Neuropsychiatry and primary Care
Introduction :
The report of health conference held in Alma-Ata in 1978 considered primary health care to be the hub of the health system around which arranged the other levels, whose actions converge on primary health care in order to support it and permit to provide essential health care on a continuing basis (WHO, 1987).
The principle of providing neuro-psychiatric services via an open door policy, which is now established as a method of choice in most of developed countries, lies a burden among the health facilities providing basic medical help. Although most of the health authorities consider the primary care doctor as the main medical support and guidance to the patient, including the Nuero-psychiatirc one. It is obvious form the that this cannot be considered as an easy nor a simple task.
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 (Andrews G., 1992). But it was proved that the prevalence of conspicuous psychiatric morbidity in the community ranges from 30 - 40 %.
Neurological complains presented 6.1 % of the total number of requests for medical care of which Headache,dizziness, partial or complex seizures accounted for 60% of total cases (Casabella B, Augilar M; 1990).This could be considered as evidence that neurological disease are not unusual, in addition the high rate of referrals to specialists reflects the need to focus on the neurological training of non- neurologists (Casabella B., Augilar M., 1990).
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.
Primary care, The Problem
In a review of different studies aiming to identify the problem. 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).
Further more a trial to detect problems facing planning and delivery of primary health care. The main problems facing the planning of delivery of neuro-psychiatric consultation at the primary care level problems are :
I - Organization of health services in general and for primary care in particular differs markedly among various cultures and countries (Orely & Sartorius,1986). Egypt, for example, suffers from dispersion of the primary health care components into different facilities and clinics (Okasha A., Seif El Dawla et al., 1994).
II - Case Identification at primary care level 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.This might be a way to an ideal solution for case identification.
III - Problem of primary care Physician is the shortage of Primary Care Team. 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. et al.,1991). But unfortunately this statement does not match with the reality.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 :The replacement model, the increased throughout model, in and the lasion attached model.
IV- The Fourth problem is to identify "WHICH" of the selected cases is referred to a higher care level.Goldeberg & 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 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.
V- Lastly the Cost of illness which 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. 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%.
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 problem. Egypt has a total population of 60,603,000. 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). This demographic presentation makes the only way to deliver Neuro-psychiatric health services is to depend entirely on the general health care practitioners.
Detriment of help seeking for Neuro-Psychiatric Disorders in Primary Care Health Setting
Detriment of help seeking for Neuro-Psychiatric Disorders in Primary Care Health Setting is tried to be identified, or simply " What makes the individual seek Medical Help ?? ". The uncleared issue of how would the patient suffering from a neurological or psychiatric disorder become in contact with the primary health service has been subjected to several studies. However, it remains a very important subject to be discussed as it presents the main aspect in any future planning for delivery of such a service to the community. It is noted that general practitioners have always had to practice psychiatry in that they are commonly faced with people bringing a mixture of physical, psychological, and social problems. The severity of psychiatric disturbance is likely to be less severe and the range of disorders is likely to feature predominantly anxiety and depression(Horder J.,1988).
In 1975 Anderson et al. conducted what is known as "Anderson Model " to detect the what are the detriments of help seeking behavior. In this Model three sets of Detriments where identified :Societal,system Detriments, both will influence Individual detriments which directly effects Health service utilization (Anderson et al.,1975,1978).
According to his model, Anderson emphasized the role of Individual Detriments and he furtherly divided them into three groups. The predisposing, enabling and illness level, he noted that assuming the presence of predisposing and enabling conditions. The individual or his family must perceive illness or the probability of its occurrence for the use of health services to take place, and that the illness level represents the most immediate cause of health services use, and thus the medical personal is to remain the most important partner in health services. Mechanic (1979) instead described a comprehensive sociopsychological approach to health services utilization behavior. He proposed a ten Detriments of help seeking behavior. It is worthy to notice that despite the differences in scale and emphasis, there are many similarities between the variables specified by Mechanic and those by Anderson (Williams P., Wilkinson G.,1991).
