- T K J Craig,
- A P Boardman
The size of the problem
Psychiatric symptoms are common in the general population: worry, tiredness, and sleepless nights affect more than half of adults at some time, while as many as one person in seven experiences some form of diagnosable neurotic disorder.
These problems are not confined to Western countries. The World Health Organisation's study of mental disorder in general health care screened over 25 000 people in 14 countries worldwide and assessed 5500 in detail. A quarter had well defined disorders, and a further 9% had subthreshold conditions. The most common disorders were depression (10%), generalised anxiety disorder (8%), and harmful use of alcohol (3%).
Anxiety and depression, often occurring together, are the most prevalent mental disorders in the general population
Mental health problems in primary care
Emotional symptoms are common but do not necessarily mean that the sufferer has a mental disorder
Many mood disorders are short lived responses to stresses in peoples' lives such as bereavement
About 30% of people with no mental disorder suffer from fatigue, and 12% suffer from depressed mood
Anxiety and depression often occur together
Mental disorder comprises about 25% of general practice consultations–In Britain up to 80% of referrals to specialist psychiatric services come from primary care
Death of a loved one is a distressing episode in normal human experience. Expression of distress varies greatly between individual people and cultures, but grieving does not constitute mental disorder. The doctor's most appropriate response is compassion and reassurance rather than drug treatment. Night sedation for a few days may be helpful, but oversedation should be avoided. Antidepressants should be reserved for those patients who develop a depressive episode
The 1993 world development report of the World Bank estimated that mental health problems produce 8% of the global burden of disease, a toll greater than that exacted by tuberculosis, cancer, or heart disease. Much of the burden falls on women and young adults.
World Health Organisation's classification* of mental disorders in primary health care
Psychoactive substance use
F10 Alcohol use disorder
F11 Drug use disorder
F17.1 Tobacco use
F20 Chronic psychotic disorder
F23 Acute psychotic disorder
F31 Bipolar disorder
Mood, stress related, and anxiety disorders
F40 Phobic disorder
F41.0 Panic disorder
F41.1 Generalised anxiety
F41.2 Mixed anxiety and depression
F43 Adjustment disorder
F44 Dissociative disorder
F45 Unexplained somatic complaints
F50 Eating disorders
F51 Sleep disorders
F52 Sexual disorders
F70 Mental retardation
Disorders of childhood
F90 Hyperkinetic disorder
F91 Conduct disorder
*ICD-10 (international classification of diseases, 10th edition
Not everyone who experiences symptoms consults a general practitioner, but having a mental disorder doubles the likelihood of consultation. About a quarter of patients with probable mental disorder in the general population will consult in any two week period. People with mental disorders consult more frequently than other patients, and almost a quarter of all consultations are attributable to psychiatric morbidity.
Poor outcome is associated with delayed or insufficient initial treatment, more severe illness, older age at onset, comorbid physical illness, and continuing problems with family, marriage, or employment
Mental disorders in primary care
The World Health Organisation's classification of mental disorders for use in primary care pays more attention to the commoner neurotic disorders, while schizophrenia and the other psychoses are classified according to their course.
Mood, stress related, and anxiety disorders
Many mood problems are reactions to distressing circumstances (such as bereavement) and resolve spontaneously: patients with such problems benefit from reassurance and time rather than drugs or specialist counselling. About three quarters of patients with new onset neurotic disorders can be expected to recover within a year, but as many as 20% are still symptomatic after three years.
A general practitioner with 2000 patients is likely to see one suicide in a four year period. Recent studies indicate that 15-22% of patients who go on to kill themselves will have seen their general practitioner in the week before their death, and 30-40% will have seen their doctor in the previous month. Those people with past contact with psychiatric services are more likely to contact their family doctor in the period leading up to suicide. An opportunity therefore exists for primary care services to help in preventing suicides, and this may be achieved by improved assessment of suicide risk, liaison with mental health services, and more effective treatment of major depression.
Misuse of psychoactive substances
General practitioners can expect to see patients who misuse all types of substances.
Factors that should prompt questions about suicide
Especially if patient is male, single, older, isolated, or shows several factors simultaneously
Previous suicidal thoughts or behaviour
Marked depressive symptoms
Misuse of alcohol or illicit drugs
Longstanding mental illness (including schizophrenia)
Painful or disabling physical illness
Recent psychiatric treatment as inpatient
Self discharge against medical advice
Previous impulsive behaviour, including self harm
Legal or criminal proceedings pending (including divorce)
Family, personal, or social disruption (such as bereavement, marital breakdown, redundancy, eviction)
Most alcohol related problems in general practice affect moderate users (that is, men who drink 21-50 units a week and women who drink 15-35 units), but a fifth of adults consume harmful amounts of alcohol. However, recent surveys suggest that fewer than a quarter of general practitioners routinely ask patients about their drinking habits. Studies in Britain have shown that 15 minutes of advice from a general practitioner may reduce alcohol consumption by as much as 15% and achieve up to a 20% reduction in the number of patients with drink problem.
