Integrating Mental Health Services Into Primary Health Care in Nigeria: A Mixed Method Study Exploring the Roles of Family Physicians in Closing the Glaring Gap

Integrating Mental Health Services Into Primary Health Care in Nigeria: A Mixed Method Study Exploring the Roles of Family Physicians in Closing the Glaring Gap | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Integrating Mental Health Services Into Primary Health Care in Nigeria: A Mixed Method Study Exploring the Roles of Family Physicians in Closing the Glaring Gap Thomas Olumide Adeleke, Eloho Joy Orji, Wulaimat Abimbolanle Adekunle, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5957751/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: The need to integrate mental health services into primary healthcare service provision in Nigeria is now more urgent than previously considering the huge and increasing gap in access to mental care at the community level. This study therefore, assessed the critical roles and responsibilities of family physicians in facilitating the successful integration of Mental Health Services (MHS) into primary healthcare settings in Nigeria, with the goal of improving health outcomes, improving patient-centered care, and promoting a more efficient and effective healthcare system. Methods: A mixed method research design was used to collect both quantitative and qualitative data from Nigerian primary care physicians (PCPs) across the six (6) geo-political zones of the country. A semi-structured questionnaire was used to elicit their socio-demographic information, their view of the current state of MHS, factors affecting MHS integration into PHC, while key-informant interview guide was used to explore their opinions on how MHS can be enhanced in the country and how MH care can be integrated into primary health care in Nigeria. Results: The most common role identified by respondents is serving as a link between primary care and mental health specialists (29.7%), followed by being managers of healthcare resources (20.3%) and researchers (19.4%). The study revealed that family physicians have diverse roles in providing comprehensive and coordinated mental health care. Family physicians can use their unique position to facilitate early diagnosis, prompt intervention, provide ongoing support, and foster a collaborative care approach that addresses the complex needs of patients with mental health conditions, ultimately improving overall health outcomes and overall well-being. Conclusion: Family Physicians have important roles to play in bridging the gap between primary healthcare and mental healthcare, particularly in low and middle-income countries like Nigeria. it is recommended that family physicians receive targeted training in mental health care, have access to updated clinical guidelines, and be supported by robust referral systems to ensure seamless collaboration with mental health specialists. Family Physicians Mental Health Integration Primary Health Care Nigeria Collaborative Care BACKGROUND The global burden of mental health disorders is a pressing public health concern, with an estimated 970 million individuals—representing 1 in 8 people worldwide—living with a mental disorder in 2019. Notably, 82% of these individuals reside in low- and middle-income countries (LMICs), highlighting the disproportionate impact of mental health challenges in resource-limited settings [1]. Compounding this issue, the World Health Organization's (WHO) World Mental Health Surveys have identified a significant treatment gap for severe mental disorders in LMICs. Alarmingly, 75% of individuals requiring mental health care in these regions do not have access to adequate treatment, underscoring the urgent need for scalable and sustainable solutions [2]. In Nigeria, as in many other LMICs, the majority of people facing mental health challenges do not have access to care in their communities. Instead, regardless of the severity of their illness, people have to seek care in the few existing overburdened psychiatric facilities [3]. The integration of mental health services into primary health care (PHC) has been identified by the WHO as a critical strategy to bridge this treatment gap. By embedding mental health care within PHC systems, populations can gain improved access to the necessary treatment for mental health conditions, thereby addressing a significant unmet need. [4 ]. This guarantees that people with mental illnesses receive care within their community that is tailored to their peculiar psychosocial contexts[5]. Family physicians are the “first in line doctors” to provide evidence-based care at the community level. Therefore, this study was conducted to assess the critical roles of family physicians in facilitating the holistic integration of mental healthcare services into primary care settings in Nigeria, with the goal of improving health outcomes, improving patient-centered care, and promoting an efficient and effective healthcare system. Nigeria's healthcare facilities are divided into three categories: primary, secondary and tertiary healthcare facilities. The provision of primary care services principally rests on the over 30,000 PHC facilities [6] which constitutes about 88% of the Nigerian health facilities[7]. The performance of Nigeria's primary health care system is plagued by many challenges, including inadequate funding, divided supply chains, a lack of basic infrastructure and equipment, and inadequate human resources[8]. Nigeria underperforms on key health outcomes due to inadequate primary healthcare services, with maternal mortality rates of 243 per 100,000, only about 60% of births attended by trained medical personnel, under-five mortality of 89 per 1,000 births and neonatal mortality of 37 per 1,000 births [9]. A recent study conducted in Nigeria further emphasizes the feasibility of this approach. The study highlighted several challenges, including a severe shortage of mental health specialists and limited mental health services, exacerbated by factors such as the "JAPA syndrome" (the migration of skilled professionals abroad). Despite these barriers, the study demonstrated a high level of acceptance and potential for successful integration of mental health services into primary care, offering a promising pathway forward. [10]. A previous study in Nigeria has also shown that primary care practitioners, including non-physician healthworkers, can be trained to provide psychological and pharmacological therapies[11]. Given the strategic importance of primary health care facilities in enhancing access to mental health services, there is an urgent need for renewed commitment from all stakeholders in Nigeria. Family physicians, in particular, play a pivotal role in this integration, as they are often the first point of contact for individuals seeking care. “Primary Care” is "a model of care that supports first-contact, accessible, continuous, comprehensive, and coordinated person-focused care," according to the World Health Organization [12] while Primary health care (PHC) is “essential health care based on scientifically sound and socially acceptable methods and technology, made universally accessible to all individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development, in the spirit of self-reliance and self-determination”[13]. The relationship between PHC and PC was succinctly captured when PHC was defined as those elements of health policy that enable populations to receive PC services[14]. The WHO has described primary health care as the most inclusive, equitable, and cost-effective approach to achieving universal health coverage. Characterized by its accessibility, affordability, and cultural acceptability, primary care is uniquely positioned to deliver mental health services that are tailored to the specific needs of individuals and their families. This approach not only promotes overall well-being but also fosters trust, respect, and patient autonomy, ultimately leading to improved health outcomes and enhanced quality of life. As the first point of contact within the healthcare system, primary care providers, including family physicians, are often the initial recourse for individuals seeking treatment for mental health conditions, making their role indispensable in addressing the mental health crisis. “Family Medicine” is unique in that it emphasizes physicians' relationship with patients and seeing the patients as a constituent of a family unity and their community using the biopsychosocial model [16]. Family physicians are well positioned to address patients’ mental health-related conditions in primary care settings [17]. The family physician who is a specialist generalist sees all patients regardless of their ages, sexes, disease conditions from cradle to grave[16]. They are referred to as the gatekeepers and first point of contact for most patients coming into the health institution and they are the first sets of doctors to see patients with mental illness[18]. Family physicians are therefore expected to play vital roles both directly and indirectly in the care of patients with mental illnesses [9]. Studies have shown that about 30%-40% of the patients seen at the general out patient clinics present with diagnosable mental illness [18] and family physicians play vital roles in attending to them [18,19 ]. Family physicians provide primary care to patients in primary care settings using the principles of PHC (equity, community participation, intersectoral collaboration and integration, appropriate technology and self-reliance) [16]. Family physicians can foster the integration through several means such as good communication chain, advocacy, research , community awareness and mobilization. Since family physicians work at the grassroot they are better equipped to educate the community because they work amongst them. Their care of patients with mental health can be enhanced with collaborative care with the psychiatrist[20] This will enhance timely consultation in cases of severe mental illnesses or difficult cases[20]. By empowering individuals and families to participate in shared decision-making, family physicians can provide effective mental health services, ensure continuity of care, and improve general well-being, especially in primary care settings that are easily accessible, reasonably priced, and socially acceptable[15]. Therefore, the input of family physicians in policies regarding mental service integration into the primary health care level is pivotal. METHODS Study Design: This study was an explanatory mixed-methods cross-sectional study design with both quantitative and qualitative data collection methods. The qualitative was used to show more insights into the quantitative data that was collected as the main data point. Semi-structured questionnaire was used to collect quantitative data from Nigerian family physicians across the six (6) geo-political