Mental health disorders are so common that 1 in 5 adults in the U.S. experienced mental illness in 2018. But only 43 percent of adults with mental illness received treatment.
Why is that? There are several possible reasons. Though attitudes are improving, there is still a stigma associated with mental illness, and for that reason some people are reluctant to seek help. But often the problem is supply not meeting demand: Many communities, especially in rural areas, have few mental health care providers—or none. Even in areas with providers, people may have to wait a long time to get an appointment.
Screening and Treating Depression in Primary Care
Primary care providers, such as family doctors and internists, play an important role in providing mental health services. According to CDC data published last year, an annual average of 30 million mental health-related physician office visits were made by adults between 2012 and 2014. Psychiatrists provided care at 55 percent of these visits, while primary care physicians covered 32 percent.
Even when a patient ends up seeing a mental health professional, his or her treatment often begins at their primary care provider’s office. In fact, says Dana M. Neutze, MD, PhD, associate medical director of the UNC Family Medicine Center at Chapel Hill, “the majority of psychiatric care now starts in the primary care setting.”
Since 2002, the U.S. Preventive Services Task Force (USPSTF) has recommended screening in primary care of the general adult population for depression. In 2016, the USPSTF updated its recommendation to specifically mention both pregnant women and postpartum women (those who have recently given birth).
As a result of that recommendation, many primary care providers now include depression screening as part of a patient’s annual visit. A simple two-question form, called the Patient Health Questionnaire-2 or PHQ-2, is often the starting point. It asks how often, over the last two weeks, a person (1) has had little interest or pleasure in doing things, or (2) was feeling down, depressed or hopeless.
The PHQ-2 results in a score that ranges from 0 to 6. If a person’s score on the PHQ-2 is 3 or higher, that indicates depression is likely, and then he or she is given a longer, nine-question form, the Patient Health Questionnaire-9, or PHQ-9. It is used to provide a more detailed assessment of the person’s mental state and produces a score ranging from 0 to 27.
Depending on the patient’s score and symptoms, they may be prescribed antidepressants, referred for psychotherapy or both.
Dr. Neutze estimates that at her practice, as many as 20 percent of adult patients receive mental health services.
“In primary care, there are several antidepressants we can choose from and safely start a patient on,” she says. For many people, antidepressants and several follow-up visits may be all they need. But if a patient fails to show improvement after a few months, medications may need to be changed or it may be helpful to start psychotherapy if it wasn’t part of the initial plan. Patients with resistant depression who have tried multiple therapies may need to see a psychiatrist, Dr. Neutze says.
Depression, anxiety and emotional distress related to grief are the mental health issues that are most commonly treated by primary care providers, Dr. Neutze says. A person who has a condition that is more difficult to treat, such as bipolar disorder or schizophrenia, will typically need to see a psychiatrist. But once the person’s condition is stable, a primary care provider can often take over the role of prescribing medication refills.
The Difference Between Primary Care and Psychotherapy
It’s important to know that primary care visits tend to be much shorter than a therapy session and most general physicians won’t have training in psychotherapies such as cognitive behavioral therapy. If it’s determined that a patient needs to see a psychotherapist, the primary care provider can help with finding a provider, though a referral usually isn’t needed.
It’s important to bring up any concerns about your mental or emotional health with your primary care provider, Dr. Neutze says.
“I really want people to know,” she says, “that it’s OK for you to talk with your primary care provider if you are feeling depressed, anxious or have any other concerns about your mental health. You don’t have to wait for an appointment with a psychiatrist.”
A primary care provider can screen you for depression and begin mental health treatment if needed. Find a primary care provider near you.
EXECUTIVE SUMMARY
Mental illness is highly prevalent in the United States and is associated with an increased risk of morbidity and mortality. There are significant gaps in the provision of mental health care services in the U.S., especially related to vulnerable populations. Family physicians are well-equipped to provide mental health services and are one of the primary sources for mental health care in the U.S. The American Academy of Family Physicians (AAFP) supports the following:
- Family physicians are well-prepared to provide many mental health services and should continue to lead and participate in these services to improve access, quality, and outcomes.
- Family physicians should work with behavioral and mental health professionals whenever possible to ensure the best care for their patients. This can range across a continuum, including collaboration and partnerships, co-locating services, or even full integration within one single care plan.
