This relatively brief manual addresses an important gap in the provision of primary care services—What to do with patients suspected as having mental illness before formal consultation and assessment are available or requested? I was recently surprised to learn from an article in the British Medical Journal that there is, on average, a 2-year delay in the formal diagnosis of schizophrenia. This means that many patients and families or caregivers are going for prolonged periods of time without much or any formal assistance and/or education about the processes affecting the family member. It is equally clear that with many other major mental health diagnoses (depression, anxiety, dementia, substance abuse, etc.) there are even longer periods of trying to cope with the mental health problem without formal evaluation and treatment.
Michael Rayel’s lucid book seeks to empower caregivers and patients to manage this early morbidity of mental health problems more successfully. He presents information to enable lay persons to identify the emotional difficulty and to give them a basic approach for dealing with the predictable risks and crises associated with mental illness. He outlines his basic approach to mental health problems for patients with the mnemonic CARE: Check for signs of mental illness; Anticipate complications; Remedy with early intervetion, and Educate yourself about the illness. Typical ‘red flags’ to look for among the early signs of mental illness include symptoms like: self-talk with such statements as ‘something is not right,’ ‘I don’t feel the same,’ ‘I feel funny,’ ‘I have to push myself’; changes in usual daily routine and activities; disturbances in energy, sleep, and appetite; and emotional symptoms such as crying for no reason or unusual suspiciousness. He then offers a simple, practical approach for caregivers represented in another mnemonic—HEAL: Help yourself throught aBCs of first aid; Encourage yourself; Address the issues; and Learn to cope. The ABCs refer to: Accepting the ongoing mental health problem—it’s not anyone’s fault, it just is; Be alert for signs of destructve thoughts and behavior; Check for worsening of symptoms; and, finally, Call for help.
The book dedicates a brief chapter to each of the major common mental health problems—depression, mania, panic, phobia,obsessions and compultsions, post-traumatic diosrders, anixiety, psychoics, substance abuse, earting disorders, dementia, and grief and bereavement. Each starts with a short clinical case desription, offers a brief general overview, including the formal DSM-IV diagnostic criteria for each disorder; this is followed by a concise presentation of the CARE and HEAL steps for the specific disorder. The clinical descriptions are taken from real patients and effectively represent typical features of the illness. Some of the specific details serve to remind clinicians of the potential medical effects of mental illness in a striking way—for example, the obsessive-compulsive whose ritual hand-washing progresses to 5 hours of showering per day; among the consequences of this are that the hot water runs out, and the patient on one occasion had to be admitted to the hospital for hypothermia. The repetitive format makes the book more effective as a reference manual rather than a simple read for information. I believe the material presented for caregivers has real value and is a significant enhancement to the primary care of mental illness. As a primary care physician, I am principally interested in it for the purpose of distributing the appropriate chapter(s) to caregivers to enhance their understanding of the illness and their readiness to cope and intervene effectively when necessary. Our current disorganized mental health system depends critically upon the capacity of these caregivers to render effective assistance to these disabled patients, but until now no one has given much thought about how best to prepare and assist the caregivers. Despite its title, this book has far less value for patients since their capacity for organization and discipline required to implement the self-care steps is so impaired during mental illness, but for high-functioning individuals with depression or anxiety, the self-care steps suggested are practical and appropriate. Dr. Rayel appropriately gives a lot of attention to sound self-care principles as practicing relaxation, exercise, eating right, practicing good sleep hygiene, and how to deal with anger and negative self-thoughts.
Since primary care physicians are the front line of the health care system in dealing with mental health problems, this book represents an important and efficient new reference tool. The material in this book will enable primary care physicians to provide concise, accessible information in an appropriate combination of lay and clinical language to make them more knowledgeable and effective in caring for their loved ones with mental health illnesses. I would specifically recommend making copies of the specific chapters relevant to their family member available and to use it in a continuing process to make them more competent in understanding, protecting, and caring for their loved ones. What I would like to see next from this author is a short book directed specifically at primary care physicians to enhance their ability to provide adequately for the needs of these families in the scope of a typical 15 minute office visit.
Colin P Kopes-Kerr, MD, JD, MPH
Program Director
Stony Brook Family Practice Residency
University Hospital
Stony Brook NY 11794