zones of the country. The instruments elicit information on their socio-demographic characteristics, their view of the current state of MHS, factors affecting MHS integration into PHC, while key-informant interview guide was used to explore their opinions on how MHS can be enhanced in the country and how MH care can be integrated into primary health care in Nigeria. Study Population: The study was conducted among family physicians in Nigeria. They cut across all the Geo-political zones of the country, and they encountered different patients across all age groups, genders and diseases. This group of doctors relate with physicians in other specialties including mental health physicians. Thus, they are in an advantageous position to give their perception on the current situation of mental health services in the country. Inclusion criteria: Consultant family physicians and senior registrars in family medicine who were currently in active service as consultants and who were willing to participate in the study were included. Exclusion criteria: Family physicians who were critically ill at the time of data collection were excluded. Study Instrument: A semi-structured questionnaire was used to elicit their socio-demographic information, their view of the current state of MHS, factors affecting MHS integration into PHC, while key-informant interview guide was used to explore their opinions on how MHS can be enhanced in the country and how MH care can be integrated into primary health care in Nigeria. Sampling Size: 424 respondents were estimated using Leslie Kish sample size calculation formula, while a purposive sampling size of 24 was used for qualitative key-informant interview following a priori estimation. One interviewee could not complete the interview due to an emergency that came up midway into the research. Sampling Procedures: An online/virtual questionnaire was used for the quantitative data collection through the recruitment of respondents from social media group, email and professional network. This was possible because of the coordinating excellence of the Society of Family Physicians of Nigeria (SOPFON). For qualitative interview sampling, a stratified sampling technique was used to select family physicians from the six (6) geo-political zones of the country. From each zone, two (2) health facilities were selected from a list of the health facilities in each zone using a simple random method. From each health facility, two (2) interviewees were selected by balloting / picking at random from a list of family physicians obtained from the heads of the Family Medicine Departments. Data Collection Procedures: For the quantitative data collection, a semi-structured questionnaire consisting of 6 parts was used. An online/virtual questionnaire was developed and administered to the respondents using platforms Google and supported by physical questionnaire when the response rate was low. The questionnaire was distributed via social medial, email and professional networks. Participants were provided with a detailed explanation of the study and gave electronic informed consent before proceeding. The data collection process was monitored to ensure completeness and accuracy, and responses were automatically stored in a secure, password-protected database. Unique identifiers were used to maintain confidentiality, and incomplete submissions were followed up with reminders to enhance response rates. Participants were contacted by telephone / mobile phone calls, and a virtual in-depth interview was conducted via zoom for each consenting participant after information was given and consent sought. The interviews were audio-recorded, with English language used in all interviews by both the interviewer and the participants. Data were stored on the computer following audio-visual recording. Qualitative data collection was guided by the principle of data saturation: that is, data collection continued until there were no new themes or insights emerging from the analysis. The a priori was adopted from the study by Probes were used for clarification and to obtain in-depth information as needed. Prior to its use, the interview guide was piloted among 6 facilities outside the selected training centers. The interview guide was administered to three participants who met the inclusion criteria and their responses were used to further improve the guide before utilizing it for the main study. To ensure methodological rigor, the following steps were taken: the credibility of this study was ensured through sampling, piloting and member checking. Transferability was ensured through the provision of a clear description of the participants’ characteristics, settings of the study and methodology. The transcriptions were also stored to serve as references. Dependability was ensured through detailed descriptions of the methodologies to enable others to repeat the study if needed. Data Analysis: Data were transcribed using a thematic analysis. A descriptive analysis was used for the quantitative data following cleaning and entry into SPSS version 22. The distribution of variables was done using frequencies and percentages. The qualitative data adopted a participatory action research (PAR) design where family physicians and the interviewer actively collaborated at all the stages of the interview. Recorded interviews were transcribed verbatim and typeset for easy analysis as transcripts were reviewed against audio files seeking clarifications from participants when necessary. The transcribed data has been backed up on an external drive where it could last for at least 5 years or more and could be re-visited if necessary. Content analysis was used for analyzing the data and presented using thematic representation of the findings, with themes developed and merged into categories. Responses were coded and entered into a spreadsheet, and relationships within the data were examined. New themes and categories were added progressively as obtained from the recordings until all the transcripts are analyzed. Conclusions were drawn to depict the participants' perspectives, with all the researchers meeting to ensure agreement on the representation of views. RESULTS Recognition and Diagnosis of Mental Health Issues Table 1 describe the roles and involvement of family physicians in the integration of mental health services. The most common role identified by respondents is serving as a link between primary care and mental health specialists (29.7%), followed by being managers of healthcare resources (20.3%) and researchers (19.4%). Supervising primary care staff (18.4%) and acting as facilitators of training (12%) were also significant roles. Only 0.2% cited other roles. In terms of direct patient care related to mental health, 51.7% of family physicians frequently engage in this, while 42.2% do so occasionally. When it comes to training others, more than half (54.4%) have not been involved, though 35.6% have participated occasionally. Regarding their involvement in facilitating mental health services integration, 39.4% describe their role as active, while 32.2% consider it neutral. A smaller percentage (10.6%) reported being very active. Support and supervision for primary care staff in mental health delivery are provided occasionally by 41.7%, while 20.6% offer support often or rarely. In terms of improving the referral pathway for mental health cases, nearly equal numbers view their role as significant (47.2%) and very significant (46.7%). This highlights family physicians' vital role in bridging care across different levels of the health system. Table 1a: Role of Family Physicians in Mental Health Services Integration. N % Role of Family Physician Facilitator of Training 50 12 Supervisor of Primary Care Staff 77 18.4 Link Between Primary Care and Mental Health Specialists 124 29.7 Researchers 81 19.4 Manager of Health Care Resources 85 20.3 Other (please specify) 1 0.2 Table 1b: Activities of Family Physicians in Mental Health Services Integration. N % How often do you engage in direct patient care related to mental health? Frequently 93 51.7 Occasionally 76 42.2 Rarely 11 6.1 Have you been involved in training other primary care providers in mental health service delivery? No 98 54.4 Yes, frequently 18 10.0 Yes, occasionally 64 35.6 How would you describe your role in facilitating the integration of mental health services in primary care? Active 71 39.4 Inactive 27 15.0 Neutral 58 32.2 Very active 19 10.6 Very inactive 5 2.8 Do you provide support and supervision to primary care staff in their mental health service delivery? Always 16 8.9 Never 15 8.3 Occasionally 75 41.7 Often 37 20.6 Rarely 37 20.6 How do you perceive your role in improving the referral pathway between primary, secondary, and tertiary care for mental health cases? Neutral 11 6.1 Significant 85 47.2 Very significant 84 46.7 Family physicians play a crucial role in integrating mental health services into primary healthcare. They serve as the first point of contact for patients, enabling them to identify and manage mental health issues at an early stage. By assessing and diagnosing mental health conditions, family physicians can determine which patients can be managed within primary care and which need to be referred to specialists. Their involvement ensures prompt and appropriate referrals, reducing the risk of delayed treatment and adverse outcomes. “I think that, most importantly to be able to make early diagnosis, identify most of these common psychiatry illnesses and make early diagnosis, institute early management and referrals for those that needs to be referred.” (Female, consultant, Ogun State) “In my experience, many patients come to primary care with mental health concerns that go unrecognized. Family physicians need to be trained to look beyond physical ailments and consider mental health as a possible factor.” (Female, consultant, Sokoto) “I have seen first-hand how family physicians can make a difference by recognizing mental health issues early. When they take the time to listen and ask the right questions, it can lead to appropriate referrals and better management of the patient's overall health.” (Male, Senior Register, Oyo state) “Family physicians are often the first healthcare providers that patients encounter. Therefore, their ability to recognize and diagnose mental health issues is vital.” (Male, consultant, Edo state) Initiation of Treatment and Preventive Services In addition to clinical diagnosis, family physicians provide first-line care, including administering necessary first aid and stabilizing patients during psychiatric emergencies. “Yes, they have roles to play. The fact that they are the first contact, the role they play is to take, I mean at the level of patient assessment and examination, holistic approach to medical management, try to at least find the sort out patients that have mental health issues, and you know when they have