L’intégration des soins en santé mentale dans les centres de santé permet-elle d’améliorer la qualité globale des soins de première ligne ?

The integration of mental health into primary care has been described as an effective strategy to tackle the ever-increasing burden of mental illness, making it a global priority. Successful experiences are reported in several studies in both developing and developed countries. In Guinea, an experiment in integrating mental health care in health centres has been underway for 20 years. Initiated by the Non-Governmental Organisation Fraternité Médicale Guinée within the framework of the project Santé Mentale en Milieu Ouvert Africain (SaMOA), this experiment currently involves 5 associative (private not-for-profit) health centres and 5 public health centres. Our doctoral research analyses this experience and examines to what extent and through what mechanisms the integration of mental health in frontline health services can not only improve access to mental health care but also strengthen the quality of care in general through a more patient-centred approach. We evaluated the experience through several studies, conducted in a theory-based evaluation approach. The first study described the experiment in detail, structuring it in a timeline, based on the documentation collected. This pilot experiment found favorable ground in the Fraternité Médicale Guinée's associative health centres, which are characterized by a non-bureaucratic culture of operation. It was then extended to other public and associative health centres. The second study aimed to understand possible attitudes of stigmatisation among first and last year medical students at the University of Conakry, based on focus groups questioning students’ representations of mental illness, the mentally ill and psychiatry. Many regret the discrimination of the mentally ill in Guinean society, but nevertheless share stigmatising attitudes with the general population. The dominant stereotype is grand insanity (la grande folie), although final year students cite a wider range of mental disorders. There is strong support for lay explanatory models incorporating occult forces and for the use of traditional care to treat them, including among final year medical students. The third study analyses the effects of mental health integration on staff attitudes: destigmatisation of mental illness on the one hand, and a patient-centred approach on the other. It is based on semi-structured interviews with 27 carers from health centres that have integrated mental health (MH+) and 11 carers from health centres that do not offer mental health care (MH-). In contrast to the stigmatising MH- carers, all MH+ carers overcame their fears and developed positive attitudes towards the mentally ill, particularly through the experience of therapeutic success. Some of the MH+ also discovered and adopted a patient-centred approach, while others remained within a biomedical logic. One factor that favored the patient-centred approach was an in-situ training scheme (joint consultations, teamwork and community action) that took into account the emotional needs of the carers and proposed a patient-centred role model. However, this system could only function optimally in the non-bureaucratic context of a community-oriented association centre in the capital with a stable and qualified team. The fourth study evaluates the use of mental health care in the five centres that have integrated this care on the basis of data from consultation registers and individual patient files. In these centres, mental health problems represent on average 3% of first contacts. All common mental health conditions are seen and treated. The use of care varied quite a lot from one centre to another. Finally, the fifth study analysed 450 consultations conducted by 18 providers in a range of health centres, in order to assess the extent to which the integration of mental health care had improved the quality of the caregiver-patient relationship in primary care in general. Data were collected through observation of 450 consultations using the Global Consultation Rating Scale (CGRS), individual interviews with patients at the end of the consultation using the Patient Participation Scale (PPS), and provider self-administered questionnaires. A comparison of the 175 consultations conducted in centres with integrated mental health care with the 275 consultations conducted in non-integrated centres shows a higher participation score for patients consulting in integrated centres. The quality of caregiver-client communication is also better for consultations conducted in these centres. The discourse of MH+ caregivers is more patient-centred and differs from the more biomedical discourse of MH- caregivers. The experience has thus shown that, under favorable conditions, it is possible to integrate mental health into the practice of health centres, with benefits in terms of access to care, pathologies treated, reduction of stigmatisation, reinforcement of a more global approach to mental health and the evolution of primary health care in general towards a more patient-centred approach. Several avenues for scaling up and further integration of mental health in Guinea and other low-income countries are discussed: (1) a training process that integrates knowledge transfer and the acquisition of patient-centred attitudes; (2) continuous supervision of caregivers; (3) a non-bureaucratic organisational culture that encourages initiative and reflexivity; (4) the availability of essential and generic psychotropic drugs; (5) the building of bridges with traditional medicine; and (6) the networking of actors in the field of mental health. The current challenge for Guinea is to scale up in order to significantly extend mental health care coverage while promoting its quality. The lessons learned can guide health system managers to develop mental health care and reap the benefits in terms of access, utilisation and quality of care.