Psychiatry in primary care

Psychiatry in primary care


The majority of people who are diagnosed with a mental illness have no contact with the psychiatric services; instead they are treated by their general practitioner (GP) and other members of the primary healthcare team. The most common mental illnesses treated by GPs are depressive disorder, generalised anxiety disorder and mixed depression and anxiety. Many more patients have emotional problems, such as low mood, and worries that do not amount to a mental illness. Many will also have a coexisting physical illness and will not complain directly about their psychological symptoms. Recognising mental illness in these circumstances poses a special challenge and is described in more detail below.




Psychiatric disorders in primary care



Mood disorders


Depressive disorder is the most common psychiatric disorder treated in primary care and is present in about 10% of all GP attenders, with a further 10% having depressive symptoms. In comparison with depressed patients seen by psychiatric services those in primary care tend to be less severely ill and have more anxiety symptoms. The presentation is often with physical symptoms rather than depressed mood. The treatment should be with antidepressant drugs in moderate or severe cases. Mild cases will often resolve with support and help to address social problems. Psychological treatments that are known to be effective in depression, such as cognitive therapy, are rarely available in primary care. The effectiveness of non-specific ‘counselling’ in depression is not known. GPs can expect one of their patients to commit suicide every 4 years. Up to 40% of patients who die by suicide have seen their GP in the month before death, and half of these in the week before death.



Anxiety disorders


There is a great overlap between depression and anxiety disorders in primary care, and patients presenting with anxiety symptoms should be asked about mood symptoms. Many cases are mild and will respond to advice, reassurance and support.



Alcohol abuse


There is evidence that patients act on advice from their GP to reduce their alcohol consumption, and reductions of up to 20% of the number of problem drinkers can be achieved by the GP routinely asking about alcohol consumption and giving appropriate advice.



Recognising mental illness in primary care


Only half of the patients presenting with the most common conditions found in primary care, depression and anxiety, are recognised as mentally ill by their GP. The reasons and some possible ways of addressing them are summarised in Figure 1. In part this is because patients frequently present with physical rather than psychological complaints. Patients come to psychiatric outpatient clinics expecting to talk about their feelings, and will often have had an opportunity to think about their emotional state in preparation for this. The expectations of a GP consultation are quite different. Patients often believe that the doctor will be interested in physical symptoms only and may not consider their emotions to be relevant to any diagnosis, and so omit to mention them. Instead, the complaint may be of the biological symptoms of depression (insomnia, anorexia, weight loss) or health concerns due to hypochondriacal preoccupations, or of an exacerbation of an existing physical illness. Pain, discomfort and disability may be more difficult to bear when depressed. In these circumstances it is up to the doctor to be alert to any indications of emotional distress demonstrated during the consultation (see Fig. 2), and to ask direct questions about psychological symptoms, for example:


image ‘You seem tense (angry, unhappy, worried …), can you tell me about that?’
< div class='tao-gold-member'>

Related posts:

Mood stabilisers and ECT Old age psychiatry I Diagnosis and classification of schizophrenia Anxiety disorders – clinical presentation and aetiology Old age psychiatry II Personality disorders – introduction and classification

Stay updated, free articles. Join our Telegram channel
Tags:
Jul 12, 2016 | Posted by in PSYCHIATRY | Comments Off on Psychiatry in primary care

Full access? Get Clinical Tree
Get Clinical Tree app for offline access