Some things never change, despite everything changing around them. In this case, what never changes is the importance of primary care services in the care and treatment of people with mental health conditions. This is the second edition of this book, which I reviewed when it was first published in 2009 and recommended as ‘an essential part of reading for trainees as well as for others within the fields of psychiatry, general practice and beyond’. I have not changed my mind.
This revised book provides an important reminder of the growing understanding of primary care mental health in the UK and internationally that took place over the second half of the twentieth century: the developments in general practice in the UK after the birth of the NHS and the burgeoning work of the World Health Organization on primary health care. In England, despite these constant reminders, primary care mental health remains a major ‘missing piece’ in both health and mental health policy. There has been a relentless focus on IAPT (Improving Access to Psychological Therapies), but we know that primary care mental health is a lot broader than IAPT, yet it is invisible in current policy relating to both primary care and mental health. GPs have expressed concern about the lack of support for people with complex mental health needs, particularly those with medically unexplained symptoms, personality disorders, traumas and complex comorbidities and those who no longer meet thresholds for community mental health teams yet need more support than IAPT or their GP can offer. Perhaps this is another reminder of the change that reinforces the need for this revised version of the book.
This second edition contains 32 chapters, one more than the first edition, and uses the same structure of four parts covering the conceptual basis of primary mental health care, clinical aspects, policy and practice, and reflective practice. All the chapters have been updated, and some new chapters have been introduced on offenders and prison populations, public mental health and the health of GPs.
Chapter 1, ‘What is Primary Care Mental Health?’, should be read by anyone wishing to know about primary care, that ‘messy swamp’ which questions our attempts to create an orderly taxonomy of mental disorders and systematic interventions: the grey areas of borderline conditions, multimorbidity and the generalist approach. Some of these matters are revisited in chapter 6, which critically covers the existing concepts of the classification of mental disorders when applied in the primary care setting. Helpfully, Gask et al focus on a patient-centred rather than a disease-based approach. Perhaps, however, the next edition should champion a ‘person-centred’ approach. Chapters 2 and 3 cover the epidemiological and social views of health and illness and raise the importance of community and social inclusion, while chapter 4 provides the important perspectives of patients. Before we forget that the UK system of general practice is only one way of conceptualizing primary care, the chapter ‘Primary Mental Health Care in Low- and Middle-Income Countries’ offers the reader a clear view of the global importance of primary care.
Section 2 of the book has to face up to the problem of how to divide this ‘messy swamp’, and it opts for an approach based predominantly on broad diagnostic categories, something that the editors apologise for in their first chapter. Nevertheless, the chapters ‘Asylum Seekers and Refugees’ and ‘Offenders and Prison Populations’ give a welcome insight into the problems faced by marginalised groups. I would like to see a future edition that includes a chapter on services for people who are homeless.
In the section ‘Policy and Practice’, the chapters prompt us to remember the exciting possibilities for primary care: population approaches, prevention, multidisciplinary teams, innovative models and pragmatic approaches to psychological therapies. Given this wealth of promise and experience, why have we not done better?
The final chapters give some valuable reflections on practice, and the book ends with a chapter that is a pertinent reminder to the reader of the importance of mental health and well-being in practitioners; remember, clinicians can be patients too.