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Toolkit for the Integration of Mental Health into General Healthcare

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Step 3. Strengthen Mental Health Services & Systems

Strengthening of mental health services at facility and community levels provided by trained and supervised healthcare staff in addition to strengthening systems through improved coordination and referral between service providers, HMIS documentation, and psychotropic medication supply.

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WHY is this step needed?

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While staff capacity building is a critical component, it is not enough to establish a functioning system of community based mental health care. Various parts of the system need to work together to ensure that persons with mental health problems can be identified, appropriately managed and cared for, have access to psychotropic medications and can be referred to essential clinical or community services and followed up, as part of a functioning system. Strengthening these systems means that persons receive the care they need, and that integration can be sustained.

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HOW is this step done?

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Use your assessment/situational analysis to identify where your planned mental health program falls within the larger systems of health, mental health and community services as well as within humanitarian response efforts. Work with national, regional and local authorities as well as with health facility staff to strengthen MH services (e.g. identification, management, referral) and systems (e.g. space and time for services, mapping of service providers, HMIS, psychotropic medication). Ensure that trained staff and other service providers understand their role in the MH system.

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MINIMUM elements of Strengthening Mental Health Services &...

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Strengthening of mental health services provided by trained health staff (doctors, nurses and CHWs) consisting of:

  • Identification, assessment and diagnosis (e.g. initial identification through CHWs, assessment by PHC providers).
  • Management of mental disorders (e.g. psycho-education for patients and family members, psychosocial interventions, psychotropic medication- if needed).
  • Follow-up (e.g. continued appointments, visits by CHWs, phone calls/text messages).
  • Referral to other services including to more specialized mental health service providers.

Strengthening of mental health system through:

  • Ensuring that trained staff understand their roles in MH service provision (e.g. outlining protocols, referral pathways, job descriptions).
  • Ensuring there is designated and appropriate space (e.g. private space, locked files) and time (e.g. afternoons one day a week) for staff to see persons with MH problems.
  • Adaptating Health Information Systems, in line with national systems, to collect data on persons with mental disorders identified in primary care.
  • Supporting procurement of essential psychotropic medications in coordination with the government.
  • Mapping of community services (e.g. protection, social services) and specialized MH service providers.
  • Setting up processes for referral to and from MH PHC services.
  • Establishing links and communication with local specialized MH services (e.g. psychiatrist) for referral of persons with severe mental health problems.
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COMPREHENSIVE additional elements of Strengthening Mental...

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Strengthening of mental health services through additional capacity building such as:

  • Training of non-specialized staff (social workers, counselors, case managers, etc.) to provide evidence based psychological interventions with mechanisms for support, follow up and supervision by specialized mental health professionals.
  • Peer to peer support activities with leadership from mental health service users.
  • Setting up mechanisms for patient identification, basic support and follow up by mobilizing community health workers.

Strengthening of mental health system through:

  • Supporting communication, care coordination and multi-disciplinary teamwork among various staff (e.g. health and social services, psychiatrists, psychologists and other MH professionals) to address multiple and complex needs of persons with mental illness and their families.
  • Supporting Health Information Systems, in line with national systems, to collect and report data on persons with mental disorders treated at different levels of care (e.g. in primary care, mental health outpatient facilities, mental hospitals).
  • Comprehensive Mapping of formal and informal service providers in the area (e.g. specialized MH services, protection services, community services, traditional healers).
  • Supporting the availability and affordability of psychotropic medications including effective maintenance or establishment of sustainable supply chains (e.g. staff know when and how to order medication and feel empowered to advocate for availability of medication with government or other stakeholders).
  • Setting up an effective monitoring and evaluation system for MH services and organizational level change.
  • Setting up interagency referral workshops to establish clear referral pathways and guidelines among different service providers.
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WHEN is this step done?

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This is a continual process which requires ongoing monitoring, planning and active participation of all stakeholders from the beginning. The resources presented as Specific Tools and Materials should be used by those who have been trained as mental health care providers.

