Integration of mental health-care with primary health-care services in the occupied Palestinian territory: a cross-sectional study

Abstract

Background Mental disorders are a leading cause of morbidity and disability worldwide. As part of a WHO-led programme to integrate mental health-care with primary health-care (PHC) services, we estimated the baseline prevalence of psychiatric morbidity in governmental PHC clinics in the Gaza Strip, occupied Palestinian territory. Methods The study sample was recruited from advanced PHC clinics (serving 10 000 people and located in main towns) that were selected by the Palestinian Ministry of Health. One clinic was selected from each of the five districts in the Gaza Strip. Every tenth adult patient attending each of the five clinics was recruited until 100 patients had been recruited from each clinic over 4 weeks. The General Health Questionnaire (GHQ)-12 was completed with a bimodal model of scoring (0-0-1-1, range 0–12, with a cutoff of 3 for caseness) by the 500 adults (280 men; mean age 40·2 years [SD 13·9]) under the supervision of specially trained PHC nurses and then assessed by general practitioners. The patient's physical complaints, diagnosis by a general practitioner, treatment, and referral were then recorded. Moreover, 24 general practitioners were recruited from the five clinics to assess the ability of the patients' general practitioners to detect mental health problems. Binary logistic regression was used to assess the association between caseness on the GHQ-12 and sex, area of residence, age, marital status, education, employment status, chronic medical illness, and number of physical complaints. The diagnoses made by the patients' general practitioners were compared with the findings from the GHQ-12. The Ministry of Health approved the study. Patients provided written informed consent. Findings 189 (38%) of 500 patients had mental health problems (GHQ-12 score >3). Mental health problems were associated positively with female sex (p=0·016), older age (p=0·027), divorced or widowed marital status (p=0·009), lower education (p=0), unemployment (p=0·003), chronic physical illness (p=0·015), and having several somatic symptoms (p=0). General practitioners were unable to detect psychiatric problems, even in patients who had many risk indicators. No referrals were made to mental health services. Interpretation The prevalence of psychological distress in adult patients attending the PHC in the Gaza Strip is high compared with rates reported for people in other countries not exposed to conflicts. Our results show inadequate recognition of mental health problems and therefore imply that referral to mental health services is inadequate in PHCs in the Gaza Strip. The Ministry of Health needs to adopt strategies to enable general practitioners to diagnose and treat patients who are in need of mental health care. Funding WHO West Bank and Gaza.