Editorial: Psychiatry and Primary Medicine in Israel

Article excerpt

This issue of the IJP is devoted to psychiatry and primary medicine. It is also my farewell contribution as a member of the editorial board of the IJP.

As known, modern clinical psychiatry is mainly engaged in the tip of the iceberg of mental disorders, namely in certain aspects of brain diseases, schizophrenic and affective disorders, while only a small part of all the other mental disorders is treated within psychiatry. Many mental disorders are not treated at all, at least not in the frame of the medical profession, others are treated by non-psychiatrist physicians, mainly in primary medicine. Especially this last category of mental disorders appears often in "comorbidity" with other (chronic) diseases of the same patient.

There is certainly a problem of under detection of psychiatric disorders in general and primary medicine. Detection of behavioral (psychosocial) problems, which may or may not reach the criteria of psychiatric nosological entities, in primary medicine are of course a prerequisite for proper treatment.

If primary physicians will detect and even diagnose more accurately e.g., depressive and anxiety syndromes, these can be treated (sometimes after referral to psychiatric services) more effectively.

A structured educational and clinical model of the doctor-patient encounter which, among others, may improve the detection and treatment of mental disorders in primary medicine is described in the paper of opt Root and Maoz.

But the problem of the detection of "psychosocial aspects of diseases" (a label used in order to avoid the term "psychosomatic") should be seen in a much broader perspective: Lamprecht, Schueffel and Maoz's paper on Psychosomatic Medicine in Germany stresses the point that it has been demonstrated that when a patient suffers from a common chronic (somatic) symptom which has been difficult to treat, and might thus have psychosomatic components, it may take years until a treating physician relates to the psychosocial background of this patient, his/her biography, including the way he/she perceives the development of the illness. This usually happens only after the patient has undergone repetitively very sophisticated and expensive tests and examinations and sometimes after the patient has already become a chronic invalid. In many cases such an interest in the patient's narrative combined with a short psychosocial intervention changed the often demanding illness-behavior of the patient radically, e.g., by the readiness to share the responsibility for the development, treatment (not cure) and rehabilitation of the illness with the physician.

The detection and treatment of mental or mixed psychosomatic disorders in primary medicine can be improved. One of the ways achieving this improvement is the establishment of cooperation between mental health professionals and the teams of primary medicine. A model of such a cooperation is described in the paper of Kates about the Hamilton project in Ontario, Canada. This project includes elements of patient care: Patients are referred to a regularly visiting psychiatrist, who sees them in the general primary clinic; and elements of mental health consultations: The regularly visiting psychiatrist helps the primary physicians, and the primary-medical social worker, with difficulties which they have when treating certain patients. …