Psychological medicine

It is becoming increasingly clear that we can improve medical care by paying more attention to psychological aspects of medical assessment and treatment. The study and practice of such factors is often called psychological medicine. Although the development of specialist consultation-liaison psychiatry (liaison psychiatry in the United Kingdom) and health psychology contribute to psychological medicine, the task is much wider and has major implications for the organisation and practice of care. The ABC on psychological medicine that starts this week (p 1567) aims to explain some of those implications.

Disorders that are traditionally, and perhaps misleadingly, termed psychiatric are highly prevalent in medical populations. At least 25-30% of general medical patients have coexisting depressive, anxiety, somatoform, or alcohol misuse disorders.¹ Several factors account for the co-occurrence of medical and psychiatric disorders. First, a medical disorder can occasionally be a cause of the psychiatric disorder (for example, hypothyroidism as a biological cause of depression). Second, cardiovascular diseases, neurological disorders, cancer, diabetes, and many other medical diseases increase the risk of depression and other psychiatric disorders. Such so called comorbidity is common, but its causal linkage with psychological conditions remains poorly understood. A third factor is coincidence—common conditions such as hypertension and depression may coexist in the same patient because both are prevalent.

Another reason for psychological medicine is the prevalence of symptoms that are unexplained by disease. Although physical symptoms account for more than half of all visits to doctors, at least a third of these symptoms remain medically unexplained.²,³ This phenomenon is referred to as somatisation—the seeking of health care for somatic symptoms that suggest a medical disorder but represent instead an underlying depressive, anxiety, or somatoform disorder. Most patients with these mental disorders preferentially report somatic rather than emotional symptoms. Further, there are the common but poorly understood symptom syndromes such as fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome, for which the relative contributions of mind and body are not yet elucidated.⁴

Psychological medicine is important in the management of all these problems; both psychotropic medications and cognitive behavioural treatments have proved effective in the treatment of common physical symptoms and syndromes in numerous studies in general practice.⁵,⁶ Although such treatments have traditionally been considered psychiatric, they are also beneficial in patients without overt psychiatric disorders. Countries on both sides of the Atlantic have a long way to go in developing psychological medicine, the chasm in America between medical and psychiatric care is particularly deep. The “carve out” of mental health services in the managed care systems in the United States is one example of how ingrained the dualism of mind and body still is and of the reconciliation that must occur.

Psychological medicine does not mean relabelling all such patients as psychiatric. Many patients prefer to have these problems regarded as medical and conceptualised in terms of a neurotransmitter imbalance or a functional bodily disturbance.⁷ Concomitant psychological distress is best framed in terms of being a consequence rather than a cause of persistent physical symptoms. Premature efforts to reattribute somatic complaints to psychological mechanisms may be perceived by the patient as rejection. A more aetiologically neutral but psychologically sophisticated approach that initially focuses on symptomatic treatment, reassurance, activation, and restoration of function has proved more effective.⁸

There are better alternatives than simply to regard such problems as the province of psychiatry. One is to train general practitioners to diagnose and treat common “psychiatric” disorders.⁹ Although treatment with psychotropic medication is their most feasible option, general practitioners can also be trained to deliver other psychological treatments. A second option is to use nurses or social workers with specialised training who can work with general practitioners or psychiatrists to manage medication as well as deliver psychotherapies and behavioural interventions. A third model is collaborative care, where the general practitioner's management is augmented but not replaced by visits to a psychiatrist, often on site in the general practitioner's surgery. Stepped care is a fourth model, in which psychiatric referral occurs only for patients who do not respond to the general practitioner's initial treatment. Most studies have been conducted in general medical practices, but patients seen by medical specialists also warrant attention.³

Psychological medicine may also be delivered in some innovative ways. Promising data exist for behavioural interventions conducted outside the doctor's office, including case management by telephone, cognitive behavioural therapy given through a computer, bibliotherapy—self study by patients—and home visits (for example, for chronic fatigue syndrome).

Psychological medicine also improves outcomes. The benefits of treating common physical symptoms and psychological distress effectively in medical patients include not only improved quality of life and social and work functioning, but also greater satisfaction on the part of patient and doctor and reduced use of healthcare services.²

What do we need to do? Better detection of these problems need not be time consuming. For example, screening for depression may require as few as one or two questions. Optimal management of patients with persistent physical symptoms and common mental disorders may require longer or more frequent visits to a doctor, help in educating and following up patients by a nurse case manager, other system changes, and mental health specialty consultation for more complex cases.¹⁰ The competing demands of general practice must be explicitly addressed if we are to enable the general practitioner to practise psychological medicine effectively.¹¹

Yet this approach is no different to what is also required for many chronic medical disorders such as diabetes, asthma, and heart disease, for which it has been proved that care in concordance with guidelines requires appreciable reorganisation of medical services.¹² Neither chronic medical nor “psychiatric” disorders can be managed adequately in the current environment of general practice, where the typical patient must be seen in 10-15 minutes or less. The quick visit may work for the patient with a common cold or a single condition, such as well controlled hypertension, but will not suffice for the prevalent and disabling symptoms and disorders comprising psychological medicine. Evidence based treatments exist. Using them in a way that is integrated with general practice will improve our patients' physical health and psychological wellbeing.

ABC p 1567