Mental Health and Primary Care Practice in Indonesia

Priorities in the field of medicine and healthcare are determined by epidemiological trends in the prevalence of individual disorders and their impact on indicators of working capacity and quality of life. Mental disorders and, more broadly, mental health problems have gained special significance in recent decades among all classes of diseases. It is no accident that mental disorders are increasingly becoming the subject of special consideration by governments, NGOs, and the World Bank. [7, 10, 11, 15]

The reason for this is; first, the growing economic burden associated with mental disorders, few  financial support for the diagnosis and treatment of these disorders, as with indirect costs: labor losses, social support cost, employment of family as caregivers, etc. in total 15% of the economic loss incurred from healthcare burden is due to mental illness and their consequences. [5,7,10,11]

The rate of diagnosis of mental disorders, especially depression, is increasing everywhere [7,11]. According to a study conducted across different countries, clinically significant mental health problems are found in 1/4 of the patients of the general medical settings: these are primarily depression, anxiety, somatoform disorders, and alcohol abuse [14]. According to another study [1], severe symptoms of mental disorders lasting at least 1 week in a year can be detected in 31.5% of the population, and disorders corresponding to certain diagnostic categories of mental disorders in 10.5% of the population. 5 out of the 10 main causes of disability in most countries are related to mental and behavioral disorders. Worldwide, according to WHO, there is a 12% decrease in opportunities and social functioning due to disability, and 23% in high-income countries associated with mental disorders [5].

Mental Disorders as a General Medical Problem

The scale of mental health problems requires a significant change in counseling and treatment, with the development of new approaches that go beyond the traditional specialized psychiatric services, and with the combined efforts of various specialists – psychiatrists, therapists, cardiologists, neurologists, as well as psychologists and social workers. Modern psychiatry is undergoing a phase of reform aimed at democratizing aid, ensuring its accessibility. However, the reform of psychiatric care will not happen within the framework of existing psychiatric services. There is an obvious need for interaction with the general health care system, in particular, in the form of integrating certain forms of psychiatric care into primary health care facilities, primarily in Puskesmas and primary care clinics.

In Indonesia, the traditional system of primary outpatient services of the population represents a significant potential for the development of mental health services and better care for patients with mental disorders, in particular, in case of non-psychotic, moderate and short-term mental disorders.

The attention of specialists and healthcare professionals increasingly focuses on mental disorders associated with somatic diseases. The frequency of the combination of somatic and mental disorders is a well-known fact of clinical practice, which is also confirmed by numerous studies. Mental disorders can: provoke somatic diseases or, more often, their exacerbations; aggravate their course, delay recovery and, extend the length of hospitalization [13]. In particular, the presence of depression in patients with coronary heart disease is not only a complicating factor in treatment and rehabilitation, but also reduces the life expectancy of patients [8]. On the other hand, mental disorders themselves may be the result of a somatic disease – both due to a psychologically understandable reaction to the disease and related activity limitations and due to possible metabolic changes or intoxication in severe somatic pathology. In some cases, causal relationships and primary or secondary psychiatric and somatic pathology remain problematic and require the joint work of internists and psychiatrists.

The ICD 10 [3], compiled by the World Health Organization, contains a rather large list of mental disorders, for which it is assumed not only diagnostics but also some therapeutic and preventive strategies for healthcare professionals working in primary care.

Interdisciplinary Collaboration: New Approaches to Care

Common clinical forms that require the joint efforts of an internist and a psychiatrist include the so-called psychosomatic disorders listed in the ICD 10, as well as panic disorder, the main clinical manifestation of the latter (often encountered in the clinical practice of primary care physicians, including Puskesmas doctors, emergency doctors) is anxiety-induced paroxysmal dyspnoea.

