Mental Health Care Services by Family Physicians (Position Paper)
While psychiatric professionals are an essential element of the total health care continuum, the majority of patients with mental health issues will continue to access the health care system through primary care physicians. The desire of patients to receive treatment from their primary care physicians, or at least to have their primary care physicians more involved in their care, has been repeatedly documented. Improving mental health treatment requires enhancing the ability of the primary care physician to screen, treat and appropriately manage the psychiatric care given to patients. To achieve those goals, the AAFP advocates the following principles:
- The AAFP, working through the accredited residency programs, will continue to emphasize the importance of mental health care through clinical rotations in both inpatient and outpatient centers of psychiatric care and continued exposure to psychiatric diagnosis and management through the resident continuity clinic.
- The AAFP will continue to advocate for the maintenance and expansion of state, federal and private insurance funding for mental health care. This funding should include adequate funding for inmate mental health care as well as funding for the growing number of military veterans and their dependents requiring mental health services.
- The AAFP will continue to advocate for parity in payment to primary care physicians for the mental health care of our patients;
- The AAFP will advocate for the reduction of mental health care “carve outs,” recognizing that through the Patient Centered Medical Home and other models of care, primary care physicians are increasingly locating psychologists, psychiatric social workers and even psychiatrists in the primary care physician office to provide better access to psychiatric services to their patients. The AAFP will further advocate for payment mechanisms that allow adequate funding of mental health care provided in such collocated practices in order to assure its continued availability in the primary care physician office.
- The AAFP supports the development of new treatment strategies to improve the percentages of patients receiving adequate treatment and follow-up through both primary care and mental health specialty care providers.
Mental health services are an essential element of the health care services continuum. Promotion of mental health and the diagnosis and treatment of mental illness in the individual and family context are integral components of family medicine.1,2
Through residency training and continuing medical education, family physicians are prepared to manage mental health problems in children, adolescents, and adults. The continuity of care inherent in family medicine makes early recognition of problems possible. Because family physicians treat the whole family, they are often better able to recognize problems and provide interventions in the family system. Family physicians are also able to treat individuals who would not access traditional mental health services because of the social stigma associated with mental illness.
Mental health issues are frequently unrecognized and even when diagnosed are often not treated adequately.3-9 Recognition and treatment of mental illness are significant issues for primary care physicians, who provide the majority of mental health care.10,11 In a recent national survey of mental health care, 18% of the surveyed population with and without a DSM-IV diagnosis of a mental health disorder sought treatment during a 12 month period, with 52% of those visits occurring in the general medical (all primary care) sector.38 Estimates are that 11% to 36% of primary care patients have a psychiatric disorder, 8,9, 13-17 with one recent survey of mental health conditions in urban family medicine practices revealing that over 40% of survey respondents met criteria for a mental health disorder.42
Traditionally, managed care organizations have "carved out" mental health services from primary care and placed put them in the hands of separate mental health management organizations. These self-contained behavioral health companies usually contract only with psychiatrists and nonphysician mental health care providers. Managed care companies that use "carve-outs" exclude coverage for mental health treatment provided by the patients' personal physicians, often family physicians. The resulting fragmentation of services disrupts continuity of care and compromises the family physician's role as a cost-effective coordinator of the patient's health services—a disruption that is particularly unfortunate in the setting of the Patient Centered Medical Home. Because of comorbidities and the effect of mental health problems in generating or exacerbating physical symptoms, fragmentation of mental health treatment is particularly detrimental to patients' overall health.
Although primary care physicians are major providers of psychiatric care, they are discriminated against by payment mechanisms that create a disincentive to thorough and comprehensive mental health screening. The issue of appropriate payment is critical when national surveys reveal that the majority of both diagnosed and undiagnosed patients of a mental health disorder sought their care from general medical providers, with this trend greatest for those in traditionally underserved groups such as the elderly, various minorities, the poor and uninsured and those in rural areas.38 Denying or discounting payment to family physicians and other primary care physicians is, in fact, denying access to care for a significant percentage of patients.
