|Partners for Mental Health - The Contribution of Professionals and Non-professionals to Mental Health (WHO, 1994, 110 p.)|
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World Organization of National Colleges, Academies and Academic Associations of General Practice, Practitioners/Family Physicians (WONCA)
The Colleges and Academies which are members of this international organization are national bodies, distinct from universities. Their shared, overall purpose is to encourage and maintain high standards in the branch of medicine described above. They follow a pattern of which the earliest example is the Royal College of Physicians of London, founded in 1518 (in order to distinguish trained physicians from untrained competitors). The earliest example from general medical practice is the American Academy, which was founded in 1947. Although the development of such colleges occurred earliest in English speaking countries, it is now more widely disseminated. There are, at present, 38 countries with institutions in membership.
The World Association was formed in 1972. Ifs overall purpose is achieved by:
1. providing a forum for exchange of knowledge and information between member organizations of general practitioners/family physicians;
It exists to support, but not to control it's constituent bodies. Ifs most important achievement hitherto has been to create an International Classification of Health Problems in Primary Care (ICHPPC) (1). This is based on the World Health Organization's classification of disease, which was not originally designed with a view to primary care.
GENERAL MEDICAL PRACTICE
General medical practice (in some countries 'family practice') can claim the longest history of any branch of medicine, starting whenever and wherever the roles of the physician and priest become distinct. It survives today as the most general among many specialized branches of medicine. The need for it has become increasingly obvious as the logic of specialization leads to increasing subdivision, fragmentation and high costs.
The following statements about this role have been agreed by the World Organization of Colleges, Academies and Academic Associations of General Practitioners/Family Physicians.
"High quality primary health care depends on the availability of well-trained general practitioners or family physicians as members of health care teams in the community.
The general practitioner or family physician is primarily responsible for providing comprehensive health care to every individual seeking medical care.., either directly or through the services of others - according to the health needs and resources available within the community which he/she serves. He or she cares for the individual in the context of the family and the family in the context of the community, irrespective of race, religion, culture or social class; is clinically competent to provide the greater part of their care, after taking into account the cultural, socio-economic and psychological background; takes responsibility for providing comprehensive and continuing care to patients."
This role is distinct from any other in medicine because of ifs combination of accessibility, broad range, continuity and the capacity to integrate the assessment and management of clinical problems when, as so frequently, these are related one to another.
The role of the general practitioner must first be set into a context. It would be short-sighted to launch immediately into describing the challenge of mental health problems only as they are presented in a doctor's consulting room. They exist in homes and working places. People do not always consult doctors. The responses now used by general practitioners are not the only ones possible; those used by others could suggest directions in which general practitioners' roles should develop. The introduction therefore sets the context by considering the extent and nature of mental health problems as they are seen through population surveys.
2. The magnitude of the problem in the general population
Surveys of a total population or of a random population sample in their homes suggest that around 150 per 1000 persons at risk have mental health problems at any one time of enquiry. These figures are based on Australia (2), Greece (3), Uganda (4), United Kingdom (5,6), USA (7, 5, 9, 10).
There are wide variations in prevalence rates (75-200 per thousand). They are attributable less to geographic location than to differences in method - especially in decisions about where to draw a precise line between those who have mental health problems - "psychiatric cases" - and those who do not; or between different degrees of severity of disturbance or impairment.
In the United States, prevalence rates of mental disorders per thousand subjects from five sites in the ECA Program study (10) are reported as 154, 191 and 322 for one month, six months and lifetime, respectively. Psychiatric disorders are consistently found to be more common among women than men (11, 12). Rates are higher for people who are separated, divorced or unemployed.
The challenge of such findings in all populations and communities studied does not need to be laboured.
2.1 What is a "case"?
We cannot evade the problem of defining what constitutes a mental health problem. Without discussion it would remain unclear whether, in what follows, we had in mind
1) only those problems which cause significant or severe disturbance and impairment or
2) every problem which might be detected by exhaustive methods of survey and enquiry.
Our context is the professional role of general practitioners. Whatever the type of morbidity they deal with - physical, psychological or social - they face both minor and major deviations from health or normality. To take into account only the most severe forms of psychological disturbance would therefore be obviously inappropriate.
Forms of psychiatric interview and screening questionnaires are now numerous.
The questionnaire most often used is the general health questionnaire (GHQ) (13) designed as a community research tool, it will allow the identification of persons with emotional disorders.
The standardized interview most often used in international studies of psychiatric illness is the Present State Examination (PSE) (14).
We believe that the figure of 150 per thousand persons suffering from emotional disturbances does include patients whose problems, though real enough, would not be classified as "major".
"Anxiety" and/or "depression" are diagnoses used to account for at least two-thirds of the cases detected in community surveys. Depression is the single most common psychiatric diagnosis among random samples of a community (with a typical rate of 60 per 100 - UK or USA (15)). The only study comparing the United Kingdom with an African village by the same methods showed rates to be three times as high in Africa (4). Alcohol and drug abuse are increasingly common in all countries. In developing countries mental disorders secondary to infective illness and to other organic pathology are also common. Half the population being under 15, a large burden of child and adolescent disorders is found (16).
2.2 Who do people consult?
In the face of all the types and degrees of problems described, some people cope by themselves or within family and friends. They do this either by seeking solutions or by accepting what seems inevitable or by not recognizing that there is a problem when this is obvious to those near them.