good knowledge of mental issues manifest, they will know who and who are the patients that are really having mental health issues. So, they play a role of picking up mental health issues patients at the early stage and try to sort them out and pick the ones that can be managed at the primary healthcare” (Male, Specialist trainer, Oyo State). "Of course, as the domain of family medicine practice, which is practiced at both. facility and then family physician at both facility and family level and community level. And at the same time, a family physician sees a patient not by disease entity, but by the whole person with his environment and family. With that, there are going to be, with this application of family medicine practice, there is a lot that you can do before or even you can take care of the issue before it's out of hand. And you may only manage a little with this one expertise. You can manage a lot of mental health illnesses. But you should admit to what you can”. (Male, Consultant, Kano State) “Prevention How do we prevent most of these mental health challenges? The family physician as the first contact doctor has the right to counsel or has the advantage to counsel the patients when they come on what to do to reduce their predisposition to mental health challenges.” (Male, Consultant, Ogun State). Utilization of Referral Systems Furthermore, family physicians act as gatekeepers and coordinators in the healthcare system. They maintain a two-way referral system, ensuring that information flows back from specialists, enabling them to manage similar cases more effectively in the future. Their proximity to patients allows them to ensure adherence to treatment plans and provide ongoing counseling, which is crucial for long-term mental health management. “ I've had quite a number of experiences. I've had cases of even schizophrenia you know that we had to refer we've had cases of major depression that I've had to refer to see the psychiatrist I've had yes I've had, yes, I've had a lot of experience in that regard because the way where I practice is structured. I get to see almost every other patient first, apart from pediatric patients. So, every patient that comes into the hospital, we get to see, we get to manage first, we get to give the first care, so we have a very Integral role to play in appropriate referrals”. (Female, Consultant, Ogun State) “I often find that patients with mental health issues require ongoing support that goes beyond what I can provide. Referring them allows me to connect them with therapists or psychiatrists who can offer specialized interventions, which is crucial for their recovery.” (Male, consultant, Ogun state) “I believe that family physicians should not only refer patients but also follow up on those referrals.” (Male, consultant, Lagos state) Community Awareness and Research Dissemination Family Physicians use holistic approach to provide patient care which involves educating patients and their families about mental health challenges, helping to reduce stigma, and promoting better understanding and support within the community. They also engage in research and contribute to the broader knowledge of mental health, helping to refine treatment approaches and improve patient outcomes. Their role extends beyond the individual patient to involve family and community-level interventions, using tools like family conferencing to address the root causes of mental health issues and leverage family support in patient care. “Creating awareness and then talking to the community and the family is within the domain of family physicians. This fosters understanding of mental health conditions in the community. And with that, we're going to reduce a lot of stigma.” (Male, Consultant, Kano State) . “They also play a role in meeting the family. There is a lot of tools in family medicine. There is family conferencing. There is also family tree which looks beyond the biological origin of diseases but also explores the psychosocial roots of the diseases. So, with that, there's a lot of help that can come with the family physician before even reaching the mental health insurance. They identify risk factors, identify who among the caregivers that can be of help and what causes the illnesses”. (Male, Consultant, Oyo State) " I also talk about the role of research too, like the one you are doing, like research which we add more to the knowledge, which we add more to our knowledge of mental health illnesses”. (Male, Resident, Ondo State) It is imperative to note that family physicians are integral to the early detection, management, referral, treatment coordination, meeting with care givers, case finding, offering psychological support, and ongoing care of patients with mental health conditions within the primary healthcare setting. Their comprehensive and patient-centered approach significantly contributes to the effective integration of mental health services into primary care. DISCUSSION This mixed method study explored the specific roles and responsibilities of Family Physicians in the effective integration of mental health services into primary care, particularly in the Nigerian cultural milieu. The study identified the following specific roles that family physicians, as the first point of contact for patients, can play in the integration process:1. Early recognition and timely diagnosis of mental health conditions, 2. Initiation of treatment and preventive services, 3. Serving as a link between primary care and mental health professionals, as well as maintaining a two-way referral system., 4. Community education and research dissemination, 5. Healthcare resource management, 6. Leadership and supervision, 7. Training and capacity building. Remarkably, the study revealed that only about one third of the respondents have been actively involved in facilitating mental health services integration into the routine primary care and less than half of them provide support and supervision for primary care staff in mental health delivery occasionally. However, about half of the study participants perceived their roles in the integration process as significant. These findings have substantial implications for successful integration of mental health services into primary care settings in Nigeria and many other countries. This study revealed that Family physicians have important roles to play in the integration of mental health services into primary care settings particularly in low and middle-income countries like Nigeria. Specifically, as the primary point of contact for patients, we discovered that Family Physicians play a vital role in identifying and diagnosing mental health conditions at the earliest possible stage, allowing for timely interventions and improving overall health outcomes. A similar study has earlier emphasized the critical role of family physicians in accurately screening and diagnosing mental health issues in the community, using a variety of cutting-edge diagnostic technologies and evidence-based techniques[21]. By leveraging their unique position in the healthcare system, Family Physicians can address their patients' physical and emotional needs and help to bridge the gap between mental and physical health. Unfortunately, primary care physicians frequently fail to recognize early, diagnose promptly , and treat mental disorders [22, 23, 24]. In terms of treatment initiation, the qualitative aspect of our study showed that in addition to making clinical diagnoses, family physicians are able to provide first-line treatment and also deliver required first aid and stabilise patients during psychiatric emergencies. However, the notable findings that emerged from the quantitative component of this study include findings that only about one third of the study participants have been actively involved in facilitating mental health services integration into the routine primary care and less than half of them provide support and supervision for primary care staff in mental health delivery occasionally. It is well documented in the literature that only a small percentage of family doctors report offering mental health services[25]. A study found that the number of primary care physicians who prescribed medication (56.1%) is much lower than the percentage who reported awareness (77.8%) of the right medicine for a common mental health disorder they have identified [26]. In another cross-sectional survey from five southeastern European nations, even though 40.9% of GPs indicated that they can manage depression with medication, 79.4% believed patients in need of antidepressants should be sent to a psychiatrist[27]. In this study, we discovered that family physicians act as gatekeepers and coordinators in the healthcare system by allowing two-way referrals. As stated earlier, family physicians play an important role in the treatment of common mental health disorders and should be prepared to give continuous care and support to patients with mild to moderate conditions. However, it is equally vital for family physicians to recognize when a patient's condition merits specialized care and support rapid referrals to mental health specialists when the severity of the disease necessitates more rigorous therapy[28,29]. By striking a balance between delivering primary care and knowing when to refer, family physicians can ensure that patients receive comprehensive and coordinated treatment, resulting in better health outcomes and a higher quality of life. Furthermore, this study highlights additional complex roles of family physicians in mental health integration into primary care which is supported by current literature. Family physicians are positioned to play a significant role in: i) Raising awareness about mental health illnesses in the community, disseminating research findings, and encouraging mental health literacy among the general public, thus empowering communities to take control of their health and wellbeing [30], ii) Effectively managing healthcare resources, including personnel, equipment, and facilities, in order to provide high-quality patient care and maximize resource utilization [31], iii) Supervising primary care workers, offering direction and support, and cultivating an environment of excellence and continuous improvement, ultimately improving overall care quality and patient outcomes[32], iv) Facilitating training and education for other primary care practitioners, sharing their skills and experience, and helping to establish a professional and competent workforce, consequently strengthening the primary care system and improving health outcomes[32]. By taking on these broad tasks, family physicians can have a significant impact on the mental health integration into primary care, going beyond direct patient care to include community participation, resource management, leadership, and teaching. This, in turn, can result in better health outcomes, more patient