Editorials

Psychological medicine
Integrating psychological care into general medical practice

I
t is becoming increasingly clear that we can the dualism of mind and body still is and of the ABC p 1567
improve medical care by paying more attention to reconciliation that must occur.
psychological aspects of medical assessment and Psychological medicine does not mean relabelling
treatment. The study and practice of such factors is all such patients as psychiatric. Many patients prefer to
often called psychological medicine. Although the have these problems regarded as medical and concep-
development of specialist consultation-liaison psychia- tualised in terms of a neurotransmitter imbalance or a
try (liaison psychiatry in the United Kingdom) and functional bodily disturbance.7 Concomitant psycho-
health psychology contribute to psychological medi- logical distress is best framed in terms of being a con-
cine, the task is much wider and has major implications sequence rather than a cause of persistent physical
for the organisation and practice of care. The ABC on symptoms. Premature efforts to reattribute somatic
psychological medicine that starts this week (p 1567) complaints to psychological mechanisms may be
aims to explain some of those implications. perceived by the patient as rejection. A more
Disorders that are traditionally, and perhaps aetiologically neutral but psychologically sophisti-
misleadingly, termed psychiatric are highly prevalent cated approach that initially focuses on symptomatic
in medical populations. At least 25-30% of general treatment, reassurance, activation, and restoration of
medical patients have coexisting depressive, anxiety, function has proved more effective.8
somatoform, or alcohol misuse disorders.1 Several fac- There are better alternatives than simply to regard
tors account for the co-occurrence of medical and psy- such problems as the province of psychiatry. One is to
chiatric disorders. First, a medical disorder can train general practitioners to diagnose and treat com-
occasionally be a cause of the psychiatric disorder (for mon “psychiatric” disorders.9 Although treatment with
example, hypothyroidism as a biological cause of psychotropic medication is their most feasible option,
depression). Second, cardiovascular diseases, neuro- general practitioners can also be trained to deliver
logical disorders, cancer, diabetes, and many other other psychological treatments. A second option is to
medical diseases increase the risk of depression and use nurses or social workers with specialised training
other psychiatric disorders. Such so called comorbidity who can work with general practitioners or psy-
is common, but its causal linkage with psychological chiatrists to manage medication as well as deliver
conditions remains poorly understood. A third factor is psychotherapies and behavioural interventions. A
coincidence—common conditions such as hyper- third model is collaborative care, where the general
tension and depression may coexist in the same patient practitioner’s management is augmented but not
because both are prevalent. replaced by visits to a psychiatrist, often on site in the
Another reason for psychological medicine is the general practitioner’s surgery. Stepped care is a fourth
prevalence of symptoms that are unexplained by model, in which psychiatric referral occurs only for
disease. Although physical symptoms account for patients who do not respond to the general
more than half of all visits to doctors, at least a third of practitioner’s initial treatment. Most studies have been
these symptoms remain medically unexplained.2 3 This conducted in general medical practices, but patients
phenomenon is referred to as somatisation—the seen by medical specialists also warrant attention.3
seeking of health care for somatic symptoms that sug- Psychological medicine may also be delivered in
gest a medical disorder but represent instead an some innovative ways. Promising data exist for
underlying depressive, anxiety, or somatoform disor- behavioural interventions conducted outside the
der. Most patients with these mental disorders doctor’s office, including case management by
preferentially report somatic rather than emotional telephone, cognitive behavioural therapy given
symptoms. Further, there are the common but poorly through a computer, bibliotherapy—self study by
understood symptom syndromes such as fibromyalgia, patients—and home visits (for example, for chronic
irritable bowel syndrome, and chronic fatigue syn- fatigue syndrome).
drome, for which the relative contributions of mind Psychological medicine also improves outcomes.
and body are not yet elucidated.4 The benefits of treating common physical symptoms
Psychological medicine is important in the and psychological distress effectively in medical
management of all these problems; both psychotropic patients include not only improved quality of life and
medications and cognitive behavioural treatments social and work functioning, but also greater
have proved effective in the treatment of common satisfaction on the part of patient and doctor and
physical symptoms and syndromes in numerous stud- reduced use of healthcare services.2
ies in general practice.5 6 Although such treatments What do we need to do? Better detection of these
have traditionally been considered psychiatric, they problems need not be time consuming. For example,
are also beneficial in patients without overt psychiatric screening for depression may require as few as one or
disorders. Countries on both sides of the Atlantic two questions. Optimal management of patients with
have a long way to go in developing psychological persistent physical symptoms and common mental
medicine, the chasm in America between medical and disorders may require longer or more frequent visits to
psychiatric care is particularly deep. The “carve out” of a doctor, help in educating and following up patients
mental health services in the managed care systems in by a nurse case manager, other system changes, and
the United States is one example of how ingrained mental health specialty consultation for more complex BMJ 2002;324:1536–7

