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Psychiatry in Primary Care. Fourth Edition

Richard Balon, MD

Wayne State University, Detroit, MI, USA

By Patricia R. Casey and Richard Byng. New York, NY: Cambridge University Press; 2011; ISBN 978-0-521-759823; pp 420; $65 (paperback, with CD-ROM).

Providing care for mental illness in the primary care setting has been a long desired goal of many health care systems. The rationale is that, as pointed out in the Foreword to this book, “Psychiatric problems are common in primary care, with about one-third of consultations having a mental health component to them” (p xi). In my mind, it is for no other reason than economic ones that various health care systems assume that because mental health problems are very common in primary care, primary care physicians must manage them. As if these physicians are not already overloaded and could easily include the care of mentally ill—care requiring more time than many other tasks—into their practice. Numerous “primary psychiatry” books have been published to help primary care physicians with this task. One of these books is Psychiatry in Primary Care (now in its fourth edition) written mostly by Patricia R. Casey, Professor of Psychiatry, University College Dublin, and Consultant Psychiatrist, Mater Misericordiae University Hospital, Dublin, Ireland, and Richard Byng, Clinical Senior Lecturer in Primary Care, Peninsula Medical School, and a General Practitioner with Special Interest in Mental Health, Plymouth Teaching Primary Care Trust, Plymouth, United Kingdom, with several guest contributors.

The book is divided into 5 sections (23 chapters), and also contains an Appendix on alternative and complementary therapies and a CD with audio demonstrations of cognitive therapy, problem-solving therapy, and solution-focused therapy. Section 1, “The scope of the problem and engaging with patients,” covers the scope and extent of mental health problems in primary care; the central position of primary care in the detection and treatment of psychiatric disorder; the consultation in primary care; and a treatise on how psychiatric disorders are described and classified. The authors write that “the high prevalence of psychiatric disorders identified in primary care has led to recommendations that patients in primary care be routinely screened for mental disorders…” (p 5), yet “…routine use of a screening questionnaire is not supported by the available best evidence” (p 5). They suggest that there “…may be benefits from screening high-risk groups” (p 5). This ambiguity signalizes some of the weaknesses of this book. Chapter 2, which emphasizes the “central position of primary care in detecting and treating mental disorders,” ends with caveats such as, “fewer than 10% of those with psychological disturbances are referred to the psychiatric service” (p 13) and “increasing complexity of community-based mental health services and more varied mental health functions in primary care indicate a need for a more complex model” (p 13). One may question the need for a more complex model within primary care. The chapter on consultation in primary care presents a rather ordinary and simplistic recipe for patient evaluation and referral (components of a good consultation, history taking, letter writing, etc.). The text is full of fillers such as, “Achieving recognition by a mutual agreement about diagnosis and understanding about the patient’s emotional distress appears to involve a number of important stages.” The chapter on diagnosis and classification provides some rudimentary information on classification and differences between the DSM and ICD in the area of mental illness. It again ends with a useless statement: “A classification for use in primary care has been developed but its value has yet to be convincingly demonstrated” (p 31). One may again wonder, why another classification?

