Community Mental Health Journal, Vol. 28, No. 2, April 1992

Comment on ' Adaptation: The Key to Community Psychiatric

Practice in the Rural Setting"

Richard Warner, M.B., D.P.M.

Many psychiatrists working in rural settings will find this a useful article. The author's emphasis on liaison with the criminal justice system, churches, social services, and primary care physicians is partic- ularly valuable as a solution to many of the problems of rural practice.

The importance of using the family doctor as a member of the rural psychiatric team can hardly be overstated. Mental heal th professionals vacationing in Europe might well enjoy a visit to the beautiful Borders region of Scotland to observe how this approach to rural psychiatry has been developed to an advanced level by the community teams of Din- gleton Hospital, Melrose, Roxburghshire. The well-known social psychi- atrist, Maxwell Jones, developed a program of regular consultation between mental health staff and family physicians (general practi- tioners, as they are known in Britain) in the 1960s. The program continues to flourish under the direction of Max's successor, the current superintendent, Dr. Dan Jones.

Multidisciplinary teams from Dingleton (usually comprised of a psy- chiatrist and other professionals, such as nurses or social workers) visit the general practitioners at their group health centers regularly. They discuss how psychiatric patients being followed by the general practi- tioner are doing, make suggestions about patient management, and accept new referrals. After years of working in this way, the general

Richard Warner, M.B., D.P.M., is affiliated with the Mental Health Center of Boulder County, Inc., 1333 Iris Ave., Boulder, Colorado 80304.

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154 Community Mental Health Journal

practitioner becomes more and more skilled in handling patients of increasing degrees of difficulty. The referral patterns tend to change over time so that the psychiatric team assumes care only for those patients where the mental health professionals' expertise or access to special t reatment programs is of particular value.

The British health care system lends itself well to this approach, as the family doctor there remains primarily responsible for every patient in the community and must, for example, prescribe whatever psychi- atric medication the patient is using, albeit at the recommendation of the psychiatrist. General practitioners carry most of the people with mental health problems in each district without recourse to psychiatric consultation, and the physician, who often has provided services to the family for years and may even have attended at the patient's birth, is well placed to understand his or her problems in living. Reinforcing the psychiatric skills of the primary physician in American rural districts similarly makes very good sense. This model makes it apparent that one of the central functions of the psychiatrist in the rural setting is to be an educator who helps develop the local human resources and ex- pand the capacity of the already established system of health care.