Introduction
A few studies have examined the prevalence of specific disorders in primary care. Prevalence rates for individual disorders were obtained ranging from 6.8% for major depression and phobic disorders to 1.6% for generalized anxiety disorder. The established prevalence for all psychiatric disorders was 26.7% (Hoeper E et al,1979). In most of these cases drug therapy would be of no benefit as they do not present with frank psychiatric disorders. Short term goal directed psychotherapy would be the preferred method of treatment for these patients.
Studies have so far indicated that this form of psychotherapy has beneficial effects in primary care in the worried and hypochondriacal patients, highly stressed patients, depressed patients, drug dependent patients and patients with unexplained medical conditions. Several studies have also identified cognitive behaviour therapy as the most cost effective technique to be employed. More and more primary care physicians in the West are taking up short psychological therapy courses to use on their patients. The role of psychotherapy in primary care seems to be quite clear in the near future.
Psychiatric Problems in GP Practice and Primary Care Centres
The established prevalence for all RDC disorders was 26.7% for private practice attenders (Hoeper E et al,1979). Other common disorders were alcohol abuse 8.2%; other substance abuse, 7.1%; and phobic disorders, 6.8%. Von Korff et al (1987) reported the prevalence of specific disorders to be 8.5% for any anxiety or depressive disorder and 25.0% for any psychiatric disorder. A recent study showed that the prevalence of depressive symptoms was 13.2%, hypochondriacal symptoms 8.2% and anxiety symptoms 6.1% (Varma SL, Azhar MZ,1995) in primary health centres in two districts of Kelantan. The same study indicated that the actual prevalence of hard core psychiatric disorders such as schizophrenia, mania, major depression, and dementia was only 1.2%. The remainder were mainly neurotic disorders especially dysthymia, anxiety, panic, and hypochondriasis. All these disorders do not require drug treatment but time and support preferably in the form of some sort of scientifically based psychotherapeutic intervention.
Experience of Others
In the West cognitive behaviour therapy (CBT) have been used in GP patients for searching for sickness among the worried well, for depression, and for working with street drug users although published reports of their success have yet to be seen. However Van Hemert et al (1993) have published their work on unexplained physical symptoms in the patients of their outpatient clinic. Work done by others include unexplained abdominal pain, fatigue, and chest pain. All their studies indicate the prevalence of very high percentages of psychiatric disorders in these groups of patients compared with patients with explained physical symptoms. A similar contrast was found between patients with irritable bowel syndrome and inflamatory bowel disease, chronic fatigue syndrome and muscle disease, atypical chest pain and ischaemic heart disease.
All these associations suggest the possibility of applying psychotherapy to treat these problems. In fact psychotherapy have been tried on these patients and several reports have indicated the develoment of specific treatment modules for these patients using cognitive therapy and cognitive behaviour therapy principles; e.g. modules have developed for chronic pain, irritable bowel syndrome, chronic fatigue syndrome, and atypical chest pain.
A recent study by Speckens AEM et al (1996) attemps to use CBT on nonspecific unexplained physical symptoms. The patients improved and maintained improvement at one year follow-up. This technique has since been employed at their outpatient clinic. Another pilot study in primary care uses abbreviated cognitive therapy for depression (Scott CS et al, 1994).Here the CBT sessions were limited to six 20 minute weekly sessions done by a GP who had training in CBT. After six sessions about 60% of patients improve by 50% in terms of depressive symptoms. The study also indicated that the intervention was well accepted by patients and feasible within time constraints. They are presently doing a randomized control trial of this brief intervention.
Which Psychotherapy to use?
There are numerous forms of psychotherapy each claiming to be better than others. The number is so huge that to classify them would be very difficult. However for practical purposes it is easy to classify them into broad categories. One way of classifying them is;
Counseling
Dynamic
Psychotherapy
Supportive
PSYCHOLOGICAL
TREATMENT
Cognitive therapy
Behaviour therapy
Others e.g. hypnotherapy, abreaction
It is of course left to the individual to practice any psychotherapy or psychological treatment he/she pleases. Counseling and support would benefit quite a number of patients if done correctly. But whichever method one chooses, the authour feels that one must be very comfortable with it and must have some training or practice in order to make it effective. Most of the reviews that the author have come across were mainly relating to work done on these patients using CBT partly due to lack of report from other types of therapy although they do practice it on GP patients and partly due to the author’s bias inclination towards CBT after having been trained and assessed in its techniques not too long ago.