It is important here, as in the rest of the field of health and illness, to recognize the extent of self-care. But it is not the focus of this paper. This is concerned with the role of one professional group among the many whose members people consult.
But who do people consult, apart from relatives and friends? The range must vary greatly in different cultures or countries. In countries similar to the United Kingdom there are clergy, counsellors, lawyers, nurses, pharmacists, the police, psychologists, as well as medical practitioners and psychiatrists. There are also practitioners of alternative or complementary medicine. As a general proposition, where GPs are found, they form the profession most frequently consulted for mental as for other health problems. They are usually already known and trusted and are traditionally the first Port of call. This is certainly true in the United Kingdom (17).
The situation in developing countries is characterized by severe shortage of trained staff of all grades. Doctors are a scarce resource, a scarcity that is often worsened by emigration. The doctor-patient ratio can range from one doctor to over a million population in rural areas to one to a thousand population in urban areas. In Africa traditional healers, herbalists and village health workers play a very important part. In South East Asia large numbers of people see traditional medicine practitioners for mental health problems. Magic and ritual are important elements in such treatment and are resorted to even by educated families, since there is a culturally determined belief in the efficacy of these rituals. Increasingly, however, people are turning to modern medicine. The need to train general practitioners in mental health is therefore urgent in developing countries, but at the present time it may be more realistic to rely on village health workers. They might have six to ten years' schooling and only three months' training in general health care. They are expected to refer people with anything more than the simplest problems to the next level, staffed usually by a health worker with 10-12 years of schooling and 2-3 years' health training. Less often physicians provide this level of care (18).
Given the steady development of specialization in all fields of medicine, it might be expected that in the most developed countries people with mental health problems predominantly consult psychologists or psychiatrists. Community surveys in Israel, which identify 45% of patients in general practices as having psychiatric symptoms, found that the vast majority of them were not referred for psychiatric help (19, 20). In the United States of America the situation may be changing. Earlier evidence (9, 21) suggested that only one person with a psychological disorder in five saw a mental-health professional; three out of five were served in the primary care outpatients sector. Nine out of ten depressed patients had seen a primary-care physician only. More recent evidence (22), mainly from urban areas, suggests that between a quarter and a third of ambulatory visits by persons with mental disorders were made to mental health specialists but the figure depends above all on their availability.
In general, even in countries where direct consultation with mental health specialists might seem most likely to occur, this is the exception rather than the rule. The reasons are obvious. First - the ratio of mental health specialists to general physicians is one to five (specialists tending to congregate in conurbations); second - the physical symptoms which so frequently accompany mental problems, as described above, lead sufferers naturally towards doctors perceived to deal with such problems. Although attitudes may be changing, this route is usually more acceptable to patients, many of them being reluctant to recognize the nature of their problem or to risk being labelled as psychiatric.
The ratio of psychiatrists to primary care physicians is even lower in the United Kingdom (1-26) than in the United States. In developing countries the ratio is incomparably lower. It is estimated that in South East Asia, for example, there are less than 750 psychiatrists (almost all in urban areas) for a population that exceeds 280 million.
2.3 Individuals or teams?
In naming the different professions consulted, it may seem to have been implied that each one works in isolation from the others. This is very often the case, but the increasing complexity of medical and social care increasingly requires collaboration and teamwork. This is usually better developed within psychiatric hospitals than in community services outside them. However, many examples of close cooperation between general practitioners, community psychiatric nurses, psychologists, counsellors and sometime social workers, working with one community, can be found in the United Kingdom and the United States and doubtless in other countries of similar development. A particularly interesting change has occurred in the United Kingdom, whereby a significant proportion of psychiatrists now spend regular periods of time working in the setting of primary care (23) - so linking the primary care team with the psychiatric team based within the hospital system.
Teamwork can involve workers with limited training. An interesting example has been developed at Porto Alegre, Brazil, where auxiliary health workers and health volunteers are members of primary teams trained to deal with physical, psychological and social aspects of illness in all members of a family while integrating preventive, curative and rehabilitative interventions (24).
2.4 What proportion of those with mental health problems consult general practitioners?
There have been a number of studies in the United Kingdom and the United States which have shown the general relationship between morbidity and consultation with doctors. This can be illustrated by Figure 1 in the Annex (25, 26, 27).
Thus in a population of a thousand in any period of one month, about 750 persons will experience symptoms of some form of ill-health, however minor. Only 250 will consult physicians - about one in three.
Does this general pattern apply to mental health problems? In a London population it was found that only about a third of those individuals identified in a community survey as having significant psychiatric disorder had consulted a GP within the previous two weeks (28).
The longer the period of observation, the higher the proportion consulting.
Not surprisingly, people with more severe problems are more likely to consult (29).
But all these studies come from countries at a particular stage of development. In less developed countries, consultation with trained physicians is much more difficult because of their relative rarity in a community, their distance and cost.
3. The Role of General Practitioners and Primary Care Teams
3.1 The frequency and nature of mental health problems among patients seen In primary care clinics
Studies reviewed from the United Kingdom and the United States showed that mental disturbance was found in 11%-36% of primary care patients (30). Goldberg and Williams found 35%-40% (U.K) (13). Three reasons mainly account for this wide range.
