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EDITORIALS: Kurt Kroenke Psychological medicine BMJ 2002; 324: 1536-1537 [Full text]

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Is "psychological medicine" a kind of psychotherapy?

David A. Levy   (29 June 2002)

Seen but not heard

Sean P Maskey   (2 July 2002)

No reference to Cynthia Belar

Dennis R. Valone   (5 July 2002)

Secondary care discovers psychological medicine

jim n Hardy   (11 July 2002)

Involving Liaison Psychiatry

James T.R. Walters   (12 July 2002)

Response to letters

Kurt Kroenke   (12 July 2002)

Is "psychological medicine" a kind of psychotherapy? 29 June 2002
David A. Levy, Consultant, Centre d'Allergie Hopital Tenon, 4, rue de la Chine, 75020 Paris, France Send response to journal: Re: Is "psychological medicine" a kind of psychotherapy?	To the Editor: There seems to be something missing from this article, namely, the words "psychotherapy" and "psychologist". Why is it that articles written by physicians and published in leading medical journals rarely take into account the existence of non-medical psychotherapists? Perhaps one explanation is that physicians are not trained in psychology and especially not trained in psychotherapy. Moreover, while they do not hesitate to refer their patients to other medical specialists when necessary, they do not seem ready to refer their patients to psychotherapists when it seems necessary and appropriate. We seemed to be locked into a Cartesian way of thinking: body (the medical sphere) and mind (the psychological sphere) are still two separate entities. I hope that the Editors of the BMJ are not trapped into this way of thinking. David A. Levy, M.D.
Seen but not heard 2 July 2002
Sean P Maskey, Consultant Child & Adolescent Psychiatrist Great Ormond St Hospital. london. WC1N 3JH Send response to journal: Re: Seen but not heard	Editor – Kroenke[1] , and Gask and Underwood[2] describe in some detail the multiplicity of psychological presentations in patients. However no mention is made of the many children seen in General Practice and by paediatricians who have primarily mental health problems, psychological factors associated with their physical illness, eg diabetic management, or medically unexplained symptoms such as recurrent abdominal pain. The best UK estimate of the prevalence of psychiatric disorders in young people is the Office of National Statistics figure of 10% of all children[3] . This figure increases significantly in inner cities, and when chronic ill health, and particularly neurological disorders are present. However only one in five of these attend Child and Adolescent Mental Health services. There is some evidence that family doctors can provide effective treatment for this group[4]. Children are in the unique position of been presented to their family doctors by parents, rather than seeking help themselves. They are therefore vulnerable in “the consultation” to the effects of mental illness and personality disturbance in their parents, which can range from the genuinely (over)anxious to the homicidal. Quite apart from the genetic transmission, the psychosocial impact of parental mental illness, separation and divorce is significant and may well present as psychosomatic symptoms in vulnerable children. At the other end of the scale, a few parents and carers actively harm children, and then seek help for their illness. Patterns of help seeking behaviour are established in childhood. Practicing Psychological Medicine in with children may well reduce undesirable adult patterns of health care usage. The ABC of Psychological Medicine is to be welcomed. If it is to truly encompass the whole person, child and adult, Psychological Medicine must consider all members of the family, not only the adult patient. 1 Kroenke K. BMJ 2002; 324: 1536-1537 2 Linda Gask, Tim Usherwood Clinical review ABC of psychological medicine. The consultation BMJ 2002;324:1567-1569 3Meltzer, H., Gatward, R., Goodman, R., et al (2000) Mental Health of Children and Adolescents in Great Britain. London: Stationery Office 4 Bower P. Garralda E. Kramer T. ,et al. The treatment of child and adolescent mental health problems in primary care: a systematic review. Family Practice. 18(4):373-82, 2001
No reference to Cynthia Belar 5 July 2002
Dennis R. Valone, Adjunct Faculty Gannon University, 16412 Send response to journal: Re: No reference to Cynthia Belar	I was surprised to not see any reference to the work of Cythia Belar (University of Florida) in this article about psychological medicine. Does the literature base used by Kroenke not include the work of Belar and others in Health Psychology? Or are there two separate tracks of study here, one medically oriented and the other psychologically oriented? I hope not.
Secondary care discovers psychological medicine 11 July 2002
