Primary care providers increasingly addressing mental health concerns

From 2006 to 2018, the proportion of primary care visits addressing mental health concerns jumped by almost 50%, highlighting the need for resources that support behavioral health integration into primary care, according to researchers.

Primary care clinicians have become more involved in treating mental health concerns due to the high prevalence of mental health diagnoses in conjunction with ongoing mental health specialists shortages, Lisa Rotenstein, MD, MBA, medical director of population health at the Primary Care Center of Excellence and a primary care physician in the division of general internal medicine and primary care at Brigham and Women’s Hospital, and colleagues wrote in Health Affairs.

“The scope of primary care has widened and primary care physicians are more likely to be delivering whole-person care, and that includes addressing mental health concerns,” Rotenstein said in a press release. “Primary care physicians welcome the opportunity to help their patients address mental health concerns, but often need better systems of support to provide the care patients want and need beyond their primary care visit.”

The researchers used nationally representative serial cross-sectional data from the 2006-2018 National Medical Surveys to characterize temporal trends in primary care visits that addressed a mental health concern. Their sample consisted of 109,898 visits representing 3,891,233,060 weighted visits.

Key findings

Rotenstein and colleagues found that, from 2006 to 2007, the proportion of primary care visits addressing mental health concerns was 10.7%. That number rose to 15.9% in 2016 and 2018.

“The prevalence of mental health concerns being addressed during primary care visits increased by almost 50% during the study period, representing 15.9% of all visits by 2016 and 2018. This percentage was higher among visits with the patient’s own primary care physician, reaching 16.8%,” the researchers wrote.

They noted that the increase “was larger than what would be expected on the basis of national estimates, which show that the prevalence of any mental illness among U.S. adults increased from 17.7% in 2008 to 21% in 2020,” an increase of 18.6%.

“These findings build on previous evidence that office based primary care physicians have significantly increased their involvement in providing mental health care, despite the competing demands of primary care practice,” they wrote.

In addition to the fact that mental health concerns were much more likely to be addressed in a visit with a patient’s typical provider, the researchers also noted that a patient’s own provider was more likely to prescribe medication for them. The researchers wrote that they were not surprised by this.

“These findings build on previous work demonstrating the importance of having an ongoing supportive relationship with a usual primary care doctor for addressing the full continuum of patient needs, and mental health needs in particular,” Rotenstein and colleagues wrote. “They additionally may underscore an underrecognized potential benefit of periodic preventive health exams, which are associated with increased chronic disease recognition and management.”

Health disparities

The researchers also noted important disparities in care. Compared with white patients, Black patients were 40% less likely to have a mental health concern addressed. The rates were similar for Hispanic patients; compared with non-Hispanic patients, they were 40% less likely to have a mental health concern addressed at their primary care visit.

“While our data do not tell us why we see differences in the proportion of visits addressing mental health concerns when we look at rates by race and ethnicity, the findings tell us that we need to be looking into the barriers — including process disparities and structural and communication barriers — that may prevent all patients from accessing care as needed,” Rotenstein said in the release.

The researchers wrote that further work is required in order to characterize the structural barriers, such as insurance coverage or access to care, communication barriers and disparities in screening rates “that have been found to contribute to less common treatment of mental health conditions in primary care” for patients from underrepresented racial and ethnic populations.

“Policy, organizational investment, and educational efforts will be needed to mitigate the impacts of bias and structural racism that potentially contribute to the disparities identified,” they wrote.

Implications

Rotenstein and colleagues wrote that their findings “have important implications” for the financing and future organization of primary care in the U.S., “given the significant prevalence of mental health diagnoses, the impact of comorbid mental health conditions on utilization, and shortages of mental health professionals.”

Overall, they wrote that their findings underscore the need for billing and payment approaches such as codes for integrated behavioral health and value-based care in addition to organizational designs and supports like longer visits, telehealth availability, colocated therapy or psychiatry providers, that ultimately ensure PCPs can appropriately address a patient’s mental health needs.

“In the context of policy and care delivery changes, equipping primary care providers to address mental health needs is crucial,” they wrote. “Resources and systems that support primary care and behavioral health integration ... may help ease the increasing pressure on primary care providers seeking to address their patients’ needs globally.”

These efforts could also “help ensure access to high-quality mental health care and continuity of care,” they wrote.

“Relatively newer billing codes that enable reimbursement for behavioral health integration also may support the financial viability of providing mental health care in the context of primary care,” the researchers wrote. “Provision of adequate resources and supports for mental health care delivery are especially important, given evidence that primary care clinicians end up providing more visit-based mental health care in the setting of primary care and behavioral health integration than in primary care models without integration.”

Rotenstein said in the release that their findings also “emphasize that the relationships we build in primary care help to give our patients an opportunity to bring mental health concerns to the forefront.”

“We know that mental health concerns are best addressed with a team approach,” she said. “Primary care can be an entry point for patients, but we need to consider strategies such as co-locating primary care providers and psychiatry providers and offering longer visits that will enable primary care physicians to adequately address mental health needs.”

References:

• Primary care physicians increasingly treat mental health concerns. https://www.eurekalert.org/news-releases/978468. Published Feb. 6, 2023. Accessed Feb. 3, 2023.
• Rotenstein LS, et al. Health Affairs. 2023;doi:10.1377/hlthaff.2022.00705.