Every Physician Should Know the Basics of Psychiatry
At the end of the twentieth century, a WHO sample survey across 15 countries and regions found that various mental disorders accounted for as many as 25%–35% of patients in general hospitals, yet at that time the recognition rate of mental disorders among internists in Shanghai was only 15.9%, far below the median for the 15 countries. A 2007 outpatient survey of 15 Grade-3A general hospitals in five Chinese cities (Beijing, Shanghai, Guangzhou, Chengdu and Changsha) found the prevalence of anxiety and/or depressive disorders to be 16.5%; among 862 attendees with depressive and/or anxiety disorders, only 8.5% were referred to psychiatry and 6.4% were given psychiatric medication. A 2007 nationwide study of gastroenterology outpatients in 13 general hospitals found that physicians recognized only 4.14% of patients with depressive disorders (prevalence 14.39%) and anxiety disorders (prevalence 9.42%).
These data all come from the Psychiatrist's Handbook (Jingshenke Yisheng Shouce), edited by Li Tao and Xu Yifeng (one volume in the series of practical handbooks for county-level hospitals). The data make abundantly clear that every physician encounters large numbers of patients with mental disorders in daily work. We often meet attendees whose thinking and speech are baffling—and even the family members of many attendees have mental disorders.
The reasons clinicians encounter so many patients with mental disorders are manifold. Some patients have primary mental disorders; others have secondary ones, their disorder being induced by other diseases. The combination of poverty and illness causes many mental disorders; chronic illnesses impose a heavy economic and psychological burden on patients, and over time all kinds of psychological problems easily arise. Mental disorders are also one of the main triggers of extreme doctor-patient disputes. If clinicians understand the basics of psychiatry, can recognize mental disorders in daily work, give patients appropriate help and support, and promptly refer those who need psychiatric treatment, medical quality will improve and the doctor-patient relationship will be better.
Diagnosing mental disorders is unlike diagnosing other diseases: it relies not on instrument tests but on the physician's clinical experience. In China, very few non-psychiatric clinicians have received psychiatry-related training, so the recognition rate of mental disorders is very low. This seriously affects medical quality. For example, a patient with depression may present to neurology with a headache; if the doctor fails to recognize that the headache is caused by depression and treats it as a neuralgic (tension-type) headache, good clinical results cannot be achieved. Similarly, constipation is a common symptom of depression; some depressed patients may attend the gastroenterology clinic for constipation, and if the gastroenterologist cannot identify the cause as depression, professional help cannot be provided. All this raises the rate of clinical misdiagnosis and also invites doctor-patient disputes.
Patients with mental disorders have some distinctive features; as long as one has received relevant training or studied psychiatry on one's own, the clinical recognition rate can be improved. The recognition rate of mental disorders among non-psychiatric physicians in Italy reaches 32.5%, and among non-psychiatric physicians in Australia it can be as high as 54.5%—both significantly higher than the recognition rate among non-psychiatric physicians in China. Medical basic education in both Italy and Australia includes relevant psychiatry content. This shows that psychiatry-related education and training are the key to improving clinicians' recognition of mental disorders.
Physicians who have received psychiatry-related training can, through conversation and observation, detect various perceptual disorders, thought disorders, affective disorders, volitional disorders, attention disorders, motor and behavioral disorders, memory disorders, disorders of consciousness, disorders of self-awareness and intelligence disorders in attendees. We can observe and analyze the patient's speech, expression and behavior to judge which mental disorder is present, and distinguish whether certain clinical symptoms are caused by psychiatric illness or by other diseases, so as to treat the patient more appropriately.
When patients with mental disorders seek care, their adherence to the physician is poor. In addition, because of the stigma attached to mental illness throughout society, such patients feel shame about their condition; many become angry when the doctor discusses mental illness and are unwilling to accept the doctor's advice. When attending for other diseases, they also lack the rationality of normal patients. This requires physicians in every specialty to learn communication skills for patients with mental disorders, so as to improve clinical outcomes while avoiding the risks that may arise.