The mental health epidemic that CAPs cannot address

The resilience It is a term that derives from Latin resilient, participate in the verb resiliency, which means "to jump back and bounce." It refers to an individual's ability to adapt and recover from an adverse or risky situation. There's no doubt that we've had a few unexpected situations in recent years, and on a global scale. Remember the 2008 financial crisis, the coronavirus pandemic, the rise in armed conflicts, and the subsequent escalation in prices? If we add to the social, economic, and political context the fact that insufficient resources are allocated to our mental health, frankly, getting through this successfully seems more heroic than resilient.

"Mental health isn't just the poor sister of healthcare; it's something that has never been addressed and continues to be unaddressed," says neuropsychologist Óscar Pino López, coordinator of the Benito Menni Adult Mental Health Center (CSMA) in Hospitalet de Llobregat.

In Catalonia, approximately one in four people over the age of 14 experiences emotional distress, an unpleasant mood that involves sadness, anxiety, and bouts of irritability in everyday situations. And almost one in ten people has been diagnosed with moderate or severe depression. according to a report mental health and personal autonomy of the Agency for Business Competitiveness (ACCIÓN) of the Government of Catalonia. In fact, another report The Ministry of Health's report shows that anxiety disorders, insomnia, and depression represent the most frequent consultations in primary care throughout the country, with an increase of 72%, 65%, and 22%, respectively, in the period 2016-2022.

"If the data before the pandemic were already bad - in the words of Pino López - The virus had direct consequences on the health of the population because it attacks the central nervous system, with various neurological symptoms." Along these lines, researchers from the Sant Pau Research Institute recently They have confirmed and quantified for the first time the increase in non-lethal suicidal behavior, that is, suicidal thoughts or attempts, as a result of the health crisis, which is over 50%. Young women and minors were the most affected.

Shortage of psychologists

With all these figures on the table, it's surprising that public mental health services still lack adequate funding to reflect the magnitude of the problem. While serious mental disorders receive preferential access to care, minor ones are left in a kind of limbo, with patients having to wait months for their first visit with a psychologist, which may not even last half an hour. Therefore, many people are forced to resort to private consultations, if they can afford it. For example, two sessions per month. They take up to 15% of young people's monthly income, which is why they are forced to leave psychological therapy out of their priorities, with the risk of worsening their emotional discomfort.

However, in Catalonia, the ratio of psychologists is 9.5 per 100,000 inhabitants, higher than the national average of 6 and far from the European average of 18. To give an idea, the Organization for Economic Cooperation and Development (OECD) recommends 24 psychologists per 100,000 inhabitants. That's why experts are calling for more mental health specialists in primary care centers (PCCs), which are the gateway for many people to the healthcare system.

In 2021, the magazine Psychological Medicine public The results of the PsycAP project, the first large-scale study in Spain on the effectiveness of group therapy for addressing emotional disorders such as anxiety and depression, compared to regular visits to the family doctor and drug treatments alone. Specifically, a total of 1,061 adult patients were recruited from 22 primary care centers in eight autonomous communities (Andalusia, the Basque Country, Cantabria, Castilla-La Mancha, Galicia, Madrid, Navarra, and the Valencian Community). The protocol consisted of seven 90-minute therapy sessions led by clinical psychologists over a period of 12–14 weeks in small groups of 8 to 10 people. Antonio Cano-Vindel, professor of psychology at the Complutense University of Madrid (UCM) and driving force behind the project, explains that "anxiety and depression disorders are reduced by around 70% with just these sessions, at a cost of €27.40 per patient per session," and that the therapeutic effects "are maintained for two years."

The results of PsycAP, says Pino López, who is also a member of the board of the Official College of Psychology of Catalonia (COPC), are aligned with those of such established programs as Improving Access to Psychological Therapies (IAPT), currently called Talking Therapies ("conversational therapies"8) the most common mental health problems of the population: depression, generalized anxiety, agoraphobia, body dysmorphic disorder, hypochondria, obsessive-compulsive disorder (OCD), post-traumatic stress, panic, social anxiety, etc. Nearly two million people benefit from this service, which can be individual or group, face-to-face or remote, accompanied or not by psychological treatment.

The effectiveness and cost-effectiveness of adding psychologists to national health systems also occurs in countries such as Norway, where its early psychological care program for mental health - Prompt Mental Health Care (PMCC) - has shown that it not only improves the well-being of participants, but also their degree of employability, compared to people who follow conventional treatment, which represents an efficient investment in terms of work productivity and reduced use of health services: for every €0.09 invested there is a return of €0.50. This figure should not seem insignificant to us, considering that last year in Catalonia 192,526 sick leaves were recorded due to mental health, 11% of all disabilities.

References of emotional well-being

The impact of the pandemic on the mental health of the population is what led the Catalan Government's Department of Health to implement, in 2021, the role of emotional well-being and community health representatives in primary care (RBEC). This role is also an attempt to reduce the abuse of psychotropic drugs: half a million prescriptions for anti-anxiety medications are written every month in Catalonia, drugs that can lead to dependence and addiction in the long run. RBECs are health science professionals—the vast majority of whom are psychologists—who treat people with adjustment disorders to prevent the worsening of symptoms. The most complex cases, with severe mental disorders that significantly interfere with daily life, are also referred to mental health centers.

Marina Calderó is one of the 359 people who, according to data provided by the department to this newspaper, currently make up the RBEC network in Catalonia—one for each CAP, taking into account that in small towns they may support more than one center. For more than three years, she has worked at the Horta 7D CAP in Barcelona. Her main task is to provide assistance to patients referred by the medical, nursing, or social work teams to conduct an initial assessment and, from there, guide them toward the most appropriate approach, which could be, in many cases, group therapy.

"Groups for anxiety and depression symptoms are widespread almost everywhere. We also have a work-related discomfort group, a fibromyalgia group, a grief group, a cognitive stimulation group for older adults, and a group for women where we work on gender perspectives," explains the psychologist. Each of these groups involves 10-12 people in 8-10 90-minute therapy sessions, one per week, with guidance from Calderó, who may also rely on occasional collaboration from professionals in fields such as physiotherapy, nutrition, nursing, social work, and medicine.

The second major task of the Horta 7 RBEC is its participation in the primary care center's community activities. This includes going out into neighborhoods to educate on healthy habits and detect health-related problems early, such as through schools, and providing citizens with access to available resources to prevent this. In this regard, one of the outstanding issues is more effectively reaching young people, who are more reluctant to go to the primary care center on their own despite being one of the population segments most affected by the pandemic.

And the mental health disorders of Catalans between 10 and 24 years old have doubled in the period 2008-2022, according to the conclusions a recent study led by the Jordi Gol Primary Care Research Institute (IDIAPJGol), which also highlights an alarming increase in cases of anxiety, depression, eating disorders, and attention deficit hyperactivity disorder (ADHD). The use of antidepressants in children under 15 has also increased by 250% in just three years. as reported in this newspaper in January.

Although there is still no official data on the social and economic benefits of introducing RBECs at the entrance to the healthcare system, the general feeling is that it has had a positive impact on users, including the centers' own professionals, who receive training and care from their peers who are experts in emotional well-being, as Calderó points out. Therefore, with the experience accumulated by the Generalitat's project, as well as by PsycAP, which is already being implemented in numerous autonomous communities in the country, and by various international programs, it seems clear that filling psychologists' offices is an urgent need.