Mental health
inside the primary care ;
a different mental health ?
Paper presented at the National
Institute of Mental Health
Meeting on 'Defining mental
health problems in primary care', July 21-22, 1994,
General practitioners, Research group, Fédération des Maisons Médicales, Bd du Midi 25, B-1000 Brussels, Belgium.
Il reste que la
fonction du médecin consiste à aider le malade à déchiffrer sa demande et
à
lui trouver des réponses, autant dire qu'il y a tout lieu de chercher à
comprendre le
désir
réel pour amorcer la négociation.
Jean Carpentier,
Médical Flipper (7)
Summary
Family medicine is
the first level of help for patients facing illness or ill-results of the
practice of medicine. Settler, listener,
defender, the general practitioner occupies a potent position but an uncomfortable
one. It is necessary to understand the highly complicated position of the
family doctor in western society before discussing mental health in the field
of primary care. The forces and weaknesses of the family doctor's position will
be summarized. The various mental health
classifications will be tied to their conceptual patterns.
"It is to take
out the evil" : This was the answer given by a mentally borderline patient
when asked why he absolutely wanted blood drawn.
The concept of
disease evolves with time. This patient
sees his problem as would Hippocrates(15) himself: his disease is an
evil humor to be eliminated. His quest will be answered with the tools of the
techno-sciences. The more blood samples are taken, the more skillful the doctor
will be in this patient's view. Understanding this patient requires in fact a
more global approach, the biopsychosocial one.
Claude Bernard has given
medicine a tremendous boost by applying the fundamental laws of physics and
chemistry.
His positivist
vision has profoundly changed our knowledge and our perception of the sick man.
He thus initiated
the biomedical trend which permitted so many victories over sickness. On the
other hand, this scientific vision is also responsible for the hypertrophy of
secondary
care.
The emergence of
psychoanalysis in General Medicine is mostly due to Balint(5). He
showed the way towards self-reflection on the profession, the patient and the
therapeutic relationship. He introduced the real life of the patient in the
consultation.
Medicine becomes
socially legitimate and its description more accurate. From biomedical concept
it has graduated to biopsychosocial(42) concept. The field of
medicine expands to include the entire experience of life. Perceiving the
patient as a complex and symbolic being has revolutionized the technique of
history taking and curing(28).
General medicine is
no longer interested in the individual alone but it will now also take in
charge the family or the group surrounding the patient. The systemic approach
becomes a working tool particularly useful in mental care(8).
As societies become
pluricultural, the GP has to appreciate his patient's complaints in the light
of their cultural background. The practice of ethnomedicine becomes essential(12).
So we find
ourselves in a highly complex(32) and risky situation. Various
models(1) (essentialist, biomedical and biopsychosocial) coexist in
a new interactive relationship with the suffering individual, family or
society.
2. Specialized Medicine and
Family Medicine : an agonist/antagonist couple
Recent
overdevelopment of technology and specialized medicine only masks temporarily
the fundamental values served by the physician of everyday life and suffering.
|
Specialized
medicine |
Family
medicine |
|
1. Specialized field.
Secondary and tertiary level of care.
Highly technological |
Primary office and home. Mostly communicational |
|
2. Fragmented knowledge |
Global knowledge |
|
3. Biomedical model |
Biopsychosocial model |
|
4. Closed history taking
Logic of questioning |
Circular exploration of complaint |
|
5. Transversal
Partial opinion and therapy |
Longitudinal Taking in charge and synthesis |
|
6. High prevalence |
Low prevalence |
|
7. Hospital care |
Community care |
|
8. Mostly curative |
Integrated (preventive + curative) |
|
9. Medical coordination |
Multidisciplinary coordination |
|
10. Material cost , techniques |
Human cost |
|
11. Provider and disease oriented |
Patients and problems oriented |
|
12. Clinical research |
Operational research |
Fig. 1 : Specialized Medicine versus Family Medicine
(Adapted from M. Roland
1991)(38).
The
agonist/antagonist relationship between the two types of medical practice is
clearly obvious from this presentation of their different levels of activities.
We can therefore expect these two different worlds to use different tools of
classification.
While
the specialist is mostly transversal and technological, the GP is longitudinal
and mostly conversational. By taking the time and talking, the family physician
is in a privileged position to unveil the hidden side of symptoms.