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KEY CONSIDERATIONS

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  • Do ensure that investment in primary care is preceded by, or at least carried out in tandem with, development of community and secondary mental health services.
  • Do invest in local human resources (displaced and host) to respond to MH needs.
  • Do help ensure provision of a quiet and private space to meet with persons with mental health problems.
  • Do address mental health needs at the appropriate level of care, while being aware of available up and down referral systems and pathways if needed.
  • Do set up a system where trained health staff can connect with MH specialists for support and guidance, and for emergencies (e.g. responding to acute suicidal ideation).
  • Do utilize CHWs and community leaders for outreach and connect with formal and informal service providers for referrals.
  • Do respect the privacy and confidentiality of persons with MH problems.
  • Do take into consideration that families/carers of people with mental disorders may also need support.
  • Do discuss in training how to establish referral links with traditional healers and religious leaders who are often the first point of contact for persons with severe mental illness.
  • Do not refer all persons to a specialized provider (e.g. psychiatrist or psychologist).
  • Do not set up a parallel system of MH care.
  • Do not forget that persons with mental health problems may have other complex needs that also need to be addressed (e.g. other general health conditions or injuries, protection concerns, housing issues).
  • Do not assume people with mental illness will come to a health care facility on their own.
  • Do not introduce expensive psychotropic medications that cannot be sustained in the long term and work in line with the ministry of health’s essential drug list.
  • Do not allow medication supply to be interrupted.
  • Do not contribute to an influx of referrals to already stretched services, without working to strengthen those existing services first.
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RESOURCES

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Category

  • Key Guidance Apply Key Guidance filter
  • Specific Tools and Materials Apply Specific Tools and Materials filter
  • Key Publications & Readings Apply Key Publications & Readings filter
  • Field Examples and Applications Apply Field Examples and Applications filter

Audience

  • Implementing agencies Apply Implementing agencies filter
  • Governments Apply Governments filter
  • Donors Apply Donors filter

Language

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  • French Apply French filter
  • Arabic Apply Arabic filter
  • Spanish Apply Spanish filter
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  • Toolkit Homepage
  • Step 1. Assess & Plan for Mental Health Integration.
  • Step 2. Build Capacity of General Healthcare Workers.
  • Step 3. Strengthen Mental Health Services & Systems.
  • Cross cutting component. Monitoring, Evaluation, Accountability & Learning.
  • Cross cutting component. Advocate, Coordinate and Network.
  • Cross cutting component. Sustain Mental Health Services.
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  • UNHCR & WHO (2015) mhGAP Humanitarian Intervention Guide (mhGAP-HIG)

    Category: Key Guidance, Service Strengthening

    Audience: Implementing agencies, Governments, Donors

    For use in humanitarian emergencies where access to mental health professionals and treatment options is limited. This guide extracts essential information from the full mhGAP-IG and includes additional elements specific to humanitarian emergency contexts.

    • PDF icon Access here
    • PDF icon Access in Arabic
    • PDF icon Access in French
    • PDF icon Access in Russian
    • PDF icon Access in Spanish
    • PDF icon Access in Ukranian
  • WHO (2016) mhGAP Intervention Guide for Mental, Neurological and Substance Use Disorders in Non-Specialized Health Settings - Version 2.0

    Category: Key Guidance, Service Strengthening

    Audience: Implementing agencies, Governments, Donors

    Use this for guidance on integrated management of priority MNS conditions using protocols for clinical decision-making. This mhGAP-IG Version 2.0 reflects updates to the initial 1.0 version, based on emerging literature and extensive feedback from the field to enhance the guide in its clarity and usability.

    e-mhGAP (Phone Application): also available in a mobile application version for download on iOS and Android.

    • PDF icon Access here
    • PDF icon Access in Spanish
  • WHO (2013) Assessment and Management of Conditions Specifically Related to Stress: mhGAP Intervention Guide Module

    Category: Key Guidance, Service Strengthening

    Audience: Implementing agencies

    Use this for guidance on assessment and management advice related to acute stress, post-traumatic stress and grief in non-specialized health settings. This resource is an annex to the mhGAP-IG.

