To get to the institute, Elisa (fictitious name, to preserve her identity) only had to cross a few courts. Although she entered at eight in the morning, she left her house minutes after seven to be the first to enter the center and not meet the crowd of students crowded at her doors. At recess, she didn’t want to go out to the playground, but stayed in class. And at dismissal time, she waited for everyone to leave the building and for her mother, the person telling this story, to pick her up by car.
Then “she started to go back and told me that she didn’t want to go to school because they insulted her. She stayed locked up for six years, without leaving the house, ”says her mother, a resident of Jinámar, one of the most impoverished neighborhoods in the Canary Islands. In some areas of this territory located on the island of Gran Canaria (one part in the municipality of Telde and the other in Las Palmas de Gran Canaria), the average income per person does not reach 6,000 euros per year and that of families barely exceeds 18,000 euros, according to the latest data (corresponding to 2019) of the Household Income Distribution Atlas prepared by the National Institute of Statistics (INE).
In the health center of this neighborhood, a pioneering experience in the field of mental health in primary care has been developed for seven years, which, among others, has helped Elisa. Thanks to this project, she was able to enter the assistance network, have a more exhaustive follow-up, with regular home visits and receive a treatment that has allowed her to make notable progress. “My parents live on the same block as us. They are on the 10th floor and we are on the 6th. Before, to go up from her, I had to go with her in the elevator. Now she is not completely well, but at least she goes out with us to my sister’s house, to a friend of ours, to people she knows, ”says her mother.
The promoter of the project is a nurse, Ricardo Santana, who arrived in Jinámar in 2013 with extensive experience in mental health. Two years later, he decided to carry out an idea that, as he explains, was not new, but an old nursing aspiration that, for one reason or another, had not yet materialized. And he began to gradually implement the case management method. It is not a question, he insistently emphasizes, of replacing the work of clinical psychologists, a figure that he considers essential in this field of care and that he hopes that, as the Ministry of Health of the Government of the Canary Islands has announced, it will settle in the near future in the health centers of the Archipelago. His work consists of “identifying mental health problems, designing a nursing intervention plan, always coordinated with the rest of the team, and achieving objectives using the resources” available to the system.
The purpose is that “no user is left without care” due to work overload in primary care and in specialized mental health units. Santana explains that family doctors see themselves as “powerless”. On the one hand, because they do not have enough time to be able to attend patients properly. And, on the other hand, because when people with less serious disorders are referred to specialized units, through interconsultations, these requests are generally rejected due to the impossibility of the system to assume that flow of cases with its limited means. It must be remembered that the Canary Islands Health Service (SCS) barely has one psychologist for every 17,000 people.
The waiting list for a first mental health assessment in Telde was, until recently, five months, highlights the nurse. The data transmitted from the coordination area indicates that, thanks to this experience of control, monitoring and referral of cases to different resources (sometimes associations), this wait has been reduced by 15% in the entire basic area of health. That is, at four months and one week. “There is a significant percentage of patients from the Telde mental health unit who reside in Jinámar. You have to keep in mind that it is a very impoverished population, that suffers a lot of depression.”
Santana affirms that the role he plays in this neighborhood does not exist in any other health center in the Archipelago. In primary care in Gran Canaria there are only three other mental health specialist nurses (a category that, on the other hand, is not yet recognized ‘de facto’ by the SCS), but they do not work in the branch in which they have been trained. When the project started, this professional dedicated three hours a week (on Fridays) to specifically attend patients in this area. So, I saw an average of two a month. Seven years later, they have released him from the rest of his duties on Fridays (seven hours) and, after a short break in 2019 and 2020, that figure has increased to 62 people on average per month. His claim is that a male or female nurse is completely freed to assume this function exclusively and, over time, extend this figure to other centers.