One of the most consistent findings in the literature on why people consult primary care physicians is that not only females consult more than males, but also the correlates of primary care utilization differ between the sexes.(Shaprio et al.,1984, Goldberg and Huxely. 1980, Jenkins & Sheperd,1983).In some cultures the tendency of psychiatric cases to present to doctors with physical symptoms are even noticed more in developing countries. for instance in Sudan, Philippine, Colombia, India (Harding et al.,1980) in Black Africa (German,1987a) In these studies, the main presenting complaints were pain weakness,palpitation and Diarrhea.
This dilemma led us to one of the most conflicting problems in primary care which is the relation between psychiatric and physical illness. For years the term psychosomatic have been used to determine physical symptoms with no biological correlates i.e., the rather complicated relation between the physical illness and the psychiatric illness. Goldeberg and Bridges in 1987 tried to solve such a problem. and identified four patterns of relations between Psychiatric & physical illness which was demonstrated.
Racial and cultural influences are also important. In a study conducted in 1987 for Treatment seeking for depression in Black and white Americans They were the same in long lasting cases but a significant decline in number of blacks in cases considered with few depressive symptoms (Sussman et al. 1987).
The last important item in these factor is disability associated with common psychiatric illnesses, whether severity of psychiatric illness and disability show synchrony of change while controlling for physical illness, and how invariant this longitudinal relationship is across baseline severity, Recency of onset, and psychiatric diagnosis.
Assessment of Symptoms and psychosocial Disabilities in Primary Care needs specific tools of assessment are required. But in order for these tools of use, most authors believe a group of specific requirements should be fulfilled (Wittchen H., Esssau C.A., 1991), being easy administrated and applicable, shorter, comprehensive of high degree sensitivity and specificity and include both the symptoms and the psychosocial axes. So, in the light of these requirements only very few of the available screening instruments could be of value at the primary care sessions.
A choice of several common Neuro-psychiatric disorders to be evaluated from the general practitioner and primary care point of view. The main aspects of reviewing such disorders does not include the new and expensive modules of investigations nor therapy. Instead a choice was made to review the differential diagnosis, community attitudes towards patients, different pathways for seeking help and ability to provide the least expensive and most efficient Medical solutions.
Common neurological disorders
Based on the previous basis, two of the most common neurological disorders are discussed. First, Epilepsy with special attention given to different symptomatology other than the classical Grand mal Fits. Second, cerebrovascular stroke with a special privilege to the control of predisposing and precipitating factors.
I- Epilepsy :
Of all neurological diseases, Epilepsy seems to have the most fame and attention.� Epilepsy is one of the most challenging neurological disorders in the primary care setting. But it is not only the matter of prevalence but there are also a number of problems, that makes epilepsy a challenge to the General practitioner.
Epileptic fits have a unique nature of illness, condition is episodic. In between the attacks the patient is usually normal, the diagnosis is essentially clinical, relying heavily on an eye witness account of the attacks (Shorvon S.D. etal.,1991). And if considering that there is a large amount of other conditions in which conscious may be transintly impaired and might be confused with epilepsy. Porter (1992) tried to show the commonest conditions which are associated with seizures or seizure like Phenomena. These conditions may resemble epileptic seizures so likely that even a highly trained specialist cannot depend entirely on his clinical skills and investigations are required (Rowan A.J., 1992).
Due the nature of epileptic fits the perceiving Epilepsy as an illness phenomenon may be initially unreported, for several reasons.The patient may be unaware of the nature of his attacks and do not seek medical. This is particularly in developing countries as Egypt, in which a number of alternative and non medical beliefs about the nature and cause of epileptic seizures is held. The patients with partial seizures or absence fits usually does not consider that a "disease" of which they should seek medical help (Shorvon S.D. et al., 1991).
One of the major problems facing management of epilepsy in most countries of the world there is some degree of stigma attached to diagnosis of Epilepsy.So the patients may be reluctant to admit their condition. It was found that people known to have epilepsy were less likely to fill in an Epilepsy Questionnaire than was the control group. This could be attributed mainly to the community attitudes.
The Difficulties of managing epilepsy does not only present in its nature nor in stigma but of the difference from the Medical point of view. For instance in Developed country, most seizures reported are of partial onset i.e. partially or secondary generalized, in many patients, The focal nature of epilepsy has been identified due to as a result of investigation, e.g. the EEG or CT scan abnormality (Eltribi, 1991).
