Referral Challenges in the Mental Health Program in the Primary Health Care System: A Qualitative Study

One of the main activities that plays a significant role in the prevalence of mental illnesses is the issue of referral. According to the evidence, the lack of proper implementation of the referral system is one of the obvious weaknesses of the primary health care (PHC) system. Therefore, this study aimed to investigate the challenges of referring mental health clients in the PHC system in Iran. We also examined the weaknesses in this process from the perspective of mental health experts.

The present study is a qualitative study with conventional content analysis approach. Data were collected through semi-structured interviews with 15 PHC psychologists selected through purposive sampling. After transcribing the interviews, the data were analyzed based on the Graneheim and Landman model.

We identified two main themes and 12 categories. The theme of intra-centered referential challenges included categories such as weaknesses in health care providers screening and low referrals, clients' lack of trust in health care providers, clients' lack of cooperation, physicians' poor cooperation, and barriers to clients' desire to visit a psychologist. Meanwhile, outer-centered referential challenges included a shortage of referral centers, lack of transparency in referrals, lack of direct referrals, poor follow-up, barriers regarding referral to a higher level, and barriers to clients’ referral to the institute.

The findings of the present study showed that poor intra-sectoral and inter-sectoral communication is one of the main challenges that has disrupted the referral process in the field of mental health in the PHC system. Many challenges such as the lack of designated referral centers, poor follow-up due to lack of referral feedback, and clients' financial inability to refer to a higher level can be improved by strengthening cross-sectoral communications such as two-way communication with support organizations and psychiatric and psychotherapy centers.