REVIEW ARTICLE

 

Mental health consultation-liaison from the perspective of the primary health care team^*

 

 

Ana Carolina Guidorizzi Zanetti^I; Sueli Aparecida Frari Galera^II; Jacqueline de Souza^III; Kelly Graziani Giacchero Vedana^IV; Edilaine Cristina da Silva Gherardi-Donato^V; Margarita Antonia Villar Luis^VI; Lisa Laredo de Camargo^VII; João Mazzoncini de Azevedo Marques^VIII

^IUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
^IIUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
^IIIUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
^IVUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
^VUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
^IVUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
^VIIUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil / Scholarship holder at the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil
^VIIIUniversidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brazil

Corresponding Author

 

 

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ABSTRACT

OBJECTIVE: analyze the consulting and liaison activities carried out by professionals specialized in mental health from the perspective of the PHC.
METHOD: an exploratory study, realized in five Family Health centers, in a municipality in the countryside of São Paulo, in 2010. Data were collected through interviews, which were submitted to content analysis.
RESULTS: as consultation-liaison activities were shown as a space for mutual learning between specialists in psychiatry and mental health and PHC teams.
CONCLUSION: it is recommended to increase the number of activities that articulate mental health actions with PHC, such as consultation and liaison, in order to favor the sensitivity of the teams to the demands of mental health in the PHC and consolidation of the integral care.

Descriptors: Mental Health; Primary Health Care; Family Health Strategy; Family Health.

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Introduction

The conditions for the Unified Health System to be consolidated as a health model, goes through the effective implementation of the Primary Health Care (PHC) network, particularly through the Family Health Strategy (FHS). Within the work process of the FHS, the concept of territorialization, a field that delimits the action of the Health Unit regarding space and population, is fundamental⁽¹⁾. The professionals of the FHS team should carry out the active search of the people inserted in a defined territory, identifying those with health problems, including psychosocial problems and mental disorders properly⁽¹⁾. It is recognized that in PHC the prevalence of psychosocial problems is of the order of 40% and of mental disorders, 25%⁽²⁾. A study carried out in Rio Grande do Sul showed that the prevalence of mental disorders of individuals attended in a PHC service was approximately 51%⁽³⁾. For most of these individuals the only care offered is the one performed by the professionals of the FHS teams⁽³⁾.

Studies show that all mental health services/professionals, even in high-income countries with universal health systems, serve a maximum of 3% of the population annually, while the annual prevalence of mental disorders is around 30% which points out important gaps between the supply and demand of care in this area^(4-5). The World Health Organization (WHO) recognizes that PHC services can function as important articulators of Mental Health (MH) networks, since, because of their proximity to communities, families and individuals, they have the potential to detect more mental health problems and provide appropriate interventions to the unique and contextual characteristics of each situation (including through referral to specialized services when necessary)^(6-7).

However, studies show that PHC teams detect approximately 50% of people with mental health problems within their territory and that even when the problem is detected, the appropriate treatment rate is low⁽⁶⁾. In Brazil, despite the efforts made in the last years, the professionals of the FHS teams often still lack capacity for the development of actions in mental health. In addition, there are difficulties in the capacity to develop actions that extend to the wider social space⁽⁸⁾.

Since 1999, in a city in the state of São Paulo, health professionals, linked to the medical and nursing courses of a public university, began actions of integrated mental health care in the FHS services, a care characterized by periodic meetings and facilitation of communication between the professionals of these services and professionals specialized in mental health, aiming to provide support to the FHS teams in the management of situations involving psychosocial problems and/or mental disorders and, consequently, in their mental health training.

The theoretical-practical references for these integrated mental health care actions were British, Canadian and North American experiences in mental health counseling and liaison in PHC^(9-12). This concept of consultation and connection in mental health in PHC is characterized by: Periodic meetings between professionals of the PHC teams and specialized professionals, which can include joint patient care and discussion of cases and topics requested by these teams; Communication facilitated by professionals also through telephone and/or internet contacts; Assistance from mental health professionals in referral of patients to specialized care outside PHC and in providing care information to the primary care team. As such, this model of consultation and liaison in PHC maintains the central role of PHC professionals/teams as providers of care for the vast majority of people monitored at this level. The professionals specialized in mental health described in the literature as actuators of this model are diverse: nurses, psychologists, doctors or social workers^{(6,9,11,13-15)}.

For example, the role of nursing professionals as mental health consultants has been in place since the 1970s in developed countries and is still in the process of being consolidated in developing countries⁽¹⁶⁾. It is believed that the involvement of the nurse in consulting activities can facilitate the resolution of less complex issues involving mental health, speed up the identification of cases of mental disorders with greater accuracy, favor the provision of less complex care, quality of life of the family's health service user and improve articulation with other health services. Also, it can promote the training and supervision of the nursing team and the recognition of the family and social bonds established between health professionals and the community^(16-17).

