5 ages of mental health; Mental illness in adults.

The National Service Framework for Mental Health recognises that primary care clinicians provide the majority of care and treatment for adults with mental illness, particularly those suffering from depression and anxiety -- so-called common mental illness.1 They have access to guidance on the diagnosis and management of mental illness, from the National Institute for Clinical Excellence and other agencies.2 The guidelines make it sound so easy, based on a detect-and-treat model of care. However, many GPs are beginning to doubt the relevance of this simplified approach to the complexities of primary mental health care.3 Furthermore, GPs working with adults are required to recognise autonomy and encourage independence. Patients' lives and illnesses are complicated and interlinked, and complex opposing psychosocial forces are at work in the consulting room. The stigma of mental illness and a healthy desire to be independent may prevent appropriate care. Conversely, desperate need and the security afforded by a diagnosis can lead to dependence and overtreatment. As GPs, we can no longer opt for either the medical or social model of illness. We have to embrace both with skill and flexibility.

COMMON MENTAL ILLNESS The expression common mental illness is generally a euphemism for nonpsychotic diagnoses. As well as depression and anxiety, it includes other neuroses such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD) and specific phobias. Patients often have associated drug and alcohol dependence and chronic physical conditions that affect their mental health. Individual personalities add further complexity, affecting the symptoms presented and the way patients engage with health professionals. Personality disorder is rarely diagnosed in primary care, and is not strictly an illness, but recognition can be useful when planning treatment. The principles of care for depression are relevant to all mental illness in adults, with the exception perhaps of acute psychosis. Patients with chronic psychosis need a similar approach, but with an emphasis on engagement and systematic review rather than diagnosis. The important areas to cover are highlighted in Box 1. These are drawn from literature on the consultation, specialist mental health care and therapy.4,5

VARIED PRESENTATIONS GPs in particular have been criticised for failing to detect depression. There is certainly a large variance between GPs in recognition rates, which suggests that some clinicians are not engaging with patients' emotional agendas.6 Some patients present with overtly…