The
"Suitcase of Symptoms" imagined by Jean Carpentier(7) , a
GP working in
3. Evolution in the
nosographic field
Emerging
from the Hippocrates' uncertain heritage, the 19th century built its first
instrument of classification around the concept of death. The International
Classification of Diseases, now in its tenth edition, was born from the
classification of the causes of death by Bertillon (34).
The
ICD is the favorite tool of biomedical research and specialized medicine.
Typically centered on diseases and health care providers, it is the result of
elaborate thinking by medical specialists and is utilized only in a static
fashion. But from there was derived the first tool specific to Family Practice,
the International Classification of Health problems in Primary Care (ICHPPC)
The
ICHPPC(43) was adapted from the ICD. It was still centered on the
health care provider but it recognized for the first time the particular
significance of the General Practitioner.
The
transition to the biopsychosocial concept took time(11). The main
tools for primary care were developed by health care providers.
Whether
the classifications are monoaxial somatic as those proposed by Braun(6),
or pluriaxial as those by Deliege(10), Jenkins(20) or the
World Health Organization (WHO-PHC)(9), they do not take into account
the interactive dynamics of a medical encounter.
These
particular dynamics were finally acknowledged with the apparition of the Reason
for encounter Classification (RFE)(25).
This
RFE, together with the ICHPPC and the
Classification of Procedures and Diagnoses (IC-Process-PC) gave birth to the
International Classification of Primary Care (ICPC)(26,47), which
was the first attempt to express the global approach so characteristic of
Family Practice.
4. The era of
information
The
concept of information and the advent of computers(19,31) have
revolutionized the application of these tools of classification. Medical
softwares offer vast possibilities for the treatment of information and the
refinement of hierarchized nomenclatures such as Read Clinical Codes(RCC)(37,46).
But
while specialized medicine develops only very static tools, family medicine is
pressed by its brilliant advances and seeks to create tools necessary for a
dynamic research(39).
The
ICPC is not just a classification. It is a multiaxial tool based on the patient
and it offers vast knowledge in primary care(16). Computers allow
in-depth study of the concept of episode which is at the center of the ICPC(35).
The
following table summarizes the evolution of classifications through time,
taking into account the main changes in medical concepts.
|
Current |
Concept |
Object |
Expression |
|
Essentialist |
Hippocratic |
inside/outside |
The Humors |
|
Scientist |
Biomedical |
Provider centered |
ICD-10 / Braun / ICHPPC |
|
Scientific* |
Biopsychosocial |
Patient
centered |
RFE
+ IcprocessPC + ICHPPC-2d CDMI / Jenkins WHO-PHC |
|
Computerized |
Information |
Health
information system |
RCC/computer dictionaries |
|
Multiple additive approach ** |
New clinical method General/Family Medicine |
Patient/family and social environment Primary Health care Health Information System |
ICPC and its episode based methodology |
* Scientific
: involves in our view the whole spectrum of knowledge, including the fields of
biomathematics, psychoanalysis and human sciences.
**
Multiple additive approach : these concepts are not isolated. They coexist most
of the time and form an integral part of the informative system thus generated.
Fig. 2 : Evolution of concepts and classifications in
medicine
As
time changes, so does the work of the general practitioner.
As
the central figure in the delivery of primary care, the GP has become necessarily
polyvalent. Besides running his health center and dealing with his personnel(40),
he must excel as a clinician, master psychosocial problems, integrate
analytical knowledge, understand transcultural attitudes, manage the
information given by his patients in a dynamic fashion, promote community
health and practice preventive
5. Medicine can be
dangerous for your health
Throughout
time, cultures and medical customs, the human being is confronted with changes in
the very concept of health. This is especially true of mental health. Hellstrom(14)
has clearly shown the dilemna of the potential patient. By integrating disease
and sickness, he describes in the patient four different self-perceptions which
are expressed in very distinct ways during the medical visit.
______________________________________________________
Not
being sick
IV / I
Having a disease Not having disease
III / II
Being
sick
________________________________________________________
Fig. 3 : Hellstrom O.W. (1994)(14)
;
"An effort to graphically represent the
relationship between a person
who is or is not sick and the fact that they have or
have not developed or been afflicted with a disease"
From
a similar perception one of us deducted some years ago an analogous figure(19).
