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The second implication involves patient health beliefs and care preferences. Primary care patients do not view their "mental diagnoses," such as we apply them, as a thing apart from their general health, and they will not tolerate our doing so. One-third to one-half of primary care patients will refuse referral to a mental health professional; 5,6 those who refuse tend to be high medical utilizers with unexplained physical symptoms, but refusers cut across all demographic and diagnostic groups.7 Securing the consent of primary care patients for clinical trials of treatment by mental health professionals for mental disorders is even more problematic, unless the primary care clinician participates in the protocol.8 In other words, a certain large proportion of primary care patients prefer to receive mental health care in medical settings, and this is in part because it is not construed as "mental health care."
Thus, one can describe the range of mental disorders that occur in primary care, and this description is accurate inasmuch as it counts symptoms and diagnoses that are actually present. But when seen from the inside, these symptoms and diagnoses are embedded in a matrix of physical symptoms, disorders, and diseases; other mental symptoms and disorders; and social predicaments and stressors. This context completely changes the meaning and consequences of the identified mental disorders and profoundly affects the manner in which the clinician approaches patients who harbor these disorders. It also changes the strategies of the researcher who wishes to gain an insider's understanding of how primary care patients with "mental" disorders appear to those caring for them. Breaking a patient's predicament into a string or list of problems is acceptable only if one continuously takes account of the relationship between the problems, sees the problems as only a part of what the person is, and understands that the patient's clinical predicament cannot be represented by even a complete list of her or his problems. There is an interaction term between every pair of problems. We need never to forget that the whole is greater than the sum of the parts.
I have belabored this at such length because it has important implications for who manages mental disorders, how they are classified, how primary care clinicians are trained to see and manage them, and how we restructure primary care to make incentives and resources available to deal with these problems. It actually has something to do with a core attribute of primary care, despite its bewildering forms: the primary care clinician has a moral responsibility to the person who is the patient. To the whole person. That person must be taken as a whole; whether we wish it otherwise or not, that means taking responsibility for mental as well as physical well-being. One aspect of this can be called comprehensive care, and another aspect can be called continuity—continuity in the sense that a physician sees a patient regularly until an understanding of the patient's individuality has taken place. Recognition of this inherent inseparability of mind and body also helps account for the vehement reaction primary care clinicians sometimes have to the news that mental disorders are prevalent and largely undiagnosed in their setting; this implies that they are not taking care of their patients, without acknowledgment