Americans Getting More Comfortable Talking Over Mental Health With Doctors
Primary care doctors are no longer just in the physical health business: Americans are increasingly turning to them for mental health care, too, a new study finds.
Looking at Americans' primary care visits between 2006 and 2018, researchers found a 50% increase in the proportion of visits that addressed mental health concerns. That figure rose from just under 11% of visits, to 16% by the end of the study period.
The reasons are unclear, experts said, but it's not just a matter of mental health conditions becoming more common: During the same period, other studies show, the national rate of mental health disorders rose by about 18%.
Instead, it seems primary care doctors are shouldering more responsibility for diagnosing and in some cases treating, mental health conditions.
"I think this study really underscores the importance of primary care in our country," said lead researcher Dr. Lisa Rotenstein, medical director of population health at Brigham and Women's Hospital in Boston.
That also means primary care doctors need the resources to make sure patients diagnosed with mental health conditions get the best treatment, she said.
The findings -- published in the February issue of the journal Health Affairs -- are based on an ongoing government survey that collects information on Americans' office-based medical care.
Rotenstein's team analyzed records from nearly 110,000 primary care visits, representing roughly 3.9 million appointments nationwide. A visit was considered to have "addressed a mental health concern" if the record listed that as the reason for the appointment, or the doctor diagnosed a mental health condition at that time.
Overall, the proportion of visits falling into that category rose by nearly 50% between 2006 and 2018.
The study cannot pinpoint the reasons -- whether it's doctors doing more mental health screenings, or patients more often bringing up mental health symptoms, for example.
But it's probably a combination of those and other factors, Rotenstein said.
Dr. Robert Trestman, chair of the American Psychiatric Association's Council on Healthcare Systems and Financing, agreed.
He noted that the Affordable Care Act -- better known as "Obamacare" -- was passed during the study period, which reduced the ranks of the uninsured nationwide.
At the same time, the stigma around mental health loosened.
"People are more comfortable talking about mental health and addiction," said Trestman, who was not involved in the study. "It's a very big deal that the stigma is being reduced."
But, both experts said, systems need to be in place to support primary care doctors in addressing mental health -- and getting patients the treatment they need.
That includes adequate insurance reimbursement. It also means primary care providers need to be able to refer patients to a mental health specialist when necessary, to make sure they get the best care.
Routine depression screening, for example, is recommended for adults and teenagers.
"But we need the capacity to treat them," Trestman said, "and right now we don't have it."
He said it's important for primary care doctors to "proactively build relationships" with mental health professionals in their community, to make it easier to refer patients when needed.
But, Trestman and Rotenstein both said, that's also a big challenge in the many areas of the country with a dearth of mental health care providers.
"Telehealth" services that connect patients and providers over distances can help to an extent, Trestman said. But that does not address the shortage of mental health specialists.
And then there are the racial and ethnic disparities. Rotenstein's team found that, in comparison to their white counterparts, Black and Hispanic Americans were 40% less likely to have a mental health concern addressed during a primary care visit.
Rotenstein said future studies need to dig into the reasons -- including whether doctors are less likely to screen patients of color, or whether differences in insurance coverage are a barrier.
Trestman said doctors' unconscious biases and communication barriers could be playing a role. So one solution could be to not only grow the health care workforce, but make sure it includes more providers of color.
As for the message for patients, Rotenstein pointed to another study finding: Mental health concerns were more likely to be addressed when patients visited their established primary care doctor -- someone who knows them, in other words.
At a time when many Americans are using walk-in clinics for as-needed health care, that's important, according to Rotenstein. It points to one of the benefits of having a regular provider you know, she said.
The National Alliance on Mental Illness has an overview of common mental health conditions.
SOURCES: Lisa Rotenstein, MD, MBA, medical director, Population Health, Brigham and Women's Hospital Primary Care Center of Excellence, Boston; Robert Trestman, MD, PhD, chair, Council on Healthcare Systems and Financing, American Psychiatric Association, Washington, D.C.; Health Affairs, February 2023