Chapter 1
Primary Care The Problem
������� It is not always appreciated that the general practitioner, rather than Neuro-psychiatrist who deals with the majority of neuro-psychiatric morbidity in the community . This chapter intends to focus on studies of the prevalence of neuropsychiatric disorders in the community , the problems identified by such studies, and the need for increased attention of mental health problems on primary care level , on the grounds on high prevalence and costs of Neuro-psychological disorders in general practice and evidence of consumer preference for the non stigmatizing treatment of primary care locations (Saltmore S. & Barrowclough ,1993 ) .
Neuro-psychiatric disorders �presenting in the community
A- Psychiatric Disorders presenting in the community:
������� About 90-95% of identified psychiatric problems will be managed by general practitioner (Pullen I.,1991) . The Neuro-psychiatrist only sees the minimum of patients . The minimum task of mental health services is estimated to treat 2.7 % of the population (Schizophrenia 0.19% , affective Psychosis 0.14% , organic psychosis 0.15 % , anxiety and depressive neurosis 1.4% , personality disorders 0.2% and Children disorders 0.64) (Andrews G.,1992) .
������� In Egypt citizens in need of mental health care is approaching 3 million , increase to 4.9 million if mentally retarded and demented are to be included (Okasha , 1995).
������� Hankin and Oktay (1979) in an extensive review of literature concerning results of more than 70 published primary care surveys done since 1960 mostly of American or British origin . Most of them indicated that at least 10- 30% of patients presented to primary care physicians in any one year with psychiatric problems , and in the United States Hankin and Shapiro (1979) reported 230 per 1000 at risk per 3 years in a private prepaid practice group .
������� In Western Australia an interesting study created by a method through which all patients consulting general practitioners in a single day were examined using 60 -item General Health Questionnaire . A result revealed 1.74 per 1000 in males and 3.72 per 1000 in women presenting 25.1% of all consultations in men and 32.2% in women (Jones & Burvill , 1978 ) .
������� Sheperdetal. (1983) conducted a search on 15,000 patients at 12 month experience approximately 14% consulted their doctor once yearly for a problem diagnosed as entirely or largely psychiatric in nature , but out of this only one out each 20 patients received any sort of mental health care .
������� These figures where nearly the same when compared to more recent diagnostic criteria .Darwick (1991) reported that the prevalence of mental health patients in primary care attenders would reach up to 40% and in Spain using a Spanish version of the General Health Questionnaire , it was concluded that about one-sixth of consultations in males and one-fifth of consultations in females could be attributed to psychiatric morbidity (Vazquez J.L. ,Wilkinson G., 1990) .
������� Narrow etal. (1993) estimated that 28.1 % met criteria for a mental disorder but only 3.6% of the population seeked treatment from a specialist . There are two explanations for such figures . If 28% of adult population is meeting the criteria and not seeking help so either they recover spontaneously or with the medical help from the general morbidity (Andrews G. , Teesson M. , 1994) .
������� In developing countries there were no significant change In a study conducted in Kenya . 20% of a primary health care attenders were suffering from a psychiatric disorder (Ndetei and Muhangi ,1979) . In India 60 general practitioners in Bangalore estimated that at least 10% of their attenders were suffering from entirely a psychiatric disorder (Gautam et al. 1980) .
������� Surveys of consecutive adult patient attending primary care facilities in defined areas in four developing countries (Columbia , India , Sudan and the Philippines ) showed prevalence rates of psychiatric morbidity varying from 10.6% to 17.7% (Harding et al. ,1980) with only a minority of these disorders.
������� In Nigeria assessment of psychological disorders among 272 primary care patients (aged 16-85 years) by a 2-stage screening procedure , using the 12-item version of the General Health Questionnaire (GHQ-12) and the Present State Examination schedule . The prevalence of psychiatric disorder was 21.3% . Depressive neurosis (51.7%) and anxiety neurosis (36.3%) were the most common disorders. The older age group, females, and those who were either widowed, separated, or divorced were more likely to suffer from psychiatric morbidity . Primary health care workers were only able to detect 13.8% of the psychiatric cases identified in the study population (Abiodun O.A. , 1993).
