CHAPTER 1                               GENERAL PRACTICE                                  PSYCHIATRY                      ...
GENERAL PRACTICE PSYCHIATRY                                                            KEY FACTS                    ■   Ge...
GENERAL PRACTICE PSYCHIATRY                    The World Bank’s Global Burden of Disease project3 has convincingly demonst...
GENERAL PRACTICE PSYCHIATRY                    following a stressor while another does not; understanding this difference ...
GENERAL PRACTICE PSYCHIATRY                        disability (i.e. impairment in one or more important areas of functioni...
GENERAL PRACTICE PSYCHIATRY                    ■   Axis I Diagnosed mental disorder or disorders.                    ■   A...
GENERAL PRACTICE PSYCHIATRY                    factors and treatment will need to address several issues. The five axes fro...
GENERAL PRACTICE PSYCHIATRY                    evaluation of psychiatric ‘caseness’ by administration of screening instrum...
GENERAL PRACTICE PSYCHIATRY                      (see Chapter 22). The high rate of physical morbidity and premature morta...
GENERAL PRACTICE PSYCHIATRY                     compulsory treatment. A working knowledge of the relevant Mental Health Ac...
GENERAL PRACTICE PSYCHIATRY                      FIGURE 1.3 Key points in the pathway to mental health care               ...
GENERAL PRACTICE PSYCHIATRY                          For example, the stepped collaborative care model, developed in Seatt...
GENERAL PRACTICE PSYCHIATRY                     a plan for appropriate intervention. This may involve you working directly...
GENERAL PRACTICE PSYCHIATRY                     14. Jablensky A, McGarth J, Herrman H, Castle D, Gureje O, Morgan V, Korte...
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General Practice Psychiatry

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General Practice Psychiatry

  1. 1. CHAPTER 1 GENERAL PRACTICE PSYCHIATRY F Judd, G Blashki and L Piterman <A1> Goldberg’s research has made it clear that mental disorder is so common that, no country, however rich it might be, can afford anything approaching sufficient specialist personnel to see and care for everyone with a mental disorder. Rather, most people with mental disorders will need to be seen and cared for by members of the primary health care unit… R JENKINS, 19991 CASE STUDY Leila is a 33-year-old mother of two young children who presents to surgery on a busy Monday morning with her active three-year-old, just ‘to pick up a script’ for the sleeping tablets your colleague prescribed for her two weeks ago. A brief history reveals two months of withdrawal from usual activities, occasional panic attacks, a persistent neck ache and spontaneous teariness, none of which has been relieved by either vitamins from the health food shop, or the three glasses of wine she’s been drinking at night to settle herself. While her three-year-old proceeds to destroy your sphygmomanometer, and the computer software reminds you that her Pap smear is overdue, she asks if you could bulk bill today as she’s had a falling out with her boss and has lost her job. As you begin to juggle the priorities in your mind for the remainder of the consultation, your receptionist beeps you to remind you that you are running late. Welcome to general practice psychiatry. 101 Blashki.indd 1 30/6/06 2:55:05 PM
  2. 2. GENERAL PRACTICE PSYCHIATRY KEY FACTS ■ General practitioners (GPs) are uniquely placed to work within the biopsychosocial model. ■ GPs manage a broad spectrum of mental health problems and mental disorders, as well as ‘normal’ reactions to a range of stressors and traumas. ■ Approximately 1 in 5 adults in the general population suffers from an anxiety, mood or substance use disorder. ■ Approximately 1 in 7 children and adolescents have mental health problems. ■ In the community many people with a mental disorder do not seek or receive help. ■ Most people with a mental disorder seek treatment from their GP; very few are seen by specialist mental health services. ■ Approximately 25% of patients seen by GPs have a mental disorder. ■ Between one quarter and half of all patients with a mental disorder who are seen by a GP are not diagnosed for that mental disorder. ■ Five of the ten leading causes of disability worldwide are mental disorders. ■ Comorbidity—either two mental disorders and/or a mix of physical illness and mental disorders—is very common. ■ Screening is an effective means of improving detection rates. ■ Referral for specialist care should be driven by patient need and the GP’s skills, experience and confidence. INTRODUCTION GPs conduct more psychiatric consultations than any other group of health care providers. Furthermore, GPs deal with a broad range of consultations, ranging from people before they become cases to those with chronic and severe mental illness. In this chapter we provide an overview of the scope, context and practice of general practice psychiatry. THE NEED FOR PRIMARY CARE PSYCHIATRY There are a variety of factors driving the development of primary care psychiatry services (see Figure 1.1). First, epidemiological studies have made it clear that mental disorders are so common that most people who suffer from these disorders will need to be seen and cared for in primary care. This driver for the development of primary care psychiatry has been strengthened by studies demonstrating high levels of unmet need in the community. For example, the Australian National Survey2 found that only 38% of those with a disorder were seen by any health service provider. Most who sought help consulted their GP. Over the past two decades, the disability and cost of mental disorders, and thus the importance of reducing the level of unmet need, has become increasingly evident. 201 Blashki.indd 2 30/6/06 2:55:05 PM
