Managing Mental Health Problems: A Practical Guide for Primary Care

Perhaps no topic in recent memory has so gripped the discourse of practicing physicians as that of managed care. Time previously spent discussing interesting cases, new treatments, and other clinical experiences now seems consumed with the exchange of “horror stories,” disgruntlements, and new “tricks” related to managed care experiences.

In this demoralizing climate, it is indeed refreshing to discover a book that is so patient-focused, so rich in wise clinical experience and advice, and such a pleasure to read. The authors, two of the most knowledgeable clinicians working at the mental health/primary care interface, promise “to provide a practical, problem-based approach to the detection and treatment of the problems [primary care providers] encounter most frequently,” and in large measure they have achieved this.

The primary care physician is constantly being implored to provide more and better care to larger numbers of people in shorter periods of time and for less recompense. The kindly physician of decades ago, depicted as spending unlimited time at the bedside or in the consulting room comforting his (it was usually a man) patients, addressing physical, social, emotional, and even financial problems, has been replaced with a man or woman trying to offer each patient at least 10 minutes of skilled listening, efficient diagnostic and therapeutic assessment, and empathic comfort, support, and reassurance. The competing demands on the primary physician’s time and attention are extraordinary, and although 60% to 70% of primary care patients are likely to have substantial emotional problems, these are apt to be given short shrift unless the physician makes a very conscious effort to make this aspect of patient care virtually a routine part of general practice. It is toward this lofty and—some might say—unattainable goal that Kates and Craven have laudably aimed their sights.

The benefits of aiming at the primary care provider is, as the authors point out, that he or she “often has the benefit of a long-term relationship with both the patient and the family, has already earned the patient’s trust, is able to place current problems in the context of the patient’s biopsychosocial history, and can take advantage of this ongoing relationship to monitor the patient, encourage positive change, and support coping strategies”—a tall and optimistic order.

The book, reasonably enough, begins with ways of approaching the patient through interview techniques, mental health assessment, understanding the family, and principles of management. It usefully discusses community resources and mental health services, not as a sterile appendix but as a living part of every physician’s required armamentarium. As is true of the whole book, this part of the text is liberally illustrated with actual clinical material, interview techniques, “how-to” pearls, and a warm personal way of addressing the reader as “you.”

Separate chapters, each introduced sensitively as “The patient with…,” discuss specific clinical problems like anxiety, depression, grief, schizophrenia, bipolar disorder, sexual problems, sexual abuse, alcohol-related problems, and others. Preceding this group of chapters is an excellent general chapter on the patient in distress, usefully addressing ways of recognizing behavior accompanying distress and suggesting ways of approaching it. Further evidence of the book’s empathic approach is a discussion of the relevance of the physician’s own feelings in treating patients.

At the risk of suggesting that the book should be longer than it already is, I would encourage the authors (in a next edition) to expand the clinical material on panic disorder and phobia because these syndromes so often confound the acute physical presentations of patients (especially in emergency settings).

As good as the point-by-point instruction is about handling difficult cases, the authors are aware that some physicians will have difficulty applying this knowledge. Most chapters, therefore, end with a helpful section on “when to refer.” This advice may incorrectly assume that physicians know how to refer and would benefit from a more discursive amplification of the topic.

Training primary care physicians to address their patients’ emotional problems has not had promising results. Repeated studies over the years have consistently reported a 50% fail rate in psychiatric diagnosis. Some attribute this discouraging news to inadequate attention to a balanced curriculum in medical school; poor teaching by psychiatrists and other mental health professionals; lack of interest on the part of physicians whose major mindset is on “physical” medicine; insufficient time; and prejudicial reimbursement for mental health care. The travails in trying to overcome such barriers are reflected in many scholarly papers in professional journals. Many of these authors, including Kates and Craven, work diligently to find new approaches to the problem.

Concluding the book is a useful compendium of further readings, mostly books that may be of use to patients and their families as well. Although this list is generally wide-ranging and thorough, it could benefit from a few “classic” single papers, as well as some expansion of such topics as somatization and hypochondriasis. Finally, we have the index, the clues to a book’s highlights. Missing there for me are words that would reflect text on alliance, Alzheimer’s disease, adherence, confidentiality, empathy, managed care, payment, referring, and reassurance.

In 1957, Michael Balint, a British psychoanalyst/psychiatrist, wrote a book entitled The Doctor, His Patient, and the Illness (1). For several decades it served as a basic text for trainees in family practice residency and undoubtedly enhanced the clinical acumen of many practitioners. This book by Kates and Craven may well become the “contemporary Balint” text, with its updated focus on the real-life challenges of the primary care physician and the need to find ways to enhance mental health care in these times. One hopes that this book of Canadian wisdom will be translatable to all physician-patient relationships elsewhere.