Postgraduate Diploma Course in Community Psychological Medicine
My experience

Sir David Goldberg as the external examiner
“Not all those satisfying research criteria for a mental disorder will either wish to have, or benefit from, a medical treatment, but many will benefit from social support.” --David Goldberg, professor emeritus,
Institute of Psychiatry, King's College.(1)

This article was written just after I had sat for an oral examination by Professor Goldberg, who was the external examiner of  a diploma course (? Yes, a diploma course!).
Not only was there a famous external examiner, there were also professional actors acting as psychiatric patients. The young schizophrenic patient with incongruent affect and pill-rolling hand tremor from extrapyrimidal side-effect of antipsychotics made me doubt his identity as a real patient who walked into my consultation room by mistake.
This was the bed-side examination, hold for the first time, of the Postgraduate Diploma Course in Community Psychological Medicine (PDCPM) jointly organised by the Department of Psychiatry and the Family Medicine Unit of HKU.

"Patients suffering mild to moderate psychiatric or psychological problems will be more willing to seek help from a general practitioner who is well equipped with practical psychiatric knoweldge so that the negative labelling from a formal evaluation from a psychiatist can be greatly reduced. Needless to say, severe mental illnesses will need specialist's care." (2)

DSM IV vs ICD 10 PC
Established psychiatric diagnostic schemes such as the Diagnostic and Statistical Manual were developed to classify the psychological and behavioral disease found among psychiatric inpatients. Although their scope has broadened with successive revisions, they remain more applicable to the 2% of the population who are seen by psychiatrists than to the much larger proportion who are considered to have mental health problems by their general practitioner. (3)

DSM IV has been useful in codifying psychiatric illnesses and making trial results measurable and comparable. However, patients seen in general practice who are symptomatic seldom meet the full diagnostic criteria in DSM IV. It would be difficult to apply evidence obtained from trials basing on DSM IV as inclusion criteria to this large group of patients.

On the other hand, ICD-10 primary health care version of the mental disorders classification (ICD-10 PHC Ch.V) deals with conditions which are frequently seen in primary health care and which can be managed effectively by general practitioners.
The essence of the PDCPM course was like a dynamic version of the ICD 10 PC. It incorporated experience sharing from psychiatrists and family physicians.

WHO & SSRI

Thanks for the introduction of the selective serotonin reuptake inhibitors (SSRIs). Not only because  we can throw out SSRI as the answer for an increasing number of psychiatric problems, but because of its effectiveness in treatment of depressive illness and its much more tolerable and safer side-effect profile.

It had been difficult to raise the level of amitrytaline to a daily dose of 150mg and to maintain it without causing considerable side-effects. The fatality of overdosing when given to depressed patients with suicidal tendency also warranted much consideration.

So, although depression was common among GP patients, not many of them were receiving antidepression treatment. Those taking medication were of much lower dosage than the standard therapeutic dosage, and for a shorter than optimal duration.

WHO estimates that unipolar major depressive disorder would rank second in global chronic disease burden in 2020, just next to ischaemic heart disease. (4) Therefore much work has been done to improve the awareness and to promote better management of depression in the general population and among general practitioners worldwide.

The PDCPM Course also devoted a significant portion of its time in discussion of the recognition and management of depression in general practice. Experience sharing with psychiatrists were vlauable especially that concerning details in the use of individual SSRIs.

SARS & PDCPM
Because of the epidemic of SARS, we saw more patients with panic attacks, acute stress disorder, adjustment disorder, panic disorder and depressive disorder. The anxiety level of the general population was also raised.

The PDCPM Course was just in time to equip us with more awareness, better knowledge and more confidence in helping our patients.


References

1. Goldberg DP. A classification of psychological distress for use in primary care settings. Soc Sci Med 1992; 35: 189-193
2. Cheng Chor Ho. Response to 'Postgraduate Diploma Course in Community Psychological Medicine, My experience'
3. Hugh Middleton. Distinguishing mental illness in primary care BMJ 2000;320:1420-1421.
4. WHO. Evidence, Information and Policy, 2000