- Graduate medical education in family medicine emphasizes the direct link between physical and mental health, and should continue to offer behavioral and mental health training as part of the core curriculum.
- Family physicians should educate themselves about mental health practices, including staying up-to-date on screening recommendations for mental health; behavioral health and primary care integration models; trauma-informed care, telemedicine and telepsychiatry; and mental health disparities and high-risk populations.
- Family physicians should advocate for the elimination of the stigma that accompanies poor mental health, as well as support policies that improve access to behavioral and mental health services.
- Advocating for the maintenance and expansion of state, federal, and private insurance funding of mental health care services for all.
- Advocating for the establishment of payment mechanisms that: adequately reimburse primary care physicians for providing mental health care services; and allows adequate funding of mental health care services provided in co-located practices to ensure its continued availability in the primary care physician’s office.
- The development of new treatment strategies to increase the number of patients who receive appropriate treatment and follow-up through both primary care and mental health specialty care providers, and through the use of new technologies, such as telehealth.
BACKGROUND
Mental illness, which includes a range of mental health conditions that affect one’s mood, thinking, and behavior, is one of the most pervasive causes of disease and disability worldwide. The prevalence of mental illness has important public health ramifications, affecting roughly 20% of all adults,1 and is the leading cause of disability in the U.S., accounting for 18.7% of years of life lost to disability and premature mortality.2 While mental illness is common in all parts of society, there are disparities, with American Indian and Alaska Natives (28.3%) experiencing higher rates than white (19.3%), black (18.6%), Hispanic (16.3%), or Asian (13.9%) adults.1 Mental illness has a substantial economic impact, accounting for $179 billion in health care spending in 2014, which is projected to increase to $238 billion in 2020.3
Challenges exist for providing high-quality mental health care services in the U.S., mainly arising from the fragmentation of medical care and mental health care.4 Mental health services are not distributed evenly throughout the U.S. and many communities lack access to these services.5 Roughly two-thirds of primary care physicians are unable to connect their patients to outpatient mental health services.6 This results in the need for primary care physicians to assume a leading role in the management of mental health care services.5 Primary care physicians serve as primary managers of psychiatric disorders in one-third of their patient panels5 and two-thirds of patients with depression receive treatment for their depression in the primary care setting.5
Family medicine, which promotes the integration of the behavioral and physical models of illness, serves a vital role in providing mental health care services. Transformations within primary care, most notably the patient-centered medical home (PCMH), have called for reintegration of mental health care into routine comprehensive care through a team-based approach.7-9 Integration can take place across a continuum, including collaboration and partnerships, co-locating services, or full integration within one single care plan.10 The current lack of integration is a barrier to improving the quality, outcomes, and efficiency of care delivery for those struggling with both mental and physical illness.11,12
This paper explores the various issues family physicians face regarding mental health and mental health care services, clarifies the family physician’s role, and provides direction to the AAFP to advocate for a better system for addressing mental health in the U.S. The paper covers topics related to: incorporating mental health care services in primary care; health disparities and high-risk populations; tobacco use as a risk factor for excess morbidity and mortality in the population experiencing mental illness; and payment.
ROLE OF THE FAMILY PHYSICIAN
While psychiatric and other mental health professionals can play an important role in the provision of high-quality mental health care services, primary care physicians are the main providers for the majority of patients. Most people with poor mental health will be diagnosed and treated in the primary care setting.13 Mental illness also complicates other medical conditions, making them more challenging and more expensive to manage.13 Together, this makes mental health an important issue for primary care physicians.
Family physicians are well-positioned to address their patient’s mental health issues. The behavioral sciences and mental health are central tenets of the specialty of family medicine,14 and family physicians receive high-quality training in these areas. The Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) for Family Medicine has stringent standards for education in family medicine residencies for mental health, including that residency programs: have faculty dedicated to the integration of behavioral health; teach residents to diagnose, manage, and coordinate care for common mental illnesses and behavioral issues in patients of all ages; require that residents demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, and their application to patient care; and structure their curriculum so that behavioral health is integrated within student’s total educational experience.15
INCORPORATING MENTAL HEALTH SERVICES IN PRIMARY CARE
Screening for Mental Illness
Screening for mental illness is not new to family medicine but has more recently been linked to quality metrics and payment. Screening for mental illness can be an important strategy for decreasing morbidity,16 as well as preventing adverse maternal and child health outcomes associated with perinatal depressive symptoms, postpartum depression, or maternal suicide.17-20 While important, screening in a busy practice can seem overwhelming, but practices can leverage technology, empower staff, and utilize wellness visits to complete this screening.21
Family physicians should be aware of screening recommendations for their patients, recognizing that identification of mental health issues is integral to ensuring appropriate treatment and reduction of complications. Mental health clinical recommendations and guidelines developed or endorsed by the AAFP are outlined on the AAFP’s website (http://www.aafp.org/patient-care/browse/topics.tag-mental-health.html).