������� �Schulberg and Burns (1988) reviewed studies that conclude prevalence of psychiatric attenders in a primary health care level about 11-36% . They concluded such a difference among researchers to methodologies , in other words The variation in results is due :
������� Case identification .
������� specification of criteria for absence, presence of ���� morbidity .
������� The design and execution of techniques to identify those responders to fulfill the criteria .
These factors proved to be an important issue for consideration of psychiatric disorders in the community (Williams P. et al. , 1991 ) .
B- Neurological Disorders presenting in the community :
������� Neurological disorders are also among the most common disorders seen in general practice settings .In 1986 Razdanetal.detected 616 cases of major neurological disorders in a rural population of 63,645 in Kashmir(India) a prevalence ratio of 9.67/1,000 . In Britain neurological complains presented 6.1 % of the total number of requests for medical care (Casabella B. ,Augilar M. , 1990) .
������� The commonest among patients presented with a neurological complaint in a primary care setting is Epilepsy (27.0%) , followed by headache (19.0%) and cerebrovascular disorders (7.8%) (Singhal B.S., Gursahani R.D., Menken M., 1992 ) .
�������
������� Cerberovascular stroke encounters 15% of total deaths in England & Wales and is considered the third leading cause of death in the United States (1995) are almost seen at first few hours by general practitioners . Stroke incidence is estimated to be about 2/1000/year or in a country like England or new case every 5 minutes (Bamford & Dennis, 1988) with a prevalence is about 5/1000 and depends mostly on population age structure (Wade & David ,1985).
������� Epilepsy has a prevalence of 10/1000 and Incidence of 20-70 /1 00,000 depending on the age group being higher at the extremities (Sander et Shorvon , 1987) . In a community-based study carried out in the UK to determine the characteristics of patients receiving treatment for epilepsy, with particular reference to the duration , nature and severity of epilepsy . The prevalence of people receiving treatment for epilepsy was estimated at 4.5/1000. Seventy per cent had epilepsy for at least 5 years , while 8% had been diagnosed in the previous year . Fifty-three per cent had one or more seizures in the year prior to the survey , and 20% had seizures at least monthly on average . These figures indicate that the majority of patients receiving treatment for epilepsy in the community have long-standing epilepsy , often intractable to medical treatment, and associated with considerable social handicap (Hart Y.M. , Shorvon S.D. ,1995) .
������� Parkinson Disease has a prevalence of 1-2/1000 and 10/1000 in age above 50 (Mutch et al. 1986) and prevalence of 1% in the population above 65 years of age (Oertel W.H. , 1995 ) .
������� The figures of this estimates continued to be rather steady although the different criteria of selecting the patients The figures of morbidity of neuro-psychiatric disorders although varies largely from one study to another they all share that most patients seems not to receive any sort of medical attention .
������� There are no definite estimates for the number of neurological patients presented to primary care in Egypt , but it is expected to be as equal due to :
������� presence of endemic infections as bacterial ���� meningitis , poliomyelitis .
������� lack of diagnostic aids to diagnose Transient � conditions as Non convulsive forms of epilepsy or TIA.
������� lack of definite health programs for detection and
������� management of neurological conditions complicating ���� prevalent diseases as Diabetes millets , hypertension .
������� The evidence that neurological disease are not unusual, in addition to high rate of referrals to specialists reflects the need to focus on the neurological training of non- neurologists (Casabella B. , Augilar M. , 1990) .
Problems Facing Planning and Delivery of Primary Health Care
������� The previous examples would suggest the important role of Primary Care in Society, but unfortunately this role is still vague, and several problems render application of such service . We identified five main problems facing the planning of delivery of neuro-psychiatric consultation at the primary care level . These problems are :
������� I - Organization of health services .
������� II - Case identification at primary care level .
������� III - Problem of primary care Physician .