The common complaints of patients with psychosomatic disorders fall to the jurisdiction of psychosomatic medicine, this branch of medicine has long been a common area of clinical and research activity of psychiatrists and internists, although the role of each of them is still not fully defined. Psychosomatic disorders, which primarily include arterial hypertension, coronary heart disease, peptic ulcer of the stomach and duodenum, ulcerative colitis, bronchial asthma, are no longer attributed to the psychogenic nature. Both psychological and physical attributes of these diseases are still an ongoing topic for discussions. During the last few decades, it has been confirmed by numerous studies that bacterial action plays an important role in the development, occurrence and progression of peptic ulcer exacerbations, hypertensive disease – a complex of metabolic and endocrine and other biological factors, bronchial asthma – toxic and allergic processes. Because of this, the diagnosis and especially the treatment of psychosomatic diseases should rather be within the competence of internists – contrary to the prevailing opinion in the past, especially in the USA, about the psychodynamic nature of classical psychosomatic disorders and, accordingly, the preference for psychotherapeutic (psychodynamically oriented) treatment methods.

Of course, the psychotherapeutic effect in the overall complex treatment of patients with psychosomatic disorders is always advisable, and it should take into account not only the alleged psychodynamic mechanisms involved in the development of the disorders but psychosocial problems associated with difficulties in family and domestic relationships, difficulties and limitations of professional activities associated with somatic disease. This aspect of the disease becomes especially important in complicated cases when psychosomatic disorders are associated with metabolic disorders or intoxication.

Of particular note is the changing position of neurosis. They have always been considered a classic example of a “borderline” between somatic medicine and psychiatry, and a wide variety of specialists, not just psychiatrists, took part in their diagnosis and therapy. Today, the concept of neurosis has changed significantly. First of all, the traditional division of neurosis into neurasthenia, obsessive neurosis, and hysterical neurosis can be considered obsolete and lacking a satisfactory scientific basis. Until now, only neurasthenia is recognized as a clinically more or less homogeneous state with well-known manifestations – predominantly emotional hyperesthesia, intolerance to mental stress, mental exhaustion, headaches, and other vegetative disturbances, in combination with other clinical manifestations. The presence of predominantly dysthymic, “subthreshold” depressive disorders is increasingly found when trying to distinguish neurasthenia as an independent clinical unit and thereby prompts researchers to bring neurasthenia closer to depression or to assume the actual depressive nature of the disease. It should be mentioned that the terms “depressive neurosis” and “neurotic depression”, have the same meaning. Today they are practically not used (and are absent in modern classifications) due to the impossibility of explaining depression, exclusively by neurotic mechanisms or by external provoking influences.

Obsessive neurosis, even with the modern possibilities of psychopharmacotherapy and its combination with psychotherapy, is part of the group of disorders, especially resistant to treatment with a chronic course and limitations of social activity: it is no accident that the term “obsessive-compulsive disorder” is used to refer to such conditions, emphasizing an almost inaccessible compulsiveness in the patient’s experiences and behavior. It is recognized by everyone that obsessive-compulsive disorder is one of the most severe mental disorders. Along with this, part of the disorder previously attributed to obsessive neurosis is considered within the framework of the so-called generalized anxiety disorder.

The concept of “hysterical neurosis” can already be considered quite historical; the notions “hysteria” and “hysterical” themselves lost their clinical meaning, being supplanted by the concepts of “dissociative”, “histrionic”, and “conversion” (although even the last term is criticized as being insufficiently correct, speculative).

In the so-called hysterical disorders, modern researchers tend to see a reflection of personality disorders and reactions to an unfavorable situation such as individual stereotypes of behavior and adaptation in a social environment. A variety of somatic and personality disorders are interpreted as expressing intrapersonal conflicts.

Diagnosis and Treatment of Depression is a Common Task for Primary Care Physicians.

As stated before, the most significant and promising clinical interaction between internists and psychiatrists is depression. Depression can be considered as a general medical and by no means only a psychiatric problem. This is due to the specifics of the clinical manifestations of depression, which significantly affect various somatic functions, sleep, general activity, and physical tone, while the actual mental activity can remain relatively intact for a long time. Therefore, the participation of various healthcare professionals in the diagnosis, treatment, and prevention of its severe, chronic, disabling form is needed.

Depression and its various clinical manifestations are now recognized as one of the main causes of reduced working capacity: in terms of the percentage of productivity loss, it is depressive disorders that are currently ahead of all other mental illnesses, including Alzheimer’s disease, alcoholism, and schizophrenia [11]. Depression takes fourth place among all diseases by the total burden that society bears. By 2020, according to this criterion, they will already take second place, second only to coronary heart disease [7].

