Submission for the Medical Student Essay Prize in General and Community Psychiatry 2013 By Michael Shea, University of Oxford Primary Care Psychiatry: a contradiction in Terms – Discuss Abstract

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Submission for the Medical Student Essay Prize in General and Community Psychiatry 2013

By Michael Shea, University of Oxford

Primary Care Psychiatry: A Contradiction in Terms – Discuss

Abstract: Mental illnesses account for three of the top five causes of disability in high-income countries, and their treatment is part of the daily routine of general practitioners. Psychiatry, however, remains rooted in secondary care. I propose that all psychiatrists should be based in primary care within the next 15 years. Primary care is the optimal setting for psychiatric treatment for financial and resource reasons. Crucially it also offers advantages in terms of continuity of care, improved therapeutic relationship, chronic disease care, treatment of comorbidities, and reduction of stigma. All the major psychiatric conditions can be successfully treated in primary care, and the requirement for a large secondary care psychiatric service does not stand up to scrutiny.I propose that in future psychiatrists work alongside GPs and social workers in holistic primary care practices that address the biopsychosocial needs of patients at their first port of call.

Word count: 2646

Primary Care Psychiatry: A Contradiction in Terms – Discuss

Mental illness is almost ubiquitous: the two-week prevalence of anxiety and depressive disorders alone was over 16% in the Adult Psychiatric Morbidity Survey in England 1, and recent news reports claim that one in five adults is prescribed antidepressants in some parts of Wales2. The first medical port of call for many individuals with mental health problems is their general practitioner (GP). A huge burden of mental illness therefore falls on primary care, i.e. services that can be accessed without referral, simply by walking in off the street. Psychiatry, on the other hand, is seen by the public very much as a secondary or tertiary care speciality: patients are referred from primary care to see a psychiatrist at a specialist clinic or hospital. Mental illness presents in primary care yet psychiatrists work in secondary care: does this make primary care psychiatry a contradiction in terms?

Far from being a contradiction, primary care psychiatry is a tautology. Indeed, the Royal College of Psychiatrists states that “mental health problems should be managed mainly in primary care”3. As managing mental health problems is the province of psychiatry, we can only conclude that the Royal College of Psychiatrists endorses primary care psychiatry.The World Health Organisation (WHO) goes further, explicitly makingthe provision of primary care psychiatry a priority4. I would argue that the Royal College of Psychiatry and the WHO do not go far enough: within 15 years there should be no psychiatrist working outside of a primary care setting in the UK. I will present evidence that primary care is the optimal setting for psychiatric treatment in general, show that all the major psychiatric conditions can be successfully treated in primary care, and then address the objections to a purely primary care model of psychiatry. Finally, I propose that in future psychiatrists work alongside GPs and social workers in holistic primary care practicesthat address the biopsychosocial needs of patients at their first port of call.

Primary care is the best place for the treatment of mental illness in general, both in terms of patient care and in terms of resource allocation. Most mental illnesses presentin primary care: the first steps of assessment and management are therefore de facto carried out in primary care. In theory, patients with mental health problems could all be referred on to psychiatric services, but the prevalence of mental illness is such that treatment out of primary care would necessitate an impossibly large secondary care mental health network 1. For practical financial reasons, primary care has to be the main setting for psychiatry.

Primary care also offers advantages in terms of continuity of care, improved therapeutic relationship, chronic disease care, treatment of comorbidities, and reduction of stigma. In a primary care setting, a patient may be diagnosed with a mental illness in childhood and followed through the transitions to adolescence, adulthood, and eventually old age without shunting from one service to another. Many 18 year olds who struggle through the transition from a Child and Adolescent Mental Health Services (CAMHS) team to an adult Community Mental Health Team (CMHT) would benefit from this continuity. As well as an improved therapeutic relationship from prolonged contact, the primary care setting itself may foster discussions around mental health. GPs spend more time on psychosocial and emotionally supportive talk than general medicine doctors working in hospital 5.

A numberof psychiatric conditions are chronic or recurrent. Chronic medical conditions like diabetes or hypertension are often best treated in primary care, using a collaborative chronic care model6. Chronic psychiatric conditions would also likely benefit from this approach.Patients with psychiatric conditions also often have medical comorbidities, and theygenerally fare worse from these other conditions than patients without a mental health problem. For example, the mortality from cardiovascular causes is twice as high in patients with bipolar disorder as in the general population 7. Primary care can offer wide enough treatment to begin to address the comorbidities. Treating the mental illness can also directly improve other medical conditions, either through direct physiological changes in the patient, or through changes to lifestyle and treatment adherence. For example, a Cochrane review found that treatment of depression in patients with comorbid depression and diabetes not only improved patient mood, it also improved glycaemic control 8.