������� IV - Management of selected cases via other Levels.
������� V - Funding problem .
I - Organization of health services
������� The first problem is that the organization of health services in general and for primary care in particular differs markedly among various cultures and countries (Orely & Sartorius ,1986). although most of search work is in Britain and The United States seem of significance to be applied on other regions . Local system and response remains a critical issue in management of the neuro-psychiatric patient attending the primary health care facility . The western models of Primary care could not be applicable for most of developing countries where vast majority of population does not have an access to mental health care (WHO , 1984) .
������� Egypt , for example , suffers from dispersion of the primary health care components into different facilities and clinics . For instance Mother and Child clinics which constitute a major component of the primary health care infra structure provide service only to pregnant mothers and their children , Other children and adults are seen in different clinics which are not called general practice clinics but rather clinics of internal medicine . Clinics which provide the whole range of primary services are confined to rural areas or affiliated to institutions like factories or companies (Okasha A. ,Seif El Dawla ,et al. 1994) .
II - Case Identification at primary care level
������� The second problem seems to be to identify who is the "CASE" . Before 1970 community surveys rarely defined what was meant by a case , and the definition depended entirely on the individual research worker after that this problem was solved but not entirely . The repetitive versions of International Classification of Disease 10th edition ( ICD-10) (world health organization ,1992) placed a diagnostic criteria for both research and clinical applications . Other classifications such as International classification of Epilepsy (1991) tried to approach the same problem .Yet most diagnostic schemes are derived from patients seen in hospital practice and it is debatable whether or not these same defining characteristics should be applied or not to individuals in the community .
������� The main hazard in defining the "CASE" is the general traditional concept that most of these patients are not " ill " by they are merely stressed by life events & by treating them they come to believe that any distress or anxiety is pathological and needs treatment (Pullen I ,1992) .
������� This can be also applied to most of neurological disorders occurring in a sudden intermittent Symptomatology. As in non convulsive forms of Epilepsy , Transient ischamic attacks and early forms of Dementia . Although the problem could be solved in other levels of care using cross culturally standardized criteria for case identification . This method is non applicable at the primary care level as it requires highly skilled medical and auxiliary staff and due to the variance of the cases itself .
III - Problem of primary care Physician
������� The Third problem is the shortage of Primary Care Team or in another words "WHO" . The World Health Organization has proposed that mental health services can best be delivered in developing countries through decentralization and integration with primary health care services .(Gatarayiha F., Baro F. etal. , 1991) . But unfortunately this statement does not match with the reality .
������� Neuro-psychiatric disorders are often treated by family physicians , pediatricians ,physicians , psychiatrists and neurologists . This is mostly due to the lack of the trained Primary care physician and also the lack of the access to the specialist . In India there are only 4 medical officers per 80000 population at community health centers and 1 per 30000 at primary care centers and only one neuro-psychiatrist for every 3 million (Kshirosagar N.A. ,Shah P.U. , 1992) .
������� It is not only the number of physicians that encounters the problem , but also their behavior towards a patient presenting with psychological symptoms . In a conducted 7-year prospective cohort study of physicians' attitudes about and intentions to provide 27 preventive care services in their future practices. 112 respondents were surveyed 3 times: during orientation to medical school, during the 3rd year, and following completion of 3rd year of residency. The majority of preventive care services were viewed as more important to clinical practice in primary care than in nonprimary care specialties . The results indicated that physicians were less likely to plan on providing preventive services than they were
to expect their residency programs (Scott C.S. , Neighbor W.E. , Brock D.M. , 1992 ) . And it seems that this attitude of behavior continue after being indulged into medical practice . This could be an important cue to the failure of The educational medical institutes to prepare general practitioners.