Primary Care and Behavioral Health Integration
Integrating mental health into primary care settings, as well as the blending of primary and preventive medicine into traditional mental health settings, represents a more holistic approach to treatment than the traditional consultative and referral models. Integrating primary care and mental health services increases access for patients by making mental health services available in their regular primary care clinics. When integrated into primary care, mental health providers can impact the care of more patients than in the specialty mental health referral sector.22 In the primary care setting, mental health providers take on a more consultative and team-based role and focus on helping primary care providers treat mental health disorders. In this context, mental health providers typically reach more patients, and have shorter and more problem-focused encounters than in the context of traditional specialty mental health.
Collaborative Care – A model for Primary Care and Mental Health Integration
The Collaborative Care Model, supported by various organizations including the American Psychiatric Association, is a model for the successful integration of primary care and behavioral and mental health.23 At its core, the idea of collaborative care is anchored in team-based care, often in the context of a medical home, and steered by primary care physicians. It involves behavioral health specialists and consulting mental health professionals delivering evidence-based care that is patient-centered. Evaluations of this model of care are ongoing, particularly in the adult population.
The collaborative care model includes four core elements: 1) team driven, 2) population focused, 3) measurement guided, and 4) evidence based. These four elements, when combined, can allow for a fifth guiding principal to emerge—accountability and quality improvement. Collaborative care is team-driven, led by a primary care clinician with support from a “care manager” and consultation from a psychiatrist who provides treatment recommendations for patients who are not achieving clinical goals. Other mental health professionals can contribute to the Collaborative Care Model. Collaborative care is population focused, using a registry to monitor treatment engagement and response to care. Collaborative care is measurement guided with a consistent dedication to patient-reported outcomes and it utilizes evidence-based approaches to achieve those outcomes. Care remains patient centered with proactive outreach to engage, activate, promote self-management and treatment adherence, and coordinate services.23
Telemedicine and Telepsychiatry
Telemedicine is the process of providing health care from a distance using technology. Telepsychiatry, a subset of telemedicine, can involve either direct or indirect interaction between a psychiatrist and the patient, where a psychiatrist supports a primary care physician and other health care providers. Several telehealth models exist for providing mental health services. A promising model is Project ECHO (Extension for Community Healthcare Outcomes). A model such as this seeks to enhance access to mental health and substance-use disorder treatment via remote and telehealth training and practice support for primary care clinicians, particularly in rural and underserved areas.24,25 Telemedicine for mental health is a growing interest in primary care and telehealth initiatives for mental health care are expanding rapidly. While the research is limited on this topic, there are a growing number of studies assessing the benefits, comparative effectiveness with face-to-face visits, and cost comparisons. Family physicians who wish to integrate mental health care services in their practice, but have limited access, should consider learning more about this topic.
Trauma-informed Care
An estimated 60% of adults in the U.S. have experienced a traumatic event at least once in their lives.26 Exposure to trauma, such as intimate partner violence, sexual abuse, rape, neglect, terrorism, war, natural disasters, and street violence predisposes those affected to poor physical and mental health outcomes.27
Trauma-informed care, an approach to engaging individuals with a history of trauma that recognizes their traumatic experiences, and how it affects their lives, is a promising practice that may facilitate healing and help prevent the consequences of exposure to trauma.28-32 The principles of trauma-informed care include: realizing that there is a high prevalence of trauma and it has serious effects; recognizing the signs and symptoms of trauma; responding to the high prevalence by integrating knowledge about trauma into practices, procedures, and policies; and avoiding retraumatizing individuals by using best-practices in screening and history taking.27
While still in its infancy in family medicine, trauma-informed care is gaining support and evidence of its benefits are accumulating.33 Family physicians who have learned about trauma-informed care have increased measurements of “patient-centeredness” after completing a continuing medical education (CME) course.34 Family physicians will undoubtedly hear more about trauma-informed care and should take advantage of training opportunities in its principles and practice.35
HEALTH DISPARITIES AND HIGH-RISK POPULATIONS
Health Disparities
While mental health conditions can affect everyone, regardless of culture, race, ethnicity, gender or sexual orientation, some populations experience those conditions at a higher rate.
