It has been known for some time that the majority of adult mental health problems within any community are seen within general practice, making up a fifth to a quarter of the general practitioner's workload (Shepherd & Clare, 1981). Most patients are not referred to specialist services. It is therefore the primary care team and not the psychiatric specialist who assumes the major burden of responsibility for the care of mental disorder. Hence, more attempts are now being made to improve the quality of psychiatric care within general practice. Most of the research on mental health morbidity within primary care has been in the field of adult mental health and it is only relatively recently that equivalent information on child mental health morbidity has become available. In parallel, an increasing number of studies examining the effectiveness of interventions in primary care have been undertaken and different models of mental health service provision within this context have been described (Strathdee & Williams, 1984). There are few evaluated studies of interventions in primary care focused on child mental health. Most guidance for the development of such services has to be obtained from the adult mental health literature, or from work with other types of childhood disorder, often in non-general practice settings.

Much attention has focused on prompt, accurate identification and treatment of depression and anxiety in primary care settings. Less is known about what to do when treatment is unsuccessful or the initial opportunity to intervene is missed. The long-term prognosis of depression and anxiety in primary care settings is not good: half of sufferers experience a relapsing remitting course and a quarter become chronic. There is also a relationship between chronicity and high service utilisation. The label “heartsink” has sometimes been applied to these patients, often pejoratively.

Community mental health teams (CMHTs) have their origin in the American Community Mental Health Centre programme of the 1960s. The teams were mandated to provide services with an emphasis on the needs of the severely mentally ill (SMI). However, over time the focus of work became ‘the worried well’, to the neglect of those with severe mental illness. CMHTs are now a firm feature of British psychiatry. A Sainsbury Centre study recently identified over three hundred CMHTs across England, defining themselves as comprising at least four members, from two or more disciplines, with a caseload of individuals with mental health disorders, largely residing in the community.

Definitions for learning disability vary depending on the context in which they are used (Box 1), as does the terminology (Box 2). In the UK, the term ‘learning disability’ was adopted in 1991 by the Department of Health. The term ‘mental retardation’ is used in the ICD-10 (World Health Organization, 1992). Fryers (1991) has commented on the need for different definitions in order to distinguish the context in which the term is used.