satisfaction, and a more efficient and effective healthcare system. This study adds to the limited literature on the essential roles of family physicians in identifying and managing mental health conditions as the first point of contact in primary care. Their participation in early detection, prevention, and referral channels enables complete and timely mental health care. The study emphasizes the need to empower family physicians through training, capacity building, and resource allocation to improve mental health treatment delivery in low-income communities like Nigeria. Family physicians play a critical role in facilitating collaborative care approaches and community-based treatments to alleviate Nigeria's mental health treatment gap. STRENGTHS AND LIMITATIONS One of the main strengths of this study is that the study used both quantitative and qualitative data to provide a thorough knowledge of family physicians' roles in integrating mental health services into primary care in Nigeria. Similarly, participants were also chosen from all six geopolitical zones of Nigeria to ensure that the findings reflect the different regional experiences and viewpoints of Nigerian family physicians. However, it should be acknowledged that there are some limitations regarding the study: firstly, the reliance on self-reported impressions and roles may generate bias, since individuals may overstate their contributions or experiences. Secondly, excluding junior residents and retired family physicians may have resulted in missing potentially significant insights from these groups of family physicians. CONCLUSION We conclude that Family Physicians are pivotal in bridging the gap between primary care and mental health services, with diverse roles in providing comprehensive and coordinated mental health care. Their knowledge and leadership are critical in integrating mental health services into primary care, ensuring that patients receive prompt, effective, and patient-centered care. Family physicians can use their unique position to facilitate early diagnosis, prompt intervention, provide ongoing support, and foster a collaborative care approach that addresses the complex needs of patients with mental health conditions, ultimately improving health outcomes and overall well-being. Declarations Ethical Approval and Consent to Participate: Ethical approval was duly obtained from the National Health Research Committee, Nigeria. Approval was also obtained from the Management of the selected training centres. Confidentiality was ensured throughout the study period as all the recordings were passworded, and only the researchers had access, and anonymity was maintained with the use of codes and pseudonyms. A written consent was explained to all the study participants and it was made clear to them that consent could be withdrawn freely. Funding : Authors did not receive any funding support for this research. Availability of Data and Materials: The dataset for this study will be made freely available on request. Competiting interest : Authors declare no conflict of interest Authors' Contributions: OTA conceived and designed the study, approved the design and implementation, and coordinated and supervised data collection. EJO drafted the initial article and was responsible for data collection. AWA contributed to the study design and data collection. AOA contributed to study design and data collection. ANO contributed to the study design and data collection. OAO contributed to the study design and participated in the data collection. OA contributed to the study design and data collection. AJA approved the design and implementation of the study and coordinated and supervised data collection. TOA was the study statistician and created and managed the database. OTA drafted the initial Article with input from EJO. All authors critically reviewed and revised the draft. Acknowledgement : We sincerely appreciate all our study participants. We acknowledge their efforts, time and contributions in ensuring proper integration of mental health services into primary care settings. References World Health Organization. World mental health report: Transforming mental health for all. World Health Organization; 2022. 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URL: https://www.who.int/teams/integrated-health-services/clinical-services-and-systems/primary-care [accessed 2024-12-31. Ata A. Declaration of Alma Ata: International conference on primary health care. InAlma Ata, USSR: International Conference on Primary Health Care 1978 Sep (Vol. 6). Starfield B. Primary care and equity in health: the importance to effectiveness and equity of responsiveness to peoples' needs. Humanity Soc. 2009;33(1–2):56–73. World Health Organization. Mental health in primary care: Illusion or inclusion? (2018): 1–17. Jamoulle M, Resnick M, Vander Stichele R, Ittoo A, Cardillo E, Vanmeerbeek M. Analysis of definitions of general practice, family medicine, and primary health care: a terminological analysis. BJGP open. 2017;1(3). American Academy of Family Physicians. Mental and behavioral health care services by family physicians (position paper) [Internet]. 2023. Clatney L, MacDonald H, Shah SM. Mental health care in the primary care setting: family physicians’ perspectives. Can Fam Physician. 2008;54(6):884–9. Al-Khathami AD, Ogbeide DO. Prevalence of mental illness among Saudi adult primary-care patients in Central Saudi Arabia. Saudi Med J. 2002;23(6):721–4. Rockman P, Salach L, Gotlib D, Cord M, Turner T. Shared mental health care. Model for supporting and mentoring family physicians. Can Fam Physician. 2004;50(3):397–402. Alsudairy NM, Aloush KM, Alzayed SM, Alsamti AI, Alsahaf AI, Al Zahrani AT, Alabdulbaqi BA, Alotaibi RN, Althenayan TO, Kamal AA, Alahmari AS. The Role of Family Physicians in Mental Health Care: Screening, Diagnosis, and Treatment Options. J Adv Zool. 2024;45(1). AlSalem M, AlHarbi MA, Badeghiesh A, Tourian L. Accuracy of initial psychiatric diagnoses given by nonpsychiatric physicians: A retrospective chart review. Medicine. 2020;99(51):e23708. Cepoiu M, McCusker J, Cole MG, Sewitch M, Belzile E, Ciampi A. Recognition of depression by non-psychiatric physicians—a systematic literature review and meta-analysis. J Gen Intern Med. 2008;23:25–36. Wittchen HU, Pittrow D. Prevalence, recognition and management of depression in primary care in Germany: the Depression 2000 study. Hum Psychopharmacology: Clin Experimental. 2002;17(S1):S1–1. Xierali IM, Tong ST, Petterson SM, Puffer JC, Phillips RL, Bazemore AW. Family physicians are essential for mental health care delivery. J Am Board Family Med. 2013;26(2):114–5. Papachristopoulos I, Sazakli E, Leotsinidis M. General practitioners’ views towards management of common mental health disorders: Τhe critical role of continuing medical education. BMC Prim Care. 2023;24(1):63. Duric P, Harhaji S, O'May F, Boderscova L, Chihai J, Como A, Hranov GL, Mihai A, Sotiri E. General practitioners' views towards diagnosing and treating depression in five southeastern European countries. Early Interv Psychiat. 2019;13(5):1155–64. Fleury MJ, Imboua A, Aubé D, Farand L, Lambert Y. General practitioners' management of mental disorders: a rewarding practice with considerable obstacles. BMC Fam Pract. 2012;13:1–2. Brown HE. Identifying risk of psychosis in a primary care setting. JAMA Netw Open. 2018;1(7):e185165. World Health Organization. World Organization of National Colleges, Academies, Academic Associations of General Practitioners/Family Physicians. Integrating mental health into primary care: a global perspective. World Health Organization; 2008. Phillips WR, Herbert CP. What makes family doctors the leaders we need in health care? Can Fam Physician. 2022;68(11):801. Mash R, Ogunbanjo G, Naidoo SS, Hellenberg D. The contribution of family physicians to district health services: A national position paper for South Africa. South Afr Family Pract. 2015;57(3):54–61. Additional Declarations No competing interests reported. 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Notably, 82% of these individuals reside in low- and middle-income countries (LMICs), highlighting the disproportionate impact of mental health challenges in resource-limited settings [1]. Compounding this issue, the World Health Organization\u0026apos;s (WHO) World Mental Health Surveys have identified a significant treatment gap for severe mental disorders in LMICs. Alarmingly, 75% of individuals requiring mental health care in these regions do not have access to adequate treatment, underscoring the urgent need for scalable and sustainable solutions [2]. In Nigeria, as in many other LMICs, the majority of people facing mental health challenges do not have access to care in their communities. Instead, regardless of the severity of their illness, people have to seek care in the few existing overburdened psychiatric facilities [3]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe integration of mental health services into primary health care (PHC) has been identified by the WHO as a critical strategy to bridge this treatment gap. By embedding mental health care within PHC systems, populations can gain improved access to the necessary treatment for mental health conditions, thereby addressing a significant unmet need. [4 ]. This guarantees that people with mental illnesses receive care within their community that is tailored to their peculiar psychosocial contexts[5]. Family physicians are the \u0026ldquo;first in line doctors\u0026rdquo; to provide evidence-based care at the community level. Therefore, this study was conducted to assess the critical roles of family physicians in facilitating the holistic integration of mental healthcare services into primary care settings in Nigeria, with the goal of improving health outcomes, improving patient-centered care, and promoting an efficient and effective healthcare system.\u003c/p\u003e\n\u003cp\u003eNigeria\u0026apos;s healthcare facilities are divided into three categories: primary, secondary and tertiary healthcare facilities. The provision of primary care services principally rests on the over 30,000 PHC facilities [6] which constitutes about 88% of the Nigerian health facilities[7]. The performance of Nigeria\u0026apos;s primary health care system is plagued by many challenges, including inadequate funding, divided supply chains, a lack of basic infrastructure and equipment, and inadequate human resources[8]. Nigeria underperforms on key health outcomes due to inadequate primary healthcare services, with maternal mortality rates of 243 per 100,000, only about 60% of births attended by trained medical personnel, under-five mortality of 89 per 1,000 births and neonatal mortality of 37 per 1,000 births [9].