First, health problems are often expressed to doctors in physical terms or accompany coincidental physical disorders. But the boundary between physical and mental is hard to define in theory and difficult to recognize in practice. For example, is insomnia a physical or a mental problem? Second, the attitude of physicians to patients with mental illness has been shown to vary. Some are prone to deny its presence or underestimate its importance; others are prone to attribute psychological causes more often than can be justified. These are matters of prejudice. Third, skills in assessment vary. All these influences account for variation in detection and recognition by primary care physicians (11).
Available evidence suggests that the frequency of mental disturbance encountered in clinics in less-developed countries is the same or greater. It has been reported that 20% of the patients attending a walk-in clinic in a Kenyan suburb had a psychiatric disorder (3). A study, using various strict criteria in Columbia, India, Sudan and the Philippines found rates varying from 10.6% to 17.7% (32). In a primary care-setting in Brazil, a rate was found for minor psychiatric morbidity of 40% (33% conspicuous and 13% hidden) (33). Cheng, studying medical attenders in Taiwan (34), found 44.4% of "psychiatric cases".
Experience in general practice clinics is largely consistent with the findings from population surveys described above. It confirms the higher consultation rate of women than men - especially middle-aged women; likewise the predominance and variety of physical symptoms; likewise the dominant importance of anxiety and depression in all cultures (35, 36). In a study of patients attending general practices, a large and slowly changing group of patients was found with chronic mental health problems, alongside a small and rapidly changing group with new disorders of recent onset (37).
General practitioners are consulted about problems which are close to, or part of, the ordinary life of most people. Their work inevitably takes in reactions of thought, feeling and behaviour which cannot be considered to be disease or illness. For example, anyone realizing or even wrongly suspecting that they had cancer, would be likely to feel anxious or depressed. People bereaved of wife or husband would be abnormal if they did not grieve. General practitioners deal every day with such threats and losses - problems in living - usually about family, work, or money, in varying degrees of severity.
It is a common experience to be faced with people bringing multiple problems -often a mixture of physical, psychological and social problems. To disentangle what matters most out of the confusion is the doctor's first and most essential task.
New problems in developing countries have come to resemble those elsewhere -drug abuse, alcoholism and chronic stress reactions. In addition there are problems of juvenile delinquency, family breakdown and loneliness.
"Most psychiatric patients have a common core of symptoms which relate to mood disturbances - notably anxiety, depression, fatigue, irritability and sleep disturbance. The exceptions fall into two groups - on the one hand ... hypomania, certain forms of schizophrenia and some organic states...; and on the other hand, various kinds of abnormal personality which may occur without the critical symptoms of mood disorder..." (15).
But general practice studies in both the United Kingdom and the United States shows that, for every patient who complains of these mainly emotional symptoms, at least twice as many offer a combination of emotional and physical symptoms (38, 39). Physical symptoms are even more common in developing countries (40). Minor and transient disorders occur far more commonly than major; they are often indistinguishable from experiences accepted by most people as part of normal life. At the other extreme, major ones can be incapacitating, prolonged, destructive of family life and lead to suicide.
Mental health problems may also show themselves in ways other than mental or physical symptoms. There may be criminal offenses, absenteeism from work, suicide attempts, alcoholism, traffic accidents or, in the case of children, withdrawal from school.
Apart from the physical presentation of many mental health problems, there are two other important linkages.
First, anyone suffering from a primary physical disorder will often have cause to be anxious or depressed. Moreover, even the fear of life-threatening or incurable illness may have the same effects.
Second, it has been repeatedly demonstrated that people who contend with significant mental health problems are at greater risk of other concomitant physical disorders.
Weyerer has reviewed these issues in detail within general practice settings (41). Goldberg (42) has indicated the proportion of cases falling in the five possible categories:
- not psychiatrically ill:
- physical illnesses with secondary psychiatric illness:
- unrelated physical and psychiatric illness:
- entirely psychiatric illness:
All these linkages have a bearing on the question of which professional roles and types of training are most appropriate for the tasks of detecting and assessing mental health problems.
It is important to consider the issues of severity and duration from the evidence about population studies rather than about patients attending general practitioners, since the former are more likely to include a representative proportion of minor cases.
Community studies of depression and anxiety show that depression is most often a recurrent disorder, anxiety being more continuous. But in a follow-up of seven years, it was found that just over a quarter of the patients with depression ran a chronic course and were never free of symptoms (43, 44). At the other extreme, a similar proportion showed remission or recovery after 5-7 years.
3.2 The response of the general practitioner and primary care team: Detection and Recognition
In most countries almost all general practitioners accept that it is their business to respond to mental health problems (45).
It is clear from what has been said that the problems of hidden morbidity in this particular field make detection and recognition the essential first tasks.
The detection of depression is particularly important because of its frequency, its many disguises and the possibility of care which can be both supportive and effective. One disguise is in increased anxiety, another is increased frequency of consultation, another the anxiety of a close relative and finally a variety of physical symptoms. Watts (46) listed ten symptoms most commonly presented in his rural general practice as 1) tiredness 2) headache 3) anxiety 4) depressed mood 5) backache 6) insomnia 7) pains in the chest 8) dyspepsia 9) giddiness 10) pains in the trunk, arms and legs.
General practitioners also have many opportunities for recognizing alcoholism and drug abuse. They need to be grasped for similar reasons (47, 48).