jim n Hardy, GP principle Bethnal Green Health Centre, 60 Florida Street, London E2 6LL. Send response to journal: Re: Secondary care discovers psychological medicine	Editor, Professor Kroenke's extraordinary editorial (1) cannot be allowed to pass without comment. He has delivered a treatise on psychological medicine of stunning naivete. His revelations have the stamp of a lower sixth form student's breathless discovery of something new and exciting. Worse still, he gives the impression that he thinks the rest of us share his ignorance. How about this for starters? "It is becoming increasingly clear that we can improve medical care by paying more attention to psychological aspects of medical assessment and treatment..." He goes on to inform us about the coexistence of chronic disease and psychological conditions; unexplained physical symptoms or somatisation; and even significant biological disorders masquerading as depression. Having identified the problems he moves relentlessly on. We are informed that "....screening for depression may require as few as one or two questions..." Really? Why didn't I know this? In his final paragraph we learn that "neither chronic medical nor 'psychiatric' disorders can be managed adequately in the current environment of general practice, where the typical patient must be seen in 10-15 minutes or less." In summary: we have a professor of medicine discoursing on psychological diagnosis and management in primary care! Unbelievable. It makes me spit blood. I trust our medical professor will know how to investigate this. Or perhaps he may wish to refer to our primary care guidelines? Jim Hardy, GP trainer. (1)Kroenze K. Psychological medicine. Integrating psychological care into general medical practice. BMJ 2002:324:1536-7
Involving Liaison Psychiatry 12 July 2002
James T.R. Walters, clinical researcher, honorary SpR F1RST Team, Institute of Psychiatry, De Crespigny Park, London SE58AF Send response to journal: Re: Involving Liaison Psychiatry	Whilst welcoming the BMJ series on 'Psychological Medicine' I would like to sound cautionary notes to Kroenke's introductory editorial (1). The term 'medically unexplained symptoms' is used deliberately to encapsulate a wide range of patients and problems. As well as those with somatization, a minority will go on to be diagnosed with a physical condition(2)(3), a fact which must remain in the minds of those caring for this patient group. I was also concerned at the ommission of the involvement of liaison psychiatric teams in this context. Those with somatization disorders suffer considerable physical and psychiatric morbidity and the early involvement of liaison psychiatric services is to be encouraged(4). Mind-body dualism,promoted at times in this article, is fostered by the conventional approach of referral to the psychiatrist as a last option. Care needs to be collaborative and shared (early) in order to serve these patients and, perhaps nurture greater integration of those working in the specialities of body and mind. (1)Kroenke K. Psychological medicine. BMJ 2002;324:1536-1537 (2)Crimlisk HL, Bhatia K, Cope H, David A, Marsden CD, Ron MA. Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms. BMJ 1998; 316: 582-5860 (3)Gotz M, House A. Prognosis of symptoms that are medically unexplained. BMJ 1998; 317: 536 (4)Bass C, Peveler R, House A. Somatoform disorders: severe psychiatric illnesses neglected by psychiatrists. Br J Psychiatry 2001;179: 11-14
Response to letters 12 July 2002
Kurt Kroenke, Professor of Medicine Regenstrief Institute, 1050 Wishard Blvd, Indianapolis, IN 46202, USA Send response to journal: Re: Response to letters	I agree with Dr. Levy that psychologists and psychotherapy play a valuable role in the management of these patients and, like psychiatrists, are important partners in either collaborative care or referral. Indeed, one of the references I cited is a review of the efficacy of cognitive- behavioral therapy, a psychotherapy commonly provided by psychologists. Dr. Maskey is correct when he reminds us that children should also be included when we discuss the domain of psychological medicine. I appreciate Dr. Valone bringing to our attendion the work of Cynthia Belar. The limited number of references allowed for an editorial did not permit me to cite the many researchers who have made invaluable contributions to this field. I am surprised by the reaction of JP Hardy. I am sure that as a GP trainer he knows well the importance of psychological medicine and transmits this information to his students. However,many students in the United States at least still have a more biomedical orientation in their training, and psychological medicine receives somewhat less attention. I myself am a general internist which, in the US, is a primary (not secondary) care physician. Thus, the audience for my message about too little time for care of these patients is addressed not at the GP (who already knows this) but the health care systems and payers which often do not appreciate the challenges we GPs face in providing the psychological medicine care we know can be effective.