  3. 3. GENERAL PRACTICE PSYCHIATRY The World Bank’s Global Burden of Disease project3 has convincingly demonstrated the importance of mental disorders as a cause of disease burden. Burden is the sum of premature death and years lived with a disability.4 Mental disorders account for a quarter of the world’s disability and 9% of the total burden. In established market economies such as the United States, the United Kingdom and Australia, mental disorders account for 43% of the disability and 22% of the total burden of disease. Five of the ten leading causes of disability worldwide are mental disorders—major depression, alcohol use, bipolar affective disorder, schizophrenia and obsessive-compulsive disorder. In established market economies, harmful drug use is also one of the ten leading causes of disability. Consistent with the finding that most people who have a mental health problem see a GP, studies have shown that members of the community regard GPs as one of the most helpful sources of professional help for mental health problems.5 However, there are a range of problems noted by those who seek care from a GP. These include difficulty finding a GP with the time, skill or commitment for mental health service provision, and a sense of not being taken seriously.6 In addition, the general public has some reservations about the standard of management skills that GPs have in relation to mental illness.7 Another factor driving the development of primary care psychiatry has been the changes to mental health service delivery over the past few decades. In particular, there has been a move from institutional to community based care. In Australia, the National Mental Health Strategy, agreed to by all Health Ministers in 1992, heralded substantial change in the design and delivery of mental health services across Australia. Major service restructuring led to reduced reliance on stand-alone psychiatric hospitals, an expansion in the delivery of community based care, integration with acute inpatient care, and the mainstreaming of mental health services with other components of health care. These changes demanded an alteration in the way GPs interacted with psychiatric services, and increased the demand on GPs to care for individuals with mental illness. FIGURE 1.1 Drivers of primary care psychiatry services ■ Prevalence of mental disorders ■ Burden of disease ■ High levels of unmet need ■ Consumer and carer preference ■ Deinstutionalisation ■ Mainstreaming of mental health service ■ High rates of physical and psychiatric comorbidity GENERAL PRACTICE PSYCHIATRY It is generally accepted that mental health problems and mental disorders develop as the result of a combination of factors that predispose an individual to illness (underlying vulnerabilities) and precipitate the onset of illness (see Chapter 7). For example, a genetic predisposition (vulnerability) in combination with one or more stressors, such as unemployment, may lead to the onset of a mental disorder; this is called the ‘stress-diathesis’ model. It is important to note that the same stressor can have different meanings for different individuals. Thus, one person may develop a mental disorder 301 Blashki.indd 3 30/6/06 2:55:05 PM
  4. 4. GENERAL PRACTICE PSYCHIATRY following a stressor while another does not; understanding this difference requires an awareness of the underlying vulnerability (for example, genetic predisposition) and the meaning of the stressor for the individual. The biopsychosocial approach to understanding and treating individuals with mental health problems and mental disorder flows from this aetiological model (see Chapter 7). GPs are uniquely placed to work in the biopsychosocial paradigm. The GP generally knows the patient, their family and often much about their social network. All too often family and carers report that their knowledge of the patient has not been sought by health providers. This is a lost opportunity, as they are usually a rich source of information that enables a greater understanding of an individual’s vulnerability to illness. Often the GP has observed the patient, and those around them, negotiate life stages and developmental tasks, and is aware of any difficulties or traumas that the patient may have experienced. Thus, the GP can readily identify situations where present-day problems rekindle old traumas, and so understand the meaning of what may objectively be minor stressors. GPs are also well placed to observe and understand the effects of an individual’s illness on those around them. This enables the GP to provide or ensure the family has access to information and support. Furthermore, family and carers usually play