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PATHWAYS TO PSYCHIATRIC CARE
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helped to advance our knowledge of pain control. We can conclude at this stage only that the mechanisms of stimulationinduced analgesia are complex, involving psychological components (suggestibility, placebo, anxiety, stress, sensory decision shifts), neurophysiological processes (peripheral and central "gate-controls" of pain impulses), and humoral opioid and non-opioid factors (endorphins and other neuroactive substances, whether neurotransmitters or neuromodulators, such as substance P, somatostatin, neurotensin, noradrenaline, gamma-aminobutyric acid, and serotonin).
PATHWAYS TO PSYCHIATRIC CARE No criminologist would claim to be an authority on crime from experience gained entirely within the walls of prisons. Similarly, only a foolhardy physician would claim that complete knowledge of a medical disorder can be gained within the bounds of the hospital. The past twenty years of high-technology medicine may have led the impartial observer to question these truisms. In many eyes the hospitals have become the health centres of the community and other less fashionable flowers of the Health Service have blushed unpraised, if not unseen. But the hospital as the base of health care is coming under increasing attack. Hospital orientation has moved to service orientation-not least amongst those who administer the finances. As Kennedyl noted in his Reith lectures, the fact that 70% of the health services budget goes to hospitals is no longer a matter for rejoicing as this is "evidence of the failures of health care". It is unfortunate that psychiatry, which prides itself on dealing with the whole man, has not devoted more attention to the filtering mechanisms that lead to psychiatric treatment. Referral to a psychiatrist is determined by a host of factors ranging from informed awareness of mental illness to ignorance and blind prejudice, and those who reach psychiatric care are a highly selected sample.2-5 Not surprisingly, most research attention and service provision in psychiatry is directed towards this unusual group and the others have rarely been considered. Paradoxically, those who have the least degree of psychiatric illness-people in the community who are not seeking any form of help-have been studied most extensively, mainly by the epidemiologists. Point-prevalence studies have shown that between 10% and 20% of the population can be regarded as psychiatrically disturbed at any one time. 6,7 It is perhaps figures like these that have led hospital based psychiatrists to keep their heads down and hope that they will not be identified by this mass of
potential customers.zThe filtering mechanisms intervening between the population at large and the psychiatrist are instructive lessons in social and medical psychology which Goldberg and Huxley8 have identified and discussed at length. The hurdles that have to be negotiated before Kennedy I. Reith lectures. Listener Nov. 13, 1980, p. 641-44. Shepherd M, Cooper B, Brown AC, Kalton GW. Psychiatric illness in general practice. London Oxford University Press, 1966. 3. Rawnsley K, Loudon JB. Factors influencing the referral of patients to psychiatrists by general practitioners. Br J Prev Sol Med 1962; 16: 174-82. 4. Kaeser A, Cooper B. The psychiatric patient, the general practitioner and the outpatient clinic: an operational study and a review. Psychol Med 1971; 1: 312-25. 5. Ingham JG, Rawnsley K, Hughes D. Psychiatric disorder and its declaration in contrasting areas of South Wales. Psychol Med 1972; 2: 281-92. 6. Goldberg D, Kay C, Thompson L. Psychiatric morbidity in general practice and the community. Psychol Med 1976; 6: 565-69. 7. Weissman MM, Myers JK, Harding PS. Psychiatric disorder in a U.S. surburban community. Acta Psychiat Scand 1978; 57: 219-31. 8. Mental illness in the community. By D. Goldberg and P. Huxley. London. Tavistock. 1980. Pp. 191. £4.25. 1. 2.
