The APEC Digital Hub-WONCA Collaborative Framework on Integration of Mental Health into Primary Care in the Asia Pacific

Figures & data

Table 1 The Digital Hub and WONCA Collaborative Framework for Integrating Mental Health into Primary Care

Engage	- Engage public to recognize and seek help for mental health problems - Build on the strengths that already exist, including family doctors, community and social networks in supporting mental health - Utilize digital media and social media to engage the wider public. Create wellness apps and online resources for consumers - Engage organizations and economies to promote mental health and well-being
Enable	- Identify gaps to achieving mental health integration into primary care at the local level to inform targeted strategy development - Disseminate best practice models, successful tools and evidence-based resources to enable implementation and scale-up - Create an adaptable, flexible implementation framework that can be adopted and customized to work effectively in the local realities of APEC economies to experience success - Develop policies, support, funding, capacity building and curriculum development - Provide online materials that are accessible at no cost^Citation39 and encourage telehealth technology and integrated platforms to assist clinicians and patients with clinical care - Enhance training on mental health for all healthcare staff, particularly family doctors and primary care workers. Training may be provided in online webinar formats for ease of accessibility
Empower	- Align with existing policies and resources to recognize the family doctor plays a key role in integrating mental health into primary care - Unite resources in one place, consider an online repository, to provide tools, such as current best practice and treatment guidelines, that can be used at the point of primary care to diagnose and treat mental health problems

Table 2 Case Studies from Across the APEC Region

APEC Economies	Case Study Synopses
ENGAGE to promote mental health care
Canada and China	Enhanced Measurement-Based Care Effectiveness for Depression (EMBED): A Canada-China Implementation Project  Authors: Raymond Lam, Jun Chen  This initiative aims to adapt and develop technologies including smartphone applications, online training programs, electronic medical records and internet-delivered self-management interventions with telephone and WeChat (SMS) coaching, to implement measurement-based care (MBC) for depression in community mental health centers across Shanghai. Technology-enabled MBC tools and training developed through EMBED have the potential to serve as models for future development and scale up in the region. The first phase of the project, a situational analysis of contextual factors, facilitators and potential challenges to global mental health, was completed in 2019.^Citation40  The situational analysis identified several barriers and facilitators at the structural and organizational levels of the Shanghai mental health system and from the perspectives of clinicians and patients. The results of situational analysis will inform the design and delivery of an implementation strategy for MBC in Phase 2 of the study.
Indonesia	Healthy Indonesia Through Family Approach Program: Integrating Mental Health into Primary Health Centers Authors: Irmansyah, Eka Viora, Sri Idaiani  Mental health is included among the 12 health indicators of Healthy Indonesia through the Program Indonesia Sehat melalui Pendekatan Keluarga (PIS-PK). The 12 indicators cover child and maternal health, common diseases, sanitation, healthy behaviors and insurance coverage.  As of January 2020, almost 44.5 million families (54%) have been assessed. 36% of people with serious mental illness had adequate treatment compared to January 2018, when only 15% of people with serious mental illness had adequate treatment. Integrating mental health in PIS-PK has successfully increased mental health awareness, service provision in primary care including treatment for those with serious mental illness.
ENABLE to promote mental health care
Chile	Implementation of the Screening, Brief Intervention and Referral to Treatment for Alcohol, Tobacco and Substance Use (DIR)^a Program in Chile Authors: Matias Irarrázaval Dominguez, Pablo Norambuena, Milena Pereira  The DIR program is a nationally funded program through which teams of health professionals and trained technicians carry out screening through validated tools and deliver mental health and substance misuse interventions stratified according to risk in primary care.  The DIR model has been adapted to be implemented using digital technologies. Remote interventions include email, web platforms, mobile applications, video calls, telephone calls and telephone messages. Telephone calls are the most available in the current context. Remote interventions as part of DIR, particularly phone calls, can be effective and especially cost-effective.  In 2019, the program was implemented in 50.4% of communes and to 87% of the population under health monitoring. 1,509,115 screens were applied, with 88,585 brief interventions and 26,869 assisted referrals for substance misuse treatment. The budget was 3,200,190 USD and 4000 professional and non-professional workers were trained. The program will be expanded to reach all communes, increasing coverage among young people and men and the impact evaluated.
Peru	Mental Health Reform in Peru: Community Mental Health Services Author: María Sofía Cuba Fuentes  Poor infrastructure and lack of health resources remain key challenges in Peru.  In 2014, the Ministry of Health and the Ministry of Economy of Peru approved “Control and Prevention in Mental Health”,^Citation41 a mental health program allocating 20 million USD for the implementation of Community Mental Health Centers (CMHC) in Lima and 6 regions.^Citation42  The CMHCs, staffed by psychiatrists, family doctors and community psychologists/therapists, received referrals from primary care and delivered a range of multidisciplinary services.  The reform increased access to community mental health care. In 2012 only 11% of people with a mental disorder received care compared with 26% in 2018. Furthermore, in areas where CMHCs were implemented, the number of people seen for mental ill health concerns increased by 229% vs 36% in areas without CMHCs.  The implementation of CMHCs has also strengthened integration with primary care and reduced the mental health care burden on general and psychiatric hospitals.
Vietnam	Delivery and Scale-Up of Community-Based Depression Care in Vietnam Authors: Vu Cong Nguyen, John O’Neil, Jill Murphy, Leena Chau, Harry Minas  Researchers from Vietnam, Canada and Australia tested a supported self-management (SSM) intervention for depression in Vietnam. The intervention involved screening adults for depression in primary care settings, with identified patients referred to a social collaborator (SC), a community-based informal provider working in the social services sector. SCs provided coaching utilizing an Antidepressant Skills Workbook over a two-month period.  SSM was effective in reducing depression in community-based settings. A key success factor was the collaboration with the Vietnamese Ministry of Labour, Invalids and Social Affairs (MOLISA). Digital delivery via a mobile phone app may help to address access and sustainability concerns, promoting effective scale-up.
EMPOWER to promote mental health care
Japan	Train the Trainers Authors: Ryuki Kassai, Chris Dowrick, Cindy L.K. Lam, Garth Manning  The 2011 Great East Japan Earthquake and nuclear accident revealed the need for better community mental health care. The WONCA Working Party for Mental Health with the International Association for Communication in Healthcare, organized an international task force to create a “Train the Trainers” program for improving depression care. This comprised two week-long workshops, six months apart, for family medicine educators in Fukushima, Japan 2018.  Digital technology was utilized and involved monthly follow-up webinars (5 times between 2 in-person workshops 6 months apart), where the participants (trainers) were able to ask the task force for expertise and feedback to deepen their understanding of the subjects and to improve their local cascading education activities.  The program expanded to include attendees from across Asia Pacific with workshops at WONCA World 2018 and Asia Pacific Regional 2019 conferences. Key success factors include a dedicated task force, follow-up webinars, cascading education model, international collaboration and financial support.
New Zealand	New Tools for GPs Treating Depression: Coaches and Online Self-Help Authors: Vanessa Cooper, Penny Marlowe, Anil Thapliyal  The Journal eCoaching Service is a digital program to support people with depression and/or anxiety. The Service utilizes an existing online self-help program, The Journal (part of the National Depression Initiative in New Zealand), and coaching from peers or health coaches via phone and text messages.  Key success factors include ease of referral through embedding the form into practice management systems in primary care and the peer-support background of the eCoaches. The service is provided free with easy accessibility, no wait times, convenient delivery from people’s own homes and self-directed care with wraparound support.

Note: ^aDIR, in Spanish, “Detección, Intervenciones Breves y Referencia Asistida”.

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