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Mental disorders are common in medical practice and may present either as a primary disorder or as a comorbid condition. The prevalence of mental or substance use disorders in the United States is approximately 30%, only one-third of whom are currently receiving treatment. Global burden of disease statistics indicate that 4 of the 10 most important causes of disease worldwide are psychiatric in origin.


The revised fourth edition for use by primary care physicians of the Diagnostic and Statistical Manual (DSM-IV-PC) provides a useful synopsis of mental disorders most likely to be seen in primary care practice. The current system of classification is multiaxial and includes the presence or absence of a major mental disorder (axis I), any underlying personality disorder (axis II), general medical condition (axis III), psychosocial and environmental problems (axis IV), and overall rating of general psychosocial functioning (axis V).


Changes in health care delivery underscore the need for primary care physicians to assume responsibility for the initial diagnosis and treatment of the most common mental disorders. Prompt diagnosis is essential to ensure that patients have access to appropriate medical services and to maximize the clinical outcome. Validated patient-based questionnaires have been developed that systematically probe for signs and symptoms associated with the most prevalent psychiatric diagnoses and guide the clinician into targeted assessment. Prime MD (and a self-report form, the PHQ) and the Symptom-Driven Diagnostic System for Primary Care (SDDS-PC) are inventories that require only 10 minutes to complete and link patient responses to the formal diagnostic criteria of anxiety, mood, somatoform, and eating disorders and to alcohol abuse or dependence.


A physician who refers patients to a psychiatrist should know not only when doing so is appropriate but also how to refer, since societal misconceptions and the stigma of mental illness impede the process. Primary care physicians should base referrals to a psychiatrist on the presence of signs and symptoms of a mental disorder and not simply on the absence of a physical explanation for a patient's complaint. The physician should discuss with the patient the reasons for requesting the referral or consultation and provide reassurance that he or she will continue to provide medical care and work collaboratively with the mental health professional. Consultation with a psychiatrist or transfer of care is appropriate when physicians encounter evidence of psychotic symptoms, mania, severe depression, or anxiety; symptoms of posttraumatic stress disorder (PTSD); suicidal or homicidal preoccupation; or a failure to respond to first-order treatment. Eating disorders are discussed in Chap. 79, and the biology of psychiatric and addictive disorders in Chap. 390.


Anxiety disorders, the most prevalent psychiatric illnesses in the general community, are present in 15–20% of medical clinic patients. Anxiety, defined as a subjective sense of unease, dread, or foreboding, can indicate a primary psychiatric condition or can be a component of, or reaction to, a primary medical disease. The primary anxiety disorders are classified according ...

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