The prevalence of depression among the population is one of the highest among all classes of diseases: estimates vary depending on the criteria used, but 2.5–5% in different countries are considered reliable [4.14]. Studies in the United States [9,12] showed an even higher proportion of people suffering from various mood disorders, including depression – 9.5–11.3% while taking into account the presence of at least 1 depressive episode within a year. This indicator may turn out to be much higher when taking into account the so-called disorders of the depressive spectrum – alcohol & substance abuse, some somatoform and initial stages of development of psychosomatic disorders. The percentage of people suffering from depression is especially high among psychosomatic patients. According to a multicentre study conducted in 12 countries, about 10% of visits to general practitioners are associated with depression [14]. Moreover, only in 10-30% of cases, depressive disorders are recognized as such by general practitioners.

Due to existing prejudices and fears, the population prefers not to go to psychiatric institutions with the most experience and the necessary arsenal of methods for diagnosing and treating depression. Meanwhile, when changing the system of care for patients suffering from depression in their usual, non-psychotic forms, treatment of depression can be carried out in a primary care setting, in particular, in the most accessible of them – Puskesmas. Of course, this implies significant changes in the training of primary care doctors (district physicians). In addition, awareness of the population regarding the appropriateness and feasibility of seeking medical help in somatic institutions regarding “emotional” and other health problems that do not have a specific physical expression is necessary.

As we know, in many countries, most antidepressants are not prescribed by psychiatrists, but by general practitioners. This is made possible thanks to the emergence of new antidepressants that do not have a pronounced side effect, the so-called behavioral toxicity. These include selective serotonin reuptake inhibitors. In contrast to these new antidepressants, the frequent adverse effects of traditional tricyclic antidepressants (primarily somnolence, lethargy, impaired fine coordination of movements, difficulties in intellectual activity), limiting the possibilities of social functioning, impede their successful use outside psychiatric institutions. Modern antidepressants are gradually becoming known to primary care doctors. At the same time, the widespread use of antidepressants should be preceded by various educational measures, as well as the development and testing of the most acceptable forms of care for patients with depression in the primary care setting. In turn, this requires the interaction between primary care physicians and psychiatrists, not limited to referring patients with obvious signs of depression to a psychiatrist, but also involving the therapeutic functions of the primary care physician. The scope and sequence of the therapeutic actions of each professional could be of mutual counseling. With a well-established professional interaction, the psychiatrist will get more opportunities for the implementation of a psychotherapeutic alliance: in many cases, some psychotherapeutic methods are necessary and are quite effective in overcoming depression, depending on the clinical features of the disease – non-pharmacologically or in combination with antidepressant therapy.

This kind of professional interaction, along with consistent psycho-educational activities, involves a significant expansion of the functions of primary care doctors. The result, as you can expect, will be the timely provision of adequate medical care to patients and the transition of the many so-called difficult patients to the category of curable. Furthermore, psychiatrists will only have to treat the truly “difficult” cases, severe and complicated forms of depression that require special treatment methods and techniques. It is possible that cooperative practice, inside a larger medical institution (such as hospital outpatients, or specialist clinics) where psychiatrists and internists will work together. Such forms seem to be justified primarily in cases of a combination of somatic diseases (for example, hypertension, diabetes mellitus, and depressive disorders), i.e. where daily monitoring of the patient’s condition is desirable for the period of active therapy.

In 2018 Basic Health Survey (Riskesdas) conducted by the Ministry of Health estimated that 0.67% of Indonesian households have at least one member with psychotic disorders. Moreover, an estimated 6.1% of the population aged 15 years and older were categorized as having depression. Seeing that even less-severe depression still correlates with lowered work performance, with a working-age population of over 180 million people, such figures are a large problem for Indonesia’s ambition to make use of its “demographic bonus” to boost economic productivity [16]. Based on the data obtained to date, one can speak of a high detectability of both mood disorders (about half of those who go to Puskesmas and primary care clinics) and the actual clinical forms of depression (about 25%, with a clinical assessment of depression in 15–20% that makes it possible to consider it appropriate prescribing antidepressants).

