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Mental Disorders
in Primary Care
A Guide to their Evaluation
and Management
Mental Disorders
in Primary Care
A Guide to their
Evaluation and
Management
Edited by

André F. Carvalho
Associate Professor, Department of Clinical Medicine, Head,
Translational Psychiatry Research Group, Faculty of Medicine,
Federal University of Ceará, Fortaleza, Brazil

Roger S. McIntyre, M.D., FRCPC

Professor of Psychiatry and Pharmacology,
University of Toronto
Executive Director, Brain and Cognition
Discovery Foundation (BCDF)
Head, Mood Disorders Psychopharmacology Unit
Toronto, Ontario Canada

1
1
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© Oxford University Press 2017
The moral rights of the authors‌have been asserted
First Edition published in 2017
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a retrieval system, or transmitted, in any form or by any means, without the
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and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
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Data available
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ISBN 978–​0–​19–​874663–​8
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 Foreword

In the year 2016, for the first time in their history, the United Nations included the pro-
motion of mental health and the treatment of mental disorders among its Sustainable
Development Goals. This was not surprising: what is astonishing is that they have not
done it earlier. The Millennium Development Goals did not mention mental health
and the discussions of the United Nations about the serious problems produced by
non-​communicable diseases focused on diabetes, cardiovascular disease, cancer and
pulmonary obstructive disease. They did not consider mental disorders –​there is only
one sentence about them in the report of the session acknowledging that “mental and
neurological diseases and Alzheimer’s disease” are also contributing to the countries’
burden of disease, although by then it was well known that a significant proportion –​
at least a third of years lost to disability because of the disease worldwide –​were caused
by mental disorders.
The delay in pointing at mental disorders as one of the major public health problems
may have been caused by the doubt that present knowledge about the treatment and
prevention of mental disorders does not allow an effective action. It might have also
been a reflection of the statistics showing that the numbers of mental health profes-
sionals are far too small to provide mental health care to five hundred million peo-
ple with mental disorders across the world. However, the latter fact should not have
stopped the United Nations to urge their member states to act; in 1973 a World Health
Organization’s Expert Committee report already spoke about the extension of mental
health care by task-​shifting and enabling primary health care staff to take on a major
part of the burden of care for the mentally ills. Somewhat later, in 1978, the members
of the World Health Organization (WHO) adopted the Declaration of Alma Ata and
the Report of the Alma Ata Conference on Primary health care which included the
promotion of mental health among the essential elements of primary health care. The
studies on extension of mental health care carried out by the WHO demonstrated that
the primary health care staff, given some training, can deal with a significant propor-
tion of mental disorders in a competent way; since then numerous other studies have
confirmed these findings.
The reluctance of the United Nations was probably, at least in part, caused by the
stigma of mental disorders which is still widely spread and presents a major obstacle
to the provision of care to people with mental illness and other progress in this field.
To dispel this and make mental health care an obvious and important priority for
the worlds’ health systems, we need additional evidence that it is possible to manage
mental disorders in primary health care, which in turn calls for tireless action to enable
primary health care staff to take on a significant part of the responsibility for the treat-
ment of mental illness. Such action depends on the willingness and capacity of the
general practitioners, nurses and other general health care workers to deal with mental
vi Foreword

disorders which they encounter in their work. An essential requirement to achieve this
is to offer primary care workers knowledge about the management of mental disorders
in a clear and pragmatic way. The book which André Carvalho and Roger McIntyre
constructed does this by its chapters based on evidence and presented in a manner that
makes it easy to understand and use the knowledge necessary for a competent treat-
ment and care for people with mental illness.
The editors of this volume made the wise decision to complement the chapters deal-
ing with the management of different groups of disorders by a chapter summarizing
the knowledge about the neurobiology of mental illness, and by chapters presenting
two major modern trends in the organization of services –​those of collaborative care
and patient centredness. They have also allowed the contributing authors to sup-
port their chapters by comprehensive and rich sets of references to work on which
their chapter was based: this makes the book not only a teaching tool but also a well-​
documented source of indications about the relevant evidence.
It is to be hoped that the Carvalho and McIntyre’s Mental Disorders in Primary
Care will be widely read and used, enabling primary care workers to deal with mental
disorders, thus providing the evidence which supports the thesis that the scarcity of
highly trained mental health personnel must not be taken as a reason to neglect mental
health care and that well-​trained primary care workers can play a significant role in
dealing with mental disorders thus offering people who suffer from them and their
families a new hope and a chance to live a life of quality while reducing the enormous
burden of disease which these disorders may represent for both the rich and the poor
countries of the world.