In developing countries a higher incidence of generalized seizures is usually reported. This difference may be apparent only, reflecting both the lack of investigatory facilities and a bias introduced by data collection methodology (e.g. the lack of good medical records, and the reliance on screening questionnaires which are more sensitive to the detection of Tonic clonic rather than of partial seizures).
Principles of treatment aiming to The control of epilepsy may be practiced at varies levels in the Hierarchy of epilepsy, at level of epilepsy itself (Epileptogensis), the individual epileptic seizures (ictogensis), or in the avoidance of consequences of the epilpsies or their component seizures (Dreifuss F.E., 1995) problems like diagnosis.
The diagnosis of epilepsy should be established beyond doubt, and there is no place for a trial of treatment in doubtful cases. The diagnosis of psuedoeplipetic or non epileptic seizures classically has been based on certain clinical signs, occurring under special environmental circumstances, superimposed on an apparent background of emotional disturbance (Lesser R.P., 1985).
Other problems as when to start treatment, choice of drugs, A very important issue in the choice of drug is that the regular availability of antieplipetic drug cannot be insured, also a very serious concept even among Medical personal is switching from a drug to another represents a continuum of treatment (Sander J.W. et al., 1991).
The patient compliance needs markedly to be supported as poor compliance is commonest cause of failure.Good compliance for anti epileptics can be achieved through simple daily regimens, regular follow up consultations, usage of simple methods of drug administration as the use of pill box and the doctor's attitude towards the patients is considered the most important factor in compliance.
Lastly the emergency treatment of seizures for a general practitioner in a developing country this would not be the same situation. Thus an important part of the general practitioner training is how to handle a seizure. Usually recurrent seizures will not need medical intervention unless the patient passes into a status.
Cerebrovascular Stroke:
The second common disorder to be discussed is Cerebrovascular Stroke. Stroke is ideally suited for prevention (Gorelick P. B. 1994). It has a high prevalence and is estimated to be the third leading death among adults in U.S.A. and Western Countries (Raps E.C., Galetta S.L.,1995). The burden of illness, and economic cost.and safe and effective prevention measures
Our knowledge of risk factors for stroke has advanced substantially during the past several decades and exceeds that of other major neurological disease (Gorelick P. B.,1995).The risk factors which make cerebrovascular stroke such a preventable disease is of encountered by the general practitioner or primary health care team.
Primary care can treat most of the cases of stroke by intervention of nearly all of the following factors. a choice is made to discuss the most important, other factors as smoking or hyperlipidemia presents a burden on General health care and can be dealt more efficiently at other levels of care.
a- Hypertension :
Hypertension is generally considered the most important treatable risk factor for stroke (Wolf PA., etal. 1992). The relative risk among hypertensive persons is approximately three to four fold greater than for nonhypertensivepersons,and even border line hypertension is associated with a relative stroke risk that is about 1.5 times that a normotensive patient.
proper management of hypertension reduce the risk of cerebrovascular stroke. It is estimated that up to 70% of the cases can be prevented by treatment of hypertension (Dunbabin D.W., Sandercock P.A., 1990).
b-Cardiac disease :
This is another major detriment of stroke. Left ventricular hypertrophy, congestive heart failure, and atrial fibrillation are independent predictors of ischamic stroke (Wolf P.A., Cobb J.L., et al., 1992). Another asymptomatic risk factor in stroke in young age is Mitral valve prolapse. Mitral valve prolapse has a high incidence among general population and is associated with a high risk of cerbrovascular stroke (Sacco R.L., 1994). In most of these cases anticoagulation may be a radical solution to decrease hazards of cerebovascular insult. But unfortunately this is not a trend in general practice.
c- Transient Ischamic Attacks (TIA) :
Transient ischamic attacks are frequently seen in physicians' daily clinical practice. TIA's are often a warning sign of a following stroke. It is important to diagnose the underlying etiology in order to prevent subsequent stroke. With knowledge of the exact etiologic diagnosis correct secondary preventive therapy may be given. The aim is to save patients from disabling strokes (Lyrer P., 1995). In community based studies, it is estimated that TIA proceedsatherothrombotic brain infractions in about 10% to 12% of persons (Wolf P.A., Kanel W.B., Verter J, 1983). Stroke usually develops in 35% with TIA and two thirds of them usually develops the insult within six months.
