eMJA: Hickie, Primary care psychiatry is not specialist psychiatry in general practice

eMJA The Medical Journal of Australia

Viewpoint

Primary care psychiatry is not specialist psychiatry in general practice

Current psychiatric diagnostic systems are not useful for general practice

Ian B Hickie

MJA 1999; 170: 171-173

→ Other articles have cited this article

Introduction - Barriers to psychiatric treatment in primary care - Classification systems in specialist psychiatry - Primary care psychiatry - Psychological disorders present with somatic symptoms - Psychological assessment in primary care - Acknowledgements - References - Authors' details
Make a comment - Register to be notified of new articles by e-mail - Current contents list - More articles on Psychiatry

Introduction

At least 30% of patients who present to primary care have psychiatric disorders, while another third have sufficient psychological symptoms to justify detailed psychological assessment.¹ While patients who present to primary care represent a minority of those with psychological disorders in the Australian community,² less than half receive a psychiatric diagnosis when seen by their general practitioner.³ Specific pharmacological treatment is provided to less than half of patients in whom a diagnosis is made.³

The public health and personal costs of this situation are large,⁴ and persist despite the increasing willingness of general practitioners to treat psychological disorders,⁵ the increased availability of safe and effective pharmacological agents, and the fact that patients prefer to be assessed by their general practitioner rather than mental health specialists.⁶ Current public health initiatives are designed to increase the likelihood that persons at risk (especially men and younger people) will present for treatment and that general practitioners will receive increased support and training to provide such treatments.⁵

Barriers to psychiatric treatment in primary care

A range of patient, doctor and service factors contribute to the ongoing problems of under-recognition and undertreatment of psychological disorders in primary care. Patient-related factors include the presentation of somatic rather than psychological symptoms,^7,8 the co-occurrence of medical and psychological problems, and the stigma associated with psychological diagnoses and treatments.⁶ Doctor-related factors include inadequate interview and diagnostic skills,^9,10 insufficient undergraduate and postgraduate training,⁵ insufficient time devoted to adequate diagnostic assessment,⁵ and a lack of acquisition of new knowledge relevant to provision of treatments. Service-related factors⁵ include insufficient remuneration for psychological interventions, insufficient support from specialist public and private mental health services, and inadequate access to non-medical mental health professionals.

An important but little-discussed factor is the current lack of a useful psychiatric diagnostic system for use in primary care. General practitioners typically report that, although they recognise behavioural disturbance, the common symptom patterns and deviant behaviours presented do not fit readily within the patterns described by specialist psychiatry. Currently, psychiatric education highlights the problems of under-recognition and undertreatment, but does not concede that much of the morbidity detected is not classical "major depression" or one of the discrete anxiety disorders.¹¹ Moreover, much of the treatment data that forms the "evidence-base" for current recommendations has not been obtained in patients from primary care settings.¹² Inevitably, therefore, practice guidelines for primary care represent extrapolations from treatment trials conducted within the specialist sector with patients without concurrent medical morbidity.¹²

Classification systems in specialist psychiatry

During the past two decades, specialist psychiatry has focused on the development of complex criteria-based diagnostic systems (eg, DSM-IV, ICD-10).^11,13 While such systems have improved diagnostic reliability for psychiatric research, they have often been inappropriately transferred directly to clinical settings. In practice, the systems frequently result in multiple diagnoses for individual patients (now termed "psychiatric comorbidity"), as the borders between the different diagnostic categories are indistinct. For example, many patients with "major depression" will also meet criteria for other anxiety disorders, such as generalised anxiety disorder and panic disorder.¹⁴

As the current systems were designed for patients who present primarily with psychiatric disorders, their application in general medical and primary care settings is problematic. Patients frequently do not meet criteria for any specific psychiatric diagnosis, or fall into one of the "waste-basket" categories such as 300.81 Undifferentiated Somatoform Disorder or 311 Depressive Disorder, Not Otherwise Specified. Much of the psychological morbidity encountered in general practice falls into the "not otherwise specified" categories, and the diagnostic systems have tended to reinforce the notion that such disorders are not worthy of further systematic study. This is despite their clear contribution to ongoing healthcare costs and disability.¹