Once a doctor or nurse suspects that he or she is dealing with a mental health problem, its nature has to be assessed. This can, of course, mean the choice of a diagnostic category - "depression", "schizophrenia", "drug addiction", "organis psychosis". These labels, though useful, are less so than similar labels in other fields of medicine and can even be harmful. "Assessment" can also imply the search for causes. Such assessment may point to a useful form of intervention. Though obviously complex and difficult, the issue of causation is of central importance. Evading it leads easily to routine or inappropriate prescribing of psychotropic drugs and to rejection of the patient as a unique person. Understanding of multiple causation is essential. Biassed pursuit of one type of cause, to the neglect of all others, is another common reason bringing harm to patients.
Traditionally understood as seeking the help of a psychiatric specialist for assessment, treatment or hospitalization, referral may also be to other members of a primary care team. In either case, the form and quality of communication matter greatly (49). Mutual acquaintance between professionals is especially valuable, since personal preferences have a larger influence here than in other fields of mental health care. Such acquaintance cannot be assumed in large conurbations.
Patients are referred to psychiatrists for assessment, treatment, hospitalization and sometimes because of difficulty in the GP's relationship with a patient. In many countries it is normal for patients to be referred back to the general practitioner when some special need has been fulfilled. In the United Kingdom only about one patient in twenty with mental health problems is referred to a psychiatrist.
3.3 Continuity of care
Recurrence and chronicity of mental health problems call for continuity of care. The nature of some disorders - for example schizophrenia or dementia -does not permit that the onus for keeping contact can be on the patient. General practitioners, although accustomed to offering a continuous service for physical disorders, may need the help of other team-members to ensure contact with such patients, many of whom lose touch with or never reach psychiatric clinics (50, 51). Where general practitioners or primary care teams (or psychiatric teams) have a responsibility for a defined list of people or a defined area, computers have provided a valuable means towards effective continuity of care.
General practitioners can use their frequent contact with patients to recognize changes in behaviour or in consultation habits. Frequent consultations about a child may indicate hidden trouble in a parent or in the relationship between both parents.
Overall, the preventive element in the role of general practitioners and primary care teams has increased in recent decades. This claim can be supported with evidence, certainly in the United Kingdom (52, 53). It could include some evidence about beneficial outcomes, for example in relation to immunization or the discouragement of cigarette smoking. The inevitable links between prevention, care and cure can be realistically represented by the term "anticipatory care", implying both a way of thinking and a set of actions (54).
In the context of mental-health problems it is difficult to point with assurance to preventive actions within the scope of routine general practice which can be demonstrated to be effective. An optimistic view might claim that opportunities for preventive action are legion, for instance in preventing anxiety or depression. But this view must meet such challenges as having to provide evidence that specific interventions do "reduce the future incidence of symptoms among people who are relatively free of them or who are suffering from symptoms not severe enough to be defined as cases" (55). Reliable studies which provide such evidence are few. Most are examples of secondary or tertiary prevention - that is early treatment or ways of limiting disability resulting from mental disorder. As with treatment, preventive interventions can be physical or psychological or social.
As an example of prevention by physical means, once a patient is recognized to be liable to episodes of depression of sufficient severity, the use of anti-depressive drugs either intermittently or continuously is justified and in many cases effective in preventing or limiting recurrence (National Institute of Mental Health, 1988).
As an example of psychological intervention, the studies of Parkes (56) and Raphael (57) comparing the effect of counselling for bereaved relatives at high risk of psychiatric disorder against a control group show convincing evidence of benefit. Much of what they did would be repeatable by general practitioners and others in the primary care team with a little training. Indeed this form of support has long been provided, but only by a minority of doctors (58).
An example of social intervention involving social workers attached to a primary care team was reported by Corney (59). She was able to show that social workers were effective in preventing some acute episodes of depression in women lacking social support from becoming chronic illnesses. Cooper et al. (60) showed a number of benefits to patients and clients with chronic neurotic illness from practices which had a social worker attached, compared with those attending practices which had no social worker.
These are all reports of controlled research studies. However, the routine experience of general practitioners would claim the impression that many other preventive functions are worthwhile. "Reassurance" is an old and comprehensive term but when aimed with precision and offered with understanding, it does indeed seem to relieve anxiety in patients, for instance, facing operations or unwelcome medical verdicts, fearing childbirth; or in those whose fears are based on some misunderstanding of their condition; or in those who approach some crisis in their work or family life - even those of normal life such as marriage or retirement (54).
The supportive role of the familiar trusted doctor or nurse must be accepted as a role of great importance in all countries; especially as the support of the extended family is less available than it was in the past (61).
In some less developed countries, the problem of family size may have important consequences for mental health. Larger families are known to have more such problems (61). The number of orphans has increased. Thus such an apparently unrelated action within the scope of general medical practice as family planning can have important preventive benefits in the present context. This example must suffice to represent many others.
Treatment, if it is not to be merely symptomatic, depends on an effort to assess the influence of such causes as are commonly recognized. General practitioners use both physical and psychological approaches, usually combined (62).
Psychotherapy is usually simple and untutored. However, many efforts have been made in recent years to provide general practitioners with limited understanding of emotional problems in their patients, in themselves and in consultations. Among the most ambitious examples, the work of Michael and Enid Balint has been influential in many countries (63). Although it is a minority of general practitioners who have done this type of training, its influence has spread indirectly to many others (64).
Some evidence of the effectiveness of both psychologists and counsellors, when working with GPs, has been provided by Anderson and Hasler (65), Earll and Kincey (66) and Robson et al. (67).
