Beyond symptoms: Defining primary care mental health clinical assessment priorities, content and process

Abstract

The assessment of undifferentiated psychological distress is a daily aspect of primary care practice. Primary care practitioners’ underlying values influence the priorities, process and content of assessment. Currently there is a lack of definition of these values in primary care clinical mental health assessment. This paper presents the case for adopting the philosophical values and principles of holistic transdisciplinary generalism to influence practice worldwide. Furthermore, it raises awareness of current constraints on practice, including an overreliance on the psychiatric paradigm of care and resulting criteria-based diagnoses. Finally, the paper seeks to promote discussion among primary care practitioners and researchers globally about how to define primary care clinical mental health assessment priorities, process and content.

Introduction

Clinical mental health assessment of psychological distress in primary care is part of everyday practice (Buszewicz et al., 2006, Cape et al., 2000, Dowrick, 1992). Encounters with this highly prevalent presentation, involving depression and other undifferentiated psychological and somatic disturbances (Arnow et al., 2006, Delany, 2007, Stone and Clarke, 2007) are integral to the role of primary care practitioners. The way in which psychological distress is assessed: the ‘expertise of knowing when, where and how to look’ (Gregory, 2009), determines not only what questions are posed but also the quality of the assessment and subsequent management and care.

Despite calls from the World Health Organisation to integrate mental health care into primary care (Ivbijaro et al., 2008, Palmer et al., 2010;), clear theoretical or practical frameworks do not exist to guide this process globally. In addition, threats to generalism, and the traditional values of general practice, in what some call a reductionist age (Gillies et al., 2009, Gregory, 2009), suggest that perhaps it is time for primary care to define what core values, skills and priorities it proposes to offer to the community in mental health assessment.

A reported rise in the diagnosis and treatment of clinical depression suggests a change in how we address normal human sorrow (Horwitz & Wakefield, 2007). The controversy over primary care practitioners’ diagnostic skills (Armstrong & Earnshaw, 2004) with claims of both under-diagnosis and under-treatment (Shedler, Beck, & Bensen, 2000), and over-diagnosis (Mitchell, Vaze, & Rao, 2009) suggests that the quality of such assessment needs to be clearly defined. There is a concern that psychiatric criteria-based diagnoses of depression and the symptom reduction treatment goals they spawn, do little to affect clinical outcomes that matter to patients (Dowrick, 2004, Hutschemaekers et al., 2007, Tyrer, 2009).Patient dissatisfaction and the concept of treatment resistant depression may also point to inadequate assessment and subsequent treatment (Gask et al., 2003, Souery et al., 2006).

This paper draws on clinical and theoretical literature pertaining to clinical assessment in mental health worldwide to argue that the field of primary care should define its own clinical assessment priorities (why assess?), process (how do we assess?) and content (what are we assessing?). Defining and honing primary care values, process and content in mental health assessment may have far reaching effects on both individual treatment outcomes and on primary care delivery globally.