Psychiatry in primary care

A quarter or more of consultations in primary care (general practice) appear to have a substantial psychological component, although the patient's presenting complaint is usually a somatic one and the underlying emotional disturbance may not be recognized by the doctor. Mixed neurotic symptoms, often accompanied by social or interpersonal problems, predominate. About 90 per cent of patients with psychiatric disorder are managed solely in primary care, and many episodes resolve quickly without specific treatment, or with brief counselling; some general practices employ their own counsellors.

Some patients require psychotropic drug therapy, and antidepressants, although often prescribed in lower doses and for shorter courses than most psychiatrists would recommend, are effective. However, in many milder cases, they are probably acting as placebos. Benzodiazepines are recommended for short periods only, but many GPs now avoid prescribing them at all.

GPs are also involved, in collaboration with psychiatric and social services, in the care of those with more severe illnesses such as schizophrenia and affective disorder, which require long-term medication and supervision. Besides being providers of primary mental health care, GPs are involved in shaping local psychiatric services.

At the time of the preparation of the previous edition of this book, 'fundholding GPs' were being introduced; the idea was that they would have a budget to purchase the services they considered necessary, including mental health services, for their patients. Political changes caused fundholding to be jettisoned, although, as is the way with the NHS, it now seems to be coming back under a different name, practice-based commissioning.

At the time of writing, it is difficult to predict the real impact of these changes. In principle, any move to build up primary care, which provides 90 per cent of NHS care, but gets only 10 per cent of the budget, has the potential to benefit low-tech specialties such as mental health care, and prevent further waste of money in the modern overspecialized and overtechnical general hospital. It will probably accelerate the trend to base CPNs and other mental health care staff at least partly in GP health centres.

There is a dynamic tension here between the possible benefits of such changes, and the real concern about such specialist resources being directed toward the 'worried well', and away from patients with severe chronic psychiatric illness.

One problem, which is unlikely to be solved completely by the changes proposed, is the apparently unlimited demand for 'counselling'. Some areas are trying out 'graduate mental health-care workers', that is, graduates who have received a modicum of training in CBT, as a way of trying to satisfy this demand.

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