Norman Sartorius, MD, PhD, FRC Psych

 Contents

Abbreviations ix
Contributors xv

1 The epidemiology, burden, and treatment of mental disorders

in primary care 1
Bernd Puschner, Markus Kösters, Lea Bouché, and Stefan Weinmann
2 Across the spectrum: strategies to improve recognition
and treatment of mental disorders in primary care 21
Victoria J. Palmer and Rob Whitley
3 Collaborative care models for the management of mental
disorders in primary care 34
Christina van der Feltz-​Cornelis, Harm van Marwijk,
and Leona Hakkaart-​van Roijen
4 Operationalizing patient-​centredness to enhance recovery
and primary care for mental disorders 45
John Furler, Victoria J. Palmer, and Jane Gunn
5 Neurobiology of psychiatric disorders 55
Valdimir Maletic and Bernadette DeMuri
6 The DSM-​5: what should general practitioners know? 82
Joel Paris
7 Anxiety disorders in primary care 90
Markus Dold and Siegfried Kasper
8 ADHD across the lifespan 99
David W. Goodman
9 Trauma and stressor-​related disorders 122
Andrea Feijo Mello and Mary Sau Ling Yeh
10 Depressive disorders 138
Andrea Fagiolini, Giovanni Amodeo, and Giuseppe Maina
11 Bipolar disorder 151
Paulo R. Nunes Neto, Cristiano A. Köhler, Michael Berk,
and André F. Carvalho
12 Suicide and suicidal behaviour 171
Erkki Isometsä
viii Contents

13 Somatic symptom and related disorders 184

Alexandra Murray, Anne Toussaint, and Bernd Löwe
14 Substance use disorders in primary care settings 201
Kathleen Broad and Tony P. George
15 Motivational interviewing: its role for the management of mental
disorders in primary care 216
Jeffrey P. Haibach, Elizabeth A. DiNapoli, Deborah S. Finnell,
John W. Kasckow, and Adam J. Gordon
16 Psychosis 234
Jayashri Kulkarni, Emorfia Gavrilidis, Shainal Nathoo, and Jasmin Grigg
17 Late-​life depression 251
Fabian Fußer, Tarik Karakaya, and Johannes Pantel
18 Psychotherapeutic interventions 265
Fiammetta Cosci and Giovanni Andrea Fava
19 Major depressive disorder: how to evaluate and manage patients
with psychiatric and medical comorbidities 277
Sheng-​Min Wang and Chi-​Un Pae
20 Untoward side effects of psychiatric drugs 294
Manu S. Sharma, Ives Cavalcante Passos, and André F. Carvalho
21 Drug interactions involving psychotropic drugs 313
Subramoniam Madhusoodanan, Marina Tsoy-​Podosenin,
Leah R. Steinberg, and Nitin Tandan

Index 337
 Abbreviations

5-​HIAA 5-​hydroxyindoleacetic acid

5-​HT serotonin
5-​HTT 5HT transporter
5HTTPR serotonin transporter promoter locus
ACC anterior cingulate cortex
ACTH adrenocorticotropin
AD anxiety disorder
ADH anti-​diuretic hormone
ADHD attention-​deficit hyperactivity disorder
ADL activities of daily living
ADORA2A adenosine 2A receptor gene
AHRQ Agency for Healthcare Research and Quality
AIDS acquired immune deficiency syndrome
ALT alanine aminotransferase
APA American Psychiatric Association
ASAM PPC American Society of Addiction Medicine Patient Placement Criteria
ASD acute stress disorder
ASRS Adult Self-​Report ADHD Scale
AUD alcohol use disorder
AUDIT Alcohol Use Disorders Identification Test
AWS alcohol withdrawal syndrome
BAI Beck Anxiety Inventory
BDI Beck Depression Inventory
BDNF brain-​derived neurotrophic factor
BPD borderline personality disorder
BSDS bipolar spectrum disorders scale
BUD benzodiazepine use disorder
CADDRA Canadian ADHD Resource Alliance
CAGE Cut Down, Annoyed, Guilty and Eye Opener
CAM complementary and alternative medicine
CBT Cognitive-​Behavioural Therapy
x Abbreviations