contact is achieved vary greatly from country to In the U.K. it is rare to have direct access to country. psychiatric care; in other countries, particularly North America, it is common. The recognition of mental distress is a necessary precursor before consultation and most patients with moderate or major psychiatric disorder do seek help-a fact that is sometimes forgotten by the antipsychiatry lobby. Most patients first attend a primary-care facility and their psychiatric disorder may or may not be detected by the doctor. There have been several investigations of the factors that determine recognition of psychiatric illness in general practice, and Goldberg and Huxley give an extremely comprehensive and detailed analysis of these. They correlated the doctor’s estimate of psychiatric morbidity with the patient’s score on a screening questionnaire (the General Health Questionnaire9), and thus arrived at a measure of successful recognition of psychiatric illness. Doctors who are interested in psychiatry, who ask questions with a psychiatric content, who have good interview style with "directive" rather than "closed" questions, who are less conservative, and who are sensitive to both verbal and non-verbal cues at interview, are better at recognising psychiatric disorder. The decision whether or not to refer to psychiatric services is not necessarily related to the recognition of psychiatric illness by primary-care physicians, although high recognisers refer more often.2 Many individuals with clear-cut psychiatric morbidity are treated for long periods without referral. The common feature of all referred patients is that they have not responded to treatment from the primary care physician. Disposal, therefore, is the chief reason for seeking psychiatric care,4 rather than recognition that the disorder is one that could yield to the special skills of the psychiatrist. Goldberg and Huxley have shown that the pathways to psychiatric care are haphazard and frequently irrational. They bring to mind the exhortation of the Irish priest who prayed for his congregation to follow "the straight and narrow path between right and wrong". In general the right people get through but many suffer unduly on the way, and a few get lost altogether. Most of these inquiries could be classified in the ethological mode, since the behaviour of doctors and patients is observed without intervention. Do they contain any lessons for the practice of psychiatry? One is that intervention by psychiatrists earlier along the chain might improve matters greatly. Although psychiatry in primary care is fundamentally different from hospital-based psychiatry,’" it is potentially more rewarding. Treatable patients are seen earlier and are more responsive to therapy, inappropriate referrals are reduced, and much better continuity of care results from closer liaison between general practitioner and psychiatrist. The psychiatrist in primary care also learns that some psychiatric disorders are only containable, not treatable, and has to shed what Kennedy describes as "the mentality that they are problem solvers, a mentality which converts modern medical care into crisis care". Movement of psychiatrists into primary care is in keeping with the developing trends of health services and should remove much of the stigma attached to psychiatry, stigma that results from the idea that psychiatry is only practised in mental hospitals and that patients are not treated at home-but "taken away"
psychiatric
Goldberg D. The detection of psychiatric illness by questionnaire. London: Oxford University Press, 1972. 10. Clare AW, Williams P. Future trends in research into primary care psychiatry a personal view. In: Williams P, Clare A, eds. Psychosocial disorder in general practice. London: Academic Press, 1979: 325-32. 9.
helped to advance our knowledge of pain control. We can conclude at this stage only that the mechanisms of stimulationinduced analgesia are complex, involving psychological components (suggestibility, placebo, anxiety, stress, sensory decision shifts), neurophysiological processes (peripheral and central "gate-controls" of pain impulses), and humoral opioid and non-opioid factors (endorphins and other neuroactive substances, whether neurotransmitters or neuromodulators, such as substance P, somatostatin, neurotensin, noradrenaline, gamma-aminobutyric acid, and serotonin).
PATHWAYS TO PSYCHIATRIC CARE No criminologist would claim to be an authority on crime from experience gained entirely within the walls of prisons. Similarly, only a foolhardy physician would claim that complete knowledge of a medical disorder can be gained within the bounds of the hospital. The past twenty years of high-technology medicine may have led the impartial observer to question these truisms. In many eyes the hospitals have become the health centres of the community and other less fashionable flowers of the Health Service have blushed unpraised, if not unseen. But the hospital as the base of health care is coming under increasing attack. Hospital orientation has moved to service orientation-not least amongst those who administer the finances. As Kennedyl noted in his Reith lectures, the fact that 70% of the health services budget goes to hospitals is no longer a matter for rejoicing as this is "evidence of the failures of health care". It is unfortunate that psychiatry, which prides itself on dealing with the whole man, has not devoted more attention to the filtering mechanisms that lead to psychiatric treatment. Referral to a psychiatrist is determined by a host of factors ranging from informed awareness of mental illness to ignorance and blind prejudice, and those who reach psychiatric care are a highly selected sample.2-5 Not surprisingly, most research attention and service provision in psychiatry is directed towards this unusual group and the others have rarely been considered. Paradoxically, those who have the least degree of psychiatric illness-people in the community who are not seeking any form of help-have been studied most extensively, mainly by the epidemiologists. Point-prevalence studies have shown that between 10% and 20% of the population can be regarded as psychiatrically disturbed at any one time. 6,7 It is perhaps figures like these that have led hospital based psychiatrists to keep their heads down and hope that they will not be identified by this mass of