- American Indian and Alaska Natives (28.3%) experience higher rates of mental illness than white (19.3%), black (18.6%), Hispanic (16.3%), or Asian (13.9%) adults.1
- Individuals from the lesbian, gay, bisexual, transgender, and questioning (LGBTQ) community are two or more times as likely as heterosexual individuals to have a mental health condition1 and LGBTQ youth are two to three times more likely to attempt suicide than heterosexual youth.1
- Nearly one-fifth (18.5%) of the veterans who returned from serving in either Iraq or Afghanistan suffer from either major depression or post-traumatic stress disorder.36
- The prevalence of mental illness is similar for individuals living in either rural or metropolitan areas, but the mental health care needs are more often unmet in rural communities due to inadequate services.37
Disparities in mental health illness and mental health care are related to coverage and availability of care, quality of care, rates of health insurance, stigma, cultural insensitivity, racism, bias, homophobia, discrimination in treatment settings, and language barriers.1
College Students
Approximately 20 million students are enrolled in U.S. colleges and universities.38 Mental health concerns, such as non-suicidal self-injury and serious suicidal ideation, have risen in this population over the past several years.39 According to the Center for Collegiate Mental Health’s 2017 Annual Report, 52.7% of students attended counseling for mental health concerns; 34.2% took a medication for mental health concerns; 9.8% were hospitalized for a mental health concern; 27% purposely injured themselves without suicidal intent; and 34.2% seriously considered attempting suicide, with 10% making a suicide attempt.39 In fact, some data suggest that suicide may be the most common cause of death in college students.40
Attention-deficit/hyperactivity disorder (ADHD) is another prevalent disorder in college students that family physicians may encounter. ADHD’s prevalence is estimated to be between 2-8% among college students, and this condition is frequently associated with other psychiatric comorbidities and increases individuals’ risk of psychosocial and substance-use problems.41
TOBACCO USE – A RISK FACTOR FOR EXCESS MORBIDITY AND MORTALITY
Tobacco use is prominent among individuals living with mental illness. Thirty-six percent of adults with any mental illness use tobacco products, compared with 25.3% for adults without a mental illness.42 In addition, people who have any mental illness are only half as likely to quit smoking compared to individuals without a mental illness.43 One study found that nearly half of all deaths were tobacco-related for persons who received substance abuse services, or who received both substance abuse and mental health services.44 Therefore, addressing tobacco addiction among individuals living with mental illness is an important strategy for decreasing preventable mortality and morbidity among individuals living with a mental illness.
The AAFP has position papers that detail substance abuse and addiction and tobacco prevention and cessation.
PAYMENT
Historically, primary care physicians have encountered barriers to receiving full reimbursement for office visits for mental health diagnoses. This limitation in reimbursement interfered with the family physician’s ability to offer comprehensive care and management of mental health conditions, as well as the ability to integrate, from a business perspective, with behavioral health services. However, new coverage policies adopted by the Centers for Medicare & Medicaid Services (CMS) are more promising and may incentivize primary care physicians to provide treatment for mental and behavioral health conditions.45 These policies, effective January 1, 2017, emphasize collaborative care, where primary care physicians are expected to work in partnership with a behavioral health care manager, and consult with mental health specialists. While targeting populations with Medicare, these policies may also encourage private insurers to offer similar options and may incentivize more family physicians to offer behavioral and mental health care to other populations.
Health care for all people with mental illness should be “affordable, nondiscriminatory, and includes coverage for the most effective and appropriate treatment.”46 Coverage for mental illness should be equal in scope to coverage for other illnesses and all clinically-effective treatments appropriate to the needs of individuals with mental illness should be covered.
CONCLUSION
Family physicians play an important role in the provision of mental health care services in the U.S. and are well trained to provide many types of mental health care services. It is imperative that family physicians work to integrate with mental and behavioral health care providers to better meet their patients’ needs when possible. A variety of models and resources exist to assist them with filling the existing gaps in the provision of mental health care services in the U.S., especially related to vulnerable populations. In this manner, family physicians can work to meet both the physical and mental health care needs of their patients.