1536 BMJ VOLUME 324 29 JUNE 2002 bmj.com

cases.10 The competing demands of general practice KK has received fees for speaking and research from Pfizer and
must be explicitly addressed if we are to enable the Eli Lilly.
general practitioner to practise psychological medicine
effectively.11 1 Ormel J, Von Korff M, Ustun TB, Pini S, Korten A, Oldehinkel T.
Common mental disorders and disability across cultures: results from the
Yet this approach is no different to what is also WHO collaborative study on psychological problems in general health
required for many chronic medical disorders such as care. JAMA 1994;272:1741-8.
2 Kroenke K. Studying symptoms: sampling and measurement issues. Ann
diabetes, asthma, and heart disease, for which it has Intern Med 2001;134:844-55.
been proved that care in concordance with guidelines 3 Reid S, Wessely S, Crayford T, Hotopf M. Medically unexplained
symptoms in frequent attenders of secondary health care: retrospective
requires appreciable reorganisation of medical serv- cohort study. BMJ 2001;322:1-4.
ices.12 Neither chronic medical nor “psychiatric” disor- 4 Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or
many? Lancet 1999;354:936-9.
ders can be managed adequately in the current 5 O’Malley PG, Jackson JL, Santoro J, Tomkins G, Balden E, Kroenke K.
environment of general practice, where the typical Antidepressant therapy for unexplained symptoms and symptom
syndromes. J Fam Pract 1999;48:980-90.
patient must be seen in 10-15 minutes or less. The 6 Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization
quick visit may work for the patient with a common and symptom syndromes: a critical review of controlled clinical trials. Psy-
chother Psychosom 2000;69:205-15.
cold or a single condition, such as well controlled 7 Sharpe M, Carson A.“Unexplained”somatic symptoms, functional
syndromes, and somatization: do we need a paradigm shift? Ann Intern
hypertension, but will not suffice for the prevalent and Med 2001;134:926-30.
disabling symptoms and disorders comprising psycho- 8 Von Korff M, Moore JC. Stepped care for back pain: activating
approaches for primary care. Ann Intern Med 2001;134:911-7.
logical medicine. Evidence based treatments exist. 9 Kroenke K, Taylor-Vaisey A, Dietrich AJ, Oxman TE. Interventions to
Using them in a way that is integrated with general improve provider diagnosis and treatment of mental disorders in
primary care: a critical review of the literature. Psychosomatics 2000;41:39-
practice will improve our patients’ physical health and 52.
psychological wellbeing. 10 Rubenstein LV, Jackson-Triche M, Unutzer J, Miranda J, Minnium K,
Pearson ML, et al. Evidence-based care for depression in managed
primary care practices. Health Aff 1999;18:89-105.
Kurt Kroenke professor of medicine 11 Klinkman MS. Competing demands in psychosocial care: a model for the
identification and treatment of depressive disorders in primary care. Gen
Department of Medicine, Regenstrief Institute for Health Care, RG-6, Hosp Psychiatry 1997;19:98-111.
1050 Wishard Blvd, Indianapolis, IN 46202, USA 12 Wagner EH, Austin BT, Von Korff M. Organizing care for patients with
kkroenke@regenstr ief.org chronic illness. Milbank Q 1996;74:511-44.

Whooping cough—a continuing problem

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ews media announced a global resurgence of strains that has led to a fall in vaccine efficacy.5 Similar
whooping cough in April this year following a studies in other countries have also revealed the emer-
session on pertussis at the 12th European gence of non-vaccine variants of pertactin and pertus-
Congress of Clinical Microbiology and Infectious Dis- sis toxin.6 In France, however, an increase in the
eases in Milan, Italy. Subsequently the European Union frequency of non-vaccine variants of both pertussis
sent an alert to member states. Pertussis is one of the and pertactin toxin has not been accompanied by a
top causes of vaccine preventable deaths, with nearly decline in the efficacy of the vaccine.7 The situation in
300 000 deaths in children worldwide in 2000.1 the United Kingdom, where there has not been a
However, reports of a global resurgence originated in re-emergence of pertussis, seems unique in that all of
countries with low mortality and high vaccination cov- the most recent isolates studied are of the same pertus-
erage. For such countries the issue is how to fine tune sis toxin type as one of the strains included in the
effective immunisation programmes. In the rest of the United Kingdom whole cell vaccine.8
world, priorities are to decrease infant mortality by In high coverage countries, further development of
improving coverage and timeliness of vaccination and national policies for the control of pertussis is a
implementing pertussis surveillance.2 challenge because of underdiagnosis and under-
Pertussis has re-emerged in low mortality countries reporting, which hinder surveillance, as well as gaps in
in the past because of low coverage after a vaccine our knowledge of levels of herd immunity generated
scare in the 1980s (in the United Kingdom) or the use by the vaccination programmes. Underdiagnosis
of vaccines with poor efficacy (Canada, Sweden).3 Swe- occurs because pertussis has mild or atypical forms,
den and Germany stopped their vaccination pro- because clinicians may not consider pertussis as a
grammes completely and only reinstituted vaccination cause of cough especially in older children and adults,
for pertussis after years of recurrent epidemics of or because sensitivity of culture, the traditional
whooping cough. More recently some countries with diagnostic method, is as low as 20-40%. Surveillance is
sustained high coverage have experienced increases in so incomplete that enhanced awareness or improved
pertussis, especially in older children and adults, the diagnostic methods can result in apparent epidemics,
reasons for which are complex.3 4 After an outbreak of which may account for some of the observed increase
pertussis in the Netherlands in 1996, polymorphisms in older individuals in several countries with high vac-
in the genes coding for the Bordetella pertussis virulence cination coverage.4 5 Methods such as enzyme linked
factors pertactin and pertussis toxin were reported as immunoassay (ELISA) based serology and polymerase
BMJ 2002;324:1537–8 evidence for a vaccine driven evolution of circulating chain reaction have increased diagnostic sensitivity and

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