As far as we are aware, this is the first study to explore and attempt to quantify knowledge by Primary Care of mental health patients treated at outpatient specialized services. This study is particularly important in the Brazilian context, given the model of functioning of its mental health network. In contrast to Cuba, Spain and the United Kingdom, middle and high income countries with a strong gatekeeping role by primary care and very low percentage of direct access (0-2.5%) [12], although the Brazilian health system works on the stepped care model, its specialized outpatient mental health services provide access by spontaneous demand.
Another development that should be highlighted in the Brazilian context is the recent reinsertion of the Outpatient Clinic as a component of the psychosocial care network by Ordinance No. 3588 (instituted December 21, 2017). As a result of psychiatric reform movements, over four decades the Brazilian health system had shifted to operating in a manner more favorable to community mental health services, such as Psychosocial Care Centers. However, due to political disputes in recent years, biomedical practice increasingly dominates mental health care [13]. In Outpatient Clinics, this has been evidenced, historically, by the hierarchy among professionals and disarticulation among components of the mental health network [13,14].
That mentioned above is relevant to understanding the results of the present study. It is noteworthy that the Outpatient Clinic and the PCC-PSM had the lowest prevalence of mental health patients known to Primary Care, while simultaneously demonstrating the highest percentage of patient intake by spontaneous demand.
Overall, knowledge by Primary Care of mental health patients treated in specialized services was 40%, while among PCC-II patients, the prevalence was 54.2%. In contrast, the Outpatient Clinic, rather than PCC-II, had the highest proportion of patients referred by Primary Care, but a prevalence of mental health patients known to Primary Care of 37%. It should be noted, however, that 47.2% of PCC-II patients were referred by other specialized services, mainly represented by the Outpatient Clinic. This scenario suggests a strongly centralized network at the Outpatient Clinic, which, despite being a specialized service, seems to function as a gateway to mental health care in the municipality studied.
In comparison, the proportion of direct access, (due to spontaneous demand) observed in our study, except for PCC-II, was higher than that found in countries such as Albania (40%), India (40%), Japan (39%) and Romania (39%), countries with the highest proportions of direct access among the 23 countries included in a review of pathways to mental healthcare worldwide[12].
Our criteria for determining the outcome included the recording of complaints related to mental health, a diagnosis report, or the use of psychotropic medications in the Primary Care records. Thus, it is assumed that some patients classified as negative for the outcome may have been assisted for other clinical conditions in Primary Care, even if their mental health treatment was not considered. Regardless, a scenario where only 40% of patients treated in specialized outpatient mental health services are known to Primary Care is troubling. Integrated teams depend on the exchange of complete, current, up-to-date information to enable independent and collaborative work by members across various professions [15].
The National Comorbidity Survey Replication, conducted in the United States of America, found that 68% of adults with mental health disorders also face physical health problems [16]. Considering a similar scenario in our context of interest, a lack of awareness by Primary Care regarding mental health patients seen in specialized services may result in patients with mental disorders not having their clinical needs adequately addressed. Alternatively, such a lack of awareness may indicate that the clinical care performed in Primary Care does not consider the totality of the health needs of the patient.
As with Outpatient Clinic patients, PCC-PSM patients were less likely to have their mental health needs known to Primary Care. It is noteworthy that historically, care for users of psychoactive substances has been taboo in Primary Care, as care in Brazil is organized in a territorial manner [17,18]. This is a problem especially for Community Health Agents (CHA), who are responsible for surveying patient needs [18]. Because they, by definition, live in the same community as their patients, these professionals do not wish to be mistaken as informants for the police or drug dealers [17]. Patients may themselves avoid seeking Primary Care for problems related to the use of psychoactive substances, although they occasionally access the service to obtain clinical health care [17,19].
Another important factor is the growing presence of private services, such as Therapeutic Communities, as a component of the pathway to care for patients at the PCC-PSM. While a study conducted in Minas-Gerais, Brazil in 2016 [20] suggested a high prevalence of patients admitted through referral from other public services (44.7%), in addition to spontaneous demand (43.7%), our study identified a proportion of 25.9% of patients referred from private services. This is undoubtedly a topic that needs to be studied in greater depth. Therapeutic Communities promote the absence of the individual from society, are largely religious in nature, and many of them are not staffed by health professionals [21]. Thus, these services tend to use the equipment of the public health system, such as the PCC-PSM, to validate their treatments, but do not have the intention to integrate with other health network services, especially Primary Care.
In the current study, patients over 31 years of age were more likely to have their mental health needs known to Primary Care. This is in line with data from previous studies on the use of Primary Care [22]. Especially due to the higher incidence of chronic diseases, older patients may be more in need of the health care offered in Primary Care [23].
We found strong evidence for an association between being referred by an emergency or hospital service and having mental health needs known to Primary Care. These findings draw attention to important contradictions in the country's health network. If, on the one hand, the proportion of referrals by hospital and emergency services was low when compared to those found in studies from the United Kingdom (28.9%) and Spain (24.3%) [12], these referrals only happened after an inability to manage the case by primary care, which was not able to make the referral to the specialized service in a timely manner.
Our results suggest that although the context studied has a matrix support service, it is still incipient and has not been effective in promoting the sharing of cases between different levels of care.
There may be several factors that lead to the difficulty of operating this service. A literature review conducted previously [9] suggested that although it has been over 10 years since the implementation of matrix support in the Brazilian health system, it remains common for health networks to face problems such as: 1) lack of clarity in guidelines regarding the sharing of cases; 2) bureaucratization of the referral between services; 3) negative attitudes of professionals in dealing with mental health related issues; and 4) lack of institutionalized space and time for sharing of cases. It is noteworthy that these aspects are also highlighted in the study of international counterparts of this methodology, such as shared care [24].
Nonetheless, it is necessary to consider the important training gap in relation to mental health care experienced by both primary care and specialized care professionals [9]. The proportion of hours devoted to the study of mental health care in undergraduate medical curricula in Brazil is still low. A study conducted in Goiás [25] estimated that this proportion was 1.2% of the total hours of the course. In the field of nursing, a national review of undergraduate courses [26] concluded that the hours allocated to the study of mental health care corresponded to 2.4% in private institutions and 3.5% in public institutions.
Thus, it is necessary to create strategies to address this scenario. In addition to strengthening matrix support teams, bottom-up change should be implemented in order to establish a setting which promotes action by professionals. One important strategy may be to raise awareness and promote training of Primary Care professionals, especially CHA, in identifying cases in a timely manner. It is also crucial for specialized services to improve the counter-referral of patients for Primary Care, thereby improving attainment of patient care and facilitating return of the patient from specialized to Primary Care.
Some limitations should be considered when interpreting our results. First, the incompleteness of data in the medical records limited the inclusion of information that could be relevant to studying the current outcome, such as ethnicity, income, paid work status, information on the screening of chronic diseases, and markers of social support, among others. Second, patients classified as negative for the outcome may have been assisted for other clinical conditions in Primary Care, even if their mental health condition was not considered. Nevertheless, our study provides valuable information for reorienting practice regarding the sharing of cases, both in the context studied and in other locations with similar arrangements.