������� The medical institutes allover the world had failed up till now to change the concepts of general practitioners towards what is diagnosed as neuro-psychological problem . On examination of the treatment for complaints the general practitioner assesses as psychosocial. Data was collected by videotaping 1,569 doctor-patient consultations among 30 Dutch general practitioners. The doctors perceived more problems as psychosocial than were actually presented, and much of their time was devoted to comorbidity. Purely psychosocial complaints were seldom neglected, but the main focus of treatment was consultation and reassurance. In cases where somatic presentation was accompanied by suspicion of psychosocial background, no action was taken in 40% of the cases. The average general practitioner treated many psycho social problems but mostly when the patient explicitly named that as the reason for the encounter (Verhaak P.F. ,Wennink H.J. , 1990) . And the ability to identify neuro-psychiatric disorders still remain far below the needed requirement .
������� It appears that there is more than one way for a Primary care physician to approach his patient and to get in contact with other levels of care . In 1986 Williams and Clare identified three methods of primary care/psychiatrist collaboration dedicated for a patient suffering from a psychiatric disorder :
1- The replacement model : Here the psychiatrist replaces the general practitioner as the doctor for the first contact . This was the prevalent view in the united states till 1993 .
2- The increased throughout model : in this model general practitioners and family physicians while retaining their role are encouraged to refer more patients to Neuropsychiatrists . Thus increasing the requirements of more specialists and exhausting the resources of other levels of care due to high prevalence of these disorders .
3- The lasion attached model :This seem to be the idealist model in identifying and managing the patients at the primary care level . In this model primary care physician are attached to psychiatrist through the primary care facility . But the family physician still holds the main role in diagnosing and managing of the case .
On studying of referrals from primary care areas permits the evaluation of health care in this level and reveals the educational requirements of the specialists in family medicine. In a study performed between January and April 1988 in Centenario , Italy . Out of 27,657 visits to primary care physician , 1,906 referrals to the different specialties were ordered . Psychiatry (1.41%), neurology (1.31%) were the specialties with the lowest referral rates .(Hernando A.J., Ramos M.T., Juez A.A. ,1991) but this appears to be due to the inability to identify cases rather than the real case prevalence .
������� These results was proved on comparing the health maintenance organization's primary providers' direct assessment of the current emotional disorders of patients with those of mental health professionals assessing the same patients . Findings indicated that the primary care providers failed to recognize almost two-thirds of their patients with a current mental disorder. The primary care providers were also able to correctly identify very few of the specific mental disorders most prevalent in a primary medical care practice. (Borus J.F., Howes M.J., et al. ,1988) , being most accurate in identifying organic disorders (Andersen S.M., Harthorn B.H., 1989 ) .
������� Even though , the identification of cases is also biased by the form of the presenting complaint . Bridges and Goldberg (1989) showed that when a patient was presented to a general practitioner with a psychological complaint he stood a chance of 95% of receiving psychiatric diagnosis but when presented with a physical complaint their chance was reduced to 47% , also doctors who has the ability to identify the cues of a psychiatric morbidity .
IV - Management of cases via other Levels
������� Our fourth problem is to identify "WHICH" of the selected cases. is referred to a higher care level . Goldberg & Huxely (1980,1992) set a biosocial model through what is known as filters . Through which a patient would pass from the mere prevalence of morbidity till Inpatient admission . Their model of five level and four filters (Fig 1.1) would be the most convenient to show how patients move from a type of care to another and show important implications for the future pattern of mental health services and the training needs of mental health services professionals .
Goldberg & Huxely Pathway to psychiatric Care
������� Level 1
The Community
260-315 /1000 per Year
- - - - - - - - - - First Filter (Illness Behavior ) - - - - - - - - -
������� Level 2
�Total Mental Morbidity
Attenders in Primary Care
230 /1000 per Year
- - - - - - Second Filter (Ability to detect disorder ) - - - - - -
������� Level 3
Mental morbidity identified by doctors
(conspicuous psychiatric morbidity )
101.5 /1000 per Year
- - - -Third Filter (Referral to mental health services )- - - -
������� Level 4
Total morbidity
mental illness services
23.5 /1000 per Year
�- - - - Fourth Filter (Admission to psychiatric beds ) - - - -
������� Level 5
psychiatric in -patients
5.71/1000 per Year
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Fig (1.1) : Five levels and Four filters ,with estimates of annual period
prevalence rates at each level (Goldberg & Huxely 1980-1992)
������� The first level presents psychiatric and emotional morbidity in the community as a whole a proportion of people with such a disorder in the community will consult a general practitioner i.e. "pass through" filter 1 and reach level 2 . Filter (1.1) is thus the decision to consult and the act of consulting .
