Why Primary Care Matters for Early Intervention in Psychiatry

CHAPTER 13
Why Primary Care Matters for Early Intervention in Psychiatry

David Shiers^1,2,3 and Helen Lester⁴

¹ National Early Intervention Programme, England

² Leek, North Staffordshire, UK

³ National Mental Health Development Unit, London, UK

⁴ Primary Care, School of Health and Population Sciences, University of Birmingham, UK

Introduction

The first challenge in writing for an international readership mainly familiar with psychiatric settings is that primary health care varies from country to country. As two English general practitioners (GPs) attempting to describe how primary care supports the paradigm of early intervention, our views are inevitably UK centric. However, what is universal is the sheer breadth and scale of mental disorder encountered in primary care. This ranges from people struggling with everyday life events to people experiencing often severe and sometimes lifelong conditions such as schizophrenia. It spans all ages from young children experiencing conduct disorder to older people with dementia. It tackles a real world in which mental and physical disorders coexist, particularly in more deprived areas [1].

For severe disorders like psychosis, describing how primary care contributes to early intervention appears relatively straightforward. The principles would be similar if we were discussing cancer care or cardiovascular diseases. Steeped in a world of diagnostic uncertainty, GPs are familiar with separating out potentially serious conditions which may present early and in an undifferentiated way. Indeed GPs are frequently consulted in first-episode psychosis and are the most common final referring agency [2] but still only encounter 1–2 patients per year with a suspected psychosis. (Is this still similar to first presentation of juvenile/type I diabetes?) GPs request better collaboration with specialists supported by low-threshold referral services rather than educational programmes to improve their diagnostic ability [3]. However, we believe primary care can contribute to early intervention beyond just detecting psychosis early. Recent research reveals that markers of ‘downstream’ physical ill health appear within weeks of initiating treatment, emphasising how mental and physical comorbidity can be predicted even at this early stage [4]. This may have important implications for primary care.

For those with milder distress the challenges are different. Contributing significantly to primary care’s daily workload, such difficulties have their origins in the complexities of peoples’ lives, their relationships with others, and the interactions between their bodies and their minds. Neat categorisation is defied. In terms of prevention and early intervention this is important, given that most serious problems start out as milder ones. Treatment strategies based on formal diagnosis and biomedical solutions offer limited help. Potentially more helpful are holistic and health promoting approaches applied at both individual and community levels. Failure of primary care to contain and respond appropriately may result in entry into formal systems of mental health diagnosis and treatment where the sheer volume would overwhelm specialist services and frustrate clients with ineffectual care.

So, although the ways in which primary care responds to intervene early for someone with a potential psychosis compared to someone with milder distress may be very different, a central theme is that primary care is a major provider of mental health care across this wide spectrum and its distinctive characteristics make it central to an effective care system [5].

The value of primary care

There is enormous international variation in what is meant by the term ‘primary care’. According to the Institute of Medicine (1996) in the United States of America, primary care is the:

‘… provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a large majority of personal health needs, developing a sustained partnership with patients, and practicing in the context of the family and community’ [6].

Primary care systems can be categorised according to whether they act as gatekeepers to specialist services (as in the United Kingdom), provide free-market services in parallel to specialist services, or function in a complex system containing both free-market and gatekeeper functionality (as in the United States); whether they are free to patients at the point of care delivery; whether they are led by doctors or non-medical personnel; and the degree to which they provide continuity of care.

Barbara Starfield, a respected researcher of primary care across different countries, described primary care as:

‘… the provision of first contact, person-focused, ongoing care over time that meets the health-related needs of people, referring only those too uncommon to maintain competence, and coordinates care when people receive services at other levels of care’ [7].

Evidence for the benefits of primary care oriented health systems is robust across a wide variety of different types of studies. In summary, primary health oriented countries:

Have more equitable resource distributions.
Have little or no private health insurance.
Are rated as better by their populations.
Have primary care that includes a wider range of services and is family oriented.
Have better health at lower costs.
Within countries, areas with higher primary care physician availability (but NOT specialist availability) have healthier populations [8, 9].

Primary care as the central provider of mental health services

A common myth runs as follows: Primary care deals with common and milder mental illnesses and specialist care with rarer and more severe ones. However, a landmark study by Goldberg and Huxley [10] revealed how primary care dealt with 90% of people with mental ill health, that only 10% required specialist community services and even fewer inpatient hospital care. Mental health problems are the sole basis for 20–25% of consultations and an important feature of around 40% of consultations [10]. Moreover for people with severe mental illness, 30–50% receive their care solely from primary care [11]. Could such levels of need ever be met by specialist services? It is also important to note that many other professions are involved in providing primary care – nurses, receptionists, social workers and pharmacists, often with minimal or no mental health training.

Advantages to providing mental health care in primary care

Primary care offers a low stigma setting close to home; by a health practitioner often with previous knowledge of the person and family, providing holistic treatment and continuity of care for the full range of problems including physical health, and links to local community services for associated social issues. In the United Kingdom, everyone is entitled to register with a GP practice enabling access to medical care free at the point of delivery. However people from disadvantaged groups, such as homeless individuals or those with severe mental illness, are less likely to be registered, increasing their disadvantage. Nevertheless, people with severe mental illness value the care their GP provides describing primary care as the cornerstone of their care [12].

