Beyond symptoms: Defining primary care mental health clinical assessment priorities, content and process
Highlights
► At present there are important aspects of personal experience missing from primary care mental health assessment. ► Clinical mental health assessment in primary care should not be limited to symptomatic pathology or disordered behavioural responses. ► Transdisciplinary generalism could be a guiding principle in defining priorities, content and processes in primary care clinical mental health assessment.
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.
Section snippets
A call to generalism
Generalism is a core value and competency in primary care. It situates the biopsychosocial model within the unique cultural and existential milieu of each patient (Freeman, 2005). As Gunn et al. (2008) state, the generalist must know and understand the interplay and influence between each life story and social context, and physical and emotional health, linking the biomedical and other aspects of being human.
Primary care clinical assessment of people with undifferentiated psychological distress
Current constraints on primary care mental health assessment
Despite calls to value the culture and strengths of primary care (including holism) and policy changes to move from hospital to primary led care worldwide (Lester, Glasby, & Tylee, 2004), the questions that are posed in primary care mental health assessment (hereafter called primary care assessment) are currently constrained by secondary care assumptions about the meaning of good quality care (Lester et al., 2004). Primary care assessment is made in a very different and unique physical and
A call to self definition
Primary care practitioners need to define their own paradigm of mental health care, maintaining their generalism and valuing their position with their patients in community, rather than as ascendant observers (Verhaeghe, 2004). Primary care commentators urge for clarification of the role and scope of primary care (Dowrick, 1992, Marshall, 2009) and affirm that it is possible to ground this within the values and built on its recognised strengths (Lester et al., 2004). Without self definition,
WHY assess? Defining priorities in primary care clinical mental health assessment
The ultimate aim of primary care assessment is to ensure that the whole person is seen, understood, and connected with, in order to facilitate thorough care and comprehensive treatment options. A key priority is to lay a relational foundation for ongoing therapeutic process. Primary care assessment priorities may be influenced by more relational and contextual treatment goals than those of tertiary care. Primary care practitioners aim not to identify psychiatric disorders and eliminate them,
Limitations
Many of the values discussed above already exist within the discipline of primary care, and yet are undervalued or constrained. This state of affairs will not be easy to address. Many of these ideas are not new; whole health systems have tried to address them (Hutschemaekers et al., 2007), yet powerful forces and discourses including economic and hierarchical ones maintain the status quo (Mitchell, 2009) worldwide. What is new, is conceptualising concerns in the primary care context as opposed
Conclusion
This discussion paper seeks to promote thought and debate on how primary care clinical mental health assessment would benefit from a clear definition and validation as a unique skill set. This approach to the assessment of psychological distress includes the robust concepts of patient-centred care, collaboration between patient and practitioner, and generalism, and is safeguarded from bias and assumptions by an intentional transdisciplinary approach. This multi-faceted approach to the whole
Acknowledgements
This work was supported by a Novice Researcher Fellowship under the Primary Health Care Research, Evaluation and Development (PHCRED) program, administered through the Discipline of General Practice, The University of Queensland and funded by the Australian Government Department of Health and Ageing. The authors would also like to thank Chris Dowrick and Pam Meredith for their early comments on the subject matter of this paper.
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