Kiev Conference Results in Call for Timely and Accessible Behavioral Health Services for Primary Care Patients

By Kathryn Utan

As AIHA primary care partners work to enhance the health of the communities they serve, many are looking to expand the scope of their services by incorporating issues that have traditionally been segregated from the family medicine model. "Research indicates the widespread prevalence of mental disorders throughout our region and the rest of the world," Dr. Yuri Yudin, head of the Mental Health Department of the Kiev City Health Administration and member of the Kiev/Philadelphia partnership, told participants at an AIHA-sponsored Behavioral Health Conference held September 27-29 in Kiev. "Most people suffering from [these conditions] go to primary care institutions for help, yet physicians, nurses, and other practitioners working in family medicine do not have the knowledge, training, or practical skills necessary to identify psychiatric disorders," Yudin continued, noting that patients who leave primary healthcare facilities without having their mental and behavioral health evaluated may continue to suffer needlessly from common conditions such as depression, anxiety, or substance abuse.

Ensuring that people have ready access to mental and behavioral healthcare services-especially at the primary care level-was the overarching goal of the three-day event, which focused on methods of integrating such services into the framework of partnership activities. Nearly 120 representatives from a wide range of AIHA programs including primary healthcare (PHC) partnerships, Women's Wellness Centers (WWCs), the International Nursing Leadership Institute, and Neonatal Resuscitation Training Centers (NRTCs) throughout Belarus, Moldova, and Ukraine gathered as members of the Kiev/Philadelphia partnership shared their strategies for incorporating behavioral health services into family medicine.

"Currently, patients are not happy that they have such limited access to psychiatric care . . . and it is ineffectual to send people with [only minor complaints] to highly specialized psychiatric facilities," Yudin said. He explained that successful integration of behavioral health services into primary care practices will help clinicians better serve the needs of their communities and result in the timely identification, treatment and, if necessary, referral for more specialized care, of patients suffering from common, easily treatable mental problems. "This process requires good communication among providers of medical, mental, and social care" as well as the support of public health officials, community stakeholders, and patients themselves, he continued.

"We have enjoyed a number of advancements in psychiatric treatment over the past few years," Dr. Alexander Napreyenko, head psychiatrist at the Ukrainian Ministry of Health, told attendees, "but many challenges still lie ahead." Calling for health professions education curricula to be amended to include basic courses in diagnosing and treating common psychiatric disorders for all students, he stated, "We hope to join the efforts of the Kiev/Philadelphia partners as they begin working to instill knowledge of [mental and behavioral] health in young practitioners from the early stages of their education."

Stressing the fact that educating clinicians and patients alike on the benefits of addressing behavioral health at the primary care level is a top priority for health reform throughout the region, Vasyl Mikhalchuk, head of the primary healthcare department of the Ukrainian Ministry of Health, stated, "AIHA partners are pioneers in the effort to include mental health programs in family medicine."

Kiev/Philadelphia Partners Share their Strategies

Setting the stage for the conference sessions, Dr. Stepan Mayilo of the Territorial Medical Unit of Kharkiv District, Kiev, and William E. Aaronson, associate professor of healthcare management at Temple University, Philadelphia, detailed how the Kiev/Philadelphia partnership approached the often-daunting task of integrating behavioral health into the programs they were developing for the Kiev Family Practice Center-a model primary care facility located in the Kharkiv District of the city. The pair discussed the development of their work plan and goals, the obstacles they encountered, and their strategies for overcoming these difficulties.

Mayilo told participants that the decision to integrate behavioral health services stemmed from community needs assessments conducted soon after the partnership was formed in 1999. "Psychological problems are often reflected in somatic health, just as physical symptoms can lead to mental disorders," Mayilo said, noting that various aspects of mental disorders play a significant role in at least 25 percent of somatic cases. "It is not possible to divide a person into soul and body-you must treat him or her as a whole."

Underscoring the fact that clinicians who provide primary care must also take into account the mental well-being of their patients, Aaronson explained, "From the beginning, partners from each side were committed to the inclusion of mental health services at the Kiev Family Practice Center. It was necessary for us to decide this early on because it determined how we would proceed with training and other activities." It also became evident that their plans would require a multidisciplinary team that included not only physicians and nurses, but a psychologist and social worker as well, he noted.

