Research on mental health in Indonesia led by Sabrina Anjara could have implications for many countries tackling the mental health crisis.
Not only were GPs able to manage mental health problems, but patients were more likely to return to see them for follow-up treatments.Dr Sabrina Anjara
Patients experiencing mild to moderate mental health issues could be managed effectively by GP practices, suggests new research by the University of Cambridge. However, specialist treatment may still prove more cost-effective in the long term, say the researchers.
The research was based on a trial carried out by Gates Cambridge Scholar Dr Sabrina Anjara  in Indonesia where patients often do not get the treatment they need due to a shortage of practitioners. The research team at the Cambridge Institute of Public Health, where Sabrina was based when she did the study, say the findings are relevant to the UK and any other country with a long waiting time for mental health appointments and a growing globalised clientele, as it opens up alternative pathways of care.
In many countries, there is a ‘treatment gap’ for mental health issues, caused in part by a confluence of the lack of mental health professionals and the social stigma attached to seeking help. While the median worldwide treatment gap for psychosis is 32% – meaning that almost in one three people with psychosis do not receive treatment – in low and middle-income countries it is estimated to be almost three times higher, above 90%.
Experts have argued that one way of bridging this gap would be to integrate mental health care into primary care, such as GP practices. Recent research confirmed that primary care clinics are the first port-of-call for most people with mental health problems. However, diagnosing mental health problems in primary care is difficult for several reasons, including time constraints during consultations, lack of mental health expertise and problems with referrals.
In 2008, the World Health Organization (WHO) launched the WHO Mental Health Gap Action Programme to support countries in scaling up services for mental, neurological, and substance use disorders, with a free online Intervention Guide and Training Manual. In 2015, the Indonesian Ministry of Health introduced the programme to selected pairs of GPs and nurses at its network of community health centres, with the aim to rolling it out nationally.
The new study evaluates the effectiveness of this programme in Indonesia:153 patients completed treatment at 14 primary care clinics that had received the WHO training, while 141 patients at 14 other clinics received treatment from specialist clinical psychologists co-located in primary care. The findings are published today in PLOS ONE.
Sabrina said: “Mental health care provided by a GP proved to be just as effective for mild to moderate conditions as care by a specialist clinical psychologist. GPs also helped large proportions of participants go into remission.”
Both groups experienced a similar improvement in health and social functioning, quality of life, and disability reduction at the six-month follow-up. A large proportion of participants from both study arms were considered in remission (152 from GP clinics, 134 from the specialist arm of the trial). The improvement was quantified using the Health of Nations Outcome Scale, the European Quality of Life Scale and the WHO disability assessment schedule.
To directly inform policy decisions, the Cambridge researchers conducted an economic analysis. Its results suggested that the cost of treatment from specialist services was lower on average, despite their patients experiencing similar improvements in symptoms as GP patients.
Sabrina, who was the first Gates Cambridge Scholar from Indonesia, added: “Not only were GPs able to manage mental health problems, but patients were more likely to return to see them for follow-up treatments. However, GP workload needs to be considered alongside the cost-effectiveness of various options. We found follow-up appointments with a clinical psychologist to cost the Indonesian health system less, so the co-location of specialist mental health professionals in primary care may be a more feasible option in the long run.”
The researchers say that the findings provide potential learning points for other countries, which may not be considered low and middle-income countries, but have similarly limited resources for mental health services due to a structural imbalance of supply and demand. In the UK, for example, the British Medical Association found in 2018 that the waiting time for a clinical psychology appointment surpassed two years in some NHS trusts.
“NHS England has committed to transform mental health services and also plans to recruit mental health therapists to be integrated into primary care settings such as GP practices,” said Dr Tine Van Bortel, senior author and supervisor from the Cambridge Institute of Public Health.
“This transformation aims to put mental health services on an equal footing with physical healthcare. Nine out of 10 adults with mental health problems seek help in primary care settings, and the transformation of mental health service delivery model will also strengthen the primary care and its workforce which will be able to offer a broader range of services for patients.”
“If GP practices provided mental health treatment for those with mild to moderate conditions, the waiting list for specialist services would reduce considerably,” said Sabrina, who is now based at University College Dublin. “In addition, getting treatment from their GP is less stigmatising, which will also lead to better continuity of care. Early intervention is key in reducing the economic and societal burden of mental health.”
In addition to fieldwork funding from the University of Cambridge School of Clinical Medicine, School of Biological Sciences, Department of Social Anthropology and the Cambridge Philosophical Society, this research was supported by crowdfunding.
*Picture credit: Sander van der Wel from Netherlands c/o Wikimedia Commons
Sabrina Gabrielle Anjara
- 2014 PhD Public Health and Primary Care
- Queens' College
Sabrina recently completed her PhD as the first Gates Cambridge Scholar from Indonesia. Her thesis focused on the implementation and outcome evaluation of mental health care policies in Indonesia, specifically in adapting service delivery models to local contexts. She is currently a Postdoctoral Research Fellow at University College Dublin, working on the implementation of Collective Leadership in the Ireland East Hospital Group.
Sabrina holds a BA in Psychology and Asian Studies from the University of Melbourne, and an MSc in Organisational Psychiatry and Psychology from King’s College London. Prior to Cambridge, Sabrina worked at the Yong Loo Lin School of Medicine, National University of Singapore and at the Ministry of Social and Family Development, Singapore. She’s a World Economic Forum Global Shaper.