Physical and Behavioral Health: Two Peas, One Pod
“The mind may undoubtedly affect the body; but the body also affects the mind. There is a re-action between them; and by lessening it on either side, you diminish the pain on both.”
These words of Leigh Hunt (a contemporary of the 19th century romantic poet John Keats) capture precisely the inextricable connection between physical and mental disorders and consequently the need for every medical provider to have some fundamental skills in behavioral health. Depression and anxiety are the second and fifth leading cause of years lived with disability in the United States and are as prevalent in primary care as common medical disorders such as hypertension, diabetes and arthritis.1 In addition, more patients with these common mental disorders are treated in primary care than in mental health settings.2 Substance use disorders and somatization (medically unexplained physical symptoms that are often an expression of psychological distress) are two other prevalent conditions which along with depression and anxiety constitute the DASS tetrad, which should be a core behavioral health curriculum.
Smith and colleagues embrace this concept of a core curriculum and their efforts have produced an efficient manual for evaluating and managing the behavioral health conditions of greatest relevance to primary care as well as other nonmental health providers. Unusual for a textbook, however, this primer is also highly readable with many memorable messages and teaching points. It can be read cover-to-cover (for those desiring an overview) or referenced at point of care when treating a specific disorder. The style is neither turgid nor encyclopedic but rather crisp and succinct. For example, the authors suggest a useful therapeutic message to patients suffering from anxiety: “Confronting what makes you anxious makes it better, avoiding what makes you anxious makes it worse.” This is a patient-centered way of expressing one of the core tenets of exposure therapy for anxiety disorders. As another example, the authors offer a pearl for recognizing borderline personality disorder by “the phenomenon of ‘splitting’ where the patient pits some staff against another. Clinicians will often discover that clinic staff has wide-ranging opinions about these patients for this reason. For example, if you find that certain office staff can’t stand the patient while others quite like them, look for a borderline personality.”
I found this book to be organized into 3 major compartments. First, there are the disorders that often will be treated in primary care either exclusively or in collaboration with mental health. These are the DASS tetrad conditions, covered in Chapters 2, 4, 5, and 6. Useful screening tools are provided (which in some cases can also be used for monitoring treatment) that are essential to the measurement-based component underlying evidence-based mental health care. After all, we would not diagnose or treat hypertension and diabetes without blood pressure readings or glucose monitoring. The brief validated measures that exist for depression, anxiety, somatization, and other mental disorders are invaluable instruments for busy clinicians. The authors also provide concise tables on disorder-specific medications and other treatments.
A second compartment of the book covers those disorders which may best be treated by psychiatrists, psychologists, or other specialists but require recognition in primary care as well as comanagement of medical problems. These include the psychotic disorders (schizophrenia and bipolar disorder), personality disorders, and other mental disorders such as attention deficit-hyperactivity disorder, eating disorders, cognitive impairment, and end-of-life palliative care issues. Chapters 8, 9, and 10 will assist the clinician in recognizing these disorders as well as sorting out what to manage in primary care versus when to refer.
A third and particularly unique compartment of this book are those chapters articulating the models and processes for behavioral health care. These include three axioms of mental health care (Chapter 1), the mental health care model (Chapter 3), and the diagnostic interview (Chapter 7). Whereas the first 2 compartments focus on the knowledge needed to care for common behavioral conditions, this third compartment focuses on the requisite skills. The authors have done seminal studies over several decades on interviewing and communicating with patients, and their findings are encapsulated in these chapters. Building on George Engel’s foundational work on the biopsychosocial model of clinical care, Smith and colleagues have done more evidence-based work in this area (including randomized trials) than any other educators while at the same time distilling their science into what is actually workable in clinical practice. Three examples are illustrative. Chapter 3 uses the ECGN acronym to capture the 4 principles of behavioral treatment: Educating the patient, obtaining a Commitment to treatment, establishing Goals for treatment, and Negotiating a specific treatment plan. The same chapter operationalizes a way to be empathic. To cite the authors:
While teachers often told you to “be empathic,” they seldom indicated exactly how to do that. Yet many clinicians feel helpless or confused when their patients become emotional, wondering with discomfort, “What do I do? He’s crying.” Consequently, we have devised an effective way to deal with this. In our model, we identify four empathic skills, sometimes descriptively called emotion-handling skills …, that help you respond to a patient’s emotions: Name the emotion. Understand the emotion. Respect the emotion. Support the emotion. They are recalled by the mnemonic NURS. For example, the clinician might say: “You were pretty angry (naming). I can understand that (understanding) after all you have been through (respecting). Thanks for sharing that (respecting). This helps me to better meet your needs (supporting).”
Chapter 5 provides an A-B-C model for patients distressed by the physical symptoms accompanying an anxiety disorder. For example, a person experiencing a panic attack is alarmed by the cardiopulmonary symptoms, believes a heart attack is eminent, and copes by calling 911 or going to the emergency room. After a successful intervention, the A-B-C is converted to: ALARM: “Here we go again, the emergency room doctor and my primary care doctor said this might happen again before my medication started to work fully.” BELIEF: “I’m having another panic attack. This will be unpleasant but not dangerous to me.” COPING: “I will sit down, start my mindfulness and breathing control exercises and manage this.”
This is not just another psychiatry book but instead a reconceptualization of mental health care and its education. It integrates rather than partitions the management of physical and psychological symptoms. It enables the nonmental health provider to manage the common problems seen on a daily basis and to recognize who and when to refer. It operationalizes Engel’s biopsychosocial model in a way that it can be actually implemented rather than given mere lip service. It also tackles in some detail topics that are particularly timely, such as the opioid crisis and how to manage tapering or discontinuation. Whereas the target audience is primary care, the messages in this book are also salient to all medical and surgical specialists. The DASS tetrad and the essential communication skills to identify and deal with symptoms related to mental health (if only to recognize, acknowledge, and refer) are relevant to all health care disciplines. This book can serve as a core text for behavioral health curricula that are used in the training of medical students, residents, and other health care professionals as well as a companion guide to practicing clinicians.
The famous Roman orator, Cicero, once said: “In proportion as the strength of the mind is greater than that of the body, so those ills are more severe that are contracted in the mind than those contracted in the body.” Smith and colleagues’ goal is to prepare clinicians caring for the “body” to give proportionate attention to illnesses traditionally associated with the “mind.” In modern parlance, we might preferentially use terms such as “body-brain,” “physical-psychological,” or “medical-mental.” Whatever the terminology, this Cartesian dualism is not only dated but in some cases counterproductive for patient-centered care. Medical and behavioral symptoms are 2 peas coexisting in 1 pod.3 Treating one category while ignoring the other is detrimental to the outcomes of both.
Chancellor’s Professor of Medicine, Indiana
University School of Medicine
Research Scientist, Regenstrief Institute
Kroenke K, Unutzer J. Closing the false divide: sustainable approaches to Integrating mental health services into primary care. J Gen Intern Med. 2017;32(4):404-410.
Olfson M, Kroenke K, Wang S, Blanco C. Trends in office-based mental health care provided by psychiatrists and primary care physicians. J Clin Psychiatry. 2014;75(3):247-253.
Kroenke K. A practical and evidence-based approach to common symptoms: a narrative review. Ann Intern Med. 2014;161(8):579-586.