Severity of disorder

Severity of disorder can be assessed in two ways—whether or not psychiatric diagnostic criteria, for what are considered major illness, are met and the level of disability associated with the disorder. The prevalence figures, reported earlier, suggest that the psychoses and dementias, the conditions usually termed 'severe mental illnesses' in psychiatric services, are relatively rare in general practice. Each GP would only have about eight patients with a psychosis on his or her own list and will come across a new patient, perhaps, every other year. Nevertheless, a community survey of all patients with schizophrenia in the London Borough of Camden showed that 25 per cent of the 540 patients, so identified, were receiving follow-ups entirely within primary care. (16) Thus, GPs make a significant contribution to the care of psychotic patients, although the load for any one GP may be small.

All patients included in the Manchester arm of the WHO study were assessed for current disability using the Brief Disability Questionnaire, which estimates the ability to function in household work, work, and leisure tasks according to the local expected standards. Twenty-seven per cent of the whole sample, but 55 per cent of those with a psychiatric disorder defined by IC-10, were rated by interviewers as having moderate or severe disability. This level of disability was similar to that obtained if the patient's own self-report was used as the measure. There was no symptom threshold where disability rapidly increased; instead, disability increases in a linear fashion with the number of symptoms that a patient has, and also varies with time as symptoms come and go.(l7>

Longitudinal studies in primary care are relatively rare, particularly those that consider the whole range of psychiatric morbidity. In a follow-up of 100 patients with diagnosed neurotic disorders, 48 per cent still met case criteria after 1 year. (1,8) Over the follow-up period, 24 per cent recovered early, 52 per cent ran an intermittent course, and 25 per cent showed persistent symptoms throughout the whole follow-up period. Very similar 1-year figures were more reported more recently, (1.9> with 34 per cent with early recovery, 54 per cent on a intermittent course, and 4 per cent on a chronic course. An 11-year outcome of the cohort reported in 1981 (!8> was that 51 per cent of those traced still met probable case criteria and, judging by self-report and inspection of GP case notes, had suffered continuous psychiatric symptoms for the whole follow-up period. (20>

Thus there are indications that psychiatric morbidity as seen in primary care, although non-psychotic in nature, is associated with significant disability and that many patients will be as depressed as those seen in the psychiatric services. A significant minority (around 20 per cent) are likely to have a protracted course.

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