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA recent study conducted in Nigeria further emphasizes the feasibility of this approach. The study highlighted several challenges, including a severe shortage of mental health specialists and limited mental health services, exacerbated by factors such as the \u0026quot;JAPA syndrome\u0026quot; (the migration of skilled professionals abroad). Despite these barriers, the study demonstrated a high level of acceptance and potential for successful integration of mental health services into primary care, offering a promising pathway forward. [10]. A previous study in Nigeria has also shown that primary care practitioners, including non-physician healthworkers, can be trained to provide psychological and pharmacological therapies[11]. Given the strategic importance of primary health care facilities in enhancing access to mental health services, there is an urgent need for renewed commitment from all stakeholders in Nigeria. Family physicians, in particular, play a pivotal role in this integration, as they are often the first point of contact for individuals seeking care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Primary Care\u0026rdquo; is \u0026quot;a model of care that supports first-contact, accessible, continuous, comprehensive, and coordinated person-focused care,\u0026quot; according to the World Health Organization [12] while Primary health care (PHC) is \u0026nbsp;\u0026ldquo;essential health care based on scientifically sound and socially acceptable methods and technology, made universally accessible to all individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development, in the spirit of self-reliance and self-determination\u0026rdquo;[13]. The relationship between \u0026nbsp;PHC and PC was succinctly captured when PHC was defined as \u0026nbsp;those elements of health policy that enable populations to receive PC services[14]. The WHO has described primary health care as the most inclusive, equitable, and cost-effective approach to achieving universal health coverage. Characterized by its accessibility, affordability, and cultural acceptability, primary care is uniquely positioned to deliver mental health services that are tailored to the specific needs of individuals and their families. This approach not only promotes overall well-being but also fosters trust, respect, and patient autonomy, ultimately leading to improved health outcomes and enhanced quality of life. As the first point of contact within the healthcare system, primary care providers, including family physicians, are often the initial recourse for individuals seeking treatment for mental health conditions, making their role indispensable in addressing the mental health crisis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Family Medicine\u0026rdquo; is unique in that it emphasizes physicians\u0026apos; relationship with patients and seeing the patients as a constituent of a family unity and their community using the biopsychosocial model [16]. Family physicians are well positioned to address patients\u0026rsquo; mental health-related conditions in primary care settings [17]. The family physician who is a specialist generalist sees all patients regardless of their ages, sexes, disease conditions from cradle to grave[16]. They are referred to as the gatekeepers \u0026nbsp;and first point of contact for most patients coming into the health institution and they are the first sets of doctors to see patients with mental illness[18]. \u0026nbsp; Family physicians are therefore expected to play vital roles both directly and indirectly in the care of patients with mental illnesses [9]. Studies have shown that about 30%-40% of the patients seen at the general out patient clinics present with diagnosable mental illness [18] and \u0026nbsp;family physicians play \u0026nbsp;vital roles in attending to them [18,19 ]. Family physicians provide primary care to patients in primary care settings using the principles of PHC (equity, community participation, intersectoral collaboration and integration, appropriate technology and self-reliance) [16]. Family physicians can foster the integration through several means such as good communication chain, advocacy, research , community awareness and mobilization. Since family physicians work at the grassroot they are better equipped to educate the community because they work amongst them. Their care of patients with mental health can be enhanced with collaborative care with the psychiatrist[20] This will enhance timely consultation in cases of severe mental illnesses or difficult cases[20]. By empowering individuals and families to participate in shared decision-making, family physicians can provide effective mental health services, ensure continuity of care, and improve general well-being, especially in primary care settings that are easily accessible, reasonably priced, and socially acceptable[15]. Therefore, the input of family physicians in policies regarding mental service integration into the primary health care level is pivotal.\u0026nbsp;\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eStudy Design: This study was an explanatory mixed-methods cross-sectional study design with both quantitative and qualitative data collection methods. The qualitative was used to show more insights into the quantitative data that was collected as the main data point. Semi-structured questionnaire was used to collect quantitative data from Nigerian family physicians across the six (6) geo-political zones of the country. The instruments elicit information on their socio-demographic characteristics, their view of the current state of MHS, factors affecting MHS integration into PHC, while key-informant interview guide was used to explore their opinions on how MHS can be enhanced in the country and how MH care can be integrated into primary health care in Nigeria.\u003c/p\u003e\n\u003cp\u003eStudy Population: The study was conducted among family physicians in Nigeria. They cut across all the Geo-political zones of the country, and they encountered different patients across all age groups, genders and diseases. This group of doctors relate with physicians in other specialties including mental health physicians. Thus, they are in an advantageous position to give their perception on the current situation of mental health services in the country.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInclusion criteria: Consultant family physicians and senior registrars in family medicine who were currently in active service as consultants and who were willing to participate in the study were included.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExclusion criteria: Family physicians who were critically ill at the time of data collection were excluded. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStudy Instrument: A semi-structured questionnaire was used to elicit their socio-demographic information, their view of the current state of MHS, factors affecting MHS integration into PHC, while key-informant interview guide was used to explore their opinions on how MHS can be enhanced in the country and how MH care can be integrated into primary health care in Nigeria.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSampling Size: 424 respondents were estimated using Leslie Kish sample size calculation formula, while a purposive sampling size of 24 was used for qualitative key-informant interview following a priori estimation. One interviewee could not complete the interview due to an emergency that came up midway into the research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSampling Procedures: An online/virtual questionnaire was used for the quantitative data collection through the recruitment of respondents from social media group, email and professional network. This was possible because of the coordinating excellence of the Society of Family Physicians of Nigeria (SOPFON). For qualitative interview sampling, a stratified sampling technique was used to select family physicians from the six (6) geo-political zones of the country. From each zone, two (2) health facilities were selected from a list of the health facilities in each zone using a simple random method. From each health facility, two (2) interviewees were selected by balloting / picking at random from a list of family physicians obtained from the heads of the Family Medicine Departments.\u003c/p\u003e\n\u003cp\u003eData Collection Procedures: For the quantitative data collection, a semi-structured questionnaire consisting of 6 parts was used. An online/virtual questionnaire was developed and administered to the respondents using platforms Google and supported by physical questionnaire when the response rate was low. The questionnaire was distributed via social medial, email and professional networks. Participants were provided with a detailed explanation of the study and gave electronic informed consent before proceeding. The data collection process was monitored to ensure completeness and accuracy, and responses were automatically stored in a secure, password-protected database. Unique identifiers were used to maintain confidentiality, and incomplete submissions were followed up with reminders to enhance response rates.\u003c/p\u003e\n\u003cp\u003eParticipants were contacted by telephone / mobile phone calls, and a virtual in-depth interview was conducted via zoom for each consenting participant after information was given and consent sought. The interviews were audio-recorded, with English language used in all interviews by both the interviewer and the participants. Data were stored on the computer following audio-visual recording.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQualitative data collection was guided by the principle of data saturation: that is, data collection continued until there were no new themes or insights emerging from the analysis. The a priori was adopted from the study by \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProbes were used for clarification and to obtain in-depth information as needed. Prior to its use, the interview guide was piloted among 6 facilities outside the selected training centers. The interview guide was administered to three participants who met the inclusion criteria and their responses were used to further improve the guide before utilizing it for the main study. To ensure methodological rigor, the following steps were taken: the credibility of this study was ensured through sampling, piloting and member checking. Transferability was ensured through the provision of a clear description of the participants\u0026rsquo; characteristics, settings of the study and methodology. The transcriptions were also stored to serve as references. Dependability was ensured through detailed descriptions of the methodologies to enable others to repeat the study if needed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData Analysis: Data were transcribed using a thematic analysis. A descriptive analysis was used for the quantitative data following cleaning and entry into SPSS version 22. The distribution of variables was done using frequencies and percentages. