H. KEITH H. BRODIE, M.D.
Mental health and • pnmary care Recent data indicate that 15% of the American population suffers some form of mental illness. Of this number, approximately 58% are treated by primary care practitioners while only 15% receive treatment by mental health professionals. Although enlightening, the fact that the majority of mentally ill patients are being cared for by the primary care provider is not totally surpnsmg. Four principal explanations have been proposed. First, public attitudes interfere to some degree with the willingness of individuals to seek specialized mental health service. Although such influences appear to be declining, there is still a certain amount of stigma connected with receiving psychiatric treatment. Second, and related to this stigma, is public concern about and lack of confidence in the effectiveness of psychiatric treatment. Third, financial limitations discourage some potential users from seeking specialized mental health services. Americans depend heavily on major medical insurance, but mental health coverage is limited and frequently includes deductible and co-insurance requirements. Fourth, a significant proportion of patients with mental illness who are referred to psychiatrists request such referral from primary care givers, suggesting thqt many patients simply do not understand how to enter the mental health care system on their own; they lack
Dr. Brodie is prOfessor and chairman, department ofpsychiaily, Duke University Medical Center. Reprint requests to him there, Durham, NC 27710. 658
basic knowledge concerning the availability and nature of these services. What type of treatment do these patients receive in the primary care sector and what impact do they have on medical practice? Relatively little data is available concerning treatment of these people when they are seen by nonpsychiatric physicians. Assumptions based on the small amount of available data are that psychotropic drugs may be used too liberally, counseling and psychotherapy may not be used enough, and the overall referral rate to mental health professionals is low. In terms of impact, several studies have surveyed these physicians about their experience with the mentally ill. Those surveyed reported that they considered their training inadequate for the most effective treatment of mental illness and that ttjey find the mentally ill difficult to treat and financially less rewarding than the physically ill because the mentally ill demand excessive amounts of time, and the majority of primary care givers operate in a fee-for-service system in which time equals money. If we accept this scenario, we are faced with the realization that primary care providers have a major responsibility for the recognition and treatment of mental illness and that they therefore need adequate training in the psychological aspects of patient care. They should demonstrate competence in when and how to treat patients themselves, when and how to refer patients to mental health professionals, and how to collaborate with mental health professionals. Moreover, mental health professionals should demonstrate PSYCHOSOMATICS
competence in collaboratIng with primary care practitioners, and in their understanding of the interface of physical and mental illness. Because of its resources and purview, psychiatry should take a major role in this training by encouraging interdisciplinary health teams, integrated health care settings, and medical education curricula that define specific competencies and means for evaluation. Interdisciplinary teams offer a framework for educating primary care providers and mental health specialists. An example is suggested in the work of consultation-liaison psychiatry. Through direct involvement with the primary care team, the liaison psychiatrist consults and teaches about the psychological aspects of medical care on ward rounds, in conferences, and at staff meetings. Such an interdisciplinary approach would be facilitated by encouraging integrated services in which patients have access to both general health professionals and mental health specialists in a single setting, and in which all health professionals have structured opportunities for collaboration and consultation. Currently, integrated services are likely to be found in some health maintenance organizations, neighborhood health centers, family practice programs, and teaching hospitals. In addition to the need for an interdisciplinary team approach and an integrated setting, there is a need to design mental health curricula for medical students, residents, and the continuing education of primary care pracuioners. Although these curricula should not du-
plicate those established for psychiatric residency training, they should define specific competencies in knowledge and skill, with instructional objectives addressing the following: psychosocial dimensions of health care, human life-span development, physical effects oflife stresses and lifestyle behaviors, psychiatric side-effects of medical problems, psychopharmacology, the usefulness of various psychotherapies, and basic psychopathology. It is essential to develop these competencies in a climate that stresses appropriate attitudes toward the psychological needs of patients. Such attitudes, built on perceptions of psychiatry'S role in health care, are continually influenced by the primary care practitioners' interaction with our specialty. We must serve as role models using a competent, empathic, and ethical approach to patient care while attending to our personal reflections on the responsibilities of mental health care providers. Finally, conscientious training of the primary care practitioner requires systematic evaluation of learning outcome, training process, and the effect of training on patient care. Evaluation is essential for an organized approach to training that consistently defines competence, encourages appropriate attitudes, establishes optimal training settings, and assesses learning progress. Using this approach at the interface of mental health and primary care, psychiatry can continue to move forward in responsible training for the mental health needsofourpatien~.
Letters to Editor Invited Brief letters commenting on published articles or other subjects of interest to readers of Psychosomatics are invited. Comments on published articles will be forwarded to the authors for reply. Correspondence may be edited and pu~lished. Write to: Wilfred Dorfman, M.D., Editor in Chief, Psychosomatics,1921 Newkirk Avenue, Brooklyn, NY 11226.
OCTOBER 1979· VOL 20 • NO 10