Integration of psychiatric and physical health

In The Netherlands the British Journal of Psychiatry is distributed among Dutch psychiatrists by courtesy of the pharmaceutical industry. For the October issue of the Dutch edition I was asked to write the editorial comment, to be circulated with the Journal as an accompanying letter. My focus is integrated psychiatry in medicine.

Reading the October issue I was struck by the lack of an integrated perspective. Current epidemiological findings underscore how the organisation of our healthcare system is epidemiologically unfair and does not take into account the frequent co-occurence of psychiatric disturbances and physical illness (Kendell, 2001; Royal College of Physicians & Royal College of Psychiatrists, 2003). The fragmentation of care is seen as one of the major problems of current healthcare (Institute of Medicine, 2001); this applies with regard to treatment of physical disorders in mental healthcare and vice versa.

The editorial by Kingdon et al (2004) on the recommendations of the Council of Europe lacks such an integrated perspective. Among the recommendations the quality of physical care is not mentioned by the Council other than in relation to restraint, and this omission is not mentioned by Kingdon et al.

Similarly, the review by Thornicroft & Tansella (2004) opens with the fact that depression leads to more disability-adjusted life-years than cardiovascular disease and cancer, but it does not report their meaningful interrelation, for instance through compliance (DiMatteo et al, 2000). In the section ‘Acute in-patient care’ it is mentioned that patients with physical comorbidity should preferentially be seen in such facilities and not in community care. The authors do not elaborate on how such treatment can be provided adequately. In the highest model of the three models presented for mental healthcare all kinds of subspecialist treatments become available. However, integrated clinics for people with comorbid physical and mental health problems are not mentioned.

Taking the current epidemiological and pathophysiological perspectives into account, the Editorial Board of a journal such as the British Journal of Psychiatry should consider inclusion of an integrated perspective in their review process. Such an approach will reduce psychiatrists’ blind spot and psychiatrists’ illusion (Cohen & Cohen, 1984) and will initiate an inspiration in health care comparable with that arising from the description of the previously fragmented and now integrated research institute (McGuffin & Plomin, 2004).