Aaronson described the process the Kiev/Philadelphia partners went through to identify members for this multidisciplinary team and bring them on board. Finding mental health professionals proved problematic at first, he said, which forced the partners to look for creative solutions. "First of all, education for social workers is relatively new in Ukraine, so there is a real shortage of trained professionals. We also faced a very tight labor market because the country has many foreign-sponsored NGOs that are able to pay much more that we could within the framework of the Medical Territorial Unit," he explained. "Our solution was to hire an experienced psychiatric nurse and provide her with training in case management and family counseling techniques." Although finding a psychologist was less of a problem, the partners were unable to hire anyone with significant experience and opted instead to go with a newly-graduated professional and provide additional training through partnership exchanges and activities.

The partners developed a collaborative team approach-a concept not widely utilized among healthcare professionals in Ukraine-implementing intensive training programs and a rigorous system of clinical supervision that includes regular consultation with an experienced psychiatrist and psychologist, Aaronson explained. They have also sought to create a curriculum for the practical instruction of family physicians and incorporate a number of ongoing staff training events, individual and group therapy sessions, and community education programs, Mayilo added. (For a more detailed account of the Kiev/Philadelphia partnership's approach, see "Integrating Mental Health Into the Primary Care Model: The Kiev/Philadelphia Experience".)

Sessions Focus on Practical Approaches to Common Behavioral Health Problems

Plenary sessions at the Conference delved into training procedures for family physicians and mental health specialists, collaborative models for team training, and ethical issues in medicine, while a variety of breakout sessions gave participants an opportunity to learn more specific skills and practices. Topics covered during these workshops included issues such as depression, HIV/AIDS counseling, substance abuse, difficult or chronic patients, domestic violence, counseling skills, and treating patients experiencing grief, loss, or trauma. Highly participatory in nature, the breakout sessions gave individuals an opportunity to learn new approaches and gain hands-on experience through the use of role-play exercises and case studies.

In the HIV/AIDS counseling session, for example, attendees were given an overview of the physical and psychological ramifications of the disease and how they, as primary care professionals, can best deal with these issues. Explaining that many people at risk of contracting HIV are afraid to get tested for the virus, Tatiana Zhur, a psychologist from the Kiev HIV Center, stated, "The unknown is like a sword that hangs over these people's heads. . . . By encouraging them to get tested, you can remove the fear of the unknown and enable them to find ways of addressing the problem-either by treating the disease if the results of the test are positive, or by helping them change the behaviors that put them at risk in the first place if the results are negative." Healthcare providers must acknowledge their own fears and concerns about HIV/AIDS in order to bridge the gap between themselves and those they are treating, according to Polly O'Keefe, a social worker at Temple University. "Education is a key element of changing attitudes toward HIV/AIDS, but finding effective methods of getting the message out is a problem because so many people do not know where to go to get good information."

In another breakout session, Mayilo, along with Philadelphia partner Barry Jacobs, associate director of behavioral sciences at the Crozer-Keystone Center for Family Health, discussed useful methods for treating chronic and difficult patients. Telling participants that in the United States roughly 15 percent of patients fall into this category, Jacobs defined chronic and difficult patients as those "whose interpersonal styles and approaches to health pose particular challenges" to healthcare providers. Specific examples include people who are angry, needy, noncompliant, somaticizing, or seeking drugs. He recommended that clinicians adopt an empathetic and nonjudgmental attitude with such patients. Noting the importance of scheduling regular, short, and focused visits, as well as setting limited treatment goals for both of these types of patients, Jacobs explained, "Listen to their complaints, make empathetic comments, and help them to feel that you understand their problems and perspectives. . . . Offer yourself as a partner who will help solve their [healthcare] problems."

Other topics highlighted during breakout sessions included depression, substance abuse, intimate partner violence, and the role of psychiatrists in a collaborative model for patient care. Additional workshops dealt with treating patients suffering from grief, loss, or trauma, as well as counseling skills, approaches to multidisciplinary team training, and continuous quality improvement. On the final day of the event, attendees were given an opportunity to meet with presenters from the Kiev/Philadelphia partnership to further discuss topics of special relevance to their own practice. Each participant also received a copy of Mental Health Clinical Guidelines for Primary Care: Screening and Information, an original publication created by AIHA's Mental Health Task Force and geared toward general practitioners. Calling the publication timely and professional, Semyon Glusman, executive secretary of the Ukrainian Association of Psychiatrists, said, "This book is extremely important to increase awareness of current trends in mental healthcare and is indispensable for the clinical practice of family medicine professionals."

Kathryn Utan is AIHA's staff writer.

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