Primary care psychiatry

In contrast with specialist psychiatry, the emerging discipline of "primary care psychiatry" deals with those issues which are pertinent to psychological assessment and intervention in the primary care sector.¹⁵ This focus is justified by the fact that most patients in this sector present an admixture of affective and somatoform symptoms,^7,16 and are managed without referral to the specialist sector.² When referring, there is a strong preference towards those patients with overt psychological syndromes (eg, major depression, panic disorder) and away from those patients with somatoform disorders (eg, chronic fatigue, chronic pain), as the latter are poorly recognised by the current classification systems.^8,17 This is despite the considerable disability associated with such disorders and the likelihood that such patients will seek a variety of treatments, including non-specific pharmacological and alternative medicine interventions.^8,17

Additionally, general practitioners frequently assess psychological disorders which occur in the context of obvious life stressors (eg, marital separation, job loss, or financial hardship). The diagnostic systems typically describe such disorders as "adjustment disorders" and imply that such maladaptive behavioural responses are usually shortlived and associated with minor degrees of disability. DSM-IV specifically describes adjustment disorders as a "residual category". This approach substantially underestimates the impact of such presentations on primary care practitioners and the degree of risk and disability which may result.

Psychological disorders present with somatic symptoms

Few patients simply report the syndromes described in DSM-IV or ICD-10. Typically, patients report prolonged fatigue, sleep disturbance and musculoskeletal aches and pains in association with mood, anxiety and/or neurocognitive symptoms.^7,16,18 Consequently, primary care psychiatry emphasises diagnostic categories that are more useful to general practitioners.

The most important of these are "mixed anxiety and depression" and "neurasthenia" (ie, nervous exhaustion or chronic fatigue). Together, these disorders are largely discounted by specialist psychiatry, even though they describe common presentations. The psychiatrist's "bible", DSM-IV, deals particularly poorly with both these disorders. Mixed anxiety and depression is presented simply as a possible form of depressive disorder that may warrant further investigation. Neurasthenia/chronic fatigue is not recognised, although the symptom pattern is described obliquely within 300.81 Undifferentiated Somatoform Disorder. The most recent and comprehensive community study of psychiatric disorders in North America (published from 1994 onwards) chose not to record the prevalence or health impacts of somatoform disorders.¹⁹ In contrast, studies supported by the World Health Organization continue to demonstrate the frequency of neurasthenia and its relevance for primary care practitioners.¹ Fortunately, the recent National Health and Wellbeing Survey,² conducted in the second half of 1997, obtained data on these conditions in Australia. Pilot data from that study support this emphasis in terms of prevalence and associated disability.²⁰ Longitudinal studies suggest that these disorders are often chronic and likely to remain prevalent in the primary care setting.²¹

Although such disorders are distinctly lacking from many educational initiatives in primary care, emerging literature can be used to guide primary care physicians.^8,22 The relevant notions include not only descriptions of key symptom sets (eg, chronic fatigue, irritable bowel, chronic pain, fibromyalgia and chronic headache), but also more coherent approaches to identification of problem behaviours (eg, rejection of medical reassurance, inappropriate investigation). This results frequently in combined medical and psychological approaches to treatment (eg, non-steroidal anti-inflammatory drugs and behavioural treatment for fibromyalgia; antidepressant drug and sleep-wake cycle behavioural management of chronic fatigue).

Psychological assessment in primary care

Current educational initiatives in primary care often emphasise the importance of simplistic diagnostic checklists for disorders such as "major depression" or "panic disorder". A more rational educational and treatment approach is based on the following framework:

The common somatic and psychological presentations of distress and the psychosocial environment within which such presentations occur must be recognised. Within the logistic constraints of general practice this process may be assisted either by relevant screening instruments⁷ and/or by improving interviewing techniques.⁹
Behavioural constructs (eg, depressed mood, panic attacks, psychomotor retardation, chronic fatigue, chronic pain, sleep disturbance, and suicidal ideation) that require specific treatments independent of the final diagnosis need to be recognised.
The degree of immediate risk to self and others should be determined.
An assessment of those comorbid medical factors (eg, co-prescription of antihypertensives) that will influence treatment choice needs to occur.

