|FAMILY MEDICINE / PRIMARY HEALTH: CASE SCENARIOS
|Year : 2017 | Volume
| Issue : 4 | Page : 290-294
Why family physicians are the best people to stop the tragedy of untreated mental illness in India
K.C. Patti Primary Health Center, Kodaikanal, Tamil Nadu, India
|Date of Web Publication||17-Nov-2017|
K.C. Patti Primary Health Center, NP Nagar, KC Patti, Perumparai, Kodaikanal - 624 212, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ramasamy R. Why family physicians are the best people to stop the tragedy of untreated mental illness in India. Curr Med Issues 2017;15:290-4
| Introduction|| |
I am proud to be a family physician working in a rural area. The reader may question what right I have to discuss the management of mental illness when that responsibility should be that of a psychiatrist! This article hopes to challenge family physicians to realize that they are the best people to manage most of those with mental illness. Mental illness can be a very distressing experience to the individual and their families. In my family medicine practice over 25 years, I have learned not only that it is possible for family physicians to successfully manage most of these patients on their own, but also that managing them can be immensely rewarding to the patient and the doctor. In this article, I will elaborate in these points – this article is not primarily intended to be about the principles of how to diagnose and manage mental illness.
| Why Must Family Physicians Manage Mental Illness?|| |
- Mental illness is the primary reason for about 10%–15% of the consultations in family medicine anywhere in the world!, There are simply not enough psychiatrists to treat this number of people even if it was considered essential that psychiatrists manage all of them
- Most of the mental illnesses are mild to moderate and often masquerade as a physical (somatic) complaint, for example, back ache. It does not usually present with florid signs of depression or psychoses. Family physicians are best able to differentiate if a somatic complaint (e.g., chest pain) is due to a true physical problem (e.g., cardiac pain) or a mental health issue (e.g., generalized anxiety disorder) and so relieve distress and save enormous expenses from unnecessary investigations
- The successful management of a mental illness requires an UNDERSTANDING of the patient and not only a DESCRIPTION of their illness: psychiatrists can mainly do the latter to establish a correct psychiatric diagnosis, but family physicians can both understand and describe, leading to better management of all but the most severe mental illness! It is acknowledged that mental illness is an outcome of genetic, personal, and social factors [Figure 1]. However, most protocols and literature focus only on the medical model (biochemical and genetic factors) because they are designed to deal with severe mental illnesses and are written by psychiatrists. Most mental health issues and somatization symptoms represent distress due to as much social and personal problems as biological “illness”– these personal and social factors must be acknowledged for the successful management of mild-to-moderate mental “illness” and the ongoing management of those with severe illness once they are stabilized. I hope that the following case histories will illustrate that better. In mild-to-moderate illness, recognizing and understanding all these aspects are more important than a precise psychiatric diagnosis. Moderate as opposed to severe mental illness cannot easily fit precise and narrow diagnoses anyway because these diagnostic criteria are designed to help manage severe mental illness
- The importance of personal and some social contributors to mental illness means that nonpharmacological aspects of treatment (e.g., various forms of cognitive behavior therapy [CBT]) can be as important as pharmacological treatment (with drugs). The lack of trained clinical psychologists able to provide effective CBT in India is very depressing, but a family physician working as a team with allied health workers can provide some of that when they know the personal family and social context in which the mental illness occurred (see case histories below)
- Mental illness complicates significant numbers of those with chronic illnesses (such as cardiovascular diseases) and failing to recognize and treat it will adversely affect the outcome of the chronic disease. The reverse is also true: those with mental illness suffer higher incidence of chronic diseases such as cardiovascular illness, respiratory illness, and diabetes. Family physicians are better able to provide the integrated care needed in these situations
- Mental illness like many other physical illnesses such as diabetes is a chronic illness and needs follow-up. Effective recall and follow-up systems are an essential part of good family medicine. Good family physicians know when someone who needed follow-up does not attend, so in family medicine those who do not attend health services matter as much as those who do. For example, home visits and simple recalls through phone calls are part of the role of family medicine in managing those with any chronic illness
- Teamwork diagnosis. The model of primary health care works ideally when there is teamwork with allied health workers. They are not only capable of identifying and recognizing important social and personal contributors to mental illness, but can also recognize when symptoms are more likely to be somatization and apply validated screening tools such as the K10 and Hospital Anxiety and Depression (HAD) scale to help screen for mental illness and help the doctor. They can also help the family physician provide psychoeducation and other aspects of nonpharmacological interventions and involve the family and community in helping with the care needed.
|Figure 1: Biological, social and psychological factors underlying mental illness|
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| Case Histories to Illustrate the above Points and Some Other Aspects of Mental Illness in Family Medicine|| |
(Names have been changed but they relate to real patients in our practice).
Mr. Palanisamy (P): P was aged 22 in 1996. He was known to be a loner who keeps to himself but works very hard on his small 1.5-acre farmland with coffee and pepper to support his family. He has a wife and two young children. His mother had schizophrenia. He smokes beedies but does not take alcohol. At that time, there was a sudden boundary dispute about his land with a large estate owner who used goondas to attack him resulting in a deep cut to his right shoulder. The wound needed suturing in a referral hospital. He recovered with slight weakness of his deltoid muscle due to a damaged axillary nerve. He needed encouragement and support to recover from this deeply distressing experience that threatened his capacity to continue the only occupation he knew. The boundary dispute was settled fortunately due to local leaders getting involved. Despite his recovery, however, he continued to complain about his shoulder even though clinical examination of the shoulder showed good range of movement and only minimal weakness of his deltoid. The health workers had talked to his wife. She said that he often expressed fears that there were people “out to get him”. He feared that his food and drink were being poisoned and developed insomnia often talking to himself at night. He became irritable and beat his children for the first time. He had been to a religious and traditional healer but they were unable to help.
Though posttraumatic stress disorder (PTSD) would have been a possibility, he had no intrusive thoughts and recollection of his traumatic events. He was still keen to work. A diagnosis of a psychotic illness was made with genetic predisposition and personality factors that contribute to it (loner, hard physical work with long hours, and unwilling to take breaks), precipitated by a violent social problem about which he remained fearful. The nearest psychiatrist was 2 h travel away and P refused any referrals. However, P was not expressing self-harm ideation or a desire to harm others. His functioning was being disturbed, but he was still going to work.
We acknowledged the distress his fears were causing him. He was strongly reassured repeatedly that the shoulder injury will continue to improve and that it will not significantly compromise his ability to work. He was started on chlorpromazine 200 mg once daily. His family members were given psychoeducation on the nature of his illness and that it will take time to settle. On this treatment, P slept well though and became calmer though his delusions as expected took some 3–4 weeks to settle. Over the next few months, his wife managed to recognize the early symptoms of relapse and learned to titrate the dose of chlorpromazine accordingly. He needed a few home visits by health workers and occasionally by a doctor over the next few years to help him take treatment regularly.
In 2004, he reluctantly had to admit his two children to a distant boarding school where education was better. At that time, he developed low mood and dysthymia and was diagnosed to have developed depression. Fluoxetine was started with an intended treatment as per guidelines in the management of depression for 6 months. However, it was stopped 3 months later afterPnot only improved but also accepted that his choice to send the children to boarding school was for good reasons and that he was a good man doing his best for the family. He developed a routine to visit the children on a regular 1–2 monthly basis. Today in 2017, 21 years after his first problems, Premains a hard worker going daily to his small land. He is now on risperidone 2 mg once daily and chlorpromazine 100 mg once daily. On occasions, his wife may need to increase the dose to 200 mg at night. He consults the doctor 6 monthly and the health team do occasional home visits, especially when he feels he ought to discontinue treatment because on a few occasions when he did so he showed obvious signs of relapsing. He has 6 monthly assessment of blood glucose and 2 yearly measurement of total cholesterol to check for cardiovascular system (CVS) disease. He has stopped smoking after interventions from the health team. P is now as successful as any small-scale farmer can be and is functioning well aged 46 years and 21 years after his initial presentation.
This case history shows why moderate mental illness can be managed by a family physician with less expense and probably better long-term outcomes.
- The initial presentation was a somatic complaint (obsession with shoulder problems despite marked improvement after the injury)
- In his initial presentation, the family medicine team not only described his illness (delusions, etc.), but also understood the personal and social circumstances in which it occurred – reassurance and help in coping with these factors were essential components of successful management
- A precise psychiatric diagnosis was not warranted; though that is not to say that the family physician should know broader definitions, in this case, PTSD or depression at the onset were possible but a psychotic illness was the most likely diagnosis. Some knowledge of the criteria for major groups of illnesses (e.g., the ICDS criteria for depression) were still needed at the family medicine level. The family physician had to look for red flags (suicide risk or harm to others). The family physician had to be familiar with selected medications used to treat the common mental illnesses. Treatment was not denied because of lack of access to a specialist service
- Some elements of CBT were provided – for example, dealing with his automatic negative thoughts that he was a bad father who sent his children away, when there were far more positive reasons (he was a good father who wanted the best for his children as local schools were of poor standard)
- The case demonstrates the principle that when there are significant social precipitants of mental illness, dealing with them effectively may shorten the need for pharmacological treatment despite what standard guidelines say about necessary duration of treatment. In this case, the antidepressants were not needed for the usual recommended duration of minimum 6 months
- Follow-up through home visits and recall when he failed to collect medications were crucial to the long-term good outcome. This demonstrates the importance of teamwork as well as the importance of engaging the family long-term in ways that a specialist may not always be able to do.
- Patients on long-term psychiatric medications need secondary screening for cardiovascular diseases and diabetes which P had as a routine part of his overall care.
- These points show that even if the initial presentation had a psychiatrist input, other crucial parts of the care needed could only be provided if the psychiatrist and family physician worked together as a team. Family physicians should identify broad-minded psychiatrists with whom they can provide a shared model of care and where the psychiatrist recognizes and respects the critical role of the family physician.
Thilagavathy, aged 25, presents with breathlessness and left-sided localized chest pain. These symptoms are not usually on effort but occur at any time even when she is talking to someone and may last minutes with a feeling of nonspecific dizziness. Her menstrual cycles were regular and she has had tubal ligation. She is married with two small children.
The health worker has assessed Thilagavathy and knows that her husband binge drinks alcohol often and helps little in the housework or children's care and contributes minimally to the home budget, but is not physically violent. HAD questionnaire scores were high on the anxiety questions and moderately raised in the depression scores. The doctor notes that she is nervous but the clinical examination was unremarkable including that she was euthyroid clinically. Further questions to look for generalized anxiety disorder (GAD) as per the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria [Box 1] led to a diagnoses of GAD with hyperventilation, the cause of her breathlessness, and muscle tension, the cause of her chest pain. The family physician and his team manage her as follows:
- They acknowledge her distress and symptoms are real but also reassure her that they are not due to a serious cardiovascular cause which is what she feared. No investigations were felt needed by the family physician as they were not clinically indicated and would distract from the treatment of the primary problem. Had the patient been an older person with risk factors such as hypertension, investigations such as electrocardiography, lipid levels, and diabetes screening may have been warranted if the diagnosis was less certain
- Psychoeducation was given about the symptoms of anxiety (The tiger story – what would you feel like if a tiger suddenly appeared when you were working? – these symptoms are due to adrenalin in your blood when you see the tiger. The effects of adrenalin help you to run away, but in some people, like you, the adrenalin appears when there is no tiger but when you get worrying thoughts, you get the same symptoms; for example, prolonged tightening of muscles caused by adrenalin can cause headaches or chest pain, etc.)
- Relaxation exercises were taught and helpful handouts about these were given. She was given encouragement in acknowledging her hard work running the family despite her lack of support and that she was a good person
- She was started on fluoxetine and propranolol with a 1 week course of diazepam at night
- Follow-up appointments were made with Thilagavathy and her husband, and his involvement in understanding the nature of Thilagavathy's problems was acknowledged. Unfortunately, he only made a few changes to his contributions for family life, but he understood better and was less irritable with Thilagavathy
- Three weeks later, Thilagavathy reported normal sleep and less symptoms. After 3 months, she felt much better primarily because of her awareness of her anxiety-induced symptoms and ability to control them through slow breathing and other relaxation techniques. She successfully stopped fluoxetine tailing it off gradually at 4 months.
A family physician can sort out the causes of physical symptoms and correctly identify anxiety as the cause. A similar patient who developed these symptoms in an overcrowded temple car when on pilgrimage spent Rs. 20,000 on useless cardiology tests when seen by a cardiologist. He was diagnosed to have the same problem as Thilagavathy by the family doctor
In this case, the DSM criteria were useful because GAD is a common problem in primary care than in specialist psychiatry; so, the DSM criteria in this instance reflect the presentation in primary care. Understanding the social and personal context was essential to treating her and teamwork enabled holistic care and psychoeducation.
Sooriyan suffered an acute ST-elevation myocardial infarction at his home and was brought to the health center. As travel time for coronary intervention would take 6 h minimum, he was thrombolysed and then referred. In hospital, he had a low ejection fraction of 40% and a dilated heart and had a single stent after angioplasty. He was stabilized on aspirin, atorvastatin, enalapril, and frusemide.
Fourteen months later, he saw his cardiologist who noted that Sooriyan had relapsed with heart failure and suggested increasing doses of enalapril and frusemide. He was seen 2 weeks later by his family physician when he felt no better and looked dull and tearful. The administration of the HAD screening tool scored high values for depression. His wife confirmed low mood and tearfulness for 4 weeks. He thinks of death but has not decided on any means of suicide or prepared to harm himself. He admits to not taking his drugs for some weeks as he felt there was no point taking them. He felt useless as he felt he could not get back to any work and his loss of role (male breadwinner) was overpowering. The DSM criteria for depression were fulfilled.
His cardiac drugs were restarted at the original doses. His wife was engaged to help make daily routines including planning of pleasurable activities. A return to work program that allowed him to do low levels of physical work was advised. He was started on fluoxetine and given psychoeducation about depression and that depression is not his fault and that it will resolve with treatment. Six weeks from then on, Sooriyan has improved well and is taking medication and his heart failure is also controlled well without any increase in doses (the cardiologist had failed to understand that the relapse in heart failure was due to failure to take drugs because of depression). He remains on fluoxetine and goes to light work daily.
People with major chronic illnesses are prone to depression. In the above case, the cardiologist missed that and his increase in medications was not helpful. A holistic team approach made the correct diagnosis. Depression can adversely affect the outcome of the primary disease by causing noncompliance. The case illustrates that understanding and describing the illness lead to effective nonpharmacological and pharmacological treatments.
| Pitfalls to Avoid!|| |
When managing depression, the possibility of bipolar disorder must be considered. Wrong treatment with antidepressants alone can make it worse. Ask screening questions like “Do you sometimes get a rush of thoughts or have lack of sleep with thoughts of having to do many things, and many ideas ?”. Treating them can be difficult, but rewarding and a joint management with a psychiatrist is ideal. Successful treatment of those with bipolar disorder can restore a creative personality to the community.
| Conclusion|| |
These case histories show how effective and feasible and rewarding primary care management of those with significant mental illness can be. The biggest obstacles can be the mindset of family doctors themselves: “Oh, it is only a mental health problem – best to refer to a psychiatrist!” or “These patients pretend they are in pain or ill but are lazy!”– these reflect poor professionalism and lack of understanding of mental illness. Mental illness causes somatic complaints that are genuine and need to be acknowledged as they can cause significant distress. Understanding and treating them can be hugely rewarding. Unfortunately, the evidence is that many people with mental illness are left untreated in India by the lack of interest, skills, and prejudices of family physicians and the inability of psychiatrists to promote the management of mental illness in partnership with family physicians. Untreated mental illness causes immense suffering and is a terrible tragedy. Only family physicians can resolve this problem. Let us take on that challenge!
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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