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Book Review

Primary Care Mental Health

Ethan S. Rofman, MD

Published: July 15, 2011

Primary Care Mental Health

edited by Linda Gask, PhD; Helen Lester, MD; Tony Kendrick, MD; and Robert Peveler, DPhil. RC Psych Publications, London, England, 2009, 490 pages, £35 ($70.00) (hardcover).

This clearly written and well-edited overview of the growing movement to provide mental health services in primary care settings is designed to meet the needs of clinicians working in primary care settings as well as administrators who plan and make policy for systems of health care. It was commissioned by the Royal College of Psychiatrists, and, not surprisingly, 76% of its contributors come from the United Kingdom, with only 1 coming from the United States. As a result, the book has a decidedly UK and international perspective that brings US readers creative insight as to how our primary care and mental health systems might better function together were our overall health care system more structured and coordinated. At the present time, its lessons may be most relevant to large, centrally organized US medical groups such as Kaiser-Permanente, Geisinger Health System, and the US Veterans Health Administration, although smaller local groups should also find them helpful.

The book is divided into 4 parts. Part I, "Conceptual Basis and Overarching Themes," covers the conceptual basis of primary care/mental health and includes chapters on definition, international policy perspectives, service user perspectives, diagnosis and classification, low- and middle-income countries’ view of mental health and primary care, and sociological and epidemiologic views of mental health and illness.

Part II, "Clinical Issues," designed for the practitioner, contains information on specific clinical situations and diagnoses such as suicide and self-harm, emergencies, depression, anxiety, psychosis, alcohol/substance misuse, and eating disorders. It then explores broader areas of practice such as perinatal health, sexual problems, medically unexplained symptoms, and the treatment of special populations such as the young and the old, ethnic minorities, asylum seekers, and refugees.

Part III, "Policy and Practice," presents policy and practice issues such as mental health promotion and prevention, improving the quality of primary care mental health, psychological treatments, and the role of nurses and includes a discussion of the strengths and weaknesses of care delivery models such as stepped care and collaborative care.

Part IV, "Reflective Practice," contains chapters on teaching, research, and the use of clinical guidelines and on the psychological needs of primary care and mental health professionals, especially physicians.

For psychiatrists and/or administrators responsible for implementing primary care mental health integration, Parts I and III of this book provide helpful background advice in addressing a number of theoretical and practical issues that inevitably arise when establishing an integrated clinic. The chapter "Collaborative Care and Stepped Care: Innovations for Common Mental Disorders" points out 5 goals essential to ameliorating the burden of common mental health problems that present to primary care: access, effectiveness, efficiency, equity, and patient-centered focus. Two models of service delivery, collaborative care and stepped care, are described. They are both noted to have strengths and weaknesses in these 5 areas. The evidence base concerning both of these models is well presented and illustrated by a case study in 2 demonstration sites.

The chapters of Part II provide excellent overviews of the common problems encountered in a primary care setting with practical advice as to how to treat them. These are like a mini-textbook of psychiatry for clinicians practicing in a primary care setting. The chapter titled "Suicide and Self-Harm" contains especially useful tables on screening and assessing suicide risk and then managing suicidal behavior. The summaries of worldwide suicide prevention strategies and their outcomes bring together very useful information for administrators who have responsibility for preventing suicide in defined populations.

The book concludes with a wonderful epilogue entitled "Racing Pigeons and Rolling Rocks: Reflections on Complex Problems in Primary Care," written by Christopher Dowrick, a Professor of Primary Medical Care at the University of Liverpool. It reveals the thinking of a busy primary care physician confronted with a patient who has alcoholism, diabetes, peripheral neuropathy, and depression. After the patient reveals he has no purpose in life anymore, a possible breakthrough occurs when Dr Dowrick discovers that, despite his many problems, the patient still has a passion for racing pigeons. The patient takes pleasure in caring for them, racing them, and appreciating their beauty and grace in flight. In discovering this element of meaning in his patient’s life, Dr Dowrick comments that he discovered a "basis for discussion, and a mutual respect which may—in time—enable us to change a few things together." This collaborative, pragmatic, existentially caring attitude is present throughout this book and directly and indirectly conveys a message that if put in practice by collaborating primary care and mental health professionals would greatly enhance the effectiveness, efficiency, and patient-centeredness of all primary care/mental health systems.

Ethan S. Rofman, MD

Author affiliations: Tufts Health Plan, Watertown; and Boston University School of Medicine, Boston, Massachusetts. Potential conflicts of interest: None reported.

Volume: 72

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