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe qualitative data adopted a participatory action research (PAR) design where family physicians and the interviewer actively collaborated at all the stages of the interview. Recorded interviews were transcribed verbatim and typeset for easy analysis as transcripts were reviewed against audio files seeking clarifications from participants when necessary. The transcribed data has been backed up on an external drive where it could last for at least 5 years or more and could be re-visited if necessary. Content analysis was used for analyzing the data and presented using thematic representation of the findings, with themes developed and merged into categories. Responses were coded and entered into a spreadsheet, and relationships within the data were examined. New themes and categories were added progressively as obtained from the recordings until all the transcripts are analyzed. Conclusions were drawn to depict the participants\u0026apos; perspectives, with all the researchers meeting to ensure agreement on the representation of views.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eRecognition and Diagnosis of Mental Health Issues\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 describe the roles and involvement of family physicians in the integration of mental health services. The most common role identified by respondents is serving as a link between primary care and mental health specialists (29.7%), followed by being managers of healthcare resources (20.3%) and researchers (19.4%). Supervising primary care staff (18.4%) and acting as facilitators of training (12%) were also significant roles. Only 0.2% cited other roles.\u003c/p\u003e\n\u003cp\u003eIn terms of direct patient care related to mental health, 51.7% of family physicians frequently engage in this, while 42.2% do so occasionally. When it comes to training others, more than half (54.4%) have not been involved, though 35.6% have participated occasionally. Regarding their involvement in facilitating mental health services integration, 39.4% describe their role as active, while 32.2% consider it neutral. A smaller percentage (10.6%) reported being very active.\u003c/p\u003e\n\u003cp\u003eSupport and supervision for primary care staff in mental health delivery are provided occasionally by 41.7%, while 20.6% offer support often or rarely. In terms of improving the referral pathway for mental health cases, nearly equal numbers view their role as significant (47.2%) and very significant (46.7%). This highlights family physicians\u0026apos; vital role in bridging care across different levels of the health system.\u003c/p\u003e\n\u003cp\u003eTable 1a: Role of Family Physicians in Mental Health Services Integration.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"615\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\"\u003e\n \u003cp\u003eRole of Family Physician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eFacilitator of Training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eSupervisor of Primary Care Staff\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eLink Between Primary Care and Mental Health Specialists\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e29.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eResearchers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e19.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eManager of Health Care Resources\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e20.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOther (please specify)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 1b: Activities of Family Physicians in Mental Health Services Integration.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eHow often do you engage in direct patient care related to mental health?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFrequently\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e51.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOccasionally\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRarely\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eHave you been involved in training other primary care providers in mental health service delivery?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes, frequently\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYes, occasionally\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eHow would you describe your role in facilitating the integration of mental health services in primary care?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eActive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInactive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNeutral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVery active\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVery inactive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eDo you provide support and supervision to primary care staff in their mental health service delivery?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAlways\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOccasionally\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e41.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOften\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRarely\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eHow do you perceive your role in improving the referral pathway between primary, secondary, and tertiary care for mental health cases?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNeutral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSignificant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVery significant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFamily physicians play a crucial role in integrating mental health services into primary healthcare. They serve as the first point of contact for patients, enabling them to identify and manage mental health issues at an early stage. By assessing and diagnosing mental health conditions, family physicians can determine which patients can be managed within primary care and which need to be referred to specialists. Their involvement ensures prompt and appropriate referrals, reducing the risk of delayed treatment and adverse outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u0026ldquo;I think that, most importantly to be able to make early diagnosis, identify most of these common psychiatry illnesses and make early diagnosis, institute early management and referrals for those that needs to be referred.\u0026rdquo;\u003c/em\u003e (Female, consultant, Ogun State)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In my experience, many patients come to primary care with mental health concerns that go unrecognized. Family physicians need to be trained to look beyond physical ailments and consider mental health as a possible factor.\u0026rdquo; (Female, consultant, Sokoto)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I have seen first-hand how family physicians can make a difference by recognizing mental health issues early. When they take the time to listen and ask the right questions, it can lead to appropriate referrals and better management of the patient\u0026apos;s overall health.\u0026rdquo; (Male, Senior Register, Oyo state)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Family physicians are often the first healthcare providers that patients encounter. Therefore, their ability to recognize and diagnose mental health issues is vital.\u0026rdquo; (Male, consultant, Edo state)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInitiation of Treatment and Preventive Services\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to clinical diagnosis, family physicians provide first-line care, including administering necessary first aid and stabilizing patients during psychiatric emergencies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, they have roles to play. The fact that they are the first contact, the role they play is to take, I mean at the level of patient assessment and examination, holistic approach to medical management, try to at least find the sort out patients that have mental health issues, and you know when they have good knowledge of mental issues manifest, they will know who and who are the patients that are really having mental health issues. So, they play a role of picking up mental health issues patients at the early stage and try to sort them out and pick the ones that can be managed at the primary healthcare\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Male, Specialist trainer, Oyo State).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026quot;Of course, as the domain of family medicine practice, which is practiced at both. \u0026nbsp; facility and then family physician at both facility and family level and community level. And at the same time, a family physician sees a patient not by disease entity, but by the whole person with his environment and family. With that, there are going to be, with this application of family medicine practice, there is a lot that you can do before or even you can take care of the issue before it\u0026apos;s out of hand. And you may only manage a little with this one expertise. You can manage a lot of mental health illnesses. But you should admit to what you can\u0026rdquo;. (Male, Consultant, Kano State)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Prevention How do we prevent most of these mental health challenges? The family physician as the first contact doctor has the right to counsel or has the advantage to counsel the patients when they come on what to do to reduce their predisposition to mental health challenges.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Male, Consultant, Ogun State).\u003c/p\u003e\n\u003cp\u003eUtilization of Referral Systems\u003c/p\u003e\n\u003cp\u003eFurthermore, family physicians act as gatekeepers and coordinators in the healthcare system. They maintain a two-way referral system, ensuring that information flows back from specialists, enabling them to manage similar cases more effectively in the future. Their proximity to patients allows them to ensure adherence to treatment plans and provide ongoing counseling, which is crucial for long-term mental health management.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo; I\u0026apos;ve had quite a number of experiences. I\u0026apos;ve had cases of even schizophrenia you know that we had to refer we\u0026apos;ve had cases of major depression that I\u0026apos;ve had to refer to see the psychiatrist I\u0026apos;ve had yes I\u0026apos;ve had, yes, I\u0026apos;ve had a lot of experience in that regard because the way where I practice is structured. I get to see almost every other patient first, apart from pediatric patients. So, every patient that comes into the hospital, we get to see, we get to manage first, we get to give the first care, so we have a very Integral role to play in appropriate referrals\u0026rdquo;. (Female, Consultant, Ogun State)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I often find that patients with mental health issues require ongoing support that goes beyond what I can provide. Referring them allows me to connect them with therapists or psychiatrists who can offer specialized interventions, which is crucial for their recovery.