RECOGNISING THE PROBLEM
Primary care is an ideal environment in which health professionals can recognise the complex inter-relationship between physical and psychological symptoms. Patients commonly present with a variety of partially understood or poorly differentiated physical, psychological and social problems. A central role for GPs is to offer a degree of clarity about the nature and cause of such problems, and provide guidance on their management.
Experiences of physical symptoms and depression raise complex issues about the distinctions between mind and body. While depression is commonly viewed as a disturbance of emotion, its behavioural aspects, such as social withdrawal or changes in eating behaviours, are equally important.
However, these complexities are not always satisfactorily reflected in our clinical practice. Our diagnostic and conceptual frameworks, deriving both from our medical training and from classification systems such as ICD-10 and DSM-IV, are based on relatively narrow, dualistic perspectives. They encourage us to see problems as primarily either physical or psychological and to introduce comorbidity as a means of recognising some degrees of complexity — with the diagnosis of ‘medically unexplained’ symptoms serving as a back-stop to deal with those patients who do not present their symptoms in ways that we can readily formulate.
Two areas of diagnostic and therapeutic concern are the confusion between depressive and somatic symptoms, in chronic disease, and in particular the neglected relationship between pain and depression.
In chronic obstructive pulmonary disease (COPD) for example, somatic symptoms such as fatigue, anorexia and weight loss may be simultaneously attributable to both the medical condition of COPD and to the psychiatric diagnosis of depression.1 This raises substantial risks of diagnostic confusion. In a Dutch study of COPD and depression in primary care,1 researchers found …