a key role in a patient’s recovery. The GP can readily facilitate and support this (see Chapter 3). GPs deal with a broad spectrum of mental health problems. These will include normal responses to stress or trauma—for example, death of a loved one or difficulty coping with a diagnosis of a medical illness—that nevertheless may require assistance to prevent the development of a disorder and/or a functional impairment. GPs also see patients with a range of milder mental health problems, sometimes labelled ‘sub- threshold’ disorders. These frequently require short-term focused interventions to facilitate recovery. Finally, GPs are called upon to assess and manage patients with a range of mental illnesses, sometimes alone and sometimes in collaboration with specialist colleagues (see Chapter 22). It is generally accepted that patients seen by GPs have a range of problems, ‘comorbidity is the rule’ and GPs are required to fill a number of roles simultaneously. For example, treating a patient’s medical problems, then detecting and managing a depressive illness and attending to their adolescent daughter’s drug abuse will require careful management of GP roles. Sometimes, the GP will need to inform the patient about aspects of their role, including any special limitations. DIAGNOSIS AND CLASSIFICATION IN PSYCHIATRY The term ‘mental disease’ was first used in the early years of the nineteenth century, emphasising the view that mental illnesses were diseases of the brain. While the territory of psychiatry is still described as mental illness or mental disorder, these terms now include a much broader range of conditions assumed to result from the complex interplay of biological, psychological and social factors. A commonly accepted definition of mental disorder that reflects this inclusive approach is: A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g. a painful syndrome) or 401 Blashki.indd 4 30/6/06 2:55:05 PM
  5. 5. GENERAL PRACTICE PSYCHIATRY disability (i.e. impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. This syndrome or pattern must not merely be an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g. political, religious or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above.8 While there is a diverse range of disorders and conditions in any classification system, the common disorders can be readily grouped into five main categories. These are: ■ Organic mental disorders The aetiology of these disorders is either a structural brain lesion, a general medical condition, or a substance (for example, drug of abuse, toxin) or a combination of these. This group includes disorders such as dementia, delirium and amnestic disorders. ■ Psychotic disorders This category includes schizophrenia and related disorders. ■ Mood disorders Such disorders include depression, dysthymia and related disorders as well as bipolar disorder. When psychotic symptoms occur as part of a severe mood disturbance they are regarded as part of the spectrum of mood disorders. ■ Anxiety and stress related disorders This group includes extremes of common emotional responses, psychophysiological reactions to stress and the range of anxiety disorders. ■ Personality disorders These are enduring patterns of perceiving, relating to and thinking about the environment and oneself, exhibited in a wide range of personal and social contexts, which are inflexible and maladaptive, and cause significant impairment or subjective distress.8 The diagnostic task for GPs is often not straightforward; patients often present with a mixture of physical and psychological problems, or with sub-threshold syndromes. Nevertheless, making a diagnosis in psychiatry is important. Just as in physical medicine, diagnosis serves several purposes—descriptive, aetiological, therapeutic and prognostic. However, in making a psychiatric diagnosis, the GP is largely dependent on the clinical skills of history taking, mental state assessment and physical examination rather than on laboratory and other special tests (see Chapter 7). There are two major diagnostic systems in use in psychiatry: one, developed by the American Psychiatric Association, the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV);8 and the other, developed by the World Health Organization, the International Classification of Diseases, 10th edition (ICD-10).9 Essentially, these systems rely on grouping together similar psychiatric symptoms and signs and thus describing clinical syndromes (see Table 1.1). Therefore, unlike most diagnoses in physical medicine, diagnoses in psychiatry are symptomatically rather than aetiologically defined. In the DSM-IV, a multiaxial system of description is used. This is a convenient method for categorising and communicating clinical information. It is commonly used for this purpose by psychiatrists. The axes are as follows: 501 Blashki.indd 5 30/6/06 2:55:06 PM