Section 2, “Psychiatric diagnoses in adults,” covers various areas of adult psychopathology, such as adjustment to stress, anxiety disorders, mood disorders, psychosis, personality disorder, substance misuse, suicidal and self-harming behavior, and problems of the mind and body (eg, medically unexplained symptoms and somatoform disorders but also premenstrual dysphoric disorder, chronic fatigue, fibromyalgia, feigned symptoms, and a brief review of sleep disorders). The most interesting and useful is the chapter on adjusting to stress, as it covers the entire range of reaction to stress and dealing with it—from normal adaptive reaction to adjustment disorder, acute stress reactions, and posttraumatic stress disorder; it also includes bereavement and normal and abnormal grief. The rest of the chapters are standard, brief reviews of a particular topic. The management parts are hindered by 2 major flaws of the entire book: a) this book clearly is written for a primary care physician in the United Kingdom and from their point of view; and b) the chapters on particular disorders include an unsatisfactory, brief, and superficial psychopharmacology management discussion. There is no separate section on psychopharmacology, while an entire section of this book is devoted to nonpharmacologic therapies. Interestingly, the chapter on sexual disorders is placed in the section on nonpharmacologic therapies and not in this part of the book. The fact that the book really is intended for practitioners in the United Kingdom and Ireland also is reflected in psychopharmacology discussions of various disorders—eg, the chapter on mood disorders does not mention bupropion, yet includes antidepressants not available in the United States (the pharmacotherapy of mood disorders is marred by many typos, lack of discussion of sexual side effects of antidepressants, and other problems). The chapter on schizophrenia again brings in filler statements such as “Kraepelin and Bleuler are the founding fathers of the concept of schizophrenia and Bleuler described the core symptoms, known colloquially as the four A’s…” (p 96). The chapter on personality disorders, like the rest of the book, uses the ICD classification of personality disorders. Interestingly, it also discusses impulse and habit disorders and adult attention-deficit/hyperactivity disorder (ADHD). This is an interesting concept. However, I am not sure if I agree with the statement, “This disorder (ADHD) is incorporated into this chapter since personality disorder is a common complication of severe, untreated ADHD” (p 134). The discussion of substance misuse devotes a lot of space to alcohol and benzodiazepines. The authors suggest that the “controlled drinking” approach to the management of alcohol misuse should not be dismissed out of hand.

Section 3, “Psychiatric problems and diagnoses through the life cycle,” includes chapters on child, adolescent (which covers eating disorders), and older adult (I expected a bit more “medically” oriented advice in this chapter) mental health care.

Section 4, “Non-pharmacologic therapies,” consists of 3 chapters on psychological therapies (cognitive-behavioral, problem-solving, and solution-focused—all 3 of which are covered on the included CD-ROM), systemic family therapy, and sexual disorders. The chapter on sexual disorders is quite superficial—eg, mentioning dapoxetine and “many other antidepressants” (p 298) for treatment of premature ejaculation, lack of discussion of possible side effects of testosterone in women, and not mentioning lubricants for female arousal problems.

The last section, “The wider mental health system,” covers topics such as care for people with enduring and complex common mental health problems; primary health care team and mental health care; mental health services and how they relate to primary care; providing care for people from diverse backgrounds; and capacity, compulsory admission and treatment. The most valuable is the discussion of care for people with enduring problems. The discussion of primary health care teams and mental health care includes a listing of common and new roles of primary care physicians. I am not sure how realistic some of these goals are, eg, developing more specific psychological skills, such as cognitive-behavioral and solution-focused approaches (p 327). Some chapters are just another hodgepodge brief review of complicated topics.

I was not thrilled with this book. I will start with listing of its good features: inclusion of recommended reading for primary care physicians, good books for patients, case discussions, websites, and the CD-ROM with examples of therapies. I almost liked some chapters, eg, chapter 5: “Adjustment to stress.” Some conceptualizations—adjustment to stress; personality disorders—are interesting and refreshing.

However, the weaknesses of this book outweigh any positive features. I was puzzled by the superficial coverage of psychopharmacology and by the devotion of an entire section to psychological treatments, as I cannot imagine busy primary care physicians conducting psychotherapies and being superficially educated about psychotropic medications. Like other books in this area, this volume focuses more on how to do it (lame job) than when to refer a patient to a psychiatrist. It is probably a reflection of the United Kingdom’s mental health care system where psychiatrists seem to be relegated to a consulting role rather than a managing one. I was not clear who—primary care vs psychiatry—should do what. The book will not be of much use to primary care physicians outside of the United Kingdom. Parts of it could be inspirational reading but not the resource to grab when looking for practical advice. I have read informative and refreshing books on mental health from the United Kingdom; this one is not one of them. Its reading reminded me of the old saying, “the road to hell is paved with good intentions.”