The future of mental health research in primary care settings.

Since the Declaration of Alma Ata (World Health Organization, 1978) there has been a steady move world wide for health care to be primary care led, with secondary care offering specialist knowledge and increasingly sophisticated investigation and treatment in support. The vast majority of illness and disease is managed in primary care, but paradoxically, while general practice contributes the greatest activity and most prescriptions, it has until recently produced but a small fraction of the knowledge base for practice (Orme et al., 1990). Application of results from research in secondary care settings to primary care may be quite inappropriate due to differences in severity and natural history of disease among those patients reaching secondary care. At the end of the 20th Century we remain unclear about the epidemiology and response to treatment of many conditions in the community, and this applies particularly to mental health problems of all kinds. There are two main reasons for this; on the one hand, is the complex nature of mental illness and disease, and the lack of aetiological clarity, leading to difficulty in defining cases at the research level in primary care. On the other, is the nature of primary care, it's organisation and delivery, which poses challenges to research design, intervention development and delivery, and valid and reliable outcome assessment. As a result it remains an open question as to how to provide care most cost effectively to patients with schizophrenia through primary care. Equally the optimal detection and management strategies for the range of depression in primary care is unclear.