\u0026rdquo; (Male, consultant, Ogun state)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I believe that family physicians should not only refer patients but also follow up on those referrals.\u0026rdquo; (Male, consultant, Lagos state)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunity Awareness and Research Dissemination\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Family Physicians use holistic approach to provide patient care which involves educating patients and their families about mental health challenges, helping to reduce stigma, and promoting better understanding and support within the community. They also engage in research and contribute to the broader knowledge of mental health, helping to refine treatment approaches and improve patient outcomes. Their role extends beyond the individual patient to involve family and community-level interventions, using tools like family conferencing to address the root causes of mental health issues and leverage family support in patient care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Creating awareness and then talking to the community and the family is within the domain of family physicians. This fosters understanding of mental health conditions in the community. And with that, we\u0026apos;re going to reduce a lot of stigma.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Male, Consultant, Kano State) .\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;They also play a role in meeting the family. There is a lot of tools in family medicine. There is family conferencing. There is also family tree which \u0026nbsp;looks beyond the biological origin of diseases but also \u0026nbsp;explores the psychosocial roots of the diseases. So, with that, there\u0026apos;s a lot of help that can come with the family physician before even reaching the mental health insurance. They identify risk factors, identify who among the caregivers that can be of help and what causes the illnesses\u0026rdquo;. (Male, Consultant, Oyo State)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026quot; I also talk about the role of research too, like the one you are doing, like research which we add more to the knowledge, which we add more to our knowledge of mental health illnesses\u0026rdquo;. (Male, Resident, Ondo State)\u003c/p\u003e\n\u003cp\u003eIt is imperative to note that family physicians are integral to the early detection, management, referral, treatment coordination, meeting with care givers, case finding, offering psychological support, and ongoing care of patients with mental health conditions within the primary healthcare setting. Their comprehensive and patient-centered approach significantly contributes to the effective integration of mental health services into primary care.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis mixed method study explored the specific roles and responsibilities of Family Physicians in the effective integration of mental health services into primary care, particularly in the Nigerian cultural milieu. The study identified the following specific roles that family physicians, as the first point of contact for patients, can play \u0026nbsp;in the integration process:1. Early recognition and timely diagnosis of mental health conditions, 2. Initiation of treatment and preventive services, 3. Serving as a link between primary care and mental health professionals, as well as maintaining a two-way referral system., 4. Community education and research dissemination, 5. Healthcare resource management, 6. Leadership and supervision, 7. Training and capacity building. Remarkably, the study revealed that only about one third of the respondents have been actively involved in facilitating mental health services integration into the routine primary care and less than half of them provide support and supervision for primary care staff in mental health delivery occasionally. However, about half of the study participants perceived their roles in the integration process as significant. These findings have substantial implications for successful integration of mental health services into primary care settings in Nigeria and many other countries.\u003c/p\u003e\n\u003cp\u003eThis study revealed that Family physicians have important roles to play in the integration of mental health services into primary care settings particularly in low and middle-income countries like Nigeria. Specifically, as the primary point of contact for patients, we discovered that Family Physicians play a vital role in identifying and diagnosing mental health conditions at the earliest possible stage, allowing for timely interventions and improving overall health outcomes. A similar study has earlier emphasized the critical role of family physicians in accurately screening and diagnosing mental health issues in the community, using a variety of cutting-edge diagnostic technologies and evidence-based techniques[21]. By leveraging their unique position in the healthcare system, Family Physicians can \u0026nbsp;address their patients\u0026apos; physical and emotional needs and help to bridge the gap between mental and physical health. Unfortunately, primary care physicians frequently fail to recognize early, diagnose promptly , and treat mental disorders [22, 23, 24].\u003c/p\u003e\n\u003cp\u003eIn terms of treatment initiation, the qualitative aspect of our study showed that in addition to making clinical diagnoses, family physicians are able to provide first-line treatment and also deliver required first aid and stabilise patients during psychiatric emergencies. However, the notable findings that emerged from the quantitative component of this study include findings that only about one third of the study participants have been actively involved in facilitating mental health services integration into the routine primary care and less than half of them provide support and supervision for primary care staff in mental health delivery occasionally. It is well documented in the literature that only \u0026nbsp;a small percentage of family doctors report offering mental health services[25]. A study found that the number of primary care physicians who prescribed medication (56.1%) is much lower than the percentage who reported awareness (77.8%) of the right medicine for a common mental health disorder they have identified [26]. In another cross-sectional survey from five southeastern European nations, even though 40.9% of GPs indicated that they can manage depression with medication, 79.4% believed patients in need of antidepressants should be sent to a psychiatrist[27].\u003c/p\u003e\n\u003cp\u003eIn this study, we \u0026nbsp;discovered that family physicians act as gatekeepers and coordinators in the healthcare system by allowing two-way referrals. As stated earlier, family physicians play an important role in the treatment of common mental health disorders and should be prepared to give continuous care and support to patients with mild to moderate conditions. However, it is equally vital for family physicians to recognize when a patient\u0026apos;s condition merits specialized care and support rapid referrals to mental health specialists when the severity of the disease necessitates more rigorous therapy[28,29]. By striking a balance between delivering primary care and knowing when to refer, family physicians can ensure that patients receive comprehensive and coordinated treatment, resulting in better health outcomes and a higher quality of life.\u003c/p\u003e\n\u003cp\u003eFurthermore, this study highlights additional complex roles of family physicians in mental health integration into primary care which is supported by current literature. Family physicians are positioned to play a significant role in: i) Raising awareness about mental health illnesses in the community, disseminating research findings, and encouraging mental health literacy among the general public, thus empowering communities to take control of their health and wellbeing [30], ii) Effectively managing healthcare resources, including personnel, equipment, and facilities, in order to provide high-quality patient care and maximize resource utilization [31], iii) Supervising primary care workers, offering direction and support, and cultivating an environment of excellence and continuous improvement, ultimately improving overall care quality and patient outcomes[32], iv) Facilitating training and education for other primary care practitioners, sharing their skills and experience, and helping to establish a professional and competent workforce, consequently strengthening the primary care system and improving health outcomes[32]. By taking on these broad tasks, family physicians can have a significant impact on the mental health integration into primary care, going beyond direct patient care to include community participation, resource management, leadership, and teaching. This, in turn, can result in better health outcomes, more patient satisfaction, and a more efficient and effective healthcare system.\u003c/p\u003e\n\u003cp\u003eThis study adds to the limited literature on the essential roles of family physicians in identifying and managing mental health conditions as the first point of contact \u0026nbsp;in primary care. Their participation in early detection, prevention, and referral channels enables complete and timely mental health care. The study emphasizes the need to empower family physicians through training, capacity building, and resource allocation to improve mental health treatment delivery in low-income communities like Nigeria. Family physicians play a critical role in facilitating collaborative care approaches and community-based treatments to alleviate Nigeria\u0026apos;s mental health treatment gap.\u003c/p\u003e"},{"header":"STRENGTHS AND LIMITATIONS","content":"\u003cp\u003eOne of the main strengths of this study is that the study used both quantitative and qualitative data to provide a thorough knowledge of family physicians\u0026apos; roles in integrating mental health services into primary care in Nigeria. Similarly, participants were also chosen from all six geopolitical zones of Nigeria to ensure that the findings reflect the different regional experiences and viewpoints of Nigerian family physicians. However, it should be acknowledged that there are some limitations regarding the study: firstly, the reliance on self-reported impressions and roles may generate bias, since individuals may overstate their contributions or experiences. Secondly, excluding junior residents and retired family physicians may have resulted in missing potentially significant insights from these groups of family physicians.