Follow-up, referrals and partnerships
Case management begins with an exhaustive and structured report that includes personal history, family history, socioeconomic data, the clinic that is present at that time and other data of interest, such as the possible existence of chronic diseases or toxic habits. From there, the plan is designed. In the most serious cases, an urgent interconsultation is made to mental health units. In some milder cases, the intervention is limited to “weekly monitoring” to control the evolution and refer to the necessary resources if the health condition worsens. Santana points out that there are “intermediate” cases in which he looks for other options, such as the Family Orientation Center (COF), a foundation that serves members of low-income and high-conflict households, or associations such as Pulseras Blancas, a therapeutic group accompaniment in grieving processes, and others dedicated to specific disorders.
Social work professionals are also referred in those cases in which the problems are caused by unemployment or a complicated employment situation. Manuel Rodríguez, coordinator of the Jinámar Popular Solidarity Network, recalls that in the neighborhood the “real” unemployment rate exceeds 40% and there is a high percentage of “underemployment”, with income coming from the shadow economy and services. of care. “In Jinámar there are many people in a situation of poverty, unemployed, there is a lot of anxiety disorder, depression… It is not the same as in Ciudad Jardín (the area with the highest purchasing power in Las Palmas de Gran Canaria), where the people have a lot of money and, if something happens to them, the first thing they do is pay for a psychologist or a psychiatrist immediately. If I am in Jinámar and something happens to me, the waiting list for them to treat me is five months,” laments Santana.
The nurse maintains that, because “many times” the interconsultations with the specialist are rejected and in others they are delayed, family doctors urge patients to make an appointment directly with him. He calculates that around 90% of users who went to the health center in the first four months reporting mental symptoms ended up going through his consultation on Fridays. One of the advantages of this system is that it allows a much more exhaustive control. “For a second mental health assessment, the patient can perfectly wait another three months. Here we can get to see them, in some cases, even every week. Even if the interconsultation is accepted”.
He went to Elisa’s house periodically to talk to her and check on her progress. Also for testing. Her intervention allowed a first psychiatrist to come to her home to assess her. “According to her, she had nothing, but Ricardo was not satisfied, he knew there was something more. Thanks to her insistence, a second psychiatrist came. They don’t usually do homes, but my daughter’s case was special, because she didn’t go out at all. And there they already began to treat her, ”says her mother. Since this second visit, Elisa receives psychological treatment (once a month or every month and a half) and pharmacology. “She (the second psychiatrist) saw symptoms of agoraphobia with an obsessive disorder because of her physical appearance, she did not like herself, but, to date, there is no clear diagnosis. My daughter can now go out to some places, but not to places where there are many people, ”says this resident of Jinámar, who recalls several especially complicated episodes, including self-harm, which forced the young woman, who is now 24, to be transferred by ambulance years, to a hospital in the capital of Gran Canaria.
“The psychologist has told her that if she, from one appointment to another, feels that she needs to talk, to call her. And if she doesn’t locate her, let her leave a message at her central office and, as soon as she can, she calls her. And so it has happened. There have been days when she has wanted to take more pills than necessary and she has talked to the psychologist for a while and she has calmed down, ”says Elisa’s mother.
Pandemic aggravates mental health problems
The pandemic has aggravated mental health problems in the population. According to the Spanish Association of Pediatrics, during this health crisis disorders of this type in minors have increased by up to 47%. Cases of anxiety and depression and diagnoses of Attention Deficit Hyperactivity Disorder (ADHD) have multiplied by three or four since 2019 and suicidal behaviors have increased by 59%. In adults, the World Health Organization (WHO) estimated the increase in the prevalence of anxiety and depression at 25% during the first year of the pandemic.
The Government of the Canary Islands announced a few weeks ago the upcoming incorporation of 18 clinical psychologists to develop a pilot experience in the approach and detection of common mental disorders present in the population of the Archipelago. The plan, which is part of the Comprehensive Strategy for Primary and Community Care 2022-2023, emphasizes the need for effective early intervention “on the symptoms of common mental disorders, avoiding their chronification, worsening or referral to a specialist”. It also seeks to “improve the ability to cope with chronic physical disorders that typically present anxious-depressive symptoms”, and promote health and disease prevention “with which to help cope with everyday problems and reduce the medicalization of processes functional emotions.