In Brazil, starting in 2003, the first guidelines for the approximation of mental health with the FHS began, with the publication of the document the Supporting Matrix of Mental Health to the FHS teams. The Matrix Health Support establishes the model of consultation and linkage based on the therapeutic link. This model values therapeutic actions within the territory, emphasizes the singularity of the individual, avoiding the fragmentation of care, and considers the family, socio-cultural, economic and biopsychosocial dimensions that involve the daily actions to promote mental health^(18).

In the national and international literature there is recognition that, although the health management agencies in Brazil and in the world point out that FHS teams play a key role in the prevention and maintenance of mental health problems, there are gaps in knowledge about how FHS teams are articulated to meet the demands of mental health^(7,19-20).

While there is an optimistic outlook for counseling and liaison activities between a specialized mental health service for FHS teams facing the possibilities of facilitating access, early diagnosis of problems, initiation of appropriate and immediate person-centered interventions and creation of a non-stigmatizing environment, FHS professionals do not always feel or are prepared to meet mental health need.

The justifications for this study were the frequent difficulties described by PHC teams/professionals to manage mental health problems and the experience gained in the consulting and liaison work developed in a city in the interior of São Paulo to deal with this issue.

 

Objectives

This study aimed to analyze the consulting and liaison activities carried out by professionals specialized in mental health and psychiatry from the perspective of the FHS professionals.

 

Method

This is an exploratory descriptive study, carried out with five FHS teams from the city of Ribeirão Preto, linked to the University of São Paulo, in 2010. The professionals of these teams had access to consulting and liaison activities, in which a physician participated and a nurse, specializing in psychiatry and mental health. Consultancy and liaison activities covered: Discussion of themes and cases; Joint care, including home visits; Attendance of specialized professionals without simultaneous participation of PHC professionals; Discussion of organizational aspects and the work process of the FHS team; Rapid referral to specialized secondary level outpatient clinic where the psychiatrist and mental health nurse also worked, if so agreed with the PHC team; Facilitation of referral to other specialized services, such as Day-Hospital, Psychosocial Care Center for Alcohol and Drug Users and full psychiatric hospitalization.

The project was approved by the Research and Ethics Committee on July 15, 2009, Protocol No. 17/2009, in accordance with resolution CNS 466/96⁽²¹⁾. The health professionals were recruited in the Family Health centers after approval of the project by the research ethics committee. Fifty-five professionals from these five FHS teams were invited to participate in the study. Seven declined to attend and one disconnected from service before their interview was scheduled. Then, a final convenience sample consisted of 50 health professionals.

Data was collected using a structured script containing the sociodemographic variables (gender, age, institution where the training took place, training in the area of mental health and psychiatry, place and current working time) and a semi-structured interview script containing the following guiding question: How do you feel about your consulting and liaison work in mental health and psychiatry at your service?

The data was obtained through interviews, at a pre-determined time by the participant, in rooms reserved in said nuclei. Firstly, the objectives and nature of the study were clarified and after the agreement and signing of the informed consent, the interview was started. The average interview time was thirty minutes and at the end, the interviewer was available for additional clarification. The data collection period was from July 2009 to January 2010.

The interviews were recorded, transcribed and the data that could identify the professional was withdrawn. After this step, the data was submitted to content analysis according to Bardin⁽²²⁾. The interviews were read in order to identify similarities and differences in the contents expressed by the participants, aiming to identify the consulting and liaison activities carried out by professionals specialized in mental health and psychiatry from the perspective of the family health strategy teams. The codification of the units of meaning was carried out by two researchers with the consulting and liaison actions described in previous studies^(9-11). After this step the codes were grouped into the following categories: mental health demands in the FHS and the role of consulting and liaison as a support element in the FHS. The parameters for the analysis of the results were the recommendations for the operationalization of the matrix support in primary health care^(23-24).

 

Results

Of the 50 (100%) professionals of the FHS teams, 19 (38%) were community health agents, women, 39 (78%), mean age 34 years (SD = 8.6), average 48 months (SD = 35.5). The totality of those investigated had no prior training as a mental health specialist. This can be seen in Table 1.

The following two categories of analysis are extracted from the participants' testimonies: mental health demands in the FHS and the role of counseling and liaison in the role of support in FHS.

