Q&A: Primary care providers 'play a crucial role' in mental health care

Key takeaways:

• Mental Health Awareness Month is observed every May.
• The president of the AAFP spoke with Healio about the role of primary care providers in addressing mental health.

May marks Mental Health Awareness Month.

In recognition of the observance, Healio spoke with Tochi Iroku-Malize, MD, MPH, MBA, FAAFP, president of the American Academy of Family Physicians, to learn about how primary care physicians can address the mental health crisis in the United States, screening strategies and more.

Healio: Can you discuss the importance of PCPs addressing mental health?

Iroku-Malize: Amid a continuing mental health crisis exacerbated by the pandemic, family physicians play a crucial role in providing mental health care. Family physicians are often the first point of contact for a patient seeking mental health care, and our trusting, longitudinal relationships with our patients make us well-positioned to address these sensitive needs.

As family physicians, we see the whole picture of our patients’ health and can identify when new concerns or changes arise. Family physicians receive extensive training in caring for patients with depression and other mental illnesses, and patients benefit when they receive care from a physician who knows and understands their entire health history.

This is more important than ever given recent studies that show mental health concerns like anxiety and depression continue to be prevalent in our country. According to the National Institute of Mental Health, in 2021, there were an estimated 57.8 million adults in the U.S. with mental illness, which represents nearly 23% of all U.S. adults. With a shortage of behavioral health specialists, many people find their first line of help in a primary care office. Research shows nearly 40% of all visits for depression, anxiety or cases defined as “any mental illness” are with primary care physicians.

Healio: How should PCPs screen for mental health concerns?

Iroku-Malize: The AAFP follows the US. Preventive Services Task Force recommendations on screening for mental health concerns. The USPSTF says certain screening tools for depression are appropriate for use in primary care, including the nine-item Patient Health Questionnaire (PHQ-9), the Center for Epidemiologic Studies Depression Scale (CES-D), the Geriatric Depression Scale (GDS) in older adults, and the Edinburgh Postnatal Depression Scale (EPDS) in postpartum and pregnant patients.

Physicians can conduct the screening by leveraging technology or permitting staff to ask questions or conduct the screening during wellness visits. The USPSTF also recommends that “all positive screening results should lead to additional assessments” to determine the best course of action and treatment.

Healio: What can physicians do to address mental health concerns?

Iroku-Malize: Family physicians can screen for, diagnose and treat mental health concerns, as well as refer patients to behavioral health specialists and prescribe medication when appropriate. The AAFP encourages family physicians to work with behavioral and mental health professionals, when possible, in capacities ranging from collaboration and partnerships to co-locating services, or even full integration within a single care plan.

Because of our long-term, trusting relationships with our patients, patients often feel more comfortable talking to their family physician about mental health concerns than they might with a specialist they’ve never met. They may confide in us and mention challenges or life events that have an adverse impact on their mental health. A natural, casual conversation can turn into a deeper discussion about how to appropriately address their needs.

Healio: What should physicians do if they feel unsure about tackling mental health concerns in their practice? Are there any resources they should use?

Iroku-Malize: The AAFP offers resources to equip family physicians with the tools they need to address mental health concerns and integrate behavioral health care into their practice. Through the AAFP, physicians can access continuing medical education opportunities, clinical tools and resources to support their patients with mental health needs, compiled on the AAFP’s Depression and Mental Health webpage. The AAFP’s peer-reviewed, practice-improvement journal FPM also has a topic collection on behavioral health with articles and resources to help family physicians integrate behavioral health care into their practice. If you’re looking for tools to share with patients, the AAFP’s consumer-facing website, familydoctor.org, provides mental health resources.

Healio: How should PCPs address mental health concerns in adolescents and children? Should they have a different approach than when addressing concerns in adults?

Iroku-Malize: The need to better integrate mental health care and primary care for children and adults has never been more urgent. More work must be done to eliminate barriers to care, and family physicians are part of the solution.

Addressing mental health concerns among children and adolescents is increasingly important as we see a growing number of young people with mental health needs. Research shows more than 14 million American children and adolescents have a diagnosable mental health disorder and CDC data indicates that suicide is the second-leading cause of death for people ages 10 to 34.

The AAFP recommends depression screening for adolescents and teens ages 12 to 18 who have symptoms, and the USPSTF recommends physicians use the Patient Health Questionnaire modified for adolescents (PHQ-A). When working with young patients, family physicians can include parents or guardians in all treatment decisions. Conversations about mental health might be difficult, but they are critically important to our personal and public health. If we’re not advocating for improved mental health care for our pediatric patients, and patients of all ages, we’re falling short of our duty.

Healio: Is there anything else you’d like to add?

Iroku-Malize: The AAFP advocates for policies to better integrate mental health care and primary care for children and adults, increase equitable access to mental health care, and eliminate the stigma surrounding mental health treatment.

We recently endorsed the bipartisan Better Mental Health Care for Americans Act, which will promote primary care and behavioral health integration and expand access to mental health care for children. This important legislation establishes an add-on payment for primary care physicians who have integrated behavioral health into their practices and establishes a Medicaid demo to improve access to integrated care for children.

References:

• AAFP Advocacy Focus: Behavioral Health. https://www.aafp.org/advocacy/advocacy-topics/prevention-public-health/Behavioral-Health.html Accessed May 10, 2023.
• Behavioral health. https://www.aafp.org/pubs/fpm/topics/by-topic.behavioral-health.html#aafp:publications/fpm/topics/behavioral-health/aafp-resources. Accessed May 10, 2023.
• Better mental health care for Americans act ensures Medicare and Medicaid plans treat mental and physical health care equally. https://www.bennet.senate.gov/public/index.cfm/2023/3/bennet-wyden-introduce-bill-to-increase-access-to-mental-and-behavioral-health-care-for-kids-seniors-and-low-income-americans. Published March 22, 2023. Accessed May 10, 2023.
• Data resource center for child and adolescent health. https://www.childhealthdata.org/browse/survey/results?q=9353&r=1. Accessed May 10, 2023.
• Depression and mental health. https://www.aafp.org/family-physician/patient-care/prevention-wellness/emotional-wellbeing/depression-and-mental-health.html. Accessed May 10, 2023.
• Garnett MF, et al. NCHS Data Brief. 2023;doi:10.15620/cdc:12570.
• Jetty A, et al. J Prim Care Community Health. 2021;doi: 10.1177/2150132721102387.
• Mental illness. https://www.nimh.nih.gov/health/statistics/mental-illness. Accessed May 10, 2023.