Mental health policy and practice across Europe: an overview

Mental health problems in primary care 225
et al. 1998; Peveler et al. 1999), although it should be noted that they are generally
much less intensive in terms of the number of interventions involved.
Qualitative research might therefore be used to examine factors inherent in the
adaptation of these models of health care to different health care systems and
local contexts. Most of the interventions are dependent on willingness to use
antidepressants, which is problematic given the negative attitudes towards
medication in Europe (Priest et al. 1996). Finally, where economic evidence has
been presented, most of the studies indicate that collaborative care is both more
effective, and more costly (Gilbody et al. 2003).
Replacement
There is good evidence that psychological therapies in primary care are clinically
effective. Information on cost-effectiveness is poor (Byford and Bower 2002;
Barrett et al. 2005), although the high cost associated with specialist therapists’
time is likely to be a key factor (Bower et al. 2003a, 2003b). However, there is
significant interest in the potential for less therapist-intensive minimal interventions
(such as written or computerized self-help), which may both increase
access and reduce costs (Bower et al. 2001; Kaltenthaler et al. 2002). One significant
disadvantage associated with the use of this model relates to the possibility
that the lack of involvement of primary care staff may lead to them becoming
deskilled. Certainly, there is little evidence that the presence of a psychological
therapist in a practice leads to widespread increases in diagnosis or treatment
(Bower and Sibbald 2002).
Deciding priorities according to available resources
Key issues in implementing evidence-based policies within primary care are
likely to relate to the total resources available for mental health, both in absolute
terms and in relation to the total health care budget. In deciding priorities
for mental health policy and practice, the WHO gives guidance in relation to
resources by dividing systems into low, medium and high resource countries.
Each of these scenarios will now be examined to establish which priorities
within mental health and primary care might follow from the evidence base
which has already been presented.
Low resource countries
This scenario refers to low income countries where mental health resources are
completely absent or very limited. Such countries have no mental health policy
programmes or if they exist they are outdated and not implemented effectively.
Governmental finances available to mental health are tiny, often less than
0.1 per cent of the total health budget. There are no mental health services in
primary or community care, and essential psychotropic drugs are seldom available.
While this scenario applies mostly to low income countries, in many high