Integrating the physician's knowledge and the patient's conscience, we can determine
four possibilities:
__________________________________________________________
Sickness
Absent
Present
Patient sees
self as healthy I II
Patient sees
self as sick IV III
___________________________________________________________
Fig. 4 : Jamoulle M. (1986)(19).
Four zones of patient/physician encounter.
Those
patients who truly belong to group I are not safe from the dangers of medicine.
They are exposed to vaccinations or health promotion campaigns. Those in group
II who are picked up as positive during a screening test will join group III.
Some in group II who are overly sensitive or who are the victims of
misconceived preventive medicine will join the hypochondriacs in group IV on
whom research will be needed to determine if the disease classifications they
fall under are accurate(33). This group IV serves as a testimony of
the excessive medicalisation
in
today's social and mental life. These patients are the victims of the wild
overgrowth of medical productivity (28).
6. Defining the
problems of mental health in primary health care
It
is clear therefore that paradigms must be changed if we are to deal with
primary health care and especially the mental health of everyday patients.
It
is not certain that physicians are willing to cope with the social field.
Indeed ethical problems caused by changes in paradigms appear in
classifications developed for primary care.
Chapters
P (psychological) and Z (social) of the ICPC contain less than 100 items, while
the 'Codes pour un Dossier Médical Informatisé '(CDMI)(10) developed
at the
Medicine
based on the subject does not draw a consensus either.
The
disease is often thought to be more interesting than the diseased, and the
diseased himself is often more interested by a "good" disease than by
an inquiry into his relationship with his surroundings. One has the physician
that one deserves. It is an illusion to believe that the power / knowledge of
the physician will not be preserved.
The
fact that a pathological state as depression is expressed by symptoms of wildly
varying intensity(36) does not facilitate the identification of the
problem by the physician(29). This difficulty is made even more
acute by the extreme fragility of psychiatric classifications(3,4).
The
parceling out of the patient by medical engineering is substituted in primary
care by a global overview of complex situations where it is not essential to
know if the patient is more depressed than anxious or more anxious than
depressed. On the other hand it is imperative to consider the patient as an
element of a system(8) in which the physician also plays an active
part.
Last
but not least, carefully listening to someone's words can very often supersede
useless classifications.
|
He has a pain in his back and his leg hurts. He's bored at home
with his sick wife and he drinks. |
Fig. 5 : Excerpt from Chronicle of a Consultation (18)
Can
this abstract of a visit by one of our patients in 1986 be classified under any
codification system? What seems important in this contact between two human
beings is that one wants to be heard by be other. The procedure itself suggests
the diagnosis.
A
new clinical method(30) based on the human being will express the
complexity of this being. The patient can not just be classified, he has to be
listened to. It is the physician's activity that needs classification, it is
his activity that has to be analyzed for an understanding of the care offered
to the patient. The principles guiding Quality Assurance will then come into
practice(1,13,21).
7. The ICPC, more
than a classification
The
ICPC seems to have proven its value. With regard to reasons for encounter, it
tolerates well reporting variations between physicians and it offers a steady
correlation between patient and provider(22).
Its
organization in episodes provides a dynamic perspective. With it the evolution
of mental health problems can be described as SSP through the uninterrupted
taking in charge. Its routine utilization allows detailed analyses and the
large amount of data already collected offers a close understanding of the
medical practice, especially in the field of mental care(23,24).
The
primary care provider carries a heavy psychiatric load(17) and he
badly needs an appropriate instrument of classification. The ICPC seems to
answer this need(41,48). It has been translated in over twenty
languages and has been fine tuned by groups of European General Practitioners(27).
It has proved useful in evaluating a patient's functional status(44),
which is the cornerstone of psychosocial problems.
Its
adjustment to primary care does not permit its use in secondary care, except in
emergency medicine. However it offers a satisfactory compatibility with the international
Classifiction of Disease- tenth revision (ICD-10)(45) which is
wildly used in the secondary sector.
From
the standpoint of mental health, the definitions now being established by
WONCA's Committee on Classification will have to take into account the tools
that are specific to the secondary sector such as the DSM-III-R(2)
and to future DSM-IV. Psychiatrists and General Practitioners will have to find
a mutual ground of reference and understanding.
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