About half of general practitioners in Britain report seeing users of illicit drugs, and many practices offer advice on reducing the risk of HIV infection, safe sexual behaviour, and on needle exchange programmes.
Benzodiazepine dependence has often been highlighted as a particular problem in general practice. Typically, a general practitioner with 2000 patients will have 60 long term users of benzodiazepines, of whom 45 will be aged over 60. Most will be women who have been taking the drug for more than five years. There has been a steady decline in prescribing benzodiazepines over the past decade, much of this being due to better practices within primary care.
The more severe mental disorders (such as bipolar affective disorder and schizophrenia) are relatively uncommon in general practice. Most of these patients will be in contact with specialist services, although as many as a quarter will eventually be discharged back to the care of their family doctor. General practitioners have a particularly important role in the shared care (with specialist services) of these patients–monitoring physical health, long term medication, and compliance with treatment.
Mental disorders presenting with physical complaints
Coexisting physical and mental disorders that are essentially independent of each other (such as heart disease in a patient suffering from depression)
Distress due to physical illness (such as anxiety or depression related to a life threatening illness)
Somatic symptoms of a mental disorder (such as palpitations due to anxiety)
Chronic somatisation disorders in which patients express hypochondriacal convictions that physical disease is present in the absence of any medical evidence for this
Common physical complaints include
Tiredness, poor sleep, lack of energy
Vague aches and pains
Worry, tension, inability to relax
Poor memory, “Can't cope”
Most patients with mental disorders consult their general practitioner with physical rather than psychological complaints. The complaint may be of “feeling tired all the time,” poor sleep, or of not coping with day to day events. Other behaviour at presentation may point indirectly to mental health problems. These presentations may initially mislead an unwary doctor, and the mental disorder may go undetected and untreated for several months.
Detecting mental disorder in primary care
Although the bulk of psychiatric morbidity is seen at the primary care level, only a small proportion of cases is referred on to the psychiatric services. In part, this reflects the low rate of detection of mental disorder by general practitioners. Failure to detect mental disorder denies patients potentially effective treatment, and enduring psychological distress has profound effects on patients' capacity to work and enjoy a reasonable quality of life and on their families.
Detection of mental disorder has been shown to reduce the number of subsequent consultations, to shorten the duration of an episode, and to result in far less social impairment in the long term. A doctor's skill in detecting mental disorder has three main components.
Bias towards making psychiatric judgments
Detection of disorder is more likely among doctors who believe that psychological factors play an important role in the aetiology and course of both physical and mental disorder, who express an interest in psychiatric problems, and who believe that mental disorder is an important, legitimate concern of medicine and that mental problems are amenable to treatment.
Vigilance in attending to verbal and non-verbal cues of disorder
Vigilance reflects the extent to which a doctor actively searches for clues about the presence of mental disorder. Many doctors respond with greater vigilance to groups of patients in whom mental disorder is known to be more prevalent (for example, older, female, widowed or separated patients and those who have often attended the doctor's surgery) but miss disorder in patients who do not match the stereotypes.
Quality of interview and diagnostic skills
Neither high bias nor high vigilance necessarily leads to accurate judgments about the presence of mental disorder (doctors with a high bias might overdiagnose disorders). Diagnostic accuracy is not simply related to experience (the number of years in practice) or to the length of time spent with a patient but is rather related to the style and focus of the interview itself.
Problems suggesting an underlying mental health problem
Seemingly inappropriate requests for urgent attention (appointments, home visits)
Increased frequency of consultation or requests for tests
Unexpected or disproportionate outbursts during consultation (tears, anger)
Excessive anxiety about another family member (child, elderly relative) or presenting a relative as the patient
Frequent consultations, “thick notes”
Unstable relationships or frequent breakdowns in relationships
Distressing or deteriorating social circumstances (eviction, redundancy, squalor)–Poverty may not cause mental disorder, but it can increase vulnerability and reduce the ability to tolerate symptoms
Factors determining the detection of mental disorder
Nature of presentation (somatic presentation less likely to be detected)
Severity of disorder (more severe problems more likely to be detected)
History of psychiatric problems known to general practitioner
Relatively high frequency of recent consultations
General practitioner factors
Positive attitude to mental disorder and psychiatric patients
Interest and knowledge of mental disorder
“Bias” in assessment
Interview skills–Doctors who are better at detection
Make early eye contact
Clarify presenting complaint
Avoid “checklist” questioning
Ask more “open” and clarifying questions
Spend less time talking and interrupt less
Seem less rushed
Are sensitive to emotional, verbal, and non-verbal cues
Doctors with good accuracy ask more open questions, confirm non-verbal cues detected at interview, and inquire about the family and home life of their patients. Patients with emotional disorder, including those who present with somatic rather than psychological complaints, display both a greater number of and more intense verbal and non-verbal cues of mental disorder when interviewed by doctors with good diagnostic skills.