The worried well and primary care

We want to now consider a group of people who frequently attend primary care and where it is often unclear whether their problems reach the level of a formal diagnosis of say anxiety, depression or somatisation. Unkindly parodied as the worried well, these groups are as disabled as most sufferers of chronic physical diseases, generating major social and financial burden to families, friends and employers, and consuming scarce health resources [13]. Their problems typically present in vague and ill-defined ways, which shift over time and often elude explanation. An American primary care study reported fewer than 20% of patients presenting persisting symptoms had a diagnosable physical disorder and 10% had a clear psychological disorder [14]. For practitioners and health systems geared to traditional ‘disease’ approaches, this uncomfortable reality can evoke a tendency to pathologise human distress and experience.

Is this the right direction? Are there alternatives? The sheer scale of human distress seen in primary care, whether overtly described or more subtle in its effects on psychological or (so-called) physical conditions constitutes business as usual for its practitioners. We shall now go on to describe how the inherent strengths of primary care can help normalise these experiences without relying on diagnosis and resource-hungry specialist treatments.

Primary care – stronghold of generalism

The question arises ‘Are the worried well served better through generalism or specialism?’ In thinking about this, let us consider some distinctive features of primary care:

Primary care is delivered by ‘specialists in generalism’ – defined by James Willis as taking an interest in whatever is of interest to its clients [15]. For a person seeking care for a newly occurring (or newly recurring) problem ‘I do not have to have a diagnosis to receive help’. Primary care bridges the worlds of clients, families, communities and professionals, negotiating meaning around health, illness and disease.
Effective consultation and continuity: at its heart lies the doctor–patient relationship developed over time. A frequent misconception portrays the GP consultation as a single ten-minute event. Nothing could be further from the reality. Patients see their GPs for short times but over long periods, as and when they want, for all their health-related needs and presenting with undifferentiated mixtures of physical, emotional, family and social problems. An evolving narrative of person-focused (rather than disease-focused) brief interventions over a lifetime, from ‘cradle to grave’, builds a continuity of relationship and a comprehensiveness of provision that no other health professional can provide.
A core competency, recognised by the UK Royal College of General Practitioners requires GPs to work in a family-centred and community-orientated way [16]: ‘GPs should aim at a holistic approach to the patient and his or her family, where the main focus would be in promoting their health and general wellbeing. GPs are seen to have a responsibility for the individual patient, his or her family and the wider community and need to understand the characteristics of the community including socio-economic, ethnicity and health features’ [16].
Another core GP competency tolerates uncertainty, exploring patients’ own health beliefs, assessing probability and marginalising danger [16]. For someone experiencing mental distress, the GP may need to hold uncertainty, allowing the passage of time to test if the psychological difficulties are transient whilst avoiding a psychiatric stigmatising diagnosis. But of course disorders like psychosis often start off as milder, more common ones, rarely presenting with clear-cut psychotic symptoms. Therefore, tolerance of uncertainty must be balanced with another core function of GPs to detect potentially serious conditions early, when they will offer assessment, treatment, information giving and referral. So alongside tolerance of uncertainty, the GP requires a high index of suspicion.

So in summary, primary care is steeped in a culture of generalism, continuity and holistic practice which makes it distinctively ‘person-focused’ contrasting the ‘disease-focused’ nature of specialist care.

In terms of early intervention, our main message here is not about primary care or specialist care being inferior/superior – simply that they are different. It is the degree to which the two systems can successfully integrate that is important to our patients.

Preventing illness and promoting wellness – a wider perspective on primary and secondary prevention

An underpinning principle is that social disadvantage, physical illness and poor mental health are inextricably linked, whether we are discussing relatively mild disorders or more severe ones. In the United Kingdom, the last 10 years have seen average life expectancy improve as a result in part of for major investment in screening/prevention/early intervention for cardiovascular disease and cancer. And yet health inequality widened over the same period. A recent landmark study by Hacking and colleagues found that inequalities in all cause mortality in the north/south divide were severe and persistent over the four decades from 1965 to 2008. The increase in this inequality from 2000 to 2008 was notable and occurred despite the public policy emphasis in England over this period on reducing inequalities in health [17].

However, this is not just an ‘impoverished-north’/‘more-affluent-south’ issue. This study is important because it compares two population blocks of 25 million people. But the principles equally apply to population groups like those with mental ill health, where similar influences play out to create major health inequalities. To better understand this paradox, consider the example of tobacco smoking, the largest cause of preventable deaths in the United Kingdom.

Increased smoking explains half the difference in survival rates to age 70 between social classes I and V [18].
Forty-two percent of all tobacco consumed in England is by those with mental disorder (75% with common mental disorders; 25% with severe disorders) [19].
Despite significant falls in overall United Kingdom smoking prevalence over the past 30 years, this hardly changed among those on low incomes and the least advantaged [20].

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