Five decades of research on psychiatric morbidity in primarycare
Authors: Jair De Jesus Mari
Journal: World Psychiatry (2003)

The extent and magnitude of minor psychiatric disorders in primary and general practice was first demonstrated by Michael Shepherd in the middle of the last century. At that time no research instruments were available in the field, psychotropics were unsafe and the doctor was much of the drug. David Goldberg made the important contribution of leading the research teams that developed two main instruments to be applied in primary care: the Clinical Interview Schedule, a semistandardized psychiatric interview, and the General Health Questionnaire, a short screening questionnaire for minor psychiatric disorders. Some years later, the World Health Organization supported the development of its own screening questionnaire, the Self Reporting Questionnaire (1). All these instruments were widely applied in general practice across the world, showing that minor psychiatric disorders have even more importance and impact than severe mental disorders. This is now well established and we owe this achievement to Shepherd, Goldberg and others, who were pioneers in the use of epidemiology for completing the picture of psychiatric morbidity in the community.

It was striking that research carried out in primary care in Brazil did demonstrate that 50% of patients attending general practices in the city of Sao Paulo present a minor psychiatric disorder (2). Moreover, general physicians were found to be the main prescribers of tranquilizers in a psychiatric morbidity survey in the city of Sao Paulo (3). All studies conducted in Brazil show that low income families have an excess of morbidity, and Lima et al (4) demonstrated an inverse relationship between level of income, schooling and prevalence of minor psychiatric disorders, but a positive relationship between income and consumption of benzodiazepines. The role of social inequality and social adversity in the development of a cluster of diseases, such as minor psychiatric disorders, post traumatic stress disorders, drug dependence, needs more attention and research as well as the development of efficacious interventions for reducing burden and suffering in developing countries.

How to integrate mental health community services with primary care physicians is still a matter of controversy. There are a variety of models described (5), but there has not been yet an agreement on what should be treated by whom. As mentioned by Goldberg, there is a certain agreement that acute psychosis, cases of drug dependence and resistant depression should be treated by mental health staff. The example of England, where psychiatrists started to provide clinics in primary care (6), sounds as a good model for interaction to be pursued anywhere in the world. However, it has not been demonstrated that such integration would produce a decrease of admission rates to psychiatric hospitals, and research on cost-effectiveness of such models is still incipient. Middle income countries like Brazil face the problems of scarcity of services and paucity of information as well as huge difficulties in health services management. Even in the richest state of the country, the State of Sao Paulo, it was shown that the majority of patients with schizophrenia remained untreated in a one year period (7). As recently pointed out by Kleinman and Han (8), the evaluation of intervention programs (i.e., of the development of new models of service delivery) is the most important direction for future research in developing countries.

The important role general physicians play in the mental health field is now more than evident, but epidemiological evidence solely has not had a major impact on medical education and physicians' attitudes. The treatment of minor psychiatric disorders in primary care and general practice is a relatively new field in medicine, despite the increasing research in the area. Indeed, models to teach physicians to deal with ordinary, psychosocial problems at the primary care level are still in their infancy and much has to be done for their implementation and testing.