There are many "social" interventions available to the general practitioner - for example, certifying sickness absence from work, seeing more than one member of a family simultaneously when there is conflict between them, arranging convalescent holidays, acting as an advocate in many different situations. Cooperation with social workers is discussed at length by Corney (68). Cooperation is obviously desirable, but mutual understanding is sometimes difficult.
Since the trend in many countries to discharge patients "into the community", the role of general practitioners in, caring for patients in hostels or half-way houses has become important (69).
Medical care is increasingly carried out by groups of people rather than by individuals, although the relationship of one group member to one patient may still be of great therapeutic importance. This one-to-one relationship is not excluded by working in a group, but it is easily diluted unless care is taken.
Groups, whether of doctors or of different professionals, are unlikely to work effectively or harmoniously unless someone attends to the processes which can favour these aims. Teamwork" implies that people make their differing contributions to a shared purpose. Purposes or objectives are often assumed to be obvious, appropriate and shared by different members of a group nominally working together. Experience shows that these assumptions do not always conform to reality.
Although doctors and nurses have always been concerned to offer the highest possible quality of service and sought means to achieve this, it is only in the last twenty years that serious attempts have been made to assess quality, so that accurate comparisons can be made between a particular element of care offered in one practice with that offered in another; or between what has been done in the past in a practice and what will be done in future, after introducing some measure intended to improve what is offered. Such review of performance ("audit") entails constructive self-criticism or criticism from colleagues or patients. This important principle has its application in the mental health field as in other fields. An example might be the systematic scrutiny of the prescribing of all psychotropic drugs in a practice with a view to identifying variations between doctors, discussion of appropriateness and, if necessary, subsequent change in usage (70).
In less developed countries the role of the general practitioner is likely to vary from the description above. It is likely to include a greater responsibility for advanced disease and a larger element of hospital work. It may also require more time in cooperating with less highly trained colleagues and in processes of mutual education and understanding.
4. Strengths and Limitations of the General Practitioner
Although trends culminating in the Alma Ata Declaration and promoted by WHO have pointed to the general practitioner as a key figure in the organization of health services at local level, it has already been indicated in this paper that there are alternative agents in dealing with mental health problems. In developed countries the issue of direct access to specialists in mental health remains open. The claim of greater expertise is strong. It is therefore important to look critically at the strengths and weaknesses of the general practitioner and the primary care team in dealing with mental health problems.
General practitioners cannot be regarded as a uniform group. They show great variation even within one country, for instance in regard to prescribing, or the use of special investigations or in referral to specialists. This paper is especially concerned with variations between them in their perception of the importance of the mental versus the physical aspects of their work and in their resulting knowledge, skills and tolerance in dealing with these patients. Shepherd (11) showed, for example, a ninefold variation in their capacity to recognize a psychiatric problem. There is a tenfold variation in the level of prescription of psychotropic drugs.
Basic medical education in most countries concentrates on physical issues and does not form an ideal preparation for work with patients who find psychological distress harder to bear than-physical (29) and who make twice as many visits to general practitioners as persons without such problems (28, 71, 44).
In most developed countries general practitioners are numerous (one to 1000-4000 population) and evenly distributed and accessible. (But there are still developed countries where rural districts are less well served than urban, despite their need for this particularly appropriate form of medical service). They offer coverage which cannot be provided by psychiatrists because of their smaller numbers.
Their most important function -assessment and diagnosis of new problems - lends itself readily to the inclusion of mental health problems, especially as these are so often presented in physical disguises or associated with other coincidental physical problems. Where general practitioners have a special postgraduate training, this is broadly based and, in recent decades, has given increasing emphasis to the psychological and social aspects of medicine.
Potential contact between general practitioners and their patients is relatively continuous (in the United Kingdom, where patients register with a particular doctor, the average duration is now about six years). This is of great importance in dealing with recurrent and chronic problems, as those of mental health tend to be. Past knowledge of a patient's illness experience can be valuable in anticipating recurrences. Ongoing responsibility favours preventive ways of thinking and acting.
The strengths already described contribute to the ideal of the personal doctor - someone who is familiar, trusted and able to act as advocate and adviser in choosing or dealing with other medical and social agents. The integrating role of the personal doctor grows in importance as specialization follows its own logic of increasing sub-division. General practitioners can be trained to think in a balanced way about the physical, psychological and social aspects of their patient's situation.
Patients with mental-health problems value the presence and support of a known person. They do not always look for action.
The trained general practitioner can have a particular value in the present context in avoiding unnecessary, harmful and expensive investigations, referrals and treatments.
Mental-health problems are difficult for some general practitioners to tolerate or understand. This relates partly to their training, but partly to a doctor's personality and motives for choosing medicine as a career.
It is difficult for some doctors to listen, to avoid being directive, to withhold their own prejudices or refrain from criticism. These qualities are more necessary in dealing with mental health problems than with other ones.
Lack of sufficient time for consultation is a weakness in some health services. It is generally accepted that mental health problems on average require rather longer consultation than other problems (72, 73). Physical presentation of these problems can easily lead the doctor into difficulty or the patient into harm through unnecessary investigations and interventions - even sometimes unnecessary surgery. "Fixation" into these false trails can create a complication which can create a complication which cannot afterwards be resolved. Clearly such cases also involve the waste of precious economic resources (74, 75, 76).