Antiplatelet therapy with aspirin or ticlopidine reduces stroke by about 25% in many patients with transient ischemic attack or initial stroke. Warfarin should not be used routinely for primary cerebrovascular disease but is useful to prevent cardioembolic stroke. (Hart RG. Rohack JJ. Solomon D.H. Feinberg WM.,1995). Other factors as Diabetes Mellitus, Hereditary Factor needs to evaluated and discussed in details in further studies.
Common Psychiatric Problems
Psychological problems are frequently encountered in general health care services in both developed and developing countries. Surveys of mental disorders among patients contacting general health services show that a quarter to one third of all patients suffer from such disorders (Burvill P.W.,1989). A choice of the syndromes in chapter IV was based not only on the fact of their prevalence in the community but also to the nature of presentation. Both are commonly presented to the primary care physician by somatic symptoms, rendering their diagnosis more difficult.
Hafner and Bickel (1989) suggested that the presentation of psychiatric illness by physical symptoms mental illness may be associated in three different ways with increased risks for physical morbidity and mortality.Through a direct relationship emanating from �� psychiatric illness, through an indirect relationship mediated by factors������ associated with mental disorder and through Relationships between physical morbidity, mortality and mental disorder may point to common underlying factors. In order to solve this problem facing the diagnosis of psychical and psychiatric symptoms (Golderberg,1989) suggested a classification to take account of the complex relationships existing between psychiatric and physical illness. In his classification Goldberg tried to clear up all comorbidity between physical and psychiatric symptoms. This seems of a great benefit to all personals working in the primary care field. As it is common for the general practitioner to meet up with symptoms that is not mounted up to neither a clear physical nor psychiatric disorders.
Somatoform disorders :
They are a group of psychiatric disorders whose essential features is repeated presentations of a physical disorder, together with persistent requests for medical investigations inspite of repeated negative findings and reassurance by the doctors that the symptom has no physical basis (ICD-10). Although these disorders have been recognized throughout history, yet no clear definition was established until the DSM-III introduced the term Somatoform for this category of disorders. Even then, an interrelationship of Somatoform Disorders and the terminology used in this field are confusing (Bass, 1993).
Although the term was introduced 20 years ago,up till now, the different diagnostic systems showed marked disagreement about which disorder should be included under this heading and about the criteria used for the diagnosis. Although ICD-10 and DSM-IV classifications has attained the term somatoform there are still a significant differences between both.
Clinical picture of Somatoform disorders include Somatization Disorder, Conversion Disorder, Hypochondriasis Somatoform pain disorder, Undifferentiated Somatoform disorder and Body dysmorphic disorder
Different treatment approaches were tried in management of somatoform disorders. However,because the exact etiology of these disorders is unknown, no curative or ameliorative therapies have been found effective (Gabbard,1995). The treatment approaches can be divided into psychological treatment (which includes cogentive-behaviouraltherapy, or psychodynamic psychotherapy) and pharmacological treatment. Prescribing tricyclic antidepressants have been tried and have shown to have analgesic effects which are independent of their antidepressant effect (Bass and Benjamin, 1993). ��� After investigating the different treatment approaches (Gabbard, 1995), it has been advised in that the primary physician, the patient's primary and if possible, the only physician.
Anxiety disorders :
They exist in about 30-35% of the population and of generalized anxiety disorder specifically 9%, and since 80% of anxiety patients present with exclusively somatic symptoms and 10-20% of these patients are seen in primary care settings, then anxiety disorder should be recognized by primary care physicians. Unfortunately, the reported cases of under recognition in primary care range from 20-80% of true cases (Kirmayer et al., 1993).
Anxiety is not always considered always as an illness behavior, in fact it can be considered at a time a normal response to life or stress, this anxiety in fact may improve performance and any attempt to reduce this anxiety is inadvisable, however if the level of anxiety is excessive then performance will deteriorate (Casey P., 1991).