  6. 6. GENERAL PRACTICE PSYCHIATRY ■ Axis I Diagnosed mental disorder or disorders. ■ Axis II Disorders of personality or intellectual disability. ■ Axis III Comorbid medical problems. ■ Axis IV Acute stressors operative in the mental illness. ■ Axis V The level of psychosocial dysfunction. Summarising these domains of information requires the assessing clinician to look at both the immediate clinical presentation and at factors that are important in treatment planning. Thus, a biopsychosocial assessment can be concisely recorded and communicated, and a comprehensive treatment plan developed. TABLE 1.1 Summary: current major classifications of psychiatric disorders DSM-IV ICD-10 ■ Delirium, dementia, amnestic and other ■ Organic, including symptomatic mental cognitive disorders disorders ■ Mental disorders due to a general medical condition ■ Substance related disorders ■ Mental and behavioural disorders due to psychoactive substance use ■ Schizophrenia and other psychotic ■ Schizophrenia, schizotypal and disorders delusional disorders ■ Mood disorders ■ Mood (affective) disorders ■ Anxiety disorders ■ Neurotic, stress related and somatoform ■ Somatoform disorders disorders ■ Dissociative disorders ■ Adjustment disorders ■ Eating disorders ■ Behavioural syndromes associated ■ Sleep disorders with physiological disturbances and ■ Sexual and gender identity disorders physical factors ■ Impulse disorders ■ Disorders of adult personality and ■ Factitious disorders behaviour ■ Personality disorders ■ Disorders usually first diagnosed in ■ Mental retardation infancy, childhood or adolescence ■ Disorders of psychological development ■ Behavioural and emotional disorders with onset usually occurring in childhood and adolescence REVISITING THE CASE STUDY After assessing Leila briefly, you see her for a long consultation to further explore her problems. After this visit and after referring to notes of her previous visits, you make a diagnosis of depression with prominent anxiety features. There are multiple contributing 601 Blashki.indd 6 30/6/06 2:55:06 PM
  7. 7. GENERAL PRACTICE PSYCHIATRY factors and treatment will need to address several issues. The five axes from DSM-IV provide a useful way of summarising the situation: ■ Axis I Major depression—moderately severe, with prominent anxiety (panic attacks) and somatic symptoms (neck ache); intermittent alcohol abuse (self-medicating). ■ Axis II Problems with assertiveness. ■ Axis III Lack of attention to preventive health measures. ■ Axis IV Recent loss of job, financial difficulties; child with behavioural problems; marital conflict (husband cannot understand what is wrong). ■ Axis V Moderate symptoms, with impairment in functioning, not managing her child at present, social withdrawal and difficulty with housework. MENTAL ILLNESS IN THE COMMUNITY Large epidemiological studies from a variety of countries have demonstrated that mental disorders are extremely common. For example, the Australian National Survey of Mental Health and Wellbeing2 found that just less than 1 in 5 Australian adults (17.7%) had an anxiety, mood or substance use disorder (or more than one of these disorders) in the past year. Similar rates have been found in studies from the UK10 and the US.11–13 In the Australian study, anxiety disorders were the most common: they affected just less than 1 in 10 adults (9.7%); substance use (predominantly alcohol) disorders affected 7.7%; and mood disorders affected 5.8% of adults. All three classes of mental disorder often occurred in persons who also had a chronic physical disorder, with just under half (43%) of those with any mental disorder having a chronic physical disorder. About 1 in 4 persons with an anxiety, mood or substance use disorder also had at least one other disorder—that is, they had two or more different classes of disorder, such as an anxiety and a mood disorder, or an anxiety and a substance use disorder. A second part to the Australian study specifically examined the ‘low prevalence disorders’.14 This revealed that the prevalence of psychotic disorders in the adult population was 4 to 7 per 1000. Schizophrenia and schizoaffective disorder were the most common disorders identified. Comorbid substance use disorder (‘dual diagnosis’) complicated the course of the psychotic disorder in a substantial proportion of cases. Thirty per cent reported a history of alcohol abuse, 25% reported cannabis abuse and 13% other substance abuse. Importantly, the Australian study also examined the prevalence of mental disorders among children and adolescents.15 The study found 1 in 7 (14%) of children and adolescents in Australia have mental health problems. Among 6- to 12-year-olds the most common problem was attention deficit hyperactivity disorder (ADHD), followed by conduct disorder and depression. In those aged 13–17 years, the frequency of ADHD fell and that of depression increased. MENTAL ILLNESS IN PRIMARY CARE FREQUENCY AND DETECTION OF ILLNESS The extent and nature of mental disorder in primary care settings has been explored using three strategies: identification of psychiatric disturbance by the attending GP; 701 Blashki.indd 7 30/6/06 2:55:06 PM
