Family doctors will provide primary psychological care

Due to the war, Ukraine is experiencing an unprecedented number of humanitarian emergencies. Millions of people are in urgent need of therapy. Every second, an average Ukrainian feels emotionally worse than three years ago. At the same time, only one out of 50 cases of mental health disorders are diagnosed in Ukraine. These are just a few of the results of an international public opinion survey conducted as part of the third Summit of First Ladies and Gentlemen dedicated to the topic of mental health. Along with inflation and poverty, mental health is one of the biggest challenges Ukraine is facing.

In Ukraine, primary care doctors, particularly family doctors, began to be involved in providing psychological care. After all, the family doctor is the doctor closest to the patient.

Training under the WHO mhGAP program, which Ukrainian doctors are currently undergoing, allows them to identify mental health problems and support patients experiencing stress, depression, and insomnia, and if necessary, refer them to specialists.

The mhGAP program and its scaling throughout the country is being implemented today as a priority project of the Ministry of Health within the All-Ukrainian mental health program "How are you?".

With the outbreak of full-scale war, mental health care became one of the priorities of the Medical Guarantee Program. That is why, in November 2022, a new package, "Support and treatment of adults and children with mental disorders at the primary level of medical care," was introduced. To increase the level of expertise of family doctors regarding mental health, the online course "Management of common mental disorders at the primary level of medical care using the mhGAP guidelines" was opened on the Academy of the National Health Service platform.

mhGAP (Mental Health Gap Action Program) is a program of the World Health Organization intended for primary care workers — family doctors, therapists, pediatricians, and nurses. The program was launched in 2008 and is currently implemented in over 100 countries.

The mhGAP management offers protocols for diagnosing and managing common mental disorders to general practitioners. These include depression, acute stress response, post-traumatic stress disorder, suicidal behavior, substance use disorders, and other significant mental health complaints. The course also teaches how to effectively communicate with patients and their relatives.

Nataliia Kostruba, doctor of psychological sciences, adviser to the head of the Volyn Regional Medical Center on mental health, and regional coordinator of the all-Ukrainian mental health program "How are you?" explains that mhGAP training is an opportunity to get the necessary basic knowledge of mental health. If this knowledge is insufficient to help, the patient is referred to a specialist.

To be able to work with patients with mental health problems, a primary doctor must complete at least the first level of the online course "Management of Common Mental Disorders in Primary Care using the mhGAP guidelines." Training can also be done offline.

In the fall of 2023, Emiliia Khutkovska, the regional coordinator of "How are you?" in the Kherson region, underwent the training. The specialist says that she found that the program is structured and offers a set of literature specially created for the program.

"Depression and anxiety disorders have increased many times over during the war. In addition, we expect many veterans from the front who will need professional help," says Khutkovska.

The psychologist notes that for general practitioners, the mhGAP course is an opportunity to expand the range of knowledge that speeds up the provision of care.

Ruslana Omelianchuk has worked as a family doctor in Mykolaiv for almost eight years. After completing the mhGAP program, she decided to become the regional coordinator of the all-Ukrainian mental health program in the Mykolaiv region. Now, she is making sure that psychological assistance services are as accessible and understandable as possible for the residents of the Mykolaiv region, which the enemy is constantly attacking.

From the moment of the full-scale invasion, Omelianchuk has worked in  Kulbakino, one of the most shelled districts of Mykolaiv. Even then, the doctor saw how important it was for people to come and talk so that they were heard.

"mhGAP training is simply a step to a new level of care. Now, we are ready for such challenges. mhGAP is a new professional standard, a new mark of quality," says the doctor.

The doctor of psychological sciences, Nataliia Kostruba, also says that the concept of mental health is still very stigmatized in Ukraine.

People have fears and prejudices, as well as myths about mental health disorders. The program "How are you?" is being implemented to overcome such stigmatization. The program expands opportunities for the population in the mental health field, including expanding the network of specialists who can provide first psychological aid.

It is essential to understand that after completing the courses, a family doctor with mhGAP does not become a psychotherapist or a psychiatrist and cannot replace a psychologist. These are simply different levels of psychological help. The knowledge provided by mhGAP makes it possible to detect symptoms and make a preliminary diagnosis and, according to this information, refer the patient to a psychologist or psychiatrist.

"The idea is that people are not afraid to talk about their mental health and the difficulties that arise with it. Namely, the family doctor has the necessary level of trust to turn to them and get help," Kostruba emphasizes.

According to the psychologist, psychological health at the state level was practically not dealt with in the country. Now, the situation has changed fundamentally. Spreading knowledge about mental health and making the service available, especially in times of war, is very important.

Sleep disturbances, persistent lack of appetite, anxiety, intrusive thoughts that something terrible might happen, apathy, irritability, exhaustion, constant fatigue — all these topics can now be discussed quite frankly with your family doctor.

Integrating mental health services at the primary level of care allows doctors to implement a new approach. Physical and mental health are considered whole — inseparable and interdependent. The advantage of such assistance is the existing level of trust in the family doctor. After all, if a client comes to a psychologist or psychotherapist, establishing relationships, communication, and trust takes time, and trust is the basis for practical work in mental health.

Family doctors are learning and adjusting their work in mental health, so the doctors themselves have questions and some technical issues. Still, each regional health department and heads of institutions conduct additional meetings and clarifications so that this process is as useful as possible for patients.

Everyone is familiar with the situation when a patient turns to a family doctor complaining of a headache. In one case, the doctor measures the pressure and prescribes medication. Otherwise, redirect to a different specialist. It works the same way with mental healthcare. With a simple survey, a medical worker trained by the WHO mhGAP can discover a person's condition and provide practical advice on caring for their mental health. 

The family doctor provides non-specialized psychological help. A professional psychologist or a clinical psychologist already provides professional specialized help according to the patient's difficulties. The work of a family doctor in the field of mental health will contribute to the early detection of mental illnesses. In the early stages, many of them are amenable to more effective treatment.

Regarding whether such an initiative would work as it should, Rubryka turned to the president of the National Psychological Association, Valeriia Palii. The specialist says that more and more Ukrainians suffer from psychological problems caused by the war, so there should be more doctors able to help them.

This large number of actual and potential requests also requires a large number of specialists in the field of mental health, of which there are currently not enough. Therefore, training family doctors in diagnosis and psychological first aid is a good decision. People with various problems often turn to family doctors, whose network is wide enough. Often, a person may not realize that they need psychological help.

Family doctors already have medical education and, subject to appropriate training, can make good diagnoses, provide crisis assistance, expand information, and refer patients to specialists. They are not competitors to professional psychologists but a kind of bridge that will lead to professional help.

The president of the National Psychological Association, Valeriia Palii: "Family doctors will be the first link of contact, who should be able to recognize, possibly urgently help and direct."

To provide psychological support to others, family doctors should also take care of their mental health and practice self-help and support methods for themselves, making them a daily habit.

By the beginning of 2024, about 70,000 medical workers (16,000 are family doctors) have received training under the WHO mhGAP program. Now, every third family doctor can provide primary mental health support to their patients.

Currently, Ukrainians can receive free mental health services in medical facilities that have a contract with the National Health Service of Ukraine (NHSHU) for a package of support and treatment of adults and children with mental disorders at the "primary level." We are talking about 865 institutions, most of which are in Dnipropetrovsk region (78), Kharkiv region (75) and Lviv region (51). Since November 2022, when the package of such services was included in the Medical Guarantee Program, more than 114,000 patients have already received them, including more than 18,000 children.