A strategy for community care

The first goal of the National Health Strategy (NHS) is to have a comprehensive world-class healthcare system, with mental health an integral part of it. The initial incarnation of the NMHS was the 2013–2018 Strategy, which evolved into the National Mental Health & Wellbeing Strategic Framework 2019–2022. The Strategy aimed to ensure access to the right care, at the right time and in the right place. The focus was on shifting from hospital-based care to community mental health service (CMH) delivery.⁷ Under the initial Strategy, a number of key achievements were made. These included a new model for primary care; psychological support clinics in primary care; new child, adolescent and women's mental health services; and new CMH facilities and community teams.⁸ Mental health training was provided to family physicians and primary care doctors; a pilot was initiated in three primary care centres to treat mild-to-moderate anxiety and depression, which are the two most common mental health conditions in Qatar, using standardised screening tools, management guidelines and indications for referral to secondary care.^{Reference Sharkey3}

The success of this pilot encouraged a wider enrolment of the programme to all primary care facilities. The focus on ‘well-being’ under the extended framework indicates the elevation of importance given to mental healthcare beyond hospital admission. This importance is reflected in priority being given to ‘high-quality’ access to community care services moving forward.⁸ Overarching the NMHS is Qatar's general NHS 2018–2022.⁶ The NHS encompasses a broader vision towards well-being through active engagement of an individual in society and contributing to the community.⁶

The evolution of the law

Another development has been the drafting of Law No. 16 of 2016 on Mental Health. The Law has yet to be implemented because the organisational structure required to start implementation remains vague. Challenges around implementing the law (especially the community treatment order provisions within it) and balancing patient autonomy with family interventions and safety for the patient, society and healthcare providers remain to be seen. As such, the Law's influence will largely be determined by the resolution of these matters.

A concerted effort could yield significant progress. The Law codifies community care under the rubric of citizen ‘rights’. Article 2 stipulates which institutions shall provide community care services (hospitals, clinics and any other place providing community care services). Currently, CMH teams provide home visits for patients through their outreach programme. However, they are not authorised to provide treatment against patients’ will, regardless of their capacity to consent or the risks they may impose. It is critical that moves towards implementation delineate the boundaries of community care services and the role of medical professionals. There is an opportunity for the right to community care to be defined under the rubric of the Law.

The type of care captured by the Law is distinct from other community care services which have recently developed for mild-to-moderate mental health needs.

Broadening access to the general population

Strategies for a more comprehensive provision of community care have been building for several years. This emphasis is manifested in the Annual Symposium for Community Mental Health Services, which has been conducted for 5 years. One purpose of the symposium is to propose strategies for promoting access to mental health and well-being services. The target is for 40% of services to be offered through primary and community care settings by 2022.⁹

Prior to the COVID-19 pandemic in 2020, strategies for greater community care were already being deployed. The first CMH hub was opened in 2015, covering west Doha, and more recently a second one opened at Al Wakrah to cover the south, with plans for two others to target all geographical areas of the country. These hubs are run by a multidisciplinary team consisting of psychiatrists, nurses, occupational therapists and a social worker, who are trained on the job in principles of CMH delivery. Some staff involved had received a period of training abroad, mainly in the UK, Ireland and Australia. The of an outreach component, day care and a small residential service. Patients are visited by a community mental health nurse, supervised by a psychiatrist, to conduct mental state and risk assessments, administer depot medication, monitor adherence to treatment plans, support activities of daily living, and address family issues and other relevant aspects of care as needed. Subspecialty CMH services have been started for the geriatric, learning disability and forensic populations. Furthermore, integration of mental health into primary care services has started, with psychiatry clinics run by consultant psychiatrists at two primary healthcare centres.^{Reference Saeed, Wadoo, Ouanes, Haque, Gilstrap and Ghuloum10} The healthcare system in Qatar is heavily subsidised. Community mental healthcare is thus provided free of charge for Qatari patients. Non-nationals are required to pay 20% of the cost of medication, but many patients receive exemption from payment because of the chronicity of their illness.

