Psychiatric and Mental Health Essentials in Primary Care

Lee Ann Hoff, Betty Morgan

• Publisher: Routledge
• Year: 2010
• ISBN:
  9781136890123
• Edition: 1
• Topic: Medicina
• Subtopic: Enfermería

Psychiatric and Mental Health Essentials in Primary Care addresses key mental health concepts and strategies for time-pressured practitioners in various healthcare settings serving diverse populations. It offers theoretically sound and succinct guidelines for compassionate, efficient, and effective service to people in emotional and physical pain and distress, capturing the essentials of mental health care delivered by primary care providers.

The text provides a theoretical overview, discussing mental health assessment, crisis care basics, alternative therapies, and vulnerable groups such as children, adolescents and older people. It includes chapters that focus on the following topics in Primary Care Practice:

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• Suicide and Violence

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• Anxiety

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• Mood disorders

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• Schizophrenia

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• Substance Abuse

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• Chronic illness and mental health.

This invaluable text is designed for primary care providers in either graduate student or practice roles across a range of primary care practice, including nurse practitioners and physician assistants.

1
Theoretical Overview and Generalist/Specialist Roles

• Mind–Body–Spirit Connections

• Key Mental Health and Psychiatric Concepts Relevant to Primary Care

• Palliative Care Essentials and Mental Illness

• Diversity Perspectives in Primary Care

• Comprehensive Treatment and Inter-professional Collaboration

• References

Mind–Body–Spirit Connections

Centuries ago, father of medicine Hippocrates said: It is better to know the man who has the disease than the disease the man has. Of course this is not an either/or proposition, but rather, the fact that both apply. A psychiatrist illustrated this practice scenario with the following statement: If I treated a person with anti-psychotic medication on the assumption that the troubling hallucinations were a symptom of schizophrenia, and he/she subsequently died from complications of a malignant brain tumor, I would never forgive myself for the failure to have made a differential diagnosis before beginning treatment.

Similarly, primary care providers (PCPs) are faced with multiple situations where patients present with physical health symptoms that may mask mental and emotional problems. For example, besides the risks of the serious physical illness itself, inattention to impending despair on learning of life-threatening cancer or heart disease could result in a preventable death by suicide. Or, a presenting symptom of delirium needs differentiation between its medical and/or psychiatric origins as a basis for treatment—whether from cognitive decline, delusions from psychosis, or a multiplicity of factors that influence brain functioning. We thus recognize the intrinsic connection between mind and body in contemporary healthcare practice, and therefore the importance of treating the whole person—a diseased or bruised body, a grieving soul, and the mind and emotions of a distressed and suffering person.

A potentially dangerous vacuum is left when primary care providers feel unprepared in the psychosocial realm of practice. This problem arises when the provider is challenged with addressing multiple medical and psychosocial issues simultaneously in a very limited amount of time. The challenge presented is to routinely incorporate essential mental health strategies into tight schedules. Although not commonplace, some patients will present with the life-threatening situation of harm to themselves or others—for example, in response to learning about a serious medical illness. It is commonplace for a depressed person to neglect ordinary hygiene or routines such as exercise and proper diet. Such situations sandwiched between a diabetic patient with a glucose level over 500 and a sore throat awaiting treatment can claim an inordinate amount of time and provoke extreme anxiety for the provider, who may also lack confidence to address them appropriately.

Keeping in mind Hippocrates’ wisdom and ideals with respect to our understanding and treatment of the whole person, let us consider these examples.

CASE EXAMPLES: UNDERSTANDING THE WHOLE PERSON

Case Example 1: Mr. Richard Ebbers

Mr. Ebbers, age 76 and recently widowed, is the father of three children, two daughters and one son. One daughter, Karen, lives with her husband and two children in the same small town as her father. Her sister Joan and brother David live with their families an hour’s drive from their father’s home. Until age 62, Richard worked as an electrical engineer in a prominent high technology company. The chief reason for his early retirement was his wife Louise’s diagnosis of leukemia which entailed a series of chemotherapy sessions over an eight-year period. During this time, Richard assumed major responsibility for his wife’s medical appointments and home-based care-taking needs, as well as routine housekeeping and cooking tasks that his wife could no longer handle. He also had to work in appointments for his own injury-related knee problems for which he had joint replacement surgery four years ago, and for routine checks on his blood sugar levels given his family history of diabetes. On his father’s side, there is a genetic risk of Alzheimer’s disease.

Following the death and burial of his wife, Richard felt some relief from the 24/7, eight-year strain of his care-taking role which left little time for personal interests. But after years of a very happy marriage and successful career, he is now aware of an “emptiness” in his life. He has begun using alcohol as a way to drown out the loneliness of long evenings alone, and has been deviating from his long-standing adherence to diet and exercise as preventive measures to avoid diabetes. Richard’s daughter Karen has noted the change in her father, including his over-indulgence in alcohol and sweets at family dinners—this, a distinct departure from his lifelong self-care habits. All three siblings have observed some “forgetfulness” in their father, and hope this is not a sign of early Alzheimer’s. Karen has urged Richard to see his primary care provider, and perhaps a counselor to help him through a difficult period of serious changes.