CBTp Cognitive-​Behavioural Therapy for Psychosis

CD conduct disorder
CDC Centers for Disease Control
CEA cost effectiveness analysis
CEN cognitive-​executive network
CHD coronary heart disease
CIDI Composite International Diagnostic Interview
CIWA-​Ar Clinical Institute Withdrawal Assessment for Alcohol
CL psychiatric consultant
CM care manager
CMD common mental disorders
CNS central nervous system
COMBINE The COMbined pharmacotherapies and Behavioral INtErventions for
alcohol dependence study
COMT catechol-​O-​methyl transferase
COPD chronic obstructive pulmonary disease
CRF corticotropin-​releasing factor
CRH corticotrophin-​releasing hormone
CRP C-​reactive protein
CSF cerebrospinal fluid
CSFs colony stimulating factors
CVD cardiovascular disease
CYP a group of approximately 50 oxidative heterogeneous isoenzymes
classified into families by numbers (e.g., CYP1, CYP2 and CYP3)
DA dopamine
dACC dorsal ACC
DALY disability-​adjusted life-​years
DAT dopamine transporter
DCPR Diagnostic Criteria for Psychosomatic Research
DDI drug-​drug interaction
DILI drug-​induced liver injury
DLPFC dorsolateral PFC
DMDD disruptive mood dysregulation disorder
DMN default mode network
DMPFC dorsomedial PFC
DSM-​5 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
 Abbreviations xi

DSM-​IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

DST dexamethasone test
EAAD European Alliance Against Depression
EAGG European ADHD Guidelines Group
ECT electro-​convulsive therapy
EF executive functioning
EMDR eye movement desensitisation and reprocessing
EPS extrapyramidal side effects
FDA Food and Drug Administration
GABA gamma-​amino-​butyric acid
GAD generalized anxiety disorder
GAD-​7 Generalized Anxiety Disorder 7-​item survey
GDNF glia-​derived neurotrophic factor
GDS geriatric depression scale
GFR glomerular filtration rate
GI gastrointestinal
GP general practitioner
GR glucocorticoid receptors
GWAS genome-​wide association studies
HAM-​D Hamilton Depression Scale
HARS Hamilton Anxiety Rating Scale
HAV Hepatitis A
HBV Hepatitis B
HCL-​32 hypomania check-​list-​32 items
HCV Hepatitis C
HDRS Hamilton Depression Rating Scale
HIC high-​income countries
HIV human immunodeficiency virus
HPA hypothalamic pituitary adrenal axis
HRV heart rate variability
HVA homovanillic acid
IAPT improved access to psychological treatments
ICD International Classification of Mental and Behavioral Disorders
ICPE International Consortium in Psychiatric Epidemiology
IDO indoleamine 2,3-​dioxygenase
IED intermittent explosive disorder
xii Abbreviations

IPT inter-​personal therapy

KA kynurenic acid
LLD late-​life depression
LMIC low-​and middle-​income countries
LOPFC lateral orbital PFC
LTC lateral temporal cortex
MAO monoamine oxidase
MAOI monoamine oxidase inhibitors
MDD major depressive disorder
MDQ mood disorder questionnaire
MHPG 3-​methoxy-​4-​hydroxyphenylglycol
MI Motivational interviewing
MI myocardial infarction
MITI Motivational Interviewing Treatment Integrity
MMSE Mini-​Mental State Examination
MRS magnetic resonance spectroscopy
MTL medial temporal lobe
MUS medically unexplained symptoms
NAcc nucleus accumbens
nAChR nicotinic acetylcholine receptor
NAPQI N-​acetyl-​p-​benzoquinone imine
NaSSA Noradrenergic and specific serotonergic anti-​depressant
NCS-​R National Comorbidity Survey Replication
NDRI norepinephrine-​dopamine reuptake inhibitor
NE norepinephrine
NET norepinephrine transporter
NMDA N-​Methyl-​D-​aspartate
NRAMP National Register of Antipsychotic Medication in Pregnancy
NRI norepinephrine reuptake inhibitor
NRT nicotine replacement therapy
NSSI non-​suicidal self-​injury
OARS Open questions, Affirmations, Reflective listening, and Summarizing
ODD oppositional defiant disorder
OFC olanzapine-​fluoxetine combination
OROS oral release osmotic system
OTC over-​the-​counter
 Abbreviations xiii

