Preface

We wrote this book for physicians, nurse practitioners, physician assistants, and nurses—and for students in each discipline, particularly for their family medicine, medicine, and psychiatry clerkships. Our aim is to provide help for clinicians in providing mental health care and to guide educators in their training of students, residents, and practitioners in these areas.

There is a compelling reason for all health care professionals to become skilled in caring for patients with mental disorders, which we define as mental and substance use disorders.¹ Mental health care is severely deficient in the United States. Only 25% of patients receive any care whatsoever, compared to 60% to 80% of those with cardiac and other medical diseases who receive expert care.^2,3 Psychiatrists now provide care for only 15% of all patients⁴ reflecting a chronic, severe national shortage.^5,6 As a result, medical practitioners provide sole mental health care for 85% of mental health care patients.^7-10 However, untrained for mental health care,^11-21 they sometimes have difficulty with diagnosis and management.^2,3,22 And it’s not just mental health care that suffers when mental health problems aren’t treated. With the frequent co-occurrence of a medical disease and a mental disorder,²³ we know that medical care suffers until the mental disorder also is recognized and treated effectively.^24-26

Greatly compounding this problem, mental disorders are the most common health problem in the United States, more common than heart disease and cancer combined.²⁷ One-half of the entire US population will have a mental disorder at some point during their lives,^28,29 one-fourth in any given year.³⁰ In the average clinic, approximately one-half of patients will have some mental disorder.²⁸

From the societal perspective, careful actuarial analysis tells us that integrating mental and medical care would produce a savings of $26 to 48 billion per year,³¹ over three-fourths of the savings from improved medical care.²⁴ Thus, we can improve medical care itself and save money for society when we diagnose and treat co-occurring mental disorders.

There have been many yeoman efforts to correct the problem, for example, collaborative care, the patient-centered medical home, alleviating clinicians’ competing demands, and improved billing for mental health care. Despite these effective efforts, however, Healthy People 2020 tells us the mental health problem is becoming worse.^32,33 Why? Because the “root cause” has never been addressed—training the clinicians who provide the care.¹⁹ This failure leads not only to suffering in our patients but also to our own frustration and burnout as clinicians.^34,35 It’s hard to give care you’re not trained to provide. That’s why we’ve written this book—to offer you some help.

The authors are psychiatrists and general internists, and we have trained medical students, faculty, and internal medicine and family medicine residents since 1986. Our clinical trials and other research^36-46 and that of others from multidisciplinary pain clinics,⁴⁷ consultation liaison psychiatry,⁴⁸ and primary care^49,50 demonstrate that the training we outline is effective and associated with improved mental and physical health outcomes.

We do not propose to make psychiatrists out of you but, rather, to prepare you to manage the common mental disorders you are likely to encounter in practice. Psychiatrists and other mental health professionals will still be needed for consultation.

Specifically, this book

1. Describes how to diagnose and treat a common core of mental disorders for which clinicians need significant mastery—depression and anxiety disorders and substance use problems.

2. Describes how to identify less common and more severe mental disorders that require early recognition and early referral—for example, schizophrenia, severe substance abuse, personality disorders.

3. Does not address counseling, psychotherapy, or specialty techniques (eg, electroconvulsive treatment or drug detoxification clinics). Some behaviorally skilled clinicians, however, may later want to expand their scope and obtain the required formal training now available in some of these areas.

Essentials of Psychiatry in Primary Care seeks to integrate medicine and psychiatry—as the systems-based biopsychosocial model proposes. The book identifies physical symptoms as a common mode of presentation of mental health problems and describes how to integrate them with psychological symptoms to make diagnoses of mental disorders. The book also proposes an overarching model for treatment, the Mental Health Care Model (MHCM), one that integrates medical and psychiatric care. The MHCM uniquely inserts the clinician-patient relationship as the centerpiece of mental health care, going still further to integrate motivational interviewing principles as vehicles to best ensure adherence to medications as other aspects of mental health care. Importantly, the MHCM has an extensive evidence base in clinical trials. It is a behaviorally defined, evidence-based mental health care model for medical settings.^36-46

In Chapters 1, “Three Axioms of Mental Health Care for Medical Settings” and 2 “Evaluating Physical Symptoms,” we introduce a new approach to diagnosing mental disorders. In contrast to some psychiatry textbooks’ focus on psychological symptoms, we address how many patients with mental disorders present in medical settings with predominant physical symptoms, often of severe, disabling proportions. The physical symptoms, thus, often are “red flags” suggesting an associated mental disorder that we must actively inquire about to make a correct mental health diagnosis and provide effective treatment.

In Chapter 3, “Mental Health Care Model,” we introduce the Mental Health Care Model (MHCM). This model provides the overarching structure for the mental health treatment we present in the book. Next, we begin to describe the psychological symptom profiles of the most common mental disorders. We advise that all clinicians need expertise with three major categories of mental disorders: “Major Depression and Related Disorders” (Chapter 4), “Generalized Anxiety and Related Disorders” (Chapter 5), and “Misuse of Prescription Substances and Other Substances” (Chapter 6). In these chapters, we address diagnostic criteria and integrate pharmacologic and other treatments into the overarching MHCM.

In Chapter 7, “The Diagnostic Interview,” we present the diagnostic interview for mental disorders. This topic comes after discussing the core disorders so that you get a better idea of what you’ll be looking for in the interview. Chapter 8, “Other Disorders and Issues in Primary Care,” provides the details of some other important mental disorders in medical settings and guidance in managing them, especially when to seek consultation from mental health professionals. Chapter 9, “Psychotic Disorders,” summarizes these severe disorders with an emphasis on early diagnosis to facilitate early referral to psychiatry and on the medical needs of these patients. Chapter 10, “Personality Disorders,” describes the features of many personality disorders with emphasis on borderline personality disorder. Chapter 11, “Enhancing Your Own Care,” focuses on 2 key issues for working with others: team care and referral. It then addresses important personal awareness issues that may arise in working with mental health patients with an emphasis on avoiding burnout.

We recognize that you face a difficult task in providing effective care for a wide range of patients. After completing this book, however, we believe that you will feel more confident and competent in addressing the basic mental health needs of your patients.