The Prevention of Mental Illness in Primary Care

The Prevention of Mental Illness in Primary Care

T Kendrick, A Tylee, P Freeling, editors

New York: Cambridge University Press; 1996. 398 p

This book describes the role of primary care physicians in the prevention of mental disorders. The literature consistently reports that 25% to 30% of patients presenting in primary care have significant psychological problems. The book is divided into 3 sections dealing with the major types of illness prevention: primary (risk factors), secondary (early identification and intervention), and tertiary (decreasing complications and recurrence). These distinctions are not consistently followed, but overlap between sections is avoided. Each chapter is well referenced, and most chapters cover the subject adequately. A preventive model of conceptualizing problems is employed, but the flaw in this approach to primary prevention is acknowledged. Many known risk factors, such as social, economic, and societal conditions and attitudes, cannot be modified by primary care professionals. Effort must be directed primarily at high-risk patients. The authors recognize that some physicians lack sufficient interest and ability to diagnose and manage psychiatric illness and throughout the book suggest ways to address this problem.

Chapters 1, 9, and 15 deal with primary, secondary, and tertiary prevention of childhood psychiatric disorders. Risk factors in the child, parenting, and environment, as well as protective factors, are very well described. Most children are seen regularly in primary care, which gives these practitioners a unique opportunity to employ all 3 types of prevention. When disorders are detected, care must be taken to avoid inappropriate reassurance and unnecessary pharmacotherapy. The role of the family in the management of chronically ill and disabled children is emphasized, along with the need to provide support to the parents. Chapter 3, on the relevance of life events in mental illness, relies mainly on the work of George Brown and his colleagues. A practical guide for intervention strategies is also included. Prevention of postnatal depression, a distinct diagnosis in British psychiatry, is discussed in Chapter 4. The unique opportunity for primary care physicians to detect this disabling condition is emphasized, but the suggested role for health care visitors is generally unavailable in this country. Chapter 5, on bereavement, has a good description of normal grief and an excellent discussion of risk factors for abnormal grief reactions. Practical suggestions for the appropriate use of counseling and medication are included.

Chapter 6, on prevention in ethnic minorities, is quite specific to British society, although the principles of how physicians perceive, interpret, and treat psychiatric problems in ethnic patients are universally applicable. The chapter on “learning disability” is initially confusing because in Britain, unlike North America, the term refers to developmental delay. The references suggest that 33% to 66% of children with “learning disability” have significant psychopathology. The important role of primary care practitioners in secondary prevention is discussed, but the use of a team for management is seldom feasible for Canadian family doctors. Chapter 8 contains a general discussion of the importance of good counseling skills but again assumes the existence of a primary care “team” of professionals.

Chapters 10, 16, and 17 describe secondary and tertiary prevention of depression. This common and treatable disorder is frequently unrecognized in general practice both because of the symptoms presented (often somatic) and the knowledge, skills, and attitudes of physicians. Ways to improve the detection rate are described, and an excellent section on long-term drug management is presented. The particularly important role of general practitioners in encouraging compliance is acknowledged. Discussion of psycho-therapeutic interventions in the management of depression is limited to a good description of cognitive therapy. Primary and secondary prevention of anxiety disorders is addressed in Chapter 11, which includes a discussion of the physical, behavioral, and environmental factors that maintain anxiety symptoms. The author recommends and briefly describes nonpharmacological management techniques, although the use of a team approach is again assumed. Chapter 12, on eating disorders, addresses the well-recognized problems in primary prevention that deeply ingrained societal attitudes are impossible to change and that prevention programs sometimes increase unwanted behaviors (for example, binging and purging). The physical consequences of these disorders are well outlined, but little reference is made to the psychological and social sequelae. Detection of eating disorders is a major responsibility of general practitioners but requires a high level of awareness of risk factors and signs and symptoms — these patients are often very secretive. Not discussed is the role of physicians in monitoring physical health or supportive counseling as an adjunct for their patients who attend specialized treatment programs. Chapter 13, on alcohol and drugs, describes the detection and management of alcohol abuse, as well as the primary prevention of medication abuse by judicious prescribing practices. Because drug seeking from multiple physicians is uncommon under the British system, the problem is not mentioned in this book. Psychosis, primarily schizophrenia, is discussed in Chapters 14, 18, 19, and 20. As in Canada, general practitioners are now expected to detect and treat 1st-episode psychosis, and the importance of early pharmacological treatment is emphasized. Increasingly, patients are managed for the long term in primary care, and physicians must be aware of the special physical, psychological, and social needs of this vulnerable group and be cognizant of the high suicide risk. Social management of patients with schizophrenia is well described, with emphasis on the role of families. In Canada, the functions proposed for primary caregivers are provided, if at all, by specialized mental health services. Finally, Chapter 21 briefly discusses suicide prevention in primary care. The major roles are to recognize patients at risk, provide treatment and/or referral, and offer support for staff and families when suicide occurs.

The authors of this book are academics from general practice and psychiatry backgrounds. The intended audience is primary care physicians and their teams, but the book should also be read by psychiatrists and mental health professionals who treat patients also seen by family doctors and who teach medical students and residents. In conclusion, this is a very readable volume which is well researched and which provides good recommendations, although some are not applicable to the Canadian system.