The first category of analysis called mental health demands in the FHS showed that FHS professionals are faced with various mental health demands of health service users. These demands are related to the needs of the users in view of the high number of cases and problems inherent in the various diagnoses of mental disorders (depression, anxiety, substance use, schizophrenia, bipolar disorder, dementia, etc.) as follows:

...many cases of depression and anxiety.(RESIDENT); ...the problems or situations are several. [...] the most common are depression and anxiety disorder. (DOCTOR); problems like depression, anxiety too, and a lot of things.(COMMUNITY HEALTH AGENT); ...about 70% of the population has some mental health related demand. (NURSE)

The testimonies also show that there are situations of social vulnerability such as low self-esteem, poor access to information, difficulties in interaction among family members, domestic and conjugal violence, child abuse and neglect, and suicide attempts and / or suicide which demand support from a health professional with specialization in psychiatry and mental health.

physical and verbal aggression from mother to child, family conflicts.(COMMUNITY HEALTH AGENT); ...so the problems are many, people who have a problem with self-esteem, people who have little information. (COMMUNITY HEALTH AGENT)

In the testimonies it is verified that the consulting and liaison activities take place through direct contact of the mental health specialists in the consultations together with the service team. The speeches show that health professionals recognize consulting and liaison as an element of support in the FHS. This recognition was found in all professional categories investigated, irrespective of the level of training.

Thus, it is understood that consulting and liaison activities from the perspective of PHC professionals increased their safety in handling mental health demands, contributed to their continued education, expanded their repertoire of theoretical and practical knowledge, and favored their the resolving ability.

....over the years we have been prepared by consulting and this is very important. (NURSE); ... in the beginning I was very insecure, (...) but with the consultancies here, both in the internship and in the Emergency Unit, today I have more security, much more than when I started.( RESIDENT); ...with consulting and liaison we learn to interview, handle, adjust the medicines, I think it helps a lot, it makes a lot of difference.(DOCTOR); We start to have a different look at mental health in the FHS (NURSE), can be verified in Figure 1.

 

Figure 1 - Click to enlarge

 

Discussion

When analyzing the consulting and liaison activities carried out by professionals specialized in mental health from the perspective of the professionals of the FHS, the participants recognize the activities of consultation and liaison as essential to assist in the management of both specific mental health demands (such as disorders mental disorders and their manifestations), as well as situations of social vulnerability. The activities of counseling and liaison stimulated the therapeutic actions that valued the singularities of the people, helping to think about actions that deal not only with the biological dimension and with psychiatric medical diagnosis, but also with social aspects (family, neighborhood, economic aspects, etc.) and psychological (the subjectivity, the experience lived by the person). The results corroborate other studies that emphasize the biopsychosocial, holistic and people-centered character that the matrix support has the power to take over^(20,26). For example, a study that evaluated the matrix support in mental health in the city of Porto Alegre, in two FHS teams, showed that this support favored the qualification of the teams in the medical monitoring, clinical evaluation and discussion of user needs, among other activities⁽²⁶⁾. Thus, the consulting and liaison activities carried out by professionals specialized in mental health and psychiatry from the perspective of the FHS professionals can point to the potential of expanding the technical capacity of health teams in FHS, corroborating previous studies^(25-27).

Regarding the high demand of users who seek the FHS for mental health treatment, our findings are in agreement with the multicenter study conducted in 14 countries and coordinated by the World Health Organization (6), which showed that, on average, 24% of people cared for in primary care had at least one current mental disorder and another 9% had clinically significant sub-syndromic conditions. According to the testimonies, the professionals of the FHS teams found that they need permanent education to increase their theoretical and technical knowledge and their abilities to manage mental health problems due to the high demand of people with these problems that they face day to day.

It is noteworthy that of the 50 (100%) participants, 19 (38%) were community health agents and constitute a significant portion of mental health professionals who are closer to the users. On the other hand, it is recognized that community workers still lack the skills to deal with people with mental disorders. The lack of training of health professionals to deal with mental health problems can produce psychic suffering and compromise the intervention's resolution⁽⁷⁾.

According to health care guidelines in the FHS, care must be expanded and should take place in the social space of the individual. In this area, comprehensive care and psychosocial rehabilitation are some of the presuppositions of psychosocial care that allow the mental health actions carried out in the FHS to be organized. This organization should involve the professionals specialized in the orientation, discussion and proposal of interventions to maintain the care of the FHS teams ⁽²⁶⁾. Thus, it is expected that psychiatry and liaison counseling can play a key role in the integrality of mental health care.

 

Conclusion

Consulting and liaison activities have proved to be a mutual learning space between psychiatric and mental health specialists and FHS staff. It is recommended to increase the number of activities that articulate mental health actions with the FHS, such as counseling and liaison, in order to favor the sensitivity of the teams to the demands of mental health in the FHS and consolidation of the integral care. In addition, such activity has the potential to promote interdisciplinarity in daily work in mental health services and to consolidate more powerful and resolute work processes. However, consulting and liaison are challenging approaches, as they constantly question the boundaries between levels of health care, knowledge, practices, and goals of health professionals, among others.

 

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Corresponding Author:
Ana Carolina Guidorizzi Zanetti
E-mail: carolzan@eerp.usp.br

Received: May 11^th 2017
Accepted: Dec 7^th 2018