������� The second level presents the total psychiatric morbidity presented to primary care level but some of these patients is not identified as psychiatric morbidity by the general practitioners ,these patients are referred as " Hidden Psychiatric morbidity ".
������� The third level presents " conspicuous psychiatric morbidity " i.e. the morbidity identified and recognized by the general practitioner . Much of this is treated by the general practitioner directly .The difference between the 2nd and 3rd is referred to as hidden or undetected morbidity and the magnitude of this is a measure of educational needs of practitioners in terms of psychiatric identification(Casey P.R., 1990 ) .
������� The fourth level presents the number of psychiatric patients which are to referred to a specialist care . And by the specialist decision they will be admitted to hospital thus presenting the fifth level (Williams P., Wilkinson G.,1991)
V - Funding problem
������� The last problem is the availability of the sources and means to establish Neuro-psychiatry as part of the primary care facilities . The cost of illness includes all direct and indirect effect of mental problems . Direct costs include all expanders to prevent , detect and treat ill health , indirect costs include loss of productive output due to mortality and morbidity (Gilchrist S. , Knapp M., 1994) . Rice et al. estimated the 1985 mental costs to be 103.7 Billion US dollar in the United States only . Grey and Funn estimated loss due to Alzheimer Disease in the UK to be 1039 million sterling pounds in 1990-1991 .
������� Egypt suffers from shortage of health facilities in general and mental health services .while the expandure of health funds is about 1.5% ,it reaches the in a country like U.S.A. to 13% . Figure (2.1) illustrates The different health expandures in several countries . Figure (3.1) illustrates the average expandure per capitum for several countries .
������� It is not only the lack of funds that is delaying the delivery of proper health services in Egypt but the demographic picture of the Egyptian population also presents a major population .
Egypt has a total population of 60,603,000 (1996 Population estimates) and is expected to be 67,923,000 by the year 2001 . The distribution of population density varies from 32955 (p/km2) in Cairo to 0.83 frontier regions . (Statistical year book ,1996) .With only 450 Neuro-psychiatrist (one for every 200,000 ) available (Okasha , 1995) . The only way to deliver Neuro-psychiatric health services is to depend entirely on the general health care practitioners .
Country Percentage*
United States 13%
United Kingdom 8.1%
France 8%
Developing countries 5.4%
Egypt 1.5%
Figure (2.1) �healthexpandures in several countries
(Okasha ,1995 abbreviated from World Bank )
Country
Funds/person
United States 3000$
Industrialized countries 1900$
Developing countries 41$
Middle East 1.3 $
Figure (3.1) health Funds in several communities
(Okasha ,1995 abbreviated from World Bank )
������� There is a good opportunity to utilize the health services available to improve the quality of Neuro-psychiatric consultation to the public . There are 2209 Social and rural centers , (Statistical year book ,1995-1996) , if neurological and psychiatric consultation is to be delivered through utilization of such facilities , then a major problem is to find a rather radical and chief solution .
������� In the Next chapter we will try identify the core of the problem in aspect of the patient doctor relationship with new research directions pursued that if mental illness is to be properly managed in primary medical care practice. Among needed studies are those pertaining to :
������� (1) The validity of diagnostic classifications specific to psychiatric morbidity in ambulatory medical settings.
������� (2) The nature of clinical decision making by primary care physicians .
������� (3) The ways in which diagnostic formulations influence treatment choices .
������� (4) The effectiveness of treatments transferred from the
������� specialist to generalist settings (Schulberg H.C.,1991) .
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