The commonest picture of anxiety as a disorder seen in general health care settings is Generalized anxiety disorder of which essential feature is anxiety. It is usually generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e. it is free-floating). The dominant symptoms are highly variable,but complaints of continuos feeling of nervousness, trembling, muscular tension, sweating, light headaches, palpitations, dizziness, and epigastric discomfort are common. Fears that the sufferer or a relative will shortly become ill or have an accident are often expressed, together with a variety of other worries and foreboding. This disorder is more common in women, and often related to chronic environmental stress. Its course is variable but tends to be fluctuating and chronic (ICD - 10, 1992). Somatized anxiety is a condition that results when psychic anxiety is transformed into muscle tension. The important aspect of this differential diagnosis is that patients with somatized anxiety usually do not have a life time history of multiple unexplained somatic symptoms. Another differential factor is that somatized anxiety usually takes the form of musculoskeletal, sympathetic cardiovascular or gastrointestinal symptoms. They usually complain of two or three symptoms accompanying anxiety, as opposed to the many symptoms described by patients with somatoform disorder, although Somatoform patients have comorbid anxiety, along with associated anxiety, rather than one of primary anxiety, rather than one of primary anxiety with a few associated somatic symptoms (Gabbard, 1995).
Before discussing the issue of management of anxiety an important factor is discussed a fact should be established that there is no formal treatment for normal or trait anxiety. The temptation of the general practitioner to pharmacological treatment should be limited mainly because of the risk of tranquilizer dependence. other methods such as relaxation techniques should be taught to chronically tense patients.
For mild anxiety an explanation of the cause and reassurance that the symptoms are not due to organic disease will not much to reassure the patient. A common fear is of collapsing during a panic, although this rarely occurs. other concern that a heart disease will result from the symptom or that severe psychiatric illness will ensue. Usually the relief from such reassurance is temporary and in of the conditions more active treatments are needed. If more psychodynamic exploration is needed then it is advisable that the condition is to be referred to the care of a specialist and the involvement of a professional psychotherapist.(Casey P.,1991)
The next approach for a general practitioner should be relaxation techniques, these are within the competence of every practitioner. The general approach is the progressive relaxation of different muscle groups throughout the body.
Practical advice about restructuring the patient's timetable, so as to avoid unnecessary stress, e.g. rushing, is given along with guidance on distraction when tension is developed, patient should be advised for avoiding coffee or alcohol so as they sometimes worsen anxiety. Sophisticated methods of cognitive psychotherapy as Anxiety management training or systemic desensitization should only be used by a trained therapist.
Pharmacological treatemnt that includes tricyclic antidepressants are superior to anxiolytics not just in depressive illness but also in anxiety (Modigh, 1987), also Beta-blockers such as propranolol were first reported as successful in treating anxiety neurosis in 1966 and since then they have been used successfully. their anti-anxiety propriety is related to their peripheral action although in higher doses they have also central activity. They are particularly useful for those presenting with somatic complaints and have no effect on psychic anxiety. Also, one of the most common drugs to be used are low dose phenothiazines but they should never be applied as first line of treatment. A new compound, Buspirone is launched within the past few years with no risk of dependence. But the delay of onset of its effects makes it inappropriate for the use of short term severe anxiety but it may have a place in those chronically anxious people who fail to respond to other measures.
Neurasthenia (Chronic Fatigue Syndrome) :
although it definitely exists as a reality in medicine. There is no established definition up till now. As similar psychiatric disorders Neurasthenia may be a primary disorder or part of symptomatology another disorder.The history of Neurasthenia is discussed from 1869 when an article entitled "Neurasthenia or Nervous exhaustion" appeared in the Boston Medical and Surgical Journal until Gosling (1987) who tried to sum up different aspects of reviewing Neurasthenia.
The signs and symptoms of Neurasthenia was discussed, being highly variable, In Beard's original article (1880), he listed more than 50 features which he classified into eight categories, The first two which were fundamental were Physical exhaustion with fatigue and Mental exhaustion with concentration and memory difficulties.
Since 1880 the symptoms of Neurasthenia were varying from different authors and classificatory systems, but in almost all of them agreed about the presence of main two features that Beard stated.
It is well known fact that operationally defined psychiatric syndromes frequently overlap (co-morbidity or association). For example, an association exists between Neurasthenia and depression,anxiety in at least 60% of cases (VollrathM.et al., 1990).