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eWe conclude that Family Physicians are pivotal in bridging the gap between primary care and mental health services, with diverse roles in providing comprehensive and coordinated mental health care. Their knowledge and leadership are critical in integrating mental health services into primary care, ensuring that patients receive prompt, effective, and patient-centered care. Family physicians can use their unique position to facilitate early diagnosis, prompt intervention, provide ongoing support, and foster a collaborative care approach that addresses the complex needs of patients with mental health conditions, ultimately improving health outcomes and overall well-being.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u0026nbsp;\u003cstrong\u003eEthical Approval and Consent to Participate:\u003c/strong\u003e Ethical approval was duly obtained from the National Health Research Committee, Nigeria. Approval was also obtained from the Management of the selected training centres. Confidentiality was ensured throughout the study period as all the recordings were passworded, and only the researchers had access, and anonymity was maintained with the use of codes and pseudonyms. A written consent was \u0026nbsp;explained to all the study participants and it was made clear to them that consent could be withdrawn freely.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e : Authors did not receive any funding support for this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u003c/strong\u003e The dataset for this study will be made freely available on request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompetiting interest\u003c/strong\u003e: Authors declare no conflict of interest\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions:\u003c/strong\u003e OTA conceived and designed the study, approved the design and implementation, and coordinated and supervised data collection. EJO \u0026nbsp; drafted the initial article and was responsible for data collection. \u0026nbsp; AWA contributed to the study design and data collection. AOA contributed to study design and data collection. ANO contributed to the study design and data collection. OAO contributed to the study design and participated in the data collection. OA contributed to the study design and data collection. \u0026nbsp; AJA \u0026nbsp;approved the design and implementation of the study and coordinated and supervised data collection. TOA was the study statistician and created and managed the database. OTA drafted the initial Article with input from EJO. All authors critically reviewed and revised the draft.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e: We sincerely appreciate all our study participants. We acknowledge their efforts, time and contributions in ensuring proper integration of mental health services into primary care settings.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. 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Primary care and equity in health: the importance to effectiveness and equity of responsiveness to peoples' needs. Humanity Soc. 2009;33(1\u0026ndash;2):56\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Mental health in primary care: Illusion or inclusion? (2018): 1\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJamoulle M, Resnick M, Vander Stichele R, Ittoo A, Cardillo E, Vanmeerbeek M. Analysis of definitions of general practice, family medicine, and primary health care: a terminological analysis. BJGP open. 2017;1(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmerican Academy of Family Physicians. Mental and behavioral health care services by family physicians (position paper) [Internet]. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClatney L, MacDonald H, Shah SM. Mental health care in the primary care setting: family physicians\u0026rsquo; perspectives. Can Fam Physician. 2008;54(6):884\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Khathami AD, Ogbeide DO. Prevalence of mental illness among Saudi adult primary-care patients in Central Saudi Arabia. Saudi Med J. 2002;23(6):721\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRockman P, Salach L, Gotlib D, Cord M, Turner T. Shared mental health care. Model for supporting and mentoring family physicians. Can Fam Physician. 2004;50(3):397\u0026ndash;402.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsudairy NM, Aloush KM, Alzayed SM, Alsamti AI, Alsahaf AI, Al Zahrani AT, Alabdulbaqi BA, Alotaibi RN, Althenayan TO, Kamal AA, Alahmari AS. The Role of Family Physicians in Mental Health Care: Screening, Diagnosis, and Treatment Options. J Adv Zool. 2024;45(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlSalem M, AlHarbi MA, Badeghiesh A, Tourian L. Accuracy of initial psychiatric diagnoses given by nonpsychiatric physicians: A retrospective chart review. Medicine. 2020;99(51):e23708.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCepoiu M, McCusker J, Cole MG, Sewitch M, Belzile E, Ciampi A. Recognition of depression by non-psychiatric physicians\u0026mdash;a systematic literature review and meta-analysis. J Gen Intern Med. 2008;23:25\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWittchen HU, Pittrow D. Prevalence, recognition and management of depression in primary care in Germany: the Depression 2000 study. Hum Psychopharmacology: Clin Experimental. 2002;17(S1):S1\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXierali IM, Tong ST, Petterson SM, Puffer JC, Phillips RL, Bazemore AW. Family physicians are essential for mental health care delivery. J Am Board Family Med. 2013;26(2):114\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePapachristopoulos I, Sazakli E, Leotsinidis M. General practitioners\u0026rsquo; views towards management of common mental health disorders: Τhe critical role of continuing medical education. BMC Prim Care. 2023;24(1):63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuric P, Harhaji S, O'May F, Boderscova L, Chihai J, Como A, Hranov GL, Mihai A, Sotiri E. General practitioners' views towards diagnosing and treating depression in five southeastern European countries. Early Interv Psychiat. 2019;13(5):1155\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFleury MJ, Imboua A, Aub\u0026eacute; D, Farand L, Lambert Y. General practitioners' management of mental disorders: a rewarding practice with considerable obstacles. BMC Fam Pract. 2012;13:1\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown HE. Identifying risk of psychosis in a primary care setting. JAMA Netw Open. 2018;1(7):e185165.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. World Organization of National Colleges, Academies, Academic Associations of General Practitioners/Family Physicians. Integrating mental health into primary care: a global perspective. World Health Organization; 2008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePhillips WR, Herbert CP. What makes family doctors the leaders we need in health care? Can Fam Physician. 2022;68(11):801.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMash R, Ogunbanjo G, Naidoo SS, Hellenberg D. The contribution of family physicians to district health services: A national position paper for South Africa. South Afr Family Pract. 2015;57(3):54\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Family Physicians, Mental Health Integration, Primary Health Care, Nigeria, Collaborative Care","lastPublishedDoi":"10.21203/rs.3.rs-5957751/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5957751/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The need to integrate mental health services into primary healthcare service provision in Nigeria is now more urgent than previously considering the huge and increasing gap in access to mental care at the community level. This study therefore, assessed the critical roles and responsibilities of family physicians in facilitating the successful integration of Mental Health Services (MHS) into primary healthcare settings in Nigeria, with the goal of improving health outcomes, improving patient-centered care, and promoting a more efficient and effective healthcare system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A mixed method research design was used to collect both quantitative and qualitative data from Nigerian primary care physicians (PCPs) across the six (6) geo-political zones of the country. A semi-structured questionnaire was used to elicit their socio-demographic information, their view of the current state of MHS, factors affecting MHS integration into PHC, while key-informant interview guide was used to explore their opinions on how MHS can be enhanced in the country and how MH care can be integrated into primary health care in Nigeria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The most common role identified by respondents is serving as a link between primary care and mental health specialists (29.7%), followed by being managers of healthcare resources (20.3%) and researchers (19.4%). The study revealed that family physicians have diverse roles in providing comprehensive and coordinated mental health care. Family physicians can use their unique position to facilitate early diagnosis, prompt intervention, provide ongoing support, and foster a collaborative care approach that addresses the complex needs of patients with mental health conditions, ultimately improving overall health outcomes and overall well-being.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003eFamily Physicians have important roles to play in bridging the gap between primary healthcare and mental healthcare, particularly in low and middle-income countries like Nigeria. it is recommended that family physicians receive targeted training in mental health care, have access to updated clinical guidelines, and be supported by robust referral systems to ensure seamless collaboration with mental health specialists.\u003c/p\u003e","manuscriptTitle":"Integrating Mental Health Services Into Primary Health Care in Nigeria: A Mixed Method Study Exploring the Roles of Family Physicians in Closing the Glaring Gap","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-10 09:03:55","doi":"10.21203/rs.3.rs-5957751/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4344d26b-982c-43c5-a568-7636c83d5fe4","owner":[],"postedDate":"February 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-25T14:38:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-10 09:03:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5957751","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5957751","identity":"rs-5957751","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}