support primary care providers in the management of complex mental and physical health problems. For example, clinical psychologists can help provide specialist support and advice to staff and to ensure timely access to evidence-based psychological treatments, something especially important for people with low economical resources who cannot access private therapy.

We spoke with Miguel Garriz, a clinical psychologist with experience working in primary care and mental health collaborative programs in Barcelona, Spain. He states that resources in public health systems are limited, so it is important to ensure that the treatment the person receives is based on evidence. Normally the psychology treatments in primary care are carried out in groups, which are cost-effective.

For example, a 2020 article published by Garriz finds that mindfulness-based cognitive therapy, an 8-week group program that combines cognitive therapy and mindfulness and that has shown evidence in preventing relapses in patients with depression, can also be effective in reducing anxiety and depressive symptoms in common mental health disorders diagnosed in primary care, such as adjustment mood or anxiety disorders.

Garriz adds that the psychologist’s role in primary care can go beyond that – they can provide support to primary care professionals in aspects related to the psychological aspects of health and management of psychological components of consultations, such as psychological strategies for coping with chronic pain, strategies for changing habits and behavior in patients with chronic and complex conditions, and management of aggressive behaviors in consultation.

A recent collaborative program called Rapid Access and Stabilization Program was launched in April 2023 in Central Nova Scotia. We spoke with Vincent Agyapong, chair of the department of psychiatry at Dalhousie University in Halifax and chief of psychiatry for Nova Scotia Health’s Central Zone. Agyapong says that the RASP represents an improvement in mental health patients’ access to specialized care. Rather than waiting for months to be seen by a mental health clinician, who then would decide if the person should or not be sent to a psychiatrist, the RASP program connects patients directly with a psychiatrist within four weeks after referral.

Agyapong adds that before the implementation of the program, an average of 100 people got direct access to the Mental Health and Addiction Program in a year in Central Zone Halifax. In contrast, within the first nine months of the program (up to end of January 2024), 642 patients who have been referred by primary care providers to the MHAP have received comprehensive psychiatric assessments. This is important because early intervention improves the prognosis of the mental health disorder.

At present, the RASP team consists of two psychiatrists who receive referrals from family doctors and nurse practitioners from Nova Scotia’s Health Central Zone. The program serves people 19 years old or older. Agyapong highlights that the program also accepts referrals from walk-in clinics and the doctors at these facilities have access to the patient’s therapeutic plan at any moment. This is important in countries like Canada, where more than one in five Canadians do not have access to family doctors.

The process consists of a pre-visit where standardized questionnaires are filled out, then the patient meets with the psychiatrist to be assessed and a therapeutic plan is developed and shared within 24 hours with the primary care provider responsible for managing the treatment. The plans can include psychological recommendations, psychoeducation, and pharmacological interventions.

The program also aims to maximize existing resources by connecting patients with the appropriate providers in the community, those who can best address the patients’ needs.

If the psychiatrist determines that a patient needs more visits, the patient is then referred to the community mental health care program. However, in the first nine months since the opening of the program, less than 10% of patients have been transferred to a more intensive mode of care. Primary care professionals also can consult cases and solve doubts via telephone with the RASP psychiatrist. Patients can then be sent for re-evaluation any time the primary care provider considers necessary.

Agyapong shares with us preliminary data about patients’ satisfaction with the RASP: 88% of patients feel that their needs have been addressed, 97% felt dignified and respected, 92.9% understood the treatment plan and 70.6% felt hopeful about the treatment.

Furthermore, Agyapong tells us that there is further gain from the RASP. Mental health clinicians, usually social workers and clinical psychologists, who were overwhelmed in the previous system, now have more time to focus on interventions rather than screening patients referred from primary care.

Agyapong is hopeful about the future of the program, however, when asked about the limitations of the program he points toward the lack of resources: “The program currently has only 2 psychiatrists that provide service to a population of 450,000 people. The program needs consistent administrative support and at least a mental health clinical coordinator who will be responsible for coordinating, facilitating and integrating resources.”

Mental health problems are increasing worldwide, and our healthcare systems need efficient services to attend to population needs. Alan’s early diagnosis and treatment was possible thanks to the implementation of one of these collaborative programs. But Alan’s case is not unique. There are many people out there who are suffering and could benefit from mental health advice or treatment. Since resources are limited, we need to optimize them, and collaborative initiatives like the ones described here are intended to do just that.

-Maria Auxiliadora Sanchez Ledesma, Contributing Writer

Image Credits:

Feature: Mohamed Hassan at Pixabay, Creative Commons

First: Serena Wong at Pixabay, Creative Commons

Second: Mohamed Hassan at Pixabay, Creative Commons