I am pleased to write this Foreword to Bob Smith’s textbook on psychiatry in primary care. We were both friends and colleagues of Dr. Wayne Katon who was a pioneer in the diagnosis and treatment of psychiatric disorders in primary care settings. Dr. Katon was also a mentor to me here at the University of Washington where I worked with him for 30 years before his untimely death in 2015. It was Wayne’s genius to recognize that depression and other common psychiatric disorders more often present themselves in the form of physical symptoms to primary care providers than in the form of psychological symptoms to mental health providers. Primary care is indeed our “de facto mental health care system.”
In this book, Dr. Smith builds on the research of the past 30 years by presenting an accessible and comprehensive approach to diagnosing and treating common psychiatric disorders in primary care. He begins by addressing the dualism that still infects much of medical care. This dualism can be found in the belief that clinicians should consider mental disorders only after physical disorders have been “ruled out” as a cause for presenting symptoms. This dualism is a serious mistake because “mental and medical disorders often coexist,” which is Axiom 1 in Smith’s model. Indeed, the likelihood of mental disorders increases in the presence of chronic or severe medical disorders.
These mental disorders often present with physical symptoms (Smith’s Axiom 2). For example, a small minority of patients presenting to the emergency department with chest pain have myocardial ischemia. An even smaller minority are having a myocardial infarction. Yet this is where all our clinical attention is directed. Perhaps this is necessary in the emergency department, but it is clearly inadequate in primary care practice, where comprehensive and longitudinal care of patients is provided. Some patients presenting with chest pain may have panic disorder and no myocardial ischemia. Other patients presenting with chest pain may have panic disorder and myocardial ischemia. This is an example of Smith’s Axiom 3, that “there are two types of chronic physical symptom presentations of a mental disorder—medical disease and medically unexplained symptoms.” Appropriate care of the patient with both panic disorder and myocardial ischemia must address both of these disorders. It is not adequate to address the ischemia and hope that the panic disorder will go away. Many of these patients will continue to return to the emergency department until they have received effective treatment of their panic disorder.
I currently provide psychiatric consultation in the University of Washington Medical Center Regional Heart Center and in our Center for Pain Relief. All the patients I see in the Regional Heart Center have both heart disorders and psychiatric disorders. This pattern of comorbidity can lead to worse quality of life, increased symptom burden, impaired function, poor adherence to medications and exercise, persistent unhealthy behaviors like smoking and drinking, and difficult relationships with medical providers. I started consulting in this cardiology clinic after a decade of research into the effects of depression on cardiac outcomes. Initially, many of the cardiologists in the clinic wondered what I was doing in their clinic. But now they send me many of their most difficult patients and my schedule is always full.
My role may be yet more essential in our Center for Pain Relief. This clinic specializes in the treatment of patients with chronic noncancer pain. We see patients with chronic painful conditions of various kinds: low back pain, fibromyalgia, neck pain, headache, and neuropathic pain. Psychiatric comorbidity is even more common and important here than in the cardiology clinic. Depression is very common, but we are recently coming to appreciate the importance of posttraumatic stress disorder (PTSD) as well. We encourage all new patients coming to the clinic to complete a battery of outcome and risk stratification measures called PainTracker.1 In a recent study, we were able to show that the number of PTSD symptom domains endorsed by new patients was significantly associated with ALL the outcome and risk measures that we assessed with PainTracker.2 This included not only the severity of anxiety (GAD-7) and depressive (PHQ-9) symptoms and sleep disturbance, but pain severity, pain activity interference and physical function. Substance abuse risk (including both alcohol and opioids) were also significantly related to PTSD symptoms.
The strong association of chronic pain with depression has been recognized for some time. Chronic pain increases the risk of depression, and depression increases the risk of chronic pain. They also interfere with treatment of the other condition. Antidepressants and psychotherapy don’t work as well to treat depression in patients who also have chronic pain. Similarly, opioid and nonopioid treatments of chronic pain don’t work as well in the presence of depression. It is difficult to activate patients with chronic pain who are also depressed.3
The rise of opioid therapy for chronic pain presents another important reason to integrate psychiatric expertise into primary care.4 Although early 20th century psychiatric textbooks often recommended opioids for treatment of both mania and melancholia (depression), there is no controlled evidence of lasting benefit. Patients may obtain some relief of anxiety and insomnia at the cost of opioid dependence and its many side effects. In fact, there are multiple observational studies that suggest that long-term opioid therapy may increase the risk of incident, recurrent and treatment-resistant forms of major depression.5,6 There is also evidence that depression increases the risk that patients prescribed long-term opioid therapy will progress to nonmedical use of opioids and possibly opioid use disorder. Attention to depression is a necessary component of responsible administration of long-term opioid therapy.7
Perhaps the most important reason of all for developing psychiatric expertise in the primary care work force is that comorbid psychiatric disorders make the management of chronic illness—that is the bread and butter of primary care—much more difficult. Not only are the symptoms, functional status and quality of life of patients with chronic illnesses like diabetes much worse, their participation in their own health care is also impaired. Depressed patients often do not adhere to recommendations concerning medications, diet, and exercise. They are not effective agents in their own health care. Indeed, depressed patients are not effective agents in their lives generally. Restoring this agency is a core responsibility of health care.8
In summary, Dr. Smith has produced an eminently practical and readable guide to the diagnosis and treatment of psychiatric disorders in primary care. I urge you to read it and take it to heart. Your patients will thank you for it.
Mark D. Sullivan, MD, PhD
Langford DJ, Tauben DJ, Sturgeon JA, Godfrey DS, Sullivan MD, Doorenbos AZ. Treat the patient, not the pain: using a multidimensional assessment tool to facilitate patient-centered chronic pain care. J Gen Intern Med. 2018;33(8):1235-1238.
Langford DJ, Theodore BR, Balsiger D, et al. Number and type of post-traumatic stress disorder symptom domains are associated with patient-reported outcomes in patients with chronic pain. J Pain. 2018;19(5):506-514.
Sullivan MD, Vowles KE. Patient action: as means and end for chronic pain care. Pain. 2017;158(8):1405-1407.
Howe CQ, Sullivan MD. The missing ‘P’ in pain management: how the current opioid epidemic highlights the need for psychiatric services in chronic pain care. Gen Hosp Psychiatry. 2014;36(1):99-104.
Scherrer JF, Salas J, Sullivan MD, et al. The influence of prescription opioid use duration and dose on development of treatment resistant depression. Prev Med. 2016;91:110-116.
Mazereeuw G, Sullivan MD, Juurlink DN. Depression in chronic pain: might opioids be responsible? Pain. 2018;159(11):2142-2145.
Sullivan MD. Depression effects on long-term prescription opioid use, abuse, and addiction. Clin J Pain. 2018;34(9):878-884.
Sullivan MD. Patient As Agent of Health and Health Care. New York, NY: Oxford University Press; 2017:448.