Doctors with low accuracy display interview behaviours that suppress their patients' expression of emotion (closed questioning, narrow focus on symptoms, abrupt manner), which correspondingly lowers the doctors' chances of correctly identifying a mental problem.
Managing mental disorder in primary care
Any member of a primary care team may encounter patients with mental health problems and require advice and guidance. A general practitioner's role will include supervising other staff as well as directly managing such patients by means of drugs or psychological treatments.
In Britain most psychotropic drugs are prescribed by general practitioners, and most moderate anxiety and depressive disorders are entirely and successfully managed in primary care
Patient characteristics influencing general practitioner's decision to refer
Experience of separation in early life
Associated misuse of alcohol or drugs
Suicide attempt or suicidal ideation
Inappropriate responses to medical attention
Although there is insufficient time in the average consultation to undertake formal psychological interventions, many general practitioners who are good at detecting disorder also use psychotherapeutic and counselling techniques to the benefit of patients. Some use double or extended consultations for this purpose. Several studies have found specific interventions by general practitioners to be highly effective.
Other effective interventions include explaining the rationale for treatments, negotiating compliance, checking that advice and treatment are understood, and providing straightforward psychosocial advice on managing distress.
Specialised services in primary care
About a third of general practices in England and Wales have psychological treatment services, most provided by trained counsellors. While there is a wide range of professional backgrounds and therapeutic skills from which to choose, most are based on “non-directive” approaches and psychoanalytical methods. The efficacy of generic counselling (the most common arrangement in primary care) is far from certain as it lacks a strong research base.
Effective interventions by general practitioners
Most moderate anxiety and depressive disorders are managed successfully in primary care
Brief structured counselling by general practitioner is as effective as anxiolytic drug in generalised anxiety disorder
No difference in outcome between acute neurotic patients managed by generic community psychiatric nurse or by general practitioner
Fifteen minutes' advice from general practitioner is effective in aiding reduction of alcohol consumption
Advice on reducing risk of HIV infection through safe sexual behaviour or needle exchange programmes
Further examples of general practitioner interventions
Teaching relaxation techniques
Supporting use of self help techniques in neurotic disorders
Supervising withdrawal from alcohol
Monitoring depot medication
Operating shared care protocols with local community mental health services
We believe that priority should be given to employing staff who can offer treatments of proved efficacy. In primary care cognitive and behavioural therapies are efficient and effective, with proved value in treating depression, generalised anxiety, phobic anxiety (both generalised disorders such as agoraphobia as well as specific fears), obsessive-compulsive disorder, stress related disorder, sexual dysfunction, and the addictive disorders. Nurse behaviour therapists are specifically trained in these techniques but are still relatively few in number. Most clinical psychologists will also be familiar with these interventions.
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Symposium: prescribing for the psychiatric patient in the non-specialist setting. Prescribers' Journal 1996;36:181-228
Pullen I, Wilkinson G, Wright A, Pereira Gray D. Psychiatry and general practice today. London: Royal College of Psychiatrists, Royal College of General Practitioners, 1994
Ustun TB, Sartorius N. Mental illness in general health care. An international study. Chichester: Wiley, 1995
Bereavement. From: Help the Aged, London EC1R 0BE (telephone 0171 253 0253)
The experience of grief. From: National Association of Bereavement Services, London E1 6DB (telephone 0171 247 1080)
Community psychiatric nurses have provided an important link with local specialist mental health services, but their role is controversial. As specialist psychiatric services focus on the needs of patients with severe mental illness, there have been moves to equip community psychiatric nurses with specialised treatment skills for the long term management of this group of patients. These skills include problem orientated case management, family psychoeducation, and psychological interventions aimed at improving compliance (adherence) with medication and coping with persistent psychotic symptoms.
The artwork is by David Ridley and reproduced with permission of the Stock Illustration Source.
T K J Craig is professor of community psychiatry, United Medical and Dental Schools, St Thomas's Hospital, London, and consultant psychiatrist, Lambeth Healthcare NHS Trust. A P Boardman is senior lecturer in social psychiatry, Keele University, Staffordshire.
The ABC of mental health is edited by Teifion Davies, senior lecturer in community psychiatry, United Medical and Dental Schools, St Thomas's Hospital, and consultant psychiatrist to Lambeth Healthcare NHS Trust, and by T K J Craig.