Neurasthenia in modern classifications is reviewed. First in Diagnostic and Statistical manual (DSM) up to DSM-IV where it does not exist under its unique identity.Then as part of ICD System where it as part of International classification of Diseases published by the World health organization since the appearance of first edition in 1960 till the tenth edition in 1992.The concept of retaining Neurasthenia coincides with the principle of ICD-10 as an international system. As mentioned before neurasthenia continues to be a major diagnostic entity in Non Western countries (Klineman A.,1985). This can be attributed to the tendency of psychiatric problems to present in developing countries in a somatic form rather than psychological form (GoldebergD.and Bridges K.,1988).
Management of Neurasthenia : As mentioned previously chronic fatigue is one of the commonest presentation encountered in general practice. Usually diagnosis can becomes clear after History, examination and simple investigations. Any neurological signs is not compatible with the diagnosis of chronic fatigue syndrome.
Overall research suggests that in anyone with fatigue lasting more than 6 months investigations is largely unhelpful (Ridsdale L., etal., 1993), nevertheless, a set of simple battery of tests remains a sensible compromise between under and over investigations in anyone before diagnosis as Chronic fatigue syndrome (Wessely S.,1995).
The problem in management of the chronic fatigue syndrome lies mainly is the conflict due to etiological factors.
also to the false concepts which reflects on the advice given by the general practitioner. Management is discussed under three titles Rest,Pharmacological Treatment and Psychotherapy.The reliability of the therapy depends mostly on patient doctor relationship. Jerome Frank (1952) wrote that the most important factor in recovery were faith in the physician, and the expectancy of recovery.
II - Depression :
It is well known for a long time that patients with depressive symptoms are treated by their general practitioner rather than by psychiatrists (Priest,1982). It is also known that a large proportion of seriously depressed patients in the community do not even seek any source of medical support. (Paykel E.S., Priest R.G., 1992)
Although the course of depression in General health care settings is not so clear it is expected to be in the form of episodic and recurrent illness (Angest J., 1992). Thus, making the depressed patient one of the main utilizers of health care facilities.
The social consequences of depression cannot be neglected. Depression interferes with personal and marital relationship, contribute to a family discord (Fadden G.B., BebbingtonP.E.,Kuipers L.,1989). can have legal repercussions. it significantly reduces the capacity for work thus has its financial consequences not only on the personal level but the economic burden of depression on the society is enormous(Stoudemire A., Frank R,Hedemark N. et al.,1986).
Symptoms of Depression in Primary Care Settings :
Symptoms of depression in primary care settings differs entirely from those encountered in Psychiatric clinics. The classical picture of depression described under the identity of
Mood Disorders in the Tenth version of International classification of Diseases (ICD - 10). is replaced by rather a mixed picture of somatic, anxiety and sleep symptoms (Baldwin D., Priest R.G.,1992). Thus the diagnosis of could neither be fulfilled nor diagnosed using such described criteria.
labeling depression as Endogenous or reactive is no longer regarded as helpful in diagnosing depression neither in General nor Specialized health care settings also it is considered of no value in deciding the need of treatment.(Burvill P.W., Hall P.W., Hall W.D., Stampfer H.G. and Emmerson J.P., 1989). Modern classifications define Depression in terms of Major or minor.
As Mentioned before most of the community cases are missed by the general practitioner. Possible reasons for under detection involve both the doctor and the patient.
patient factors include lack of awareness by patient or his relatives that depression is distinct and treatable illness. Often patients perceive symptoms as shameful, and tends to emphasize their physical complaints. Doctor factors include that belief that depression is a natural consequence of old age and such "understandable" Depression does not require treatment. Even with awareness of depression, general practitioner may hesitate to give drugs which have side effects that might be perceived by the patient as frail (Katona C., Freeling P., Hinchcliffe K. et al., 1995). ����
Depression in primary care is not only presented as a sole diagnosis. There are multiple medical, disorders that depression constitutes a main feature.AlsoIt is well known that depressive illness is a common association with neurological disorders,
The effects any illness and its treatment on quality of life have become important considerations in mode of therapy. Quality of Life is difficult to define, showing great individual variability. Quality of Life is concerned with satisfaction of primary and secondary needs, satisfaction with life, and achievement of a sense of well being. Depression is a common disorder whose characteristic features are likely to impair Quality of Life. Patients suffering from depressive symptoms have been shown to have worse physical and social functioning, spend more days in bed, have more bodily pains and worse current health. (Beaumont G.,1994).