potential customers.zThe filtering mechanisms intervening between the population at large and the psychiatrist are instructive lessons in social and medical psychology which Goldberg and Huxley8 have identified and discussed at length. The hurdles that have to be negotiated before Kennedy I. Reith lectures. Listener Nov. 13, 1980, p. 641-44. Shepherd M, Cooper B, Brown AC, Kalton GW. Psychiatric illness in general practice. London Oxford University Press, 1966. 3. Rawnsley K, Loudon JB. Factors influencing the referral of patients to psychiatrists by general practitioners. Br J Prev Sol Med 1962; 16: 174-82. 4. Kaeser A, Cooper B. The psychiatric patient, the general practitioner and the outpatient clinic: an operational study and a review. Psychol Med 1971; 1: 312-25. 5. Ingham JG, Rawnsley K, Hughes D. Psychiatric disorder and its declaration in contrasting areas of South Wales. Psychol Med 1972; 2: 281-92. 6. Goldberg D, Kay C, Thompson L. Psychiatric morbidity in general practice and the community. Psychol Med 1976; 6: 565-69. 7. Weissman MM, Myers JK, Harding PS. Psychiatric disorder in a U.S. surburban community. Acta Psychiat Scand 1978; 57: 219-31. 8. Mental illness in the community. By D. Goldberg and P. Huxley. London. Tavistock. 1980. Pp. 191. £4.25. 1. 2.
contact is achieved vary greatly from country to In the U.K. it is rare to have direct access to country. psychiatric care; in other countries, particularly North America, it is common. The recognition of mental distress is a necessary precursor before consultation and most patients with moderate or major psychiatric disorder do seek help-a fact that is sometimes forgotten by the antipsychiatry lobby. Most patients first attend a primary-care facility and their psychiatric disorder may or may not be detected by the doctor. There have been several investigations of the factors that determine recognition of psychiatric illness in general practice, and Goldberg and Huxley give an extremely comprehensive and detailed analysis of these. They correlated the doctor’s estimate of psychiatric morbidity with the patient’s score on a screening questionnaire (the General Health Questionnaire9), and thus arrived at a measure of successful recognition of psychiatric illness. Doctors who are interested in psychiatry, who ask questions with a psychiatric content, who have good interview style with "directive" rather than "closed" questions, who are less conservative, and who are sensitive to both verbal and non-verbal cues at interview, are better at recognising psychiatric disorder. The decision whether or not to refer to psychiatric services is not necessarily related to the recognition of psychiatric illness by primary-care physicians, although high recognisers refer more often.2 Many individuals with clear-cut psychiatric morbidity are treated for long periods without referral. The common feature of all referred patients is that they have not responded to treatment from the primary care physician. Disposal, therefore, is the chief reason for seeking psychiatric care,4 rather than recognition that the disorder is one that could yield to the special skills of the psychiatrist. Goldberg and Huxley have shown that the pathways to psychiatric care are haphazard and frequently irrational. They bring to mind the exhortation of the Irish priest who prayed for his congregation to follow "the straight and narrow path between right and wrong". In general the right people get through but many suffer unduly on the way, and a few get lost altogether. Most of these inquiries could be classified in the ethological mode, since the behaviour of doctors and patients is observed without intervention. Do they contain any lessons for the practice of psychiatry? One is that intervention by psychiatrists earlier along the chain might improve matters greatly. Although psychiatry in primary care is fundamentally different from hospital-based psychiatry,’" it is potentially more rewarding. Treatable patients are seen earlier and are more responsive to therapy, inappropriate referrals are reduced, and much better continuity of care results from closer liaison between general practitioner and psychiatrist. The psychiatrist in primary care also learns that some psychiatric disorders are only containable, not treatable, and has to shed what Kennedy describes as "the mentality that they are problem solvers, a mentality which converts modern medical care into crisis care". Movement of psychiatrists into primary care is in keeping with the developing trends of health services and should remove much of the stigma attached to psychiatry, stigma that results from the idea that psychiatry is only practised in mental hospitals and that patients are not treated at home-but "taken away"
psychiatric
Goldberg D. The detection of psychiatric illness by questionnaire. London: Oxford University Press, 1972. 10. Clare AW, Williams P. Future trends in research into primary care psychiatry a personal view. In: Williams P, Clare A, eds. Psychosocial disorder in general practice. London: Academic Press, 1979: 325-32. 9.