The role of primary health care in the treatment of persons with mental disorder

We studied 1128 patients that came with psychiatric problems at the health Centres that are linked to the General Hospital "G. Hadzikosta", Ioannina, Greece, in the years 2000-2002.

The age of patients ranged from 18-83 years, with mean age 47,4 years.

65% of them were women.

They were assessed according to ICD-10 criteria and a semi structured psychiatric interview. Sociodemographic factors were recorded and also the previous psychiatric history.

25% of the individuals were presented with anxiety disorders, 20% with somatomoform disorders, 12% with depression, 8% with personality disorders, 1,5% with bipolar disorder, 1,2% with schizophrenia, 2% with obsessive-compulsive disorder, 5% with adjustment disorders, 7% with alcoholism and 4% with substance abuse problems. The remaining 14,3% were presented with claims for compensation and early retirement due to illness.

The appearance of psychiatric disorders in primary health care are extremely frequent and tend to increase.

The psychiatric disorders that appear more often are: depression, anxiety disorders, and alcohol and substance abuse. Comorbility is also too frequent.

The factors that are implicated are the speed of social changes, poverty and unemployment, and increasing aging of the population and also economic immigration and refugees.

Immigration in the last decade became a major problem for Greece.

Immigration entails a number of psychosocial and environmental stressors that may contribute to the development or the exacerbation of a psychiatric disorder.

There is a slight only difference in the prevalence of major psychiatric disorders, between immigrant and native populations (possibly explained by the social causation hypothesis for schizophrenia). There is though a significantly higher prevalence of adjustment and behavioral problems in immigrants and their families, related to the "cultural shock", poor education, low Socioeconomic level, language problems and social isolation. Children may develop behavioral and attention-deficit problems and adolescents may be rejective.

It has been reported that psychopathology sometimes preexists in immigrants or their families and may contribute to the decision for immigration.

The early detection and proper assessment of the psychiatric disorders in primary care and also the transfer for more specialized treatment. On the other hand, the recognition of factors that are implicated and are responsible for the worsening of these conditions, are of paramount importance. Together with the raising of awarnness and the psychoeducation of the general population, are the main ways for the more effective recognition and transfer to the more specialized psychiatric services and for the continuity of treatments.

The investigation of issues relevant to the provision of effective psychiatric services in primary care requires a systemic view in which the complex web of inter-relationships between the various subsystems is a major focus of inquiry. This requires a shift away from a reductionist approach to explaining complex biological or social systems. It also requires the collaboration of interested people from a variety of relevant disciplines, including psychiatry, psychology and social work.

The different methods of questioning witch each of these disciplines can bring to bear, will reveal different aspects of the system and need to be integrated and understood if sensible changes are to be made.

It is to be hoped that creative collaboration between people who approach understang from a variety of perspectives will indeed lead to developments wich are both interesting and of benefit to the communities concerned and to service system as a whole.

The primary health care is of tentamount importance in the overall attitude of the patient and his family towards the psychiatric illness in general and towards the psychiatric services.

The successful inclusion of mental health in primary health care delivery is very important as it can approach the persons in need more easily and people with psychiatric disorders can more easily contact the primary care system for help, because they are afraid of stigma that often accompanies the utilization of psychiatric services directly.

As with primary health care in other fields, in the mental health area, the primary health worker (usually general practitioner) has to be trained to recognize the early signs of psychiatric disorder, especially psychotic illness, so that the patient can be sent to a competent practitioner for a proper diagnosis to be made and appropriate treatment to be started. The primary health worker takes over again to give the patient maintenance treatment in the setting of his own home miliew after the acute phase of illness. For such program to work, mental health knowledge must be included in the training of the primary health workers.

In most cases the help needed may nothing more than crisis intervention, ongoing support or the maintenance of psychotropic medication.

The more aware is the community in which the person lives the more supportive is the social context. With the increased social support, the personal effectiveness of the patient increases, and also increases his self-esteem, factors that are all very important in the utilization of services.

Key words: Primare healthcare, mental illness, psychiatric services.