Management Strategies For depression is discussed including Antidepressant Drugs, both classical and Newer Antidepressants.One of the very important factors of compliance of the patient to drug therapy is informing him about the time lagging between the administration of the drug and appearance of response This ranges from 4-6 weeks. The unawareness of such a simple factor may cause the non compliance of he patient (Georgotas A., Mccue R.E., Coper T.B. et al.,1989).
Also Psychosocial Management as the primary care physician is commonly familiar with the patient coming for help, patient expects from his doctor understanding, support and a regular review of his condition. Treatment of depression should be based on the fact that depression is a relapsing disease.
�Primary Care.CurrentSatus
Most of the developed countries have a goal for supplying health care for all citizens by the Year 2000 through primary health care (Alarcon N. G., 1994). primary health care must foster self-responsibility, self-reliance, self-confidence, self-respect, and belief in self-potentials and capabilities in people. Specific new critical health problems primary health care must as AIDS, accidents.
Despite the World Health Organization's approach to primary health care, progress toward health systems based on social justice, intersectoral integration, and participation by communities in developing comprehensive and holistic treatment and preventive services has been slow (Malcolm L.,1994).
Newly developed techniques as Self Help Materialswhich are suggested extend care provision. These can be used as an alternative to formal treatment for individuals not requiring specialized help, and as a adjunct to specialized help for others. (Sorby, Reavly et al. 1991) to overcome ������� The shortage of skilled psychological services available to the general practitioners.
The second problem discussed is the relation between the Practitioner and patient.Problems like Causes of low attendance rates and causes which are attributed to patient or to wrongly based assumptions some mistaken assumptions about local cultures.
Another main problem is discussed which is the ability of the general practitioner to identify undiagnosed patients.�� It was found that doctors who have high identification index are when rated by an independent observer as having more interest and concern for the patient, having a greater interest in psychiatry, being older, more experienced (Thoms K., 1987).
Classifications for Diagnosis and research Psychiatric Classification Designed for use in primary Health Care this is a major point in dealing with the any services designed to link the prevalence of Neuro-psychiatric Disorders in the community that is most of Classifications and criteria of diagnosis is placed through a high academic institutes which tend to be as accurate as possible regarding Symptomatolgy. but through their trial these institutes tends to drop or underestimate vague symptoms or diagnosis in order to make the diagnosis reliable.thus missing a large proportion of health care patients at primary level. (Cooper E, 1991).The surprising point that this problem tend to exist over decades. Thirty six years ago.
Kessel (1960) released a study which still stands as one of the best examples how the classification influence the results. In his study different sets of criteria were used to detect morbidity in a general health care attenders. The prevalence rate rose from 50 per 1000 using ICD-I to 90 per 1000 when detecting "conspicuous psychiatric morbidity " and to 380 per 1000 on adding physical symptoms with no detectable cause and even to 520 per 1000 when psychosomatic disorders were added.
To judge the classification in a right manner Cooper et al. (1991) differentiated the classifications used by general practitioners into two types. Those designed by specialists and classifications designed by General practitioners.The problem of classification is not a hypothetical problem. Primary care settings are increasingly important sites for psychiatric research. A broader range of many psychiatric disorders is encountered here than in the mental health arena, and their study will therefore provide us with a more representative picture of the true nature of these disorders (Barsky AJ.,1993).
Much of primary care practice consists of the management and palliation of somatic symptoms, yet the phenomenology of somatic symptoms has barely been investigated. However, ambulatory medical settings impose particular constraints and demands upon consultation-liaison researchers.
The relation between the General practitioner and Neuropsychiatrist holds a promise of better treatment in health care individuals who are not referred for specialized health care (Williams P. etal,1991). We would like to emphasize that The primary health care is and will never be a road block in proper management of the ideal management of patient, and that the concept of Primary Care Service as a filtering and sorting service should be replaced by a concept that Primary health care facility is and important and integrated part in the management of Neuropsychiatric services. Also it would be the easiest way for reutilization of health services for the sake of these patients in morbidity.