  8. 8. GENERAL PRACTICE PSYCHIATRY evaluation of psychiatric ‘caseness’ by administration of screening instruments; and psychiatric evaluation using a diagnostic interview. Those studies relying on the GP in a primary care setting to identify the prevalence of mental disorders have yielded highly varying rates, from 5% to over 50%.16 By contrast, studies using screening instruments such as the General Health Questionnaire (GHQ) to assess mental disorder generate prevalence figures of around 40% and those using structured psychiatric interview suggest a prevalence of 20–30%.17 Overall, studies suggest that approximately 25% of patients in primary care have a mental disorder. Studies have demonstrated that GPs vary considerably in their ability to detect mental disorders, and in general, they do not recognise a large proportion of these types of health problems. For example, Goldberg and Blackwell18 found a quarter of patients with mental disorders went undiagnosed, while a World Health Organization multisite study found that about half of the psychological problems of patients were unrecognised.19 A variety of factors have been identified as barriers to the recognition and diagnosis of mental illness in primary care, and together they may contribute to the high level of unmet need. These factors include the following: ■ Mental disorders are commonly associated with a physical disorder. ■ The patient often has multiple presenting symptoms. ■ The patient may selectively focus on somatic rather than psychological symptoms of a mental illness. ■ The patient may present with physical complaints and a conviction of physical illness—for example, a patient with depression presents with chronic pain, or a patient with anxiety presents with palpitations or nausea. ■ The patient’s mental disorder may be long-standing, and the symptoms or effects accepted by the patient as ‘just the way it is’. ■ The patient may have atypical symptoms—for example, depression with overeating and oversleeping. ■ The patient may be fearful of the stigma and discrimination. In addition, studies have identified a range of GP behaviours that may influence the likelihood of detection of mental illness in patients. GP behaviours that increase the likelihood of cues being given by patients about their problems and thus increase the likelihood of detection of problems include: maintenance of eye contact with the patient, attentive posture, use of facilitating words, refraining from interrupting the patient or offering information early in the consultation, and an appearance of not being in a hurry. Cues from patients are reduced by certain GP behaviours such as directed questioning, questions without psychological content and interruptions to the patient’s account of their problems early in the consultation.20 THE NATURE OF MENTAL ILLNESS Goldberg and Gournay21 have suggested that mental disorders encountered in general practice can be practically grouped as follows: ■ Severe mental disorders, which tend to be relapsing and/or chronic and disabling. Patients usually require care from both the GP and specialist mental health services 801 Blashki.indd 8 30/6/06 2:55:06 PM
  9. 9. GENERAL PRACTICE PSYCHIATRY (see Chapter 22). The high rate of physical morbidity and premature mortality in patients with the severe mental disorders underscores the need for GPs to address medical and mental disorders. ■ Well defined mental disorders for which there are effective psychological and pharmacological therapies—for example, depression and anxiety disorders (see Chapters 8, 9). ■ Somatised presentations of distress such as prolonged fatigue, musculoskeletal aches and pains and gastrointestinal symptoms (see Chapter 11). These symptoms are most often associated with a diagnosis of depression or anxiety. ■ Transient adjustment disorders, which tend to resolve spontaneously, and for which supportive and/or non-specific interventions such as stress management are usually sufficient. GPs may assume a variety of roles in the assessment and management of patients with these disorders. In some circumstances, management will be provided predominantly or exclusively by the GP (for example, for transient adjustment disorders) while in others, shared care arrangements with specialist providers will be most appropriate (for example, for those with severe mental disorders). PSYCHIATRIC EMERGENCIES IN GENERAL PRACTICE In addition to providing diagnosis and care of acute and chronic illness, GPs may also be called upon to provide emergency care. Emergency presentations may include one or more of the following: ■ Suicidal behaviour, which may be manifest as thoughts or intent to harm oneself or an attempt to self-harm. Often, but not always, this is associated with a mental disorder, most often depression (Chapter 8), substance abuse (Chapter 10), psychosis (Chapter 12) or personality disorder (Chapter 18). ■ Acute behavioural disturbance—for example, aggression or self-harm resulting from the onset or exacerbation of a psychotic illness (see Chapter 12), an acute organic brain syndrome (delirium) (see Chapter 16), alcohol and/or drug intoxication or withdrawal (see Chapter 10). ■ Acute disturbance in those with known chronic psychiatric illness such as psychoses—for example, an individual with persistent paranoid delusions and/or auditory hallucinations (see Chapter 12). ■ Difficult or dangerous behaviour to self or others resulting from personality difficulties, or personality disorder (see Chapter 18). GPs may be required to make a diagnosis, perform a risk assessment, and determine immediate management. The latter may involve a variety of other service providers, including ambulance, police, hospital emergency departments and community mental health teams. However, often the GP is the first person called upon and the person who determines immediate management. Important priorities for the GP include: determining that the presentation is due to a mental illness and not, for example, the result of physical illness or injury; ensuring the safety of the ill person and others; and if appropriate, organising inpatient treatment. The latter may include consideration of the need for 901 Blashki.indd 9 30/6/06 2:55:07 PM