In 2018, a website was launched providing mental health support, called ‘Your Mind Matters’, and a referral-based community service called Enaya Community Care Center was launched. This strategy also involved working with primary health centres to provide assessments and consultations for patients with mild-to-moderate mental health needs.¹¹ The Minister of Public Health released a public Guide to Mental Health Services in 2019 detailing available services.

Following the COVID-19 pandemic, there has been an acceleration in the provision of services. For example, a Mental Health Service Helpline was set up in 2020 and had received 3000 calls by April.¹² In-person services were available to those not wishing to speak over the phone. Mental health guides were distributed to construction workers, greater coordination efforts were made with primary health centres, and the Mental Health Friends Association (Weyak) ran programmes throughout the pandemic to assist those in need of mental health support.^{Reference Varghese13} The introduction of telepsychiatry as an urgent need during COVID-19 proved very successful. Patients were contacted by phone for out-patient appointments. Many expressed an appreciation of this option, as it addressed the high level of stigma in the community as well as practical challenges in attending clinics in person. It is evident that telepsychiatry will continue to expand after the pandemic.

Such efforts extend beyond the health sector to educational institutions. Universities, in particular, have recognised the importance of providing mental health services for students. In part, this is influenced by the number of American branch campuses based in the country, where the culture of attention towards mental health issues has been transposed on the ground in Qatar. Northwestern, Georgetown, Weill Cornell Medicine, Texas A&M, Virginia Commonwealth and others provide counselling services to students. This effort extends to the major local universities such as Qatar University and Hamad Bin Khalifa University (HBKU). Qatar University offers a Student Counselling Service with psychologists and psychiatrists from mental health services. HBKU offered free online consulting sessions for staff and students during the COVID-19 pandemic, led by a senior consultant from a local hospital.¹⁴

The challenges moving forward

Establishing CMH services has faced many obstacles over the years. People would refuse home visits from hospital staff wearing uniforms and cars bearing the hospital logo. That hesitance made simple changes quite challenging to implement. The publication of the NMHS provided significant support for implementing change and enhancing services. Nevertheless, more public awareness is needed regarding the availability of community services, and effort is still needed to tackle stigma. At the same time, public attitudes towards mental illness need to be measured and compared with previously published data. This will help to evaluate the influence of ongoing awareness efforts and guide future ones. A notable increase in adherence to out-patient appointments occurred during the COVID-19 pandemic as telepsychiatry was implemented instead of in-person attendance. This may reflect the public's preference, especially in the context of high levels of stigma. Expanding the utilisation of telepsychiatry may, therefore, indicate the path forward.

Indeed, reluctance among locals to seek mental healthcare at the main hospital persists. The current CMH services are understaffed. Greater resources are needed in terms of staffing, transportation and structural facilities to ensure coverage of all geographical areas. There is a need to recruit psychologists and social workers to ensure that a more comprehensive biopsychosocial approach to treatment is adopted. To expand services across the country, a significantly larger number of mental-health-trained nurses must be recruited. The service is yet to provide comprehensive mental healthcare, including psychotherapy, rehabilitation and vocational training, as well as residential care for an increasing number of patients with chronic illness who need longer-term care.

Qatar has a highly multi-ethnic population; communication with patients from different backgrounds and with different languages spoken is a challenge in a medical specialty primarily based on communication. Addressing this challenge requires targeted recruitment and investment in technology to support communication efforts.

Local cultural and spiritual beliefs must be considered in a successful CMH service. Many of the treatment models currently used are predominantly Western-based; these need to be adapted to the local context for them to be accepted by the public.

Finally, the law was published in the official gazette in November 2016 and came into force 60 days later. However, the procedures required for its implementation are yet to be established within the health sector. The Mental Health Law must move towards implementation to enshrine the mandate for establishing community care services while reinforcing the rights of citizens to such services.