At the same time, one can note a significantly higher curability of depressions during their treatment in a primary care clinic (probably due to its uncomplicated mild to moderate severity) compared with depressions, which psychiatrists usually deal with in psychiatric institutions. Whereas for the usual contingent of patients with psychiatric institutions, curability, as you know, does not exceed 70–80%, as it is possible to treat 95% of all depression cases in a primary care setting.

In addition to the direct effect of the therapy on depression, there is undoubtedly a more humane meaning of the proposal and the provision of timely and adequate assistance to patients suffering from depression in primary care where they are more readily accessible and where the patients are still in a familiar and non-stigmatizing conditions.

References

1. Goldberg D., Huxley P. Common mental disorders: Biosocial model / Per. from English – Kyiv: Sphere, 1999

2. Dharmono S. Diagnosis & Tatalaksana Gangguan Depresi & Anxietas di Layanan Kesehatan Primer, Yogyakarta, 2014.

3. ICD – 10. Section U. Version for primary care. Mental disorders in general medical practice. Diagnostics and treatment and preventive measures. Per. from English M. Phoenix. 1997

4. Angst J. Epidemiologie der Depression: Resultate aus der Zurich – Studie –Depressionen. Therapiekonzepte in Vergleich. Berlin – Heidelberg: Springer – Verlag, 1993, s. 3–12

5. Brundtland G.H. Editorials: Mental health in the 21st century – Bulletin of the World Health Organization, 2000, N 78, p. 411

6. Burton S.W., Akiskal H.S. (Eds.) Dysthymic Disorder. – London, Gaskell, 1990

7. Desjarlais R., Eisenberg L., Good B., Kleinman A. World mental health. Problems and priorities in low-income countries. – NY: Oxford University Press, 1995

8. Glassman A.H., Shapiro P. Depression and course of coronary artery disease. – Am. J. Psychiat., 1998, vol. 155, N1, p. 4–11

9. Kessler R.C. et al. Lifetime and 12 – month prevalence of DSM – W – R psychiatric disorders in the United States. – Arch.Gen. Psychiat., 1994, vol. 51, p.8–19

10. Mental Health: A report of the surgeon general. – Rockville: US Department of Health and Human Services, 1999

11. Murray Ch. J.L., Lopes A.D. The global burden of disease. – Cambridge, MA: Harvard University Press, 1996

12. Regier D.A., et al. The de facto US mental and addictive disorders service system: epidemiologic catchment area prospective 1 – year prevalence rates of disorders and services.– Arch. Gen. Psychiat., 1993, vol. 50, p. 85–94

13. Rundell J.R., Wise M.J. (Eds) Essentials of Consultation-Liaison Psychiatry.– Washington: American Psychiatric Press, 1999

14. Ustun T. B., Sartorius N. (Eds.) Mental Illness in General Health Care: An International Study. – Chichester: Willey, 1995

15. World Bank. World development report: Investing in health. – Oxford, UK: Oxford University Press, 1993

16. Kementrian Kesehatan Republik Indonesia. Riskesdas 2018, Jakarta, Balitbangkes, 2018

Published by dewantoandoko

Dewanto Andoko Psychiatry Resident, Cipto Mangunkusumo Hospital - Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia 1. Educational Background: 1998 – 2000 : Petra Elementary School, Kediri 2000 – 2002 : BPK Penabur Elementary School, Bandar Lampung 2003 – 2004 : Brookfield State Primary School, Brisbane, Australia 2004 – 2007 : Immanuel Junior High School, Bandar Lampung 2007 – 2010 : St. Francis Senior High School, Bandar Lampung 2010 – 2017 : Maranatha Christian University Medical School, Bandung (GPA 3,35) 2. Work Experience: April 2019 - January 2020 : Assistant Researcher of dr. Profitasari Kusumaningrum, Sp.KJ, Psychogeriatric Division, Psychiatry Department, Faculty of Medicine University of Indonesia / Cipto Mangunkusumo Hospital February 2018 – February 2019 : Internship Medical Doctor at Bhayangkara Hospital Tulungagung & Puskesmas Kauman.

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