BRIDGING THE GAP BETWEEN PSYCHIATRIC PRACTICE AND PRIMARY CARE

The recognition and treatment of psychiatric illness in general practice is a skilled and difficult task and it is estimated that about 30% of psychiatric diagnoses may be missed. Patients whose illness is recognized are more likely to recover at follow-up than those whose illness is missed, demonstrating the importance of adequate training in recognizing psychiatric illness. Many general practitioners find difficulty in using tricyclic antidepressants to treat depression. The usual dose is lower than research evidence accepts as therapeutic and side effects often result in patient refusal to take a full dose. Additionally, the tricyclics are highly toxic in overdose. Many general practitioners in the UK are wary of new treatments because of previous experience of rare side effects leading to withdrawal of some new drugs. However, prescriptions of the selective serotonin reuptake inhibitors (SSRIs) for depression are gradually increasing here and in other countries such as the USA, France and Canada, where the SSRIs as a class account for upwards of 30% of new antidepressant prescriptions. The SSRIs are well suited to general practice; they have a greater therapeutic index than tricyclics, are much safer in overdosage, and have a different range of side effects (mainly nausea) which are better tolerated by patients at therapeutic doses. Furthermore, the SSRIs generally do not require dosage escalation for most patients and evidence indicates that they are effective in the treatment of depression associated with anxiety and insomnia. The safety and efficacy of the new SSRI sertraline has been established in comparative trials versus amitriptyline, imipramine and dothiepin (Reimherr et al., 1990; Cohn et al., 1990; Fontaine, 1991; Langdon, 1991). The dothiepin study was in general practice and the results are summarized in this paper. A further 3000 patient open study, ''Sertraline in General Practice, A Multicentre Assessment'' (SIGMA) is being conducted in the UK, and preliminary results from analysis of the first 2053 patients are presented here. Patients started on sertraline, 50 mg/day rising to a maximum of 200 mg/day if necessary (only 10% took more than 100 mg/day). Good or excellent improvement was noted in 70% of patients and 84% of patients tolerated the drug to a good or excellent degree. Some caution is still understandable with any new class of drug. However, it is becoming increasingly obvious that the efficacy and safety profile of the SSRIs is well suited to general practice, and it seems likely that in the future they may become first-line treatment for depressive episodes in primary care.