Primary Care Psychiatry and Behavioral Medicine

Abstract

In this era of managed care and fixed consciousness, primary care physicians have received weakened training in psychiatry. This book demonstrates that psychiatry is a specialty that does not stand alone but continues to be intricately involved in all areas of patient care. An effective collaboration between family medicine and psychiatry educators and clinicians, this text capably examines the nuances of the physician-patient relationship while remaining practical. It covers each subject thoroughly while remaining true to its title and presenting clearly written discussions on brief office treatment and management of both medical and psychiatric illnesses. The guidelines on how to focus each office visit are particularly relevant in this era of brief patient encounters. The book is divided into 3 parts: the common psychiatric disorders encountered in primary care, the utilization of behavioral medicine theory in primary care, and the psychosocial treatments used in the primary care setting. All 3 sections are anchored to a framework of different psychosocial models without confining the reader to one specific model, allowing the clinician to explore which model is most effective for his or her practice and education. Part I lays out the psychiatric disorders in primary care as classified by the DSM-IV-PC. I found the discussion of anxiety disorders, including the differential diagnosis of coexisting medical disorders, particularly helpful. The depression chapter includes useful suggestions on conducting an effective clinical interview and outlines appropriate triggers for a mental health professional referral. Substance abuse, a topic usually covered with an outlook of defeatism, is addressed with optimism, and useful advice is given on interventions and patient feedback. The table pairing patient's stages of change with appropriate questions is particularly helpful. Chapter 7 gives important information on assessing and controlling a potentially violent situation and addresses relevant legal issues. The table in chapter 8 detailing office-based management of personality disorders is comprehensive and useful. Chapter 9 covers schizophrenia and other psychotic disorders, providing enough information for a primary care physician to approach the initial management of these patients, but emphasizes the need for a low threshold for consulting a mental health professional. A notable weakness in this section was the absence of a discussion of eating disorders. Part II shifts the focus from psychiatric disorders encountered in primary care to the role of behavioral modification therapy in common medical illnesses. Chapter 12 discusses the relationship between stress, hostility, depression, and coronary artery disease, emphasizing the need for physicians to address their patients' social support and coping mechanisms. Chapter 13 has useful health risk assessments and critical pathways concerning many of the components of cardiovascular disease, with a helpful breakdown of which types to address at each office visit. Chapter 14 switches the focus to reproductive and sexual health, with an informative discussion of the treatment of menopause. “Death and Dying” is the focus of chapter 15, with examples of the proper environment and manner in which to deliver bad news and a discussion of the Kubler-Ross stages of grief. This section includes a discussion of physicians' emotions when they deal with the loss of a patient. Part III discusses psychosocial treatment in primary care and the different methods to integrate psychiatric and medical care in one's practice. Chapter 16 deals with consulting and counseling with a focus on the nonpsychiatric patient who enters the primary care physician's office for the treatment of a medical illness. It includes a discussion of the Balint model and important questions a physician should ask before proceeding with counseling or consulting a mental health professional. Crisis intervention is comprehensively explored with helpful case studies. The “Fourteen Steps” set out by Dr. Feinstein appear very useful. Chapter 18 deals with family counseling and, with the advent of preventive medicine and the shift of medical treatment from acute disease to chronic illness, the necessity for the family's involvement in therapy is obvious. The chart in chapter 19 outlines the stages of behavioral change with the patient's presentation, common clinician mistakes, and necessary interventions. The authors examine how the family meeting should be arranged and conducted; provide questionnaires; and give practical advice on seating, communication, and assessment in the future. This book would be an excellent study tool for all medical students as well as for all physicians interested in how to more effectively treat the full spectrum of their patients' illnesses. It sets out clear diagnoses, patient-physician encounter guidelines, and course of treatment for the more prominent psychiatric illnesses, as well as instructs on utilizing behavioral modification theory in preventive medicine and lifestyle improvement. It was informative and thorough, while remaining concise and easy to read, a task not often accomplished by medical texts.