  10. 10. GENERAL PRACTICE PSYCHIATRY compulsory treatment. A working knowledge of the relevant Mental Health Act is an important skill in general practice psychiatry (see Chapter 4). PATHWAYS TO MENTAL HEALTH CARE An important area for consideration and action by GPs is pathways to care. Most people with a mental illness do not seek or receive effective treatment. This situation has been elegantly described by Goldberg and Huxley22 in a practical model outlining three distinct populations of subjects with mental illness: people in the community, people seen in primary medical care and people seen by specialist psychiatric services (see Figure 1.2). This model has been depicted as a ‘cone of morbidity’,23 which emphasises that most people with mental health problems and mental illness are in the general community or are managed in primary care settings. Importantly, Goldberg and Huxley identified a series of filters or barriers and enabling factors for passing from one level to the next. These filters provide a focus for understanding the key roles of the GP in the management of people with mental illness. Interventions at three key points (see Figure 1.3) may act to reduce the level of unmet need. Detection of illness is clearly a key step in the pathway to care. Several strategies have been developed to support developments in primary care psychiatry. Overall these have been directed to three main areas: improved detection of those with a mental illness; support for GPs delivering treatment; and opportunities for appropriate referral—that is, interventions at Goldberg and Huxley’s levels 2 to 4. Together, these strategies are designed to facilitate the pathways to care, thereby increasing the likelihood of symptomatic people receive the most effective treatment. FIGURE 1.2 Cone of morbidity ������������ ������� ����������� ���������� ������������� ������������ ��������������������� �������� ������� ���������������������� ���������������������������� ������� ������������������������ �������������� ������� ���������������� ����������� ������������ �������� ������� ����������������� ���������������������������������������������� ������� ��������������������������� ������������ ��������� 1001 Blashki.indd 10 30/6/06 2:55:07 PM
  11. 11. GENERAL PRACTICE PSYCHIATRY FIGURE 1.3 Key points in the pathway to mental health care ■ HELP SEEKING Moving from level 1 to level 2 is influenced by factors such as mental health literacy; attitudes of family, friends and the community about mental illness; severity and type of symptoms; and past experience of illness and help seeking. ■ DETECTION OF ILLNESS Moving from level 2 to level 3 is determined by the doctor’s ability to detect mental disorders among their patients, and this in turn is determined by characteristics of both the doctor and the patient. ■ REFERRAL TO SPECIALIST CARE Moving from level 3 to level 4 will be determined by the nature and severity of the patient’s problems as well as the knowledge, skills and confidence of the general practitioner. IMPROVING DETECTION OF MENTAL DISORDERS Many individuals with a mental disorder attend their GP for treatment of other problems and/or present with symptoms that are not recognised by the patient and/or the GP as symptoms of a mental illness. In order to progress up the cone of morbidity from level 2 to level 3, a variety of strategies have been suggested and/or implemented in general practice. These include: ■ Screening The use of screening tools to aid detection is widely debated. Advocates highlight the benefits of early detection and treatment of mental disorder. Commonly used instruments include the Kessler-10 Questionnaire (K-10), the General Health Questionnaire (GHQ) and the Prime-MD. The last is reported to have doubled the detection rate of mental disorder when compared to GP assessment alone.24 Those who argue against screening highlight the poor specificity of some screening instruments,25 and high rates of ‘false positives’ for persons who are in temporary distress or who have significant physical health problems.26 ■ Structural change Relatively low patient load and longer than standard consultations are factors associated with improved detection of disorder. In Australia, recent changes to payment arrangements for GPs undertaking mental health assessments have enabled longer interviews and encouraged the use of screening instruments.27 ■ Education and training Improved GP training has been advocated as a way of improving recognition skills.28 Skills based training programs can increase GPs’ rates of diagnosing common mental disorders. However, intensive training and ongoing practice support are likely to have more significant effects than less intensive forms of education.29 SUPPORT FOR GPs DELIVERING TREATMENT A variety of models have been developed to help GPs effectively manage mental disorders (see Chapter 22). These generally involve the provision of education to GPs who see patients with mental health problems and can provide direct treatment. They are also supported by opportunities for referral for patients with complex presentations or who do not respond to usual care and so require specialist care. This approach has been clearly articulated in a stepped collaborative care model.30, 31 1101 Blashki.indd 11 30/6/06 2:55:08 PM
