Distinguishing mental illness in primary care

We need to separate proper syndromes from generalised distress

Two studies in the BMJ last year make challenging reading set alongside one another. Kessler et al reported that over half the patients attending general practice surgeries are depressed,1 and the Norwegian naturalistic treatment study of depression in general practice concluded that the best treatment for depression in primary care is a combination of antidepressant medication and counselling.2 Read uncritically, these findings imply that half of all general practice patients should be taking antidepressants and undergoing counselling. Clearly few people would agree with this, but the apparent folly does draw attention to a gap in our understanding of mental ill health in primary care.3

Uncertainties about the best way to provide for such patients, and indeed questions about the propriety of doing so at all within the NHS, have a long history. These uncertainties largely revolve around differences between medical and sociological approaches to psychological distress. The medical approach argues that such distress reflects an underlying illness which merits treatment. The sociological perspective argues that it is the consequence of a failure to respond adaptively to social challenge. The former focuses …