Mental illness is still the subject of much suspicion and prejudice 9. Because of this stigma, treatment in a primary setting might be easier to access than treatment in an overtly psychiatric institution. Some older patients may for example feel uncomfortable visiting a psychiatrist in a mental hospital for a memory clinic, but not feel the same aversion in primary care or with a geriatrician. Primary care psychiatry can play a role in de-stigmatizing mental illness by normalising its assessment and treatment 10.

The above general advantages of primary care apply to most mental illnesses. However, there is also good evidence for managing specific disorders in primary care. The ten most important mental illnesses worldwide in terms of morbidity are, in order, unipolar depression, alcohol misuse, schizophrenia, bipolar disorder, dementia, illicit drug use, panic disorder, obsessive compulsive disorder (OCD), insomnia, and post-traumatic stress disorder (PTSD) 11. All of these conditions can be successfully treated by primary care psychiatry.

Unipolar depression is the single most important cause of disability in high-income countries, and third overall worldwide 12. To manage such a prevalent condition, the National Institute for Clinical Excellence(NICE) guidelines recommend an evidence-based stepped approach with most treatment taking place in primary care 13.Patients may also express a desire to be treated in primary care. Many older people express a strong preference for staying in their own home rather than moving into a nursing home, and indeed have a right to do so where possible 14. Similarly, many patients with dementia might prefer to be managed in the community, rather than admitted to a secondary care institution. Primary care is therefore often a more humane setting for treating dementia.

Alcohol misuse is also very common in the UK.One of the first steps in treating hazardous or harmful drinking is an early brief intervention consisting usually of advice and a motivational interview 15. Brief interventions have been shown to work more consistently in primary care than in a hospital setting 16, emphasizing the importance of primary care psychiatry for addiction.Moreover, higher intensity interventions don’t seem to lead to a greater reduction in alcohol use according to the AESOPS and SIPS trials, suggesting that treatment outside of primary care would be a waste of resources17,18. The primary care setting has also been successfully used for treating drug addiction. For example, heroin users who underwent long-term opiate substitution therapy in primary care had excellent results over an 11 year follow-up, with over 50% no longer using illicit drugs 19.

Schizophrenia and bipolar disorder can present with disordered thinking or behaviour, and psychotic and manic patients make up a significant proportion of adult psychiatric inpatients. However, many patients with schizophrenia or bipolar disorder do not access secondary care. In a study of GP surgeries in the UK, nearly a third of patients receiving care for schizophrenia or bipolar disorder in primary care had no contact with secondary care 20. While we cannot know exactly how these patients differed from those that were referred, we can conclude that in the eyes of their GP, they were managing their conditions well enough in primary care not to require specialist input.With the arrival of primary care psychiatry, we can expect many more patients with psychotic illnesses to be successfully managed in the community.

Anxiety is common in both adults and children. Disorders such as panic disorder and PTSD have been successfully treated in primary care using strategies like Coordinated Anxiety and Learning Management (CALM) 21. The primary care setting may also encourage patient attendance. For example, as many veterans with PTSD require physical health services, they may be easier to reach in primary care than in specialist mental care 22. OCD can be treated in primary care by psychologists. Moreover, a controversial randomised controlled trial(RCT) even suggests that health care staff with minimal training can achieve good therapeutic results for OCD by carefully following a set protocol 23. Similarly, an RCT of cognitive behavioural therapy (CBT) for insomnia demonstrated that the technique could be successfully used by ordinary primary care staff in GP surgeries24.

The most common mental illnesses can therefore be treated in primary care most of the time. However, a number of obstacles remain to a purely primary care psychiatry model: management of severe cases as inpatients, access to specialist equipment, access to specialist services, the lack of expertise of generalist psychiatrists, and the management of forensic psychiatry cases.

Where a patient is deemed to be a danger to themselves or to others, they are currently managed as inpatients on psychiatric wards that are clearly not part of primary care. What is the evidence for this practice? The number of psychiatric inpatient beds has decreased in several countries over the last decades, without a corresponding increase in harm to patients. For example, the number of inpatient beds in Austria for patients with severe depression decreased by 30% from 1989 to 2009, but there was no rise in suicide rates 25. (The decrease in beds may have been compensated by faster turnover, however). Similarly, a decrease of 50% in acute inpatient capacity at San Francisco general hospital did not lead to any of the expected adverse events: there were no rises in demand for emergency services, no increases in suicide, and no increases in crime among the community mental health patients 26. Perhaps inpatient treatment is not as obvious a solution as is commonly assumed.

