The guide to mental health for nurses in primary care
International Journal of Integrated Care, 7 February 2003 - ISSN 1568-4156
Book review
The guide to mental health for nurses in primary care
Edited by Elizabeth Armstrong
Radcliffe Medical Press, Oxford: 2002, pp 159,
ISBN 1 85775 435 2
Shona M. Barcus, Chief Executive Scottish Association for Mental Health

The book's theme appears to be partly aimed at helping primary care nurses rise to the challenge and play their part in implementing the National Service Framework (NSF). Applicable in England and Wales, the NSF was produced by the Department of Health to improve not only specialist services, but mental health care generally. While recognising the multidisciplinary nature of the primary care team and the fact that the NSF challenges apply to all members, the guide adds that many current primary care texts have been written by doctors and reflect a medical perspective. Its introduction informs the reader that it is written ‘by and for nurses’ and is a ‘celebration of the nursing contribution to primary mental health care’.

In eleven chapters, topics such as depression; anxiety, stress and related conditions; eating disorders; alcohol and illegal drugs; mental illness in older people and promoting mental health and preventing mental illness are discussed. Chapter 9, ‘Developing a Team Strategy’ is the chapter focusing most specifically on an integrated care approach.

Having worked as a CPN with a Primary Care Team and also having managed District Nurses, Health Visitors, Clinic Nurses and Health Centre staff, I have some concerns about the emphasis of this book. A clear strength is its recognition that primary care staff and non-mental health trained community nurses do need to be better able to recognise mental health problems and should have a knowledge of local resources and it does endeavour to address this. But nurses are not therapists and they are generally not counsellors, nor should they be. Although Chapter 2 on anxiety, stress and related conditions cautions against nurses undertaking work, which involves specialist skills, the general impression the book gives is that they can identify and indeed in some cases offer ‘treatment’. This, however, causes grave concerns about the risk of misdiagnosis, missed diagnosis and inappropriate treatment.

The index does not show any key words such as principles and values, recovery, service user participation and involvement. I found little about self-harm, a growing problem and a manifestation of distress which is often very poorly dealt with by health care staff. I found a predominantly medical model and a worrying reliance on assessment and rating scales and on closed questions.

I found only two references to sexual abuse and a suggestion that there ‘may be an association’ between this and eating disorders and depression. Most practitioners in mental health would probably say that sexual abuse was a key factor in the difficulties of a great number of people seen—whether with depression, eating disorders, substance misuse or psychosis.

The authors state that ‘antidepressants are not addictive’. Many recipients would not agree. A growing body of evidence casts doubt over both the effectiveness and the safety of a number of these products, notwithstanding their potential to create dependency or the problems people have when they experience withdrawal symptoms coming off them.

I also found a statement about Electro Convulsive Therapy bringing about a ‘rapid relief’ of symptoms, but nothing is said about the controversy which surrounds its use or the sometimes distressing and irreversible effects experienced, such as memory loss described by many of its recipients.

I was pleased to discover a whole chapter on the hugely important subject of stigma. However, I found the stigma of mental health problems accorded less attention than to the stigma associated with race and gender which were all wrapped up together here. A chapter on stigma and discrimination should arguably have introduced this book. Staff should be exposed to the facts and some of the lived experiences arising from stigma and discrimination. For example, the fact that 84% of people with severe and enduring mental health problems are out of work and are more excluded from employment than those with a physical or sensory impairment; the fact that mortality rates for those diagnosed with schizophrenia are two and a half times the national average; and that two thirds of media reports misleadingly portray people with mental health problems as violent. The experience of those with mental health problems is frequently that health services can themselves be stigmatising and indeed mental health workers including psychiatrists can be stigmatised within their own wider professional groups.

On p 136, the authors mention mental health problems in staff, e.g. stress and depression in doctors and increased risk of suicide in female nurses. This book could have begun by looking at the attitudes, understanding and experience of staff. It could have tried to break down the artificial divide between ‘us’—the ‘professionals’ and ‘them’—the ‘patients’ because we can all suffer from mental health problems and mental health and wellbeing is important to all of us whether or not we have mental health problems. In fact this important area, which could usefully be given much greater emphasis in Primary Care is the subject of the book's final chapter.

It seems to me that empathy, listening skills and a willingness to be with someone in distress are important skills in primary care staff. A knowledge of where people can go for information and for help where they need it, and a knowledge of alternatives to medication, or of complimentary treatments could help people to make informed choices about their treatment. Also, for many people, staff with knowledge of the welfare benefit system could be of huge assistance—staff who can encourage applicants for benefits not to be put off by the daunting forms and the almost inevitable first rejection. These are some of the things which people with mental health problems and their carers have often said would be of most help.

I therefore found this a rather confusing and frustrating book. It seemed to offer some helpful information although the emphasis could be broader and less medical. However, it misses huge opportunities to widen the understanding of Primary Care staff about mental distress within the wider agenda, which takes into account the role of social exclusion and inequalities as determinants of mental health problems. It fails to pick up on the self-help and recovery movements and it fails to convey or promote empathy.