  12. 12. GENERAL PRACTICE PSYCHIATRY For example, the stepped collaborative care model, developed in Seattle by Katon and colleagues, defines four levels of professional support for managing illness (see Figure 1.4). It allocates intervention resources in a stepwise fashion, which aims to match the intervention to patient preference and clinical need. Such a model also aims to enable effective treatment to be provided to a larger group of people. This approach defines several key roles for the GP, including making the initial diagnosis, initiating treatment in less complex cases and ensuring overall continuity of care. Other important tasks for the GP, or other members of the primary care psychiatry team, include provision of education to patients, monitoring the adherence to treatment and outcomes, and counselling and support for behaviour change. Specialist provider roles include the provision of consultation services to GPs when managing more complex cases, collaborative care or co-management of patients in the practice who do not respond to initial treatment provided by the GP, and ongoing speciality care for the most severe and complex cases. A second development, complementary to and consistent with this, has been the adoption of a chronic disease management model for the treatment of relapsing or chronic mental disorders.32 This includes components such as proactive care; patient education about signs and symptoms of the illness, treatments and early warning signs that herald relapse; and clear criteria for specialist consultation and/or treatment. FIGURE 1.4 Stepped collaborative care model ���������������������������������������������������������� ������� ��������������������������������������������������������������������������� ������� ����������������������������������������������������������������������� ������� ������������������������������������������������������������������������������������������ ������� REFERRAL TO SPECIALIST MENTAL HEALTH PROVIDER OR SERVICES Referral to a specialist provider may thus be made for advice about diagnosis and/ or management or for ongoing treatment. The decision about who should provide treatment and which treatments are most appropriate generally flows from the diagnostic assessment and formulation (see Chapter 7). In essence, four main considerations should guide the decision to refer: diagnostic difficulty; clinical severity, as judged by symptom severity and disability; response to any treatment already initiated; and the nature of the service to which referral could be made—for example, referral for a particular type of treatment or therapy. It’s worth noting that the GP may also refer for advice and/or reassurance that their planned management is appropriate. REVISITING THE CASE STUDY Having defined Leila’s problems along the five DSM-IV axes, your role as the treating GP is to assess the severity of depression, in particular the level of suicidality, and develop 1201 Blashki.indd 12 30/6/06 2:55:09 PM
  13. 13. GENERAL PRACTICE PSYCHIATRY a plan for appropriate intervention. This may involve you working directly with Leila, especially if you feel trained and competent to do so, or it may involve others, particularly if the problem is a major depressive illness. This may take the form of shared care or stepped care, using a local psychiatrist, psychologist and social welfare agencies. CONCLUSION General practice psychiatry has now been recognised as a core component of the mental health system. GPs see patients with a broad range of problems in a variety of circumstances. In recognition of this, new resources and supports have been developed in order to help GPs provide effective management to patients and their families/carers. It is hoped that recognition of the importance of the role of GPs, and supporting them so they can fulfill this role, will lead to more people with mental health problems seeking and receiving effective treatments. REFERENCES 1. Jenkins R. The contribution of David Goldberg: a British perspective. In: Tansella M, Thornicroft G, eds. Common Mental Disorders in Primary Care. Essays in Honour of Professor Sir David Goldberg. London: Routledge, 1999;xvi–xxii. 2. Andrews G, Hall W, Teesson M, Henderson S. The Mental Health of Australians. Canberra: Mental Health Branch, Commonwealth Department of Health and Aged Care, 1999. 3. World Bank. World Development Report 1993: Investing in Health. New York: Oxford University Press, 1993. 4. Murray CJL, Lopez AD, eds. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries and Risk Factors in 1990 and Projected to 2020. Cambridge, MA: Harvard University Press, 1996. 