Mental health policy and practice across Europe: an overview

Mental health disorders in primary care
Mental health problems in primary care 217
A distinction is often made between ‘severe and long-term mental health
disorders’ (most often associated with schizophrenia), and ‘common mental
health disorders’ (most often associated with anxiety and depression). Although
primary care has an important role to play in the management of more severe
disorders, recent policy in the United Kingdom has highlighted the role of
specialist services (such as community mental health teams – CMHTs) in their
management. ‘Common’ disorders are viewed as being more appropriately
within the remit of primary care, partly by default, as specialist services have
refocused their energies, and partly by design, as primary care is seen as being
able to provide appropriate, patient-sensitive care to this population.
‘Common’ disorders can be described using the standard diagnostic classifications
(WHO 1992; Ustun et al. 1995), but a more useful typology for present
purposes has been presented (Goldberg and Gournay 1997) which defines three
key categories of disorders in terms of the availability of relevant pharmacological
and non-pharmacological treatments, and the roles of the primary care
team. The categories are:
1 Well-defined disorders which are also associated with disability, for which
there are effective pharmacological and psychological treatments. Even when
these disorders remit, they are likely to relapse once more. These include
anxious depression, pure depression, generalized anxiety, panic disorder and
obsessive-compulsive disorder. These disorders can usually be managed
entirely within primary care.
2 Disorders where drugs have a more limited role, but where psychological
therapies are available, including somatized presentations of distress, panic
disorders with agoraphobia and eating disorders. These disorders are rarely
treated within primary care, and only a small proportion of cases are treated
by specialist services.
3 Disorders which resolve spontaneously, including bereavement and adjustment
disorder. In these cases, supportive help, rather than a specific mental
health skill, is required.
Primary care services for common mental disorders
Generally, primary care services for mental health problems are viewed in terms
of a ‘pathways to care’ model (Goldberg and Huxley 1980, 1992). The pathway
has five levels and four filters (see Figure 9.1). Of all those individuals in the
community, a high proportion consult their doctor in any one year while a lesser
number suffer an episode of psychological illness during the same time span.
These patients pass the first filter (‘the decision to consult’). Of those reaching
primary care services, a proportion is recognized by the primary care clinician
as suffering from psychiatric disturbance and thus pass the second filter (‘ability
to detect a disorder’). Passing the third and fourth filters involves referral to
specialist psychiatric services or admission as inpatients. Although there may
be exceptions to this referral process, and variations depending on the local