Editorials

Psychological medicine
Integrating psychological care into general medical practice
t is becoming increasingly clear that we can improve medical care by paying more attention to psychological aspects of medical assessment and treatment. The study and practice of such factors is often called psychological medicine. Although the development of specialist consultation-liaison psychiatry (liaison psychiatry in the United Kingdom) and health psychology contribute to psychological medicine, the task is much wider and has major implications for the organisation and practice of care. The ABC on psychological medicine that starts this week (p 1567) aims to explain some of those implications. Disorders that are traditionally, and perhaps misleadingly, termed psychiatric are highly prevalent in medical populations. At least 25-30% of general medical patients have coexisting depressive, anxiety, somatoform, or alcohol misuse disorders.1 Several factors account for the co-occurrence of medical and psychiatric disorders. First, a medical disorder can occasionally be a cause of the psychiatric disorder (for example, hypothyroidism as a biological cause of depression). Second, cardiovascular diseases, neurological disorders, cancer, diabetes, and many other medical diseases increase the risk of depression and other psychiatric disorders. Such so called comorbidity is common, but its causal linkage with psychological conditions remains poorly understood. A third factor is coincidencecommon conditions such as hypertension and depression may coexist in the same patient because both are prevalent. Another reason for psychological medicine is the prevalence of symptoms that are unexplained by disease. Although physical symptoms account for more than half of all visits to doctors, at least a third of these symptoms remain medically unexplained.2 3 This phenomenon is referred to as somatisationthe seeking of health care for somatic symptoms that suggest a medical disorder but represent instead an underlying depressive, anxiety, or somatoform disorder. Most patients with these mental disorders preferentially report somatic rather than emotional symptoms. Further, there are the common but poorly understood symptom syndromes such as fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome, for which the relative contributions of mind and body are not yet elucidated.4 Psychological medicine is important in the management of all these problems; both psychotropic medications and cognitive behavioural treatments have proved effective in the treatment of common physical symptoms and syndromes in numerous studies in general practice.5 6 Although such treatments have traditionally been considered psychiatric, they are also beneficial in patients without overt psychiatric disorders. Countries on both sides of the Atlantic have a long way to go in developing psychological medicine, the chasm in America between medical and psychiatric care is particularly deep. The carve out of mental health services in the managed care systems in the United States is one example of how ingrained
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the dualism of mind and body still is and of the reconciliation that must occur. Psychological medicine does not mean relabelling all such patients as psychiatric. Many patients prefer to have these problems regarded as medical and conceptualised in terms of a neurotransmitter imbalance or a functional bodily disturbance.7 Concomitant psychological distress is best framed in terms of being a consequence rather than a cause of persistent physical symptoms. Premature efforts to reattribute somatic complaints to psychological mechanisms may be perceived by the patient as rejection. A more aetiologically neutral but psychologically sophisticated approach that initially focuses on symptomatic treatment, reassurance, activation, and restoration of function has proved more effective.8 There are better alternatives than simply to regard such problems as the province of psychiatry. One is to train general practitioners to diagnose and treat common psychiatric disorders.9 Although treatment with psychotropic medication is their most feasible option, general practitioners can also be trained to deliver other psychological treatments. A second option is to use nurses or social workers with specialised training who can work with general practitioners or psychiatrists to manage medication as well as deliver psychotherapies and behavioural interventions. A third model is collaborative care, where the general practitioners management is augmented but not replaced by visits to a psychiatrist, often on site in the general practitioners surgery. Stepped care is a fourth model, in which psychiatric referral occurs only for patients who do not respond to the general practitioners initial treatment. Most studies have been conducted in general medical practices, but patients seen by medical specialists also warrant attention.3 Psychological medicine may also be delivered in some innovative ways. Promising data exist for behavioural interventions conducted outside the doctors office, including case management by telephone, cognitive behavioural therapy given through a computer, bibliotherapyself study by patientsand home visits (for example, for chronic fatigue syndrome). Psychological medicine also improves outcomes. The benefits of treating common physical symptoms and psychological distress effectively in medical patients include not only improved quality of life and social and work functioning, but also greater satisfaction on the part of patient and doctor and reduced use of healthcare services.2 What do we need to do? Better detection of these problems need not be time consuming. For example, screening for depression may require as few as one or two questions. Optimal management of patients with persistent physical symptoms and common mental disorders may require longer or more frequent visits to a doctor, help in educating and following up patients by a nurse case manager, other system changes, and mental health specialty consultation for more complex
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Editorials
cases.10 The competing demands of general practice must be explicitly addressed if we are to enable the general practitioner to practise psychological medicine effectively.11 Yet this approach is no different to what is also required for many chronic medical disorders such as diabetes, asthma, and heart disease, for which it has been proved that care in concordance with guidelines requires appreciable reorganisation of medical services.12 Neither chronic medical nor psychiatric disorders can be managed adequately in the current environment of general practice, where the typical patient must be seen in 10-15 minutes or less. The quick visit may work for the patient with a common cold or a single condition, such as well controlled hypertension, but will not suffice for the prevalent and disabling symptoms and disorders comprising psychological medicine. Evidence based treatments exist. Using them in a way that is integrated with general practice will improve our patients physical health and psychological wellbeing. Kurt Kroenke professor of medicine
Department of Medicine, Regenstrief Institute for Health Care, RG-6, 1050 Wishard Blvd, Indianapolis, IN 46202, USA kkroenke@regenstr ief.org

KK has received fees for speaking and research from Pfizer and Eli Lilly.