There are several issues to be discussed concerning the relation between the General practitioner and the specialist. The choice of referred cases, exchanging information and skills. One of the most methods of communication between the primary care physician and specialist is referral letters,the future role Of clinical neur-psychiatrists in the health care system of the future should have a multifaceted role in integration with the primary care. Advances in the basic understanding of the nervous system and therapeutics of neurological disease have requires such cooperation.
Implementation of Primary Care Plan
From the previous discussion it appears that the designing and introducing health services needs more than knowledge of nature of neuropsychiatric services. The subjects involves a multi aspects of scoio demographic and economic burdens. Thus any research work aiming to plan a primary care service should consider these aspects. ���� A plan for implementing primary Health service is illustrated. The steps necessary for a research project aiming to implement the best neuropsychiatric service on the national level through utilization of primary care resources without laying a burden on the available resources is concluded (Refaat M., 1996).and clear objectives of such a project is determined before moving into field work, such objectives should be based on clear and realistic bases.
Neuro psychiatric Education
To master the art of medical discipline, the student has to pass through the following six well known phases of education and learning : Premedical, preclinical, medical, graduate, postgraduate and finally continuing education with possibility of further training or subspecialisation.
The question of training curriculums for the primary care physicians and undergraduate medical students.Under the statement that a medical education system should have the means of ensuring the students graduate, or obtain a license to practice medicine, only if they have acquired the necessary skills and abilities. (Costa E Silva J.A., 1991).
The problem of education of neuropsychiatry was always judged through the specialist point of view (Okasha,1995). A main bias in teaching is the dependence on Central and university Hospitals which usually attracts a variant of cases different than that the General practitioner is likely to see during his field practice. the use of rather expensive and sophisticated methods of treatments which are not usually available (Okasha A.,1993).
on Evaluation a university-based psychiatry curriculum for primary care through reviewing Physician interviews and chart audits, 79% of patients were unrecognized by Primary care physicians. Primary care physicians assumed that patients were functioning well emotionally, and psychiatric dimensions of patient complaints were not examined in the majority of patients. These patients generally received a diagnosis of adjustment disorder in response to medical treatment (Jones L.R. etal., 1988).
Principles of Neuro-Psychiatric Education : The most essential elements which contribute to any initiative aimed at developing an adequate national capacity for psychiatric training (Blackwood G.W., Alexander D.A.,1983) is discussed and summarized into :
1- Establishment of professional units
2- Development of an integrative approach
3- Psychology should be taught at the preclinical
4- Special attention should be paid to clinical psychiatry
5- Medical students should be attached to a psychiatric unit
6- The teaching program must be systematically evaluated.
�World Health Organization Primary Care Project
In 1993 the material of ICD-10 Primary health Care was distributed on a number of regional centers (including Egypt) aiming to improve the quality of services delivered by Primary Care Physicians.The core of the system included a 24 flipcard system of the most common psychiatric problems encountered in the primary care setting.The material of ICD-10 Primary health Care can form a core for a system, not only to the primary health care. But the subjects and material could be expanded to form a course of undergraduate teaching.
Major problem in medical education of Neurology is the lack of integration between basic sciences and clinical information into a cohesive whole. If either of these is taught in a vacuum, the medical students frequently is unable to reason through clinical problems and this can result in anxiety, dislike and eventual disinterest in the subject material. Students perceive that the neural sciences and clinical neurology are overly complex, and many of these students develop a up to what can be termed "Neuroophobia". Neurophobia can be defined as a fear of the neural sciences and clinical neurology that is due to the students inability to apply their knowledge of basic science to clinical situations
(Jozefowicz R.F., 1995).�
Neurology, on the other hand, should be taught as one unit, the student must learn that with all points of history and examination should be fulfilled.
Neuro-psychiatric Education in Egypt :A main bias in teaching in Egypt is the dependence on Central and university Hospitals which usually attracts a variant of cases different than that the General practitioner is likely to see during his field practice. the use of rather expensive and sophisticated methods of treatments which are not usually available (Okasha A.,1993).
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