    [an mhGAP supplementary resource]

    • PDF icon (WHO, 2013). WHO Assessment and Management of Conditions Specifically Related to Stress- mhGAP Intervention Guide Module.pdf
    • PDF icon Access in Arabic
    • PDF icon Access in French
    • PDF icon Access in Russian
    • PDF icon Access in Spanish
    • PDF icon Access in Ukrainian
  • WHO (2009) Improving Health Systems and Services for Mental Health

    Category: Key Guidance, System Strengthening

    Audience: Implementing agencies, Governments, Donors

    Use this to learn about the essential ingredients for strengthening mental health systems within a context of overall health system development.

    • PDF icon Access here
  • WHO (2018) mhGAP Operations Manual

    Category: Key Guidance, System Strengthening

    Audience: Implementing agencies, Governments, Donors

    Use the mhGAP Operations Manual for practical, step-by-step guidance for integrating mental and health services, with sections relevant to service & system strengthening [See page 57 for guidance on systems integration into humanitarian response].

    • PDF icon Access here
  • WHO (2013) Building Back Better: Sustainable Mental Health Care after Emergencies

    Category: Key Guidance, System Strengthening

    Audience: Implementing agencies, Governments, Donors

    Use this resource to access examples and lessons learned from countries that build stronger mental health systems after emergencies.

    • PDF icon Access here
    • PDF icon Access the supplementary report
    • File Access the supplementary PowerPoint presentation
    • PDF icon Access the executive summary in Arabic
    • PDF icon Access the executive summary in Chinese
    • PDF icon Access the executive summary in English
    • PDF icon Access the executive summary in French
    • PDF icon Access the executive summary in Russian
    • PDF icon Access the executive summary in Spanish
  • IMC (2017) MHPSS Services Framework

    Category: Key Guidance, Setting up MH Service Programs

    Audience: Implementing agencies, Governments, Donors

    Use this framework for conceptualizing a stepped mental health care model. This outlines which staff are responsible for certain tasks and at which level, which forms should be used for service provision, summarizes M&E indicators as well as what should be provided to beneficiaries at each level.

    • File Access here
  • IMC Lebanon (2015) Guidance Document for Community Based Mental Health and Psychosocial Support

    Category: Key Guidance, Setting up MH Service Programs

    Audience: Implementing agencies, Governments, Donors

    Read this for a comprehensive overview of how elements of referrals and adherence to treatment and medication fit within the broader framework of setting up integrated community based MHPSS programming, describing linkages between activities and services at various levels of intervention, including PHC, and referral pathways within and across.

    • PDF icon Access here
  • UNHCR (2009) Health Information System (HIS) Categories

    Category: Key Guidance, Health Management Information System

    Audience: Implementing agencies, Governments, Donors

    Utilize this resource to access the annex with specific categories for mental disorders, and definitions based on IASC MHPSS Guidelines action sheet 6.2. 

    An IMC adaptation of the same categories, broken down into sub-categories can be found in the IMC HIS guidance Scoring Sheet, and outpatient record summary.

    [Updated Version Coming Soon]

    • PDF icon Access here
    • PDF icon Supplementary to this resource is the UNHCR HIS reporting form
  • WHO (2017) Improving Access to and Appropriate Use of Medicines for Mental Disorders

    Category: Key Guidance, Psychotropic Medication

    Audience: Implementing agencies, Governments, Donors

    Use this document to access evidence-based guidance for policy-makers, public health professionals and prescribers, especially in low- and middle-income countries, to improve access to and appropriate use of medicines for mental disorders.

    • PDF icon Access here

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This Toolkit is made possible by the generous support of the American people through the United States Agency for International Development (USAID).

The content are the responsibility of International Medical Corps and do not necessarily reflect the views of USAID or the United States Government.

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