Across the spectrum: Strategies to improve recognition and treatment of mental disorders in primary care

There is an abundance of published literature documenting the important role of primary care in the recognition, treatment and management of mental disorders. Despite this, general practitioners, nurses, social workers, occupational therapists, physiotherapists, and other primary health care professionals remain under acknowledged, and the multidisciplinary team arrangements needed for effective management elusive. Individual and community stigma attached to seeking help has not been removed. This chapter provides an overview of these existing barriers and outlines strategies for implementation to improve recognition and treatment of mental disorders across the spectrum in primary care. These strategies are focused on the delivery of whole person, resulting in integrated and person-centred care.

Psychosis

Treating patients with psychotic disorders like schizophrenia can be challenging for many primary care practitioners. Many health professionals are intimidated by the prospect of treating severe mental illness, and most do not have the training or experience required to deliver newer psychosis interventions.

Depressive disorders

Depressive disorders are one of the leading causes of death and disability worldwide, affect both mind and body, and are distressing for both the patient and the carer. Those with depression often experience troubles with sleeping, concentration, appetite, and a reduction in the ability to work or enjoy daily activities.

ADHD across the lifespan

Attention deficit/hyperactivity disorder (ADHD) is a chronic neuropsychiatric condition that affects most patients throughout their lives and is associated with substantial underachievement and psychosocial dysfunction. Furthermore, ADHD is associated with a greater likelihood for psychiatric comorbidity and substance related disorders. Primary care practitioners are at the forefront of helping patients with ADHD manage their symptoms and overcoming functional impairments. The differential diagnosis of ADHD is challenging and the presentation of the illness is similar to other psychiatric conditions (e.g. ADHD in adults may appear similar to mood episodes, anxiety, or personality disorder). The developmental trajectory of ADHD appears to be moderated by family environment, personality characteristics, life events, and adaptive skills. The pharmacological treatment of ADHD is highly effective with stimulants as recommended first-line medications. The clinical use of these medications will be highlighted in this chapter along with behavioural/psychotherapeutic interventions individualized for patients and families.

Untoward side effects of psychiatric drugs

Adverse effects are an unavoidable risk of medication treatment. Clinical trials alone do not adequately assess the entire side effect profile, and it is important to pay attention to post-marketing surveillance and long-term follow up studies. Psychotropic medications are responsible for a wide variety of adverse effects, which can affect almost any part/system of the body. Adverse effects can vary from mild nausea and vomiting to life-threatening blood dyscrasias and arrhythmias. A high number of adverse effects are associated with the action of the psychotropic medications on their primary targets outside the brain, and the additional action on the autonomic nervous system. In order to minimize the risk of adverse effects most psychotropic medications should be started with low-dose trials followed by slow titration. Care should be taken to look for drug-drug interactions and pre-existing medical and metabolic conditions which may pre-dispose a patient to certain adverse effects.

Major depressive disorder: how to evaluate and manage patients with psychiatric and medical comorbidities

Major depressive disorder (MDD) is a highly prevalent, chronic, and recurring mental health condition. A substantially high rate of psychiatric and medical comorbidities occurs in individuals with MDD. Furthermore, MDD and these related comorbidities often exhibit bidirectional and reciprocal relationships, where psychiatric and medical comorbidities worsen the prognosis of MDD, and vice-versa. However, the significant symptomatic overlap between MDD and other chronic psychiatric and medical comorbid conditions imposes significant challenges for the assessment and management of these patients in primary care settings. Thus, the influence of psychiatric and medical comorbidities in the treatment of MDD has increasingly become an issue of major public health concern. Collaborative care models hold promise as an effective strategy for the management MDD and comorbid conditions in primary care. This chapter comprehensively reviews evidence pertaining to the evaluation and treatment of MDD and comorbid chronic health conditions in primary care.

Psychotherapeutic interventions

Primary care physicians may offer a comprehensive care of patients having psychiatric ailments. Psychological interventions are effective in treating major depressive disorder, anxiety disorders, somatic symptom disorders, and tobacco use disorders in primary care settings. Psychotherapeutic approaches are effective either as an alternative or as an adjunct to pharmacotherapy, with enduring benefits after discontinuation of drug treatment. Psychotherapy also represents a pilot area of intervention to treat withdrawal symptoms and disorders due to the tapering or discontinuation of psychotropic medications, in particular selective serotonin reuptake inhibitors (SSRIs). This chapter illustrates the basic steps to establish routine evidence-based psychotherapy for unipolar depression, anxiety disorders, somatic symptom disorder, and substance use disorders in primary care settings. Some factors should be considered to formulate a proper treatment plan for mental disorders in primary care, including primary care physicians’ clinical judgment, availability of treatment, and patient’s preference.

Late-life depression

Depression is one of the most prevalent mental diseases in late life, and is a tremendous burden on patients, their families and carers, and the healthcare system. Late-life depression (LLD) often affects people with chronic somatic illnesses, cognitive impairment, and disability. In the elderly, core symptoms of depression are much less pronounced. Instead, unspecific somatic complaints and cognitive impairment may dominate the clinical presentation, and a significant proportion of individuals with LLD goes undiagnosed. This may lead to increased mortality rates, in part attributed to the deleterious consequences of LLD on comorbid somatic illnesses or increased suicide rates. In order to improve prognosis, general practitioners in primary care settings have a prominent but challenging role in recognizing LLD. The diagnostic challenge also includes the differential diagnosis between depression, dementia, and delirium. The optimal management of LLD may include antidepressant drugs, non-pharmacological interventions such as psychotherapy (e.g. cognitive-behavioural therapy), as well as physical exercise.

Somatic symptom and related disorders

Somatoform disorders are common in primary care and are associated with impairment and high health care costs. The biopsychosocial approach is central to the foundations of optimal care for these patients. Potential psychosocial influences on patient suffering should be identified and discussed early in the diagnostic process which is consistent with the new emphasis on positive psychological symptoms in DSM-5. Primary care practitioners (PCPs) should use a stepped-care approach when considering treatment depending on risk profiles. While patients with lower severity can be managed by the PCP, patients with a higher risk profile may need psychotherapy or other specialist care. Psychotherapy, new generation antidepressants, and natural pharmacological products are potentially effective interventions. This chapter also describes Sofu-Net, an example of a complex intervention to help strengthen the connection and communication between PCPs and psychotherapists. An alternative collaborative care approach integrates mental health care and management into primary care.

Trauma and stressor-related disorders

After a traumatic event most people experience a period of distress, and usually a resilient response is observed and no intervention is necessary. However, one-fifth of subjects can develop an Acute Stress Disorder (ASD) within the first month after exposure, and if the reaction lasts for more than a month, a diagnosis of Posttraumatic Stress Disorder (PTSD) is usually made. Despite its prevalence, PTSD is likely to be under-recognized and under-treated, mostly in primary care settings. Primary care physicians can play an important role in identifying people with symptoms of ASD and PTSD, early detection and collaborative care treatment may improve prognosis.