Within this framework there is the potential to bring a much larger group of currently untreated patients, particularly those with somatoform or adjustment disorders, into the diagnostic and treatment process. For individual management to succeed, the practitioner needs then to use very specific knowledge with regard to the patient's current personal and social circumstances and past experiences.

Further developments will depend on a growing awareness of the inadequacies of the current classification systems and an increased demand for relevant aetiological and treatment research within the primary care sector. As this process gains momentum so will the capacity to identify and treat more effectively the large number of patients who present to primary care.

Acknowledgements

This research in general practice settings is supported by a National Health and Medical Research Council Program Grant (No. 953208). The editorial assistance of Tracey Davenport was greatly appreciated.

References

Ustun TB, Sartorius N, editors. Mental illness in general health care: an international study. Chichester: John Wiley and Sons, 1995.
Mental health and wellbeing: profile of adults, Australia. Canberra: Australian Bureau of Statistics, 1998. (Catalogue no. 4326.0.)
Harris MF, Silove D, Kehag E, et al. Anxiety and depression in general practice patients: prevalence and management. Med J Aust 1996; 164: 526-529.
Murray CJL, Lopez AD, editors. The Global Burden of Disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Boston: Harvard University Press, 1996.
A report of the Joint Consultative Committee. Primary care psychiatry -- the last frontier. Canberra: Royal Australian College of General Practitioners and Royal Australian and New Zealand College of Psychiatrists, 1997.
Jorm AF, Korten AE, Jacomb PA, et al. "Mental health literacy": a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Med J Aust 1997; 166: 182-186.
Hickie I, Hooker A, Hadzi-Pavlovic D, et al. Fatigue in selected primary care settings: sociodemographic and psychiatric correlates. Med J Aust 1996; 164: 585-588.
Hickie IB, Scott EM, Davenport TA. Somatic distress: developing more integrated concepts. Curr Opin Psychiatry 1998; 11: 153-158.
Goldberg DP, Jenkins L, Millar T, Faragher EB. The ability of trainee general practitioners to identify psychological distress among their patients. Psychol Med 1993; 23: 185-193.
Tobin M, Hickie I, Urbanc A. Increasing general practitioner skills with patients with serious mental illness. Aust Health Rev 1997; 20: 55-67.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994.
American Psychiatric Association. Practice guidelines for major depressive disorder in adults. Am J Psychiatry 1993; 150 Supl: 1-26.
World Health Organization. The tenth revision of the International Classification of Diseases and related health problems (ICD-10). Geneva: World Health Organization, 1992.
Blazer DG, Kessler RC, McGonagle KA, Swartz MS. The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey. Am J Psychiatry 1994; 151: 979-986.
Sartorius N, Ustun TB, Costa e Silva JA, et al. An international study of psychological problems in primary care. Preliminary report from the World Health Organization Collaborative Project on 'Psychological Problems in General Health Care'. Arch Gen Psychiatry 1993; 50: 819-824.
Goldberg D, Gater R. Implications of the World Health Organisation study of mental illness in general health care for training primary care staff. Br J Gen Pract 1996; 46: 483-485.
Hickie I, Hadzi-Pavlovic D, Ricci C. Reviving the diagnosis of neurasthenia. Psychol Med 1997; 27: 989-994.
Mason P, Wilkinson G. The prevalence of psychiatric morbidity: OPCS survey of psychiatric morbidity in Great Britain. Br J Psychiatry 1996; 168: 1-3.
Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51: 8-19.
Hickie I, Pols R, Koschera A, Davenport T. Why are somatoform disorders so poorly recognised and treated? In: Andrews G, editor. Unmet needs for psychiatric care. Darlinghurst, Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse. In press 1999.
Merikangas K, Angst J. Neurasthenia in a longitudinal cohort study of young adults. Psychol Med 1994; 24: 1013-1024.
Wessely S, Hotopf M, Sharpe M. Chronic fatigue and its syndromes. New York: Oxford University Press, 1998.

Authors' details

School of Psychiatry, University of New South Wales, Sydney, NSW.
Ian B Hickie, MD, FRANZCP, Professor of Community Psychiatry.

Reprints: Professor I B Hickie, Academic Department of Psychiatry, 7 Chapel Street, Kogarah, NSW 2217.
Email: i.hickieATunsw.edu.au

Other articles have cited this article: