Literature primary care i.e. collaboration between family physicians

Literature reviewThe literature review in this study was conducted systematically using several databases. We used PubMed, Google Scholar, and Google Search engine to detect studies in the same scope. We used combinations of keywords to find the suitable studies: mental illness, mental disorders, primary care, family medicine, family physicians, general practitioner, family practice, training, psychotherapy, treatment, recognition, diagnostic, management, and other key words. The initial search obtained several studies that linked primary care and family medicine practice with psychotherapy.

However, most of the studies concentrated on using integrated care in primary care i.e. collaboration between family physicians and psychiatrists in diagnosing and treating patients or using certain types of interventions to improve the health status of mental illness patients.19, 20Michael bailent in his renound book ‘The Doctor, His Patient and The Illness’ emphasized the importance of psychotherapy for the general practitioner and that the medical training at the time was not up to par to the work expected from a general practitioner.

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referencen 1964 Michael Balint in his book “The Doctor, His Patient and The Illness” stated that, “It is generally agreed that at least one quarter to one third of the work of a general practitioner consists of psychotherapy pure and simple. Some investigators put the figure at one half or even more, but, whatever the figure might be, the fact remains that present medical training does not properly equip the practitioner for at least a quarter of the work he has to do.”A recent study addressed the complexity of capturing mental illnesses in primary care settings.21 The study identified the considerable differences between primary care and specialists clinics. In primary care settings “problems are presented in undifferentiated forms, with consequent difficulties in distinguishing between distress and disorder, and a complex relationship between psychological, mental and social problems and their temporal variations. Existing psychiatric diagnostic systems, including ICD-10-PHC and DSM-IV-PC, are often difficult to apply in primary care. They do not adequately address co-morbidity, the substantial prevalence of sub-threshold disorders or problems with cross-cultural applications.

Their focus on diagnosis may be too restrictive, with a need to consider severity and impairment separately.” The authors recommended developing a new classification system in primary care that can be easier to implement by the primary care physicians. Additionally, this new system should consider severity, chronicity and disability, feasible for routine data gathering in primary care as well as for training; and enabling efficient communication between primary and specialty mental health care. There is a relative lack of studies addressing mental illnesses recognition, treatment, and management in primary care settings.

19 However, this lack of studies may indicate a substantial room of improvement of patients’ outcomes in mental illnesses.14 Psychotherapy training and its importance:Norwegian general practitioners experience on CBT use was explored, which recommended that tailored training programs for GP’s on CBT will improve its use and make it more frequent. As those that underwent training courses reported positive effect on their consultation skills.

(11)(according to NICE)Referral to a psychiatrist is only recommended for those that failed to respond to pharmacotherapy , psychotherapy or a combination of both.(12) It is important to mention that in all the guidelines provided by the NICE, it is recommended that the psychotherapy be provided by a trained and competent practitioner. (4, 12) So perhaps the scope and nature of psychotherapy needs to be different in primary care. It could be more focused on brief psychotherapies such as motivational interviewing, solution focused psychotherapy, and modified CBT, which would provide family physicians with some skills in psychotherapy.(17) (REPHRASE TAKEN VERBATUM FROM SAADEAS STUDY)Mention something of most well established psychotherapies in primary care included CBT, psychodynamic therapy, interpersonal therapy (with references – just like he did before no need to elaborate to avoid paigirism) +/- problem solving therapy.

Despite the fact that 32% of participants reported using CBT, most physicians (78%) had not received training in CBT and reported having little knowledge of CBT.(3) This raises the question: how are family physicians practicing psychotherapy? Psychological therapies may be effective (4)(5)(6)(7)(8), but they often require much training to deliver, and require many supervised treatment hours to master (6)(7)(9)(10), as elaborated in chapter 2. If family physicians are not adequately trained to provide psychotherapy then how are they practicing it?For many of the participants who practiced psychotherapy on a regular basis, informal training in psychotherapy included: mentorship, peer support, training in psychotherapy prior to medical school, practicing in a shared care model, reading and trial and error.The type of training envisioned ranged from more training during undergraduate medical education, postgraduate residency training, more continuing medical education (CME) courses, more hands on and observed training, resource management skills, mentoring and role modeling. Participants felt that if they had more training, they would be more likely to do more psychotherapy. (DIRECT FROM SADEAS STUDY)This study comes as an effort to shed light on the issue of mental illnesses recognition, treatment and management in primary care setting in Saudi Arabia.

We hope that our study will contribute toward better health service in the future.


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