Goldberg and Blackwell (38), showed that, for every two patients recognized by GPs, another one goes undetected although their scores on General Health Questionnaire assessment are no different. Hoeper et al. (77) found an even larger level of failure. When patients somatize their distress, they have only a 47% chance of it being recognized, compared with a 95% chance when they present psychological complaints. Ormel and Giel (76) showed clearly that recognition has a substantial impact on outcome.
In regard to assessment and treatment, evidence is confusing as to whether those GPs who are more interested and more skilled in mental health refer less or more patients (78, 11). There are economic consequences here also. But the evidence from the United Kingdom does confirm that the attachment of psychiatrists to larger general practices does reduce both out-patient referrals and hospital admissions (23).
One point of detail must be made about physical treatment. It is a frequent experience that general practitioners make heavy prescribing of tranquilizers. Their prolonged use has led to problems of habituation (79), but there has also been inappropriate use. For instances in treating depression, tranquilizers have been seen as a substitute for anti-depressive drugs which are more specific and effective. There are also problems over insufficient dosage. These problems, like those of detection, can be remedied if doctors have access to continued training and appreciate the need for it.
5. Strategies for Development and Improvement
5.1 Education and training
The pattern by which future general practitioners, like other doctors, receive a common basic education in a university medical school and a post-qualification training specific to one branch of the profession has recently been established in a number of countries. But it is not yet universal. Life-long readjustments to what was learned at the start of a career are now essential, because of changes in society and in science and technology. Continuing education is needed for this reason, but also to maintain enthusiasm and a habit of critical reflection in those whose work is largely practical, sometimes pressurized and often exhausting.
5.1.1 Undergraduate basic medical school
In 1950 the education of medical students was entirely based in hospitals and concerned overwhelmingly with normal and abnormal bodily functions. Since then, in the United Kingdom and the United States, there has been an increase in attention to psychology, sociology, anthropology, epidemiology and psychiatry. More recently, a variety of influences have been shifting the focus of medical education from its traditional base towards the world outside the hospital. This shift favours greater awareness of mental health problems. It has also included the involvement of general practitioners as teachers and the creation of professorial departments of primary care in medical schools.
It is no longer the purpose of undergraduate medical education to train "safe" general practitioners by the time of qualification. What is learned about mental health at this stage must be relevant to all future careers in medicine. So, essential learning must be basic and cover, for example, the skills of communication or the routines of collecting information which can lead to an awareness of the wide range of symptoms and behaviour which may reveal mental health problems among others. Such practical experience must be supplemented by knowledge of the main features of the mental disorders which occur commonly or have the most important effects; by familiarity with the principle of multiple causation and its application to prevention and treatment; and by opportunities for students to discuss their difficulties in dealing with unusual personalities and unusual behaviour. These examples of basic learning, necessary for any career in clinical medicine, will be relevant in any country, although the concepts used must be adjusted to the particular culture.
5.2 Specific postgraduate education
The special training of general practitioners after qualification should develop similar themes in greater depth mainly in the setting of general practice itself. There is a particular need to emphasize recognition of mental problems when they are disguised and to provide experience and supervision in helping patients themselves to recognize the nature of their problem. This is often difficult for them to do.
Canadian workers (80) studying the general issue about what elements in primary care consultation give positive outcomes, stressed the importance of agreement between doctor and patient about the nature of the problem. In the field of mental health problems such agreement is especially dependent on careful discussion.
The period after qualification is also the time when methods of treatment must be learned, whether in the proper use of psychotropic drugs, simple forms of psychotherapy, social interventions or by calling in other agencies to help.
Psychiatric emergencies, including the threat of suicide, are important in all cultures and require specific training for their management; so too the management of alcoholism and substance abuse.
Direct experience of patients at this stage may expose a doctor to the problems in his own relationship with them. If these are to be faced or helped, small group learning (or rarely one-to-one discussion with a trainer) offers the most promising educational approach, providing that the teacher has suitable skills.
In some countries general practitioners have themselves become accustomed to the role of teacher and enjoy supportive educational networks. But even then, the help of psychiatrists, psychologists and others is needed in what is an area of complexity, difficulty and uncertainty.
Training which is confined at this stage to work in psychiatric hospitals, though it can be valuable, is not sufficient because it will prove to be relevant only in part to the needs of the future general practitioner (20).
Selected references to articles about training in psychological skills for primary care are listed in Appendix 1 of Sartorius et al. "Psychological Disorders in General Medical Settings" (81).
5.3 Continuing education
Continuing education must above all be based on the problems encountered from day to day by the doctor and must be closely related to his or her existing attitudes, skills and knowledge. There is, of course, also a need to introduce new ideas. Here, again, general practitioners will require the help of others - psychiatrists, psychologists and sociologists.
In the United Kingdom, although older doctors may be accustomed to lectures, younger ones prefer discussion in small groups (82). This is consistent with the principle of active learning and the need of adult learners to give as well as to receive. Balint seminars offer a well-established example of one appropriate method used in many countries (63). Current cases form the essential focus of these seminars. They are concerned, above all with the problems of the relationship between doctor and patient, even when the case has predominantly physical aspects. Members of the seminar teach each other and learn from each other, in the presence of a group facilitator, who may or may not be a psychiatrist.
The selection of topics in this sort of small group work will usually be problem-based and therefore unlikely to be systematic or comprehensive. It may need to be supplemented by other methods. Learning is increased when the learners have a large say in the choice of topic, but there is a risk that they will choose what interests them, to the neglect of their ownareas of ignorance (83).
