practice habits. This will require a coherent, sustained educational effort. We have no idea about the most effective way to accomplish this.

Clinical

We must come to terms with what we have learned about mental health in primary care—we cannot unlearn what we have discovered. We must either mobilize our clinical resources to address mental problems or explicitly acknowledge that their prevalence and salience are insufficient to justify the expense and effort that it takes to address them. In some cases, for some disorders, this is probably the best course of action, but the evidence suggests that reordering primary care to accommodate the mental distress of patients would be a good investment.

Therefore, we must proceed to provide the incentives and resources necessary to force a restructuring of primary care along these lines. Nobody knows how to do this yet. For some years this will most likely involve experiments with modified caseloads, interjection of new personnel into the primary health care team, acquisition of skills and tasks by current members of the primary health care team, and new collaborative and consultative relationships with mental health professionals. It will involve the development of clear, explicit clinical expectations coupled with the knowledge, skills, and attitudes necessary to accomplish the expected clinical care. Management guidelines and diagnostic instruments are being developed for the most common mental diagnoses in primary care; now we must learn how to implement these tools into our routine clinical activities. This process will need to transpire under the eye of services researchers, economists, mental health professionals, and primary care clinicians—but mostly patients themselves should decide who will do what to whom.

References

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2. Kroenke K, Spitzer RL, Williams JB, et al. Physical symptoms in primary care. Predictors of psychiatric disorders and functional impairment. Arch Fam Med. 1994;3:774–779.

3. Kirmayer LJ, Robbins JM, Dworkind M, Yaffe MJ. Somatization and the recognition of depression and anxiety in primary care. Am J Psychiatry .1993;150:734–741.

4. Katon W, Von Korff M, Lin E, et al. Distressed high utilizers of medical care. DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry. 1990;12:355–362.

5. Orleans C, George L, Houpt J, Brodie H. How primary care physicians treat psychiatric disorders: A national survey of family practitioners. Am J Psychiatry. 1985;142:52–57.

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8. Schulberg HC, Block MR, Madonia JJ, Rodriguez E, Scott CP, Lave J. Applicability of



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