CBT Somatization Model That has been used in Treatment
There have been several models described but the one the author is most used to is the one by one of my teachers Paul Salkovskis (1989). Central in the CBT conceptualization of somatic symptoms is the way patients think about bodily sensations. Beliefs that patient have about the nature of their symptoms can result in a confirmatory bias with respect to illness-related information. As a result, such patients selectively notice and remember information that is consistent with their beliefs about their problems. If benign bodily sensations are regarded as being symptomatic of disease, several consequences ensue. First, patients will experience emotional distress, which may cause further bodily sensations. Second, increased attention will be paid to these sensations. Third, the type of behaviours adopted to cope with the symptoms may be dysfunctional in that they act to exacerbate the problem rather than relieve it. Fourth, other people including doctors may respond to patients in a way that intensifies, rather than reduces their concern with disease, attention to bodily sensations and dysfunctional coping. All these processes may become linked in self-perpetuating vicious circles. Patients with somatic symptoms commonly believe that their symptoms have a physical cause. Functional somatic symptoms have been found to be associated with both anxiety and depression which are consequences of the dread or false beliefs of having a disease. Patients with high levels of health anxiety have been shown to consider more symptoms indicative of sickness and to have an enhanced perceptual sensitivity to illness cues. Salkovskis and Warwick (1986) demonstrated that avoidance behaviour, such as reassurance seeking and checking bodily status, could be an important maintaining factor in health anxiety. Jones et al (1989) found that illness coping responses associated with hypochondriacal traits were rather passive strategies that promoted increased vigilance and concerns about symptoms while providing few opportunities to reduce uncertainty regarding health status.
Thus with an understanding of this hypothesis, the doctor can modify his/her therapy technique to treat these patients. Using actual CBT techniques will obviously be difficult but counseling using CBT hypothesis might suffice in most patients while the more resistant ones can be sent for further management to a psychiatrist or psychotherapist. Besides the CBT model for depression is very easy to grasp and can be used to treat all patients since depression is an ingredient present in many patients with the above problems.
Conclusion and Suggestions
A high percentage of patients attending GP clinics and Primary Health Centres suffer from psychological disorders that presents with physical manifestations. Drugs will not help these patients. Some form of short-term goal directed psychological treatment should be the preferred method of treatment. An active movement to train GPs in the West in short-term goal directed psychotherapy has been instituted. Some GPs there have started to use simple CBT techniques for some patients. Most have not but have understood the psychopathology and have started to refer patients to psychotherapists. In Germany for example Linden (1996) reported that in 1992, 32,065 patients received short-term behaviour therapies while another 19,124 patients had long-term treatments and most of them were referred by GPs. Most of the referrals were for lack of assertiveness and psychosomatic dysfunctions and CBT was the most prominent type of treatment used.
In Malaysia of course we are unable to
cope with such a high number of referrals should the GPs and Primary Health
doctors decide to refer them. What we can do is to train these doctors
in basic psychotherapy techniques or at least counseling skills. In that
way it is hoped that doctors will stop prescribing benzodiazepines or multivitamins
unnecessarily to these patients while helping to maintain their illness
through reassurances and other avoidance phenomenon. It is also high time
that we relook at our undergraduate teaching curriculum. It is a must that
we incorporate psychotherapy training in their programs as the majority
of them will become GPs or at least Primary Health doctors before they
specialize or leave the service. In my experience, most undergraduates
have very little exposure to managing these types of patients at clinics
when in actual practice these are the types of patients they will commonly
encounter. Psychotherapy training is incorporated in most medical schools
in the West including Russia. Perhaps the time has come for us to follow
them. PERSIKOL will take the initiative to train them in the near future.
References
Hoeper E, Nyez G, Clearly P, et al (1979). Estimated prevalence of RDC mental disorder in primary medical care, Int. J. Ment. Health,6,6-15.
Jones LR, Mabe III, Riley WT (1989). Illness coping strategies and hypochondriacal traits among medical inpatients, Int. J. of Psychiat. in Med.,19,327-339.
Linden M (1996). Cognitive behaviour therapy under conditions of routine treatment in the general health care system, Behav. & Cog. Psychotherapy, 24,39-50.
Salkovskis PM, Warwick HMC (1986). Morbid preoccupations,health anxiety and reassurance: A cognitive behavioural approach to hypochondriasis, Behav. Res. & Therapy,24,597-602.
Salkovskis PM (1989). Somatic problems. In KE Hawton, PM Salkovskis, J Kirk and DM Clark (Eds.) Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide, Oxford: Oxford University Press.
Scott CS, Scott JL, Tacchi MJ, et al (1994). Abbreviated cognitive therapy for depression: A pilot study in primary care, Behav. & Cog. Psychotherapy,22,57-64.
Speckens AEM, Spinhoven P, Hawton KE, et al (1996). Cognitive behavioural therapy for medically unexplained physical symptoms: A pilot study, Behav. & Cog. Psychotherapy,24,1-16.
Van Hermert AM, Hengeveld MW, Bolk JH, et al (1993). Psychiatric disorders in relation to medical illness among patients of a general medical outpatient clinic, Psychological Medicine,23,167-173.
Varma SL, Azhar MZ (1995). Psychiatric symptomatology in a primary health setting in Malaysia, Med. J. Malaysia,50,11-16.
Von Korff M, Shapiro S, Burke JD, et al
(1987). Anxiety and depression in a primary care clinic: Comparison of
Diagnostic Interview Schedule, General Health Questionnaire, and practitioner
assessments,Arch. Gen. Psychiat.,44,152-156.