OUD opioid use disorder

PARC Prevention and Recovery Centres
PCC posterior cingulate cortex
PCMH patient-​centred medical home
PCP primary care practitioner/​primary care physician
PD personality disorder
PD panic disorder
PET positron emission tomography
PFC prefrontal cortex
P-​gp P-​glycoprotein
PHQ-​15 15 item Patient Health Questionnaire
PHQ-​9 Patient Health Questionnaire-​9
PMDD pre-​menstrual dysphoric disorder
PNS parasympathetic nervous system
PST problem-​solving therapy
PTSD post-​traumatic stress disorder
QUIN quinolinic acid
RCT randomized controlled trial
RDoC Research Domain Criteria
RNS reactive nitrogen species
ROS reactive oxygen species
SAIB Scale for the Assessment of Illness Behavior
SAMSHA Substance Abuse and Mental Health Services Administration
SARI serotonin antagonist-​reuptake inhibitor
SBIRT Screening, Brief Intervention, Referral and Treatment
SCUD stimulant and cannabis use disorder
SDM shared decision making
SERM selective estrogen receptor modulators
SERT type of monoamine transporter protein that transports serotonin from
the synaptic cleft to the presynaptic neuron
sgACC subgenual anterior cingulate cortex
SHIP Survey of High Impact Psychosis
SIADH syndrome of inappropriate antidiuretic hormone
SJS Steven Johnson’s Syndrome
SMI severe mental illness
SN salience network
xiv Abbreviations

SNP single nucleotide polymorphism

SNRI serotonin norepinephrine reuptake inhibitors
SNS sympathetic nervous system
SODAS spheroidal oral drug absorption system
SSD somatic symptom and related disorders
SSRI selective serotonin reuptake inhibitor
STAR-​D Sequential Treatment Alternative to Relieve Depression
SUD substance use disorder
T2DM type 2 diabetes mellitus
TAU treatment as usual
TCA tricyclic antidepressants
TdP torsades de pointes
TEN toxic epidermal necrolysis
TMS transcranial magnetic stimulation
TPH2 tryptophan hydroxylase-​2
TRH thyrotropin releasing hormone
TSH thyroid stimulating hormone
TUD tobacco use disorder
UGT 5’-​diphosphate glucuronosyltransferase
VEGF vascular endothelial growth factor
VLPFC ventrolateral PFC
vmPFC ventromedial PFC
WBC white blood count
WFSBP World Federation of Societies of Biological Psychiatry
WHO World Health Organization
WMH World Mental Health Surveys
WML white matter lesions
WONCA World Organization of Family Doctors
YLD years lived with disability
YMRS Young Mania Rating Scale
 Contributors

Giovanni Amodeo Elizabeth A. Dinapoli

Associate Professor of Psychiatry, Postdoctoral Fellow,
Department of Molecular Medicine, Department of Psychiatry,
University of Siena, Italy University of Pittsburgh,
Michael Berk Pittsburgh, USA
Professor and Alfred Deakin Markus Dold
Chair of Psychiatry, Department of Psychiatry and
Deakin University, Psychotherapy,
Victoria, Australia Medical University of Vienna,
Lea Bouché Vienna, Austria
student, Ulm University, Andrea Fagiolini
Günzburg, Germany Professor of Psychiatry,
Kathleen Broad Department of Molecular Medicine,
Fifth year resident in psychiatry, University of Siena, Italy
Department of Psychiatry, Giovanni Andrea Fava
University of Toronto, Professor, Department of Clinical
Toronto Canada Psychology,
André F. Carvalho University of Bologna,
Associate Professor, Bologna, Italy
Department of Clinical Medicine Head, Deborah S. Finnell
Translational Psychiatry Research Associate Professor,
Group, Director of the Masters and Doctor of
Faculty of Medicine, Nursing Practice Programs,
Federal University of Ceará, Johns Hopkins School of Nursing,
Fortaleza, Brazil Baltimore, USA
Fiammetta Cosci John Furler
Associate Professor of Clinical Associate Professor,
Psychology, Department of General Practice,
Department of Health Sciences, University of Melbourne,
University of Florence, Melbourne, Australia
Florence, Italy Fabian Fußer
Bernadette DeMuri Consultant Psychiatrist,
Clinical Instructor, Department of Psychiatry,
Department of Psychiatry and Psychosomatic Medicine and
Behavioral Medicine, Psychotherapy,
Medical College of Wisconsin, University Hospital Frankfurt,
Wisconsin, USA Frankfurt am Main, Germany
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1854
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