Ormel J, Von Korff M, Ustun TB, Pini S, Korten A, Oldehinkel T. Common mental disorders and disability across cultures: results from the WHO collaborative study on psychological problems in general health care. JAMA 1994;272:1741-8. 2 Kroenke K. Studying symptoms: sampling and measurement issues. Ann Intern Med 2001;134:844-55. 3 Reid S, Wessely S, Crayford T, Hotopf M. Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study. BMJ 2001;322:1-4. 4 Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet 1999;354:936-9. 5 OMalley PG, Jackson JL, Santoro J, Tomkins G, Balden E, Kroenke K. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract 1999;48:980-90. 6 Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychother Psychosom 2000;69:205-15. 7 Sharpe M, Carson A.Unexplainedsomatic symptoms, functional syndromes, and somatization: do we need a paradigm shift? Ann Intern Med 2001;134:926-30. 8 Von Korff M, Moore JC. Stepped care for back pain: activating approaches for primary care. Ann Intern Med 2001;134:911-7. 9 Kroenke K, Taylor-Vaisey A, Dietrich AJ, Oxman TE. Interventions to improve provider diagnosis and treatment of mental disorders in primary care: a critical review of the literature. Psychosomatics 2000;41:3952. 10 Rubenstein LV, Jackson-Triche M, Unutzer J, Miranda J, Minnium K, Pearson ML, et al. Evidence-based care for depression in managed primary care practices. Health Aff 1999;18:89-105. 11 Klinkman MS. Competing demands in psychosocial care: a model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry 1997;19:98-111. 12 Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74:511-44.

Whooping cougha continuing problem

Pertussis has re-emerged in countries with high vaccination coverage and low mortality
ews media announced a global resurgence of whooping cough in April this year following a session on pertussis at the 12th European Congress of Clinical Microbiology and Infectious Diseases in Milan, Italy. Subsequently the European Union sent an alert to member states. Pertussis is one of the top causes of vaccine preventable deaths, with nearly 300 000 deaths in children worldwide in 2000.1 However, reports of a global resurgence originated in countries with low mortality and high vaccination coverage. For such countries the issue is how to fine tune effective immunisation programmes. In the rest of the world, priorities are to decrease infant mortality by improving coverage and timeliness of vaccination and implementing pertussis surveillance.2 Pertussis has re-emerged in low mortality countries in the past because of low coverage after a vaccine scare in the 1980s (in the United Kingdom) or the use of vaccines with poor efficacy (Canada, Sweden).3 Sweden and Germany stopped their vaccination programmes completely and only reinstituted vaccination for pertussis after years of recurrent epidemics of whooping cough. More recently some countries with sustained high coverage have experienced increases in pertussis, especially in older children and adults, the reasons for which are complex.3 4 After an outbreak of pertussis in the Netherlands in 1996, polymorphisms in the genes coding for the Bordetella pertussis virulence factors pertactin and pertussis toxin were reported as evidence for a vaccine driven evolution of circulating
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strains that has led to a fall in vaccine efficacy.5 Similar studies in other countries have also revealed the emergence of non-vaccine variants of pertactin and pertussis toxin.6 In France, however, an increase in the frequency of non-vaccine variants of both pertussis and pertactin toxin has not been accompanied by a decline in the efficacy of the vaccine.7 The situation in the United Kingdom, where there has not been a re-emergence of pertussis, seems unique in that all of the most recent isolates studied are of the same pertussis toxin type as one of the strains included in the United Kingdom whole cell vaccine.8 In high coverage countries, further development of national policies for the control of pertussis is a challenge because of underdiagnosis and underreporting, which hinder surveillance, as well as gaps in our knowledge of levels of herd immunity generated by the vaccination programmes. Underdiagnosis occurs because pertussis has mild or atypical forms, because clinicians may not consider pertussis as a cause of cough especially in older children and adults, or because sensitivity of culture, the traditional diagnostic method, is as low as 20-40%. Surveillance is so incomplete that enhanced awareness or improved diagnostic methods can result in apparent epidemics, which may account for some of the observed increase in older individuals in several countries with high vaccination coverage.4 5 Methods such as enzyme linked immunoassay (ELISA) based serology and polymerase chain reaction have increased diagnostic sensitivity and
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