Let us however admit that some inpatient careis needed for some patients in extremis. How far does this care need to be psychiatric? If psychiatrists are based in primary care (as I propose below), then the initial assessment and prescription of medication can be done in primary care on presentation. The purpose of the acute inpatient setting can then be to provide a safe environment in the short-term, rather than necessarily to provide treatment. We can imagine a nurse-led inpatient ward reserved for those at greatest risk, seen as a safe-house while the medication begins to work rather than as a treatment centre. The primary care psychiatrist who admitted the patient would still be in charge of treatment, which would be continuous from the first presentation at the primary care surgery.

What of the complex psychiatric interventions that require a specialist setting such as electroconvulsive therapy (ECT)? It would certainly be difficult for a primary care practice to have access to the machinery for ECT and to an anaesthetist. An argument can be made however that ECT should not be carried out by secondary care psychiatrists either. In terms of infrastructure, it would be more cost-effective to set up ECT facilities within a medical hospital. As well as having access to anaesthetists and medically-trained nurses, the treatment rooms could be used for other purposes when no ECT is booked. Delivering ECT in a medical hospital might also contribute to reducing the stigma associated with the treatment, and thus increasing the number of people who could benefit from it.

The health care system currently operates on a tiered system, based on the assumption that no primary care provider can offer all services to all patients. For example, GPs currently refer patients with memory problems to a memory clinic (in secondary care), where the patients are assessed by a psychiatrist. However, the psychiatrists running the memory clinic typically remains part of a CMHT: in other words, they run a specialist clinic part of the week, and work in the community the rest of the week. It would certainly be too much of a stretch to refer to a specialist memory clinic as primary care. However, it is not unreasonable to plan for such clinics to be held in certain primary care surgeries, and delivered by primary care psychiatrists. Specialist services would therefore be at the “1.5ary” or “sesquiary” care level: patients go to a primary care surgery, patients are seen by a psychiatrist whose work is largely in primary care at that practice, but the patients have been referred by their own primary care psychiatrist.

The sesquiary model allows psychiatrist some degree of specialisation, while expecting them to work in primary care. Might it however prevent a psychiatrist from becoming truly expert in a niche? Patients with particularly complex presentations, or patients with symptoms refractory to treatment, may currently find themselves referred to a psychiatrist with very specific interests. For example, a specialist may work almost exclusively with patients with bipolar disorder, and therefore have a much greater experience of the condition and its treatment than a psychiatrist who works with the full range of mental illnesses.There is a place for such a specialist, outside of primary care, and that place is academia. Patients with particularly problematic cases may benefit from referral to research psychiatrists for assessment or enrolment in clinical trials. These academic psychiatrists would certainly fall into the secondary care rather than primary care categories. However, having a small number of academic psychiatrist conducting research does not invalidate the primary care model for the vast majority of clinicians.

Finally, can forensic psychiatric services be reconciled with primary care psychiatry? There are currently nearly 4000 psychiatric patients in high and medium security hospitals in the UK27. Other countries, however, use psychiatric services within prisons to treat mentally ill offenders.Just as there are primary care GPs working in prisons, there can be primary care psychiatrists working in prisons. Indeed, the prison population suffers from a particularly high burden of mental disorders, and may be the population most in need of primary care psychiatrists.

I therefore propose a model for primary care practices, based on the current GP surgery model, but with the integration of psychiatric and social services. GPs would still form the core of the practice, but would express an interest for working to a greater extent on the medical, psychological, or social management of patients. Alongside these GPs, primary care psychiatrists would be directly accessible to practice patients with mental health problems. The GPs could also move patients horizontally to their practice psychiatrist, or ask for psychiatric supervision on complex cases. The practice social worker or social care assistant would likewise be directly available to patients, or could help the GP or psychiatrist with the management of their patients. With clear signposting from the practice staff, many patients will be able to get the most suitable help directly. The psychiatrists would also be expected to specialise further, and to run clinics from their primary care practices (Figure 1). Some degree of coordination would be necessary to make sure that basic child, adult, and old-age psychiatric services were covered by psychiatrists in different practices in the each geopgraphical area.

Having psychiatrists working in primary care practices will not only allow the management of major psychiatric disorders in the community, it will also improve the treatment of less severe disorders. With psychiatrists working in primary care, patients with mild depression will either be seen by a psychiatrist directly, or will be seen by a GP with an interest in mental health, and with input from the practice psychiatrist. Common mental illnesses like anxiety are currently underdiagnosed by GPs 28, and only 30% of GPs report having read the NICE guidelines for conditions like OCD. Having psychiatrists on hand will therefore likely improve mental health diagnosis and treatment in primary care. Mental illness accounts for three of the top five causes of disability in high-income countries 12: it is high time that psychiatry moved to primary care to deal with this epidemic on the front line.

Figure 1: Schematic representation of a primary care practice (shaded box) that incorporates general practitioners, social workers, and primary care psychiatrists


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