5. Jorm AF Korten AE, Jacomb PA, Christensen H, Rodgers B, Pollitt P. ‘Mental health literacy’: a , survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia 1997;166:182. 6. McNair BG, Highet NJ, Hickie IB, Davenport TA. Exploring the perspectives of people whose lives have been affected by depression. Medical Journal of Australia 2002;176(20 May 2002): S69–76. 7. Wirthlin Worldwide Australasia. National Mental Health Benchmark. Sydney: Royal Australian College of General Practitioners, 2001. 8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edn. Washington DC: American Psychiatric Association, 1994. 9. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: WHO, 1992. 10. Jenkins R, Lewis G, Bebbington P, Brugha T, Farrell M, Gill B, Meltzer H. The national psychiatric morbidity survey of Great Britain—initial findings from the household survey. Psychological Medicine 1997;27:775–89. 11. Robins LN, Helzer JE, Weissman MM, Orvaschel H, Gruenberg E, Burke JD, Regier DA. Lifetime prevalence of specific psychiatric disorders in three sites. Archives of General Psychiatry 1984;41:949–58. 12. Kessler R, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen H, Kindler KS. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry 1994;51:8–19. 13. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 2005;62:617–27. 1301 Blashki.indd 13 30/6/06 2:55:09 PM
  14. 14. GENERAL PRACTICE PSYCHIATRY 14. Jablensky A, McGarth J, Herrman H, Castle D, Gureje O, Morgan V, Korten A. People Living with Psychotic Illness: An Australian Study 1997–1998. Canberra: Mental Health Branch, Commonwealth Department of Health and Aged Care, 1999. 15. Sawyer MG, Arney FM, Baghurst PA, Clark JJ, Graetz BW, Kosky RJ, Nurcombe B, Patton MR, Raphael B, Rey J, Whaites LC, Zubrick SR. The Mental Health of Young People in Australia. Canberra: Mental Health and Special Programs Branch, Commonwealth Department of Health and Aged Care, 2000. 16. Goldberg DP, Lecrubier Y. Form and frequency of mental disorders across centres. In: Ustun TB, Sartorius N, eds. Mental Illness in General Health Care. An International Study. Chichester: Wiley, 1995. 17. Vazquez-Barquero JL, Herran A, Simon JA. Epidemiology of mental disorders in the community and primary care. In: Tansella M, Thornicroft G, eds. Common Mental Disorders in Primary Care. London: Routledge, 1999. 18. Goldberg D, Blackwell B. Psychiatric illness in general practice. A detailed study using a new method of case identification. British Medical Journal 1970;2:439–43. 19. Sartorius N, Ustun B, Costa e Silva J, Goldberg D, Lecrubier Y, Ormel J, Von Korff M, Wittchen H. An international study of psychological problems in primary care. Archives of General Psychiatry 1993;50:819–24. 20. Goldberg DP, Jenkins L, Millar T, Faragher EB. The ability of trainee general practitioners to identify psychological distress among their patients. Psychological Medicine 1993;23:185–93. 21. Goldberg D, Gournay K. The General Practitioner, The Psychiatrist and the Burden of Mental Health Care. Maudsley Discussion Paper No. 1. London: Institute of Psychiatry, 1997. 22. Goldberg D, Huxley P. Mental Illness in the Community. The Pathway to Psychiatric Care. New York: Tavistock Publications, 1980. 23. Henderson S. Conclusion: the central issues. In: Andrews G, Henderson S, eds. Unmet Need in Psychiatry. Problems, Resources, Responses. Cambridge: Cambridge University Press, 2000; 422–8. 24. Spitzer RL, Williams JB, Kroenke K, Linzer M, Verlion deGruy F Hahn SR, Broady D, Johnson JG. , Utility of a new procedure for diagnosing mental disorders in primary care—the PRIME-MD 1000 study. Journal of the American Medical Association 1994;272:1749–56. 25. Leon AC, Olfson M, Weissman MM, Portera L, Fireman BH, Blacklow RS, Hoven C, Broadhead WE. Brief screens for mental disorders in primary care. Journal of General Internal Medicine 1996;11:426–30. 26. McDowell I, Newell C. Measuring Health: A Guide to Rating Scales and Questionnaires. 2nd edn. New York: Oxford University Press, 1996. 27. Hickie I, Groom G. Primary care-led mental health service reform: an outline of the Better Outcomes in Mental Health Care Initiative. Australasian Psychiatry 2002;10:376–82. 28. Kroenke K, Taylor-Vaisey A, Dietrich AJ, Oxman TE. Interventions to improve provider diagnosis and treatment of mental disorders in primary care. A critical review of the literature. Psychosomatics 2000;41(1):39–52. 29. Naismith SL, Hickie IB, Scott EM, Davenport T. Effects of mental health training and clinical audit on general practitioners’ management of common mental disorders. Medical Journal of Australia 2001;175:S42–7. 30. Katon W, Von Korff M, Lin E, Walker E, Simon GE, Bush T, Robinson P, Russo J. Collaborative management to achieve treatment guidelines: impact on depression in primary care. Journal of the American Medical Association 1995;273:1026–31. 31. Simon GE, Katon WJ, Von Korff M, Unutzer J, Lin EH, Walker EA, Bush T, Rutter C, Ludman E. Cost-effectiveness of a collaborative care program for primary care patients with persistent depression. American Journal of Psychiatry 2001;158(10):1638–44. 32. Andrews G. Should depression be managed as a chronic disease? British Medical Journal 2001;322:419–21. 1401 Blashki.indd 14 30/6/06 2:55:09 PM

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