The organization of continuing education for general practitioners is now extensive in some countries and opportunities copious. The evidence from controlled studies about the capacity of educational initiatives at this stage to create lasting change in behaviour is, however, disappointing (84, 85).
Much attention is now being given in many countries to quality assessment (performance review or "audit") as an active method of continuing education. By these terms is implied a systematic examination of some unsatisfactory aspect of clinical work or organization, whether by the doctor or by others, followed by a change in method; after an interval, re-examination on the same aspect to test improvement. Accurate measurements are used for comparison whenever possible. This approach, originating in the United States (86) is as relevant to mental health problems as to others, but may be more difficult to apply to them. It is a promising development, but too recent for its widespread application in primary care to be assessed.
The educational value of a psychiatrist working in the setting of primary care is discussed below. The principles involved are relevant to working with a psychologist, a counsellor, a psychiatric nurse - always subject to the educational skills of the individual in question (20).
5.4 Training of health-workers
To confine discussion of training to the training of general practitioners would be to neglect the fact that in large areas of the world they are not to be found. Something must be said about the training of those who fill this gap - taking the village health worker as an example. This training should concentrate as much on the psychological aspects of health care generally as on specific mental disorders, e.g. the skills of communicating well with patients and of taking account of their own beliefs and expectations. Priorities in dealing with mental disorders are likely to include the management of emergencies, maintenance treatment for chronic conditions and, in some countries, the use of medication for states of excitement (16, 24).
6. Health Services Organization
6.1 Within a practice or primary care team
Given the varying attitudes and abilities of general practitioners, partnerships and group practices may find one or more members especially interested or skilled in dealing with mental health problems. Ideally they should be shared equally by all partners, but this is not realistic. Since some of these problems demand above average expenditure of consultation time, this must be understood by all partners.
Recent work has demonstrated numerically what has been long suspected. A study involving varying appointment intervals (72) has shown that longer consultations favour the likelihood of detection and treatment for mental health problems. Howie's study of fast and slow doctors confirms this (73).
Consultation length in general practice is the resultant of many different influences - ratio of doctors to population, methods of payment, efficiency of organization, patient attitudes and, not least, doctor attitudes. Some of these influences can be modified -for instance, by delegation. In countries where payment is by item of service, it has been unusual to identify payments for psychotherapy. When reimbursement for this was instituted in Canada, a dramatic rise in the amount of psychotherapy provided by general practitioners was observed (87).
This may be within a primary care team - so with nurses, psychiatric nurses, counsellors, social workers or receptionists. It may be with the psychiatric team - psychiatrists, psychologists, psychiatric nurses. Included must also be cooperation with carers and with patients themselves, since a basic principle, where possible, is to foster self-esteem and independence.
Trained counsellors are now attached to an increasing number of practices in the United Kingdom, promising a large new resource for short-term psychotherapy (88, 89). However, this paper will, concentrate on cooperation with psychiatrists and psychologists.
The traditional method of communication is by letter. Among others, Pullen and Yellowlees (49) have proposed the essential characteristics required for this form of communication. Telephone discussion of a difficult case is a method much valued by many GPs.
In the United Kingdom there has been a steady development for ten years by which increasing numbers of psychiatrists and psychologists spend time in the setting of general practice. For example, this may now be true for half the psychiatrists in Scotland. There has been dispute about whether the cases seen are less severe than those seen in hospital out-patients, but a recent study in London (90), using standardized measures, showed that both groups had similar degrees of physical and social dysfunction and comparable levels of psychiatric morbidity. Chronic schizophrenia, alcohol and drug problems predominated in primary care, while personality problems and affective psychoses were more common in out-patients.
The reaction of patients, general practitioners and psychiatrists to this form of working has been consistently favourable (91).
Where there has been separation of health and mental health services as in the United States, there have been low rates of referral. When they have been brought together through integrated organizations, attachment schemes or linkage models, primary care doctors are more likely to identify mental disorders and to use mental health specialists for consultation and referral (92).
The WHO Regional Office for Europe working party on psychiatry and medical care (93) has stressed that "the crucial question is not how the general practitioner can fit into the mental health services, but rather how the psychiatrist can collaborate most effectively with primary medical services, and reinforce the effectiveness, of the primary physician as a member of the mental health team."
There has been a rapid development of research in this field in the last twenty years, particularly in Australia, Germany, the United Kingdom and the United States of America.
7.1 Defection of mental health problems
Methods of improving the proportion of hidden problems detected in primary care have been examined in existing studies (76, 94). Further studies are needed to test the outcome of these methods and their application in different types of practice, different countries - and by team members other than doctors. The use of simpler screening tools needs further trial both for detection and for following progress of cases.
A related issue is how to ensure recognition of vulnerable groups at special risk of anxiety and depression, e.g. the physically ill, the disabled, the bereaved, the seriously deprived (for example, unmarried mothers), people approaching retirement, children of divorced or divorcing parents and those known to have been seriously depressed in the past. Who among them needs extra support? Which team member is best suited to provide this?
7.2 Assessment and classification
Methods of communication in the consultation have been the subject of many recent studies (95). Their influence on outcomes is a particularly interesting focus for further study (96). So, too, the comparison of methods used by different types of professionals engaged in primary care.
