specialty mental health care, and the relative cost and effectiveness of mental health care rendered by clinicians within these different systems.

The Range And Complexity Of Primary Care

A Paradigm Problem: The Indivisibility of Mental and Physical Health

I will be speaking of mental health, mental disorders, and mental diagnoses throughout this paper. This convention of language is convenient and powerful and is thoroughly ingrained into contemporary conceptual formulations. It is also fundamentally wrong to speak of mental health as though it were distinct from physical health or health in general; this convention can mislead the unwitting into dangerous and expensive errors. A definitive treatment of this problem would begin with a critique of Meditations on First Philosophy, published in 1641 by Rene Descartes, in which he divided reality into two domains, the physical and the mental. Even if such a critique were within my competence, my purpose here is more concrete and practical, and such an excursion would not be justified. Therefore, I will deal with more practical implications. Whether or not it is inherently impossible to portray accurately the clinical reality of primary care within a Cartesian dualism, one of the consistent consequences of this dualism is inattention to the relationships between these two domains. In primary care these relationships pervade all aspects of the clinical enterprise. Two implications of this disintegration of the psyche from the soma are salient.

First, let us consider the clinical relationship between physical and mental problems. Mental distress, symptoms, and disorders are usually embedded in a matrix of explained or unexplained physical symptoms, as well as acute and chronic medical illnesses.13 Generally, primary care clinicians deal with mental symptoms as part of something—part of a larger, more general problem. The nature of primary care, as we will see in a moment, is integrative. The more pronounced the physical symptomatology, whether or not the symptoms have a physical explanation, the greater the likelihood that a primary care patient has a mental diagnosis.2 In other words, mental symptoms and disorders are concentrated in precisely those patients who are visiting their primary care clinician for other reasons—physical disease or at least biomedical problems. Conversely, psychologically distressed patients experience increased physical symptomatology.4 This means that mental illness itself produces symptoms likely to lead one to a primary care clinician. The relationship between physical and mental symptoms is complex and interesting, but I need to note here only that it is inextricable—inevitable. Systems of care that force the separation of "mental" from "physical" problems consign the clinicians in each arm of this dichotomy to a misconceived and incomplete clinical reality that produces duplication of effort, undermines comprehensiveness of care, hamstrings clinicians with incomplete data, and ensures that the patient cannot be completely understood.



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