This scenario and similar mind/body challenges to maintaining health and well-being over the life-span are played out for many families in North America (including immigrants) where children don’t live geographically close to their parents. In a situation such as Richard’s the primary care provider indeed may be the only one who can zero in and follow up on the changes noticed by his children. The PCP response to a client like Richard—what to ask and what to do—is addressed in detail in Chapter 2, “Assessment,” especially ascertaining Richard’s suicide risk level around his use of alcohol in response to loneliness, and his long-term risk of cognitive impairment.

Case Example 2: Ms. Denise Evans

Denise Evans, age 35, is the mother of three children ages 15, 12, and 8. She is employed as an administrative assistant in a biotechnology laboratory. Denise has been seeing a family nurse practitioner for the past three years, usually for sleep disturbance, chronic fatigue, and periodic intestinal pain. She confided her concerns about her marriage and expectation by her husband to continue working full-time, and his failure to ease her workload through help with the children’s homework and after-school activities. Although Denise has considered divorce, she has decided to stick with the marriage primarily out of financial concerns for herself and her children. After referral to a gastroenterologist, she was diagnosed with irritable bowel syndrome. Despite stress-reduction activities like exercise and meditation, her symptoms continued, and she expressed concern about her need to rely increasingly on medication to get a good night’s sleep. One day Denise came to the NP’s office after referral from a nearby emergency department where she was treated for bruises and a broken arm from assault by her husband. During the NP’s intake interview, Denise revealed that she had been suffering verbal abuse and threats of divorce from her husband over three years, but did not think it would escalate to violence, since he held a prestigious position in a local corporate office. Complicating the situation, the couple’s children overheard many of their parents’ arguments, and the youngest one witnessed the physical assault.

Together, these two cases illustrate a pivotal point in primary care practice: Understanding who the whole person is—not just a patient’s presenting symptoms—lays the foundation for next steps in the assessment and treatment process, of which ascertaining immediate risk to life is paramount (discussed in Chapter 2). Healthcare providers’ responses to these clients can make the difference between positive or negative outcomes—for example, empathic listening, risk assessment, crisis intervention, and referral for follow-up counseling or therapy vs. a message of disinterest and lack of time that can hasten a person’s downward spiral toward substance abuse, suicide, or violence toward others in response to acute distress. Major mental health concepts that aid PCPs’ understanding of clients and their families are discussed next.

Key Mental Health and Psychiatric Concepts Relevant to Primary Care

Increasingly, the general public and healthcare providers accept and expect attention to mind/ body connections in health matters. Yet, doing justice to holistic practice remains challenging—not only because of the Cartesian mind/body split influencing our cultural legacy, but also because time and financial constraints confound the continuing bias against those with emotional/mental problems. It takes knowledge of behavioral, psychosocial, addictive, psychosomatic, and mental disorders for an effective holistic response to clients’ medical needs and attendant emotional responses—in essence, mental health and psychiatric basics are fundamental to primary care practice.

A summary of key mental health and psychiatric concepts relevant to primary care practice are presented with recognition that it is mental health specialists who are expected to master the complexities and multiplicities of this body of knowledge. These theoretical underpinnings are drawn from nursing, psychiatry and community mental health, psychosomatic medicine, psychology (especially developmental theory, ego psychology, and client-centered therapy), and socio-cultural theory applied to mental health. Among the multi-disciplinary concepts affecting primary care and psychiatric specialty practice today, three discoveries that evolved into movements over the past century are significant for their lasting influence on the health provider–client relationship and quality of care, regardless of one’s discipline or the presenting clinical problems:

1. Freud’s discovery of the impact that repressed emotions (the unconscious facet of personality) can have on one’s physical and mental health;

2. the discovery of psychotropic drugs in the 1950s that rivaled Pinel’s work a century earlier by releasing the mentally ill from the “chains of demonology” (Dossey & Guzzetta, 1994);

3. the launching of crisis theory and its public health premise of early detection and preventive intervention.

An overview of these and complementary concepts relevant to primary care practice includes brief reference to the cases of Richard Ebbers and Denise Evans. This will lay the foundation for Chapter 2 in which mental health assessment in primary care will be discussed and illustrated with examples.

Primary Healthcare and Community Mental Health

The World Health Organization’s (WHO) 1978 Alma Atta Declaration, and national and international agencies increasingly recognize the fundamental place of primary healthcare in the health status of a nation’s people (U.S. Department of Health and Human Services, 2010). WHO’s original focus was on immunization, sanitation, nutrition, maternal and child health, and the economic, occupational, and educational underpinnings of health status. Currently, health planners and policymakers acknowledge that mental health status is also tied to socioeconomic and cultural factors a...

Table of contents

• Psychiatric and Mental Health Essentials in Primary Care
• Contents
• Figures
• Tables
• Boxes
• About the Authors
• Preface
• Acknowledgments
• 1 Theoretical Overview and Generalist/Specialist Roles
• 2 Mental Health Assessment and Service Planning
• 3 Crisis Care Basics in Primary Care
• 4 Suicidal and Self-destructive Persons
• 5 Violence and Sexual Assault
• 6 The Anxious Patient
• 7 Problems of Depression and Mood Disorders
• 8 The Person with Schizophrenia
• 9 Substance Abuse, Addiction, and Mental Health
• 10 Chronic Pain in Medical and Psychiatric Illness
• 11 Children, Adolescents, and Family Issues
• 12 The Older Person, Preventive Mental Health, Cognitive Impairment, and End-of-Life Issues
• 13 Complementary and Alternative Treatments-CAM
• Epilogue: Do No Harm
• Index