The classification of mental health problems is still unsatisfactory - whatever the setting. Following Jenkins et al. (97), neither the international classification of diseases (ICD) nor the international classification of health problems in primary care (ICHPPC) can be applied consistently by general practitioners. A multi-dimensional approach is desirable; but it is certainly not yet in use by general practitioners. Jenkins proposed a four-dimensional system - psychological symptoms, social problems and supports, personality difficulties and physical disorders. Something simpler is needed.
The mixed states of anxiety and depression, at mild and moderate levels of intensity, especially need attention.
The most obvious needs for research concern the effectiveness of treatments, whether physical, psychological or social. Since there is usually competition for resources, their relative cost is also an important consideration.
Further evaluation of single psychological methods is needed, not least in order to diminish the use of tranquilizers. Psychological methods which can be used by nurses and social workers and others are needed.
The personal difficulties of doctors or nurses dealing with patients with mental disorders create problems of relationship which need analysing. Those frequent attenders sometimes referred to as "heart-sink" offer an interesting focus in this connection.
The outcome of different forms of collaboration between different types of professional - experiments whereby psychiatrists, psychologists and community psychiatric nurses work in general practice settings are particularly important. What sort of problems are presented to them? Is this method cost-effective compared with alternatives?
Care by general practitioners or in community mental health clinics? Evaluation of self-help groups? Methods of ensuring that no undue proportion of secondary-care staff time is devoted to people with less severe disorders at the expense of the more severe. Evaluation of a model practice.
8. Influencing attitudes to mental illness
As has been mentioned earlier, there is a wide range in the attitudes or habitual reactions of different general practitioners to mental as compared with physical illness. Attitudes will include their estimate of the importance of these problems, compared with physical ones; their capacity to detect them; their interest in them; time spent in dealing with them and tolerance of patients presenting them. To varying extents they may share the sense of stigma which patients have themselves. There may be a wide discrepancy between the attitudes of doctors and those of patients, for whom mental suffering can be more overwhelming, mysterious, frightening and disruptive of all important aspects of living than physical illness of comparable severity.
In less-developed countries this discrepancy is exacerbated by the persistence of life-threatening physical illness - mainly infective in nature - which preoccupies the attention and resources of sparse medical services at all levels.
General practitioners, since their proper concern spans all these areas, are in a good position to influence opinion - whether of patients, other professionals or policy-makers (through personal contacts or through representative organizations). As methods of intervention and prevention develop and understanding of causes increases, the need to use this influence becomes more urgent, while the negative image of mental health problems diminishes. The need to conceal them is less powerful than it was when help was less available.
Policy-makers are by no means themselves immune to mental health problems. There are famous examples where problems experienced in a politician's family have led to valuable publicity and a switch of resources to mental health care.
9. Influencing attitudes to general practice
In all developed countries the role of the general doctor has been threatened in the last fifty years by the development of specialization and the benefits which have resulted from it. In the United States, for example, the ratio of generalists to specialists dropped dramatically between 1930 and 1970 (98). Many people have questioned whether there is any future role in medicine for generalists.
Paradoxically, the increasing development of specialization, by fragmenting clinical practice and medical education, has revealed an increasing need for coordination and continuity. These can only be provided by generalists. Moreover, they alone can provide a widely accessible and broadly oriented point of entry to a system of medical care.
The revaluation of general practice, which has occurred in many developed countries more recently, is due partly to this realization, partly to economic influences and partly to the efforts of general practitioners to put their own house in order.
The high and ever rising cost of specialist and hospital care has pointed to generalist and home care as a possible and less costly alternative. Their provision in health maintenance organizations in the United States has been shown sharply to reduce the extent of hospitalization (99). There has been a similar demonstration in Sweden (100). Overall, however, it is uncertain whether home care is in reality cheaper than institutional care. The difference is probably marginal (101, 102, 103).
In mental health, the flight from hospital care has been based also on the discovery that long-term psychiatric hospitalization produces its own harmful effects and on the belief that care outside hospitals is ideally better for patients. The reality does not always match with the belief.
In a number of countries, general practitioners have united to take responsibility for developing their own role in medicine - by defining it; creating a special training for it, introducing it as a university discipline, conducting research and representing it to other institutions, including governments. In particular, Colleges and Academies of General Practice have started in many countries and these are linked through the World Organization of National Colleges and Associations of General Practice (WONCA). In some countries the effects have been dramatic. In the United Kingdom, for example, this branch of medicine is, since 1978, a leading career choice for final year students and young qualified doctors (thirty years ago it was usually the career undertaken only if a doctor failed to enter a career of first choice). There has been a striking change in the attitude of specialists who now see general practitioners as doctors with a different, but complementary and effective, role which allows them to concentrate on what they themselves do best.
This change has not yet occurred in all countries of similar development. In less-developed countries there are still influences which result in the building of prestigious specialist hospitals - unsupported by the "community" services which allow them to function efficiently.
Improvements in mental health and in the care of people with mental health problems depend to a large extent on the development of primary care, where the general practitioner is at present the central figure. Where the potential of general practice goes unrecognized, resources are withheld or the role is devalued (as, for instance, in countries where the most promising students are always selected or attracted into specialist careers), the field of mental health and illness is deprived of a positive force which could be widely available to it.
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Figure 1. Monthly prevalence estimates of illness in the community and the roles of physicians, hospitals and university medical centres in the provision of medical care (adults sixteen years of age and over).