How PCPs can address gaps in mental health care

Key takeaways:

• Primary care providers are increasingly addressing mental health concerns.
• Screening and improving diagnostic accuracy are some important ways they can help close gaps in care, a speaker said.

BOSTON — Primary care providers are addressing mental health more than ever before and can take simple steps to close gaps in care, according to a speaker at the ACP Internal Medicine Meeting.

Mental health has been “increasingly an aspect of the care” that PCPs offer, Patrick Hemming, MD, MPH, a general internist and associate professor of medicine at Duke University, said in his presentation. He referenced a recent Health Affairs survey that revealed roughly 16% of primary care visits addressed a mental health concern.

“Mental and medical disorders often coexist in the same patient,” Hemming said. “Many mental health disorders present with chronic and disabling physical symptoms, and for us, frequently, the presentation that we encounter is not the person coming in and saying ‘I'm sad,’ or ‘I'm hopeless.’ It's the person coming in saying ‘I hurt’ or ‘I'm in physical distress,’ and we have to find out in the time that we have where the mental health problem might be in this situation.”

Hemming said many patients suffering from a mental health disorder present with chronic physical, medically unexplained symptoms, which can be difficult for PCPs.

“We often find people who are coming to us that we can't give them the concrete diagnosis that they want to help explain what they're experiencing, and so we have this challenging work to do with our patients to understand these phenomena, to communicate our understanding of these things,” he said. “So where does our care for the mental health of our patients fail?”

Not detecting a disorder, misdiagnosing the issue or undertreatment in some way — whether that is from prioritizing other conditions, a patient not following up, etc. — are all spots where gaps in treatment occur.

“Even in the best circumstances, with doing all the right things ... sometimes our treatments are going to be ineffective for patients and we’re going to need other avenues,” Hemming said.

But he said there are three ways PCPs can work to fix the pitfalls: systematically screening for certain conditions, improving diagnostic accuracy for patients and improving therapeutic use.

Hemming mentioned some of the more popular screening tools he said PCPs should be aware of: the Patient Health Questionnaire (PHQ)-2 and PHQ-9, Generalized Anxiety Disorder (GAD)-2, Panic Disorder Screener (PADIS) and the Mood Disorder Questionnaire (MDQ).

Further down the continuum of care, Hemming said, “diagnostic accuracy is obviously incredibly important.”

“Depression is the leading cause of disability worldwide, as measured by years living with disability,” he said. “Because of the high prevalence, as well as the chronic relapsing nature of this disorder, [diagnosing it is] a major public health priority.”

Finally, Hemming said PCPs “have a lot of things at our disposal to help us” treat the challenging condition. He referenced the ACP’s living guideline for major depressive disorder treatment, which recommends cognitive behavioral therapy (CBT) or second-generation antidepressants as an initial treatment for patients in the acute phase of moderate to severe major depressive disorder.

“Patients may have more difficulty accessing CBT than using antidepressants,” he said. “So it's important to individualize approaches and increase options for treatments.”

Ultimately, Hemming said the PCP has a “responsibility here,” which is “to heal and to relieve the stress and in an important way for our patients.”

“We do that through our screening, we do that through our work on diagnostic accuracy, do it through the therapeutics we offer to our patients, the counseling that we help them find,” he said. “This is one of the best ways we have to build our understanding of patients and deliver some of the most personal and meaningful care that we might provide and provide some really important improvements in quality of life.”

References:

• Hemming P. Depression and anxiety treatment by the internal medicine physician. Presented at: ACP Internal Medicine Meeting; April 18-20, 2024; Boston.
• Qaseem A, et al. Ann Intern Med. 2023;doi:10.7326/M22-2056.
• Rotenstein LS, et al. Health Aff. 2023;doi:10.1377/hlthaff.2022.00705.