More and more often, the poor and disadvantaged have limited access to traditional secondary sources of mental health care, with a resulting increase in demand for those services from primary care practices, hospitals and other institutions, which are sometimes inadequately prepared to provide that care. The reasons for that decline in mental health services are numerous, including but not limited to a decrease in state and federal funding for those services. The net effect has been a reduction in the resources available to provide mental health care to those in greatest need of it.
Psychiatric problems are a major health issue. In the United States, neuropsychiatric disorders have now surpassed other disorders such as cardiovascular diseases and malignant neoplasms as the number one cause of disability as expressed as disability-adjusted life years.19 According to the most recent data available, mental health expenditures in the United States, expressed as a percentage of total health care expenditures, were more than 6%. For the year, that amounted to a cost approaching $100 billion.20 Analysis of the sources of payment for those expenditures for the same year revealed that 10% of Medicaid funding and more than 20% of state and local funding was spent on mental health care. Suicide remains a significant cause of death and lost productive lives, with the most recent U.S. data (from 2007) showing that almost 35,000 people died that year from all forms of suicide.21
Among adults, depression ranks as a significant cause of disease and disability, with a lifetime prevalence of over 16%21 and a 12 month prevalence at any time of 6% to 7%.22 When analyzed by sex, the 12 month prevalence of depression averages about 8% to 9% for women and 4% to 5% for men.20 Lifetime prevalence of depression is 70% greater for women than men.21 When depression is broken down into various degrees of severity, more than 30% of U.S. adult cases identified in 2007 are listed as being in a “severe” category.21 Approximately 52% of those adults received some form of treatment, with 38% receiving what was considered adequate treatment.22
Similarly, anxiety disorder represents a significant cause of disease and disability among adults, with a 12 month prevalence of 18% in 2004. Twenty three percent of those affected patients were classified as having “severe” disorder.12
Approximately 37% of adults with anxiety disorder receive treatment in any 12 month period, with only 34% of those patients receiving adequate treatment.12
Depressive disorders of all types are found to have a lifetime prevalence of 11% of 13- to 18-year-olds, with 3% of those affected having “severe” disorder.23 The prevalence of depressive disorders at any one time is thought to be approximately 8%.23 As in adults, the prevalence of depression in girls age 13 to 17 is nearly 3 times as great as that in boys for the same age group.23 Anxiety disorders of all types occur with a lifetime prevalence of 25% of 13- to 18-year-olds, with approximately 5% to 6% of those affected classified as having “severe” disorder.23 Again, statistics for anxiety disorder in this age category show a significant female predominance.23
Two subgroup of adults have a higher-than-average prevalence of mental health disorder and deserve special mention. A higher-than-average number of U.S. military veterans of Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom (Iraq) reported mental health problems, (11.3% and 19.1% respectively) compared with the entire population of post-deployment U.S. military veterans in the survey period.24 Thirty-five percent of Iraq veterans were reported to have accessed mental health services during the year after returning home.25 The suicide rate in this population was not appreciably higher than in the general population of post-deployment veterans, although certain subgroups (those veterans with selected mental health diagnoses) were observed to have a higher than normal rate.25 The other subgroup of U.S. adults with higher than average occurrence of mental health disorder is the U.S. inmate population. In data from surveys of inmates in state, federal and local jails, the 12 month occurrence of all mental health disorders was found to be 56%, 45% and 64% respectively.26,27 Fewer than 50% of the affected inmates ever received any treatment for their disorder.26,27
Information about mental health care delivered in physicians' offices is available through the National Ambulatory Medical Care Survey (NAMCS), conducted by the Centers for Disease Control and Prevention (CDC). According to 2008 data, the most recent available, an estimated 956 million visits were made to physician offices, of which 39,831,000, or 4%, were for psychiatric diagnoses.28 Based on an assumed need of 10%, there should have been almost 96 million psychiatric visits. The Surgeon General estimates that less than one third of adults with a diagnosable mental disorder receive treatment in one year. The National Mental Health Association (NMHA) states that only 49% of patients with clinical depression and 52% of patients with generalized anxiety disorder are receiving treatment.29
When considering the costs associated with mental illness, it is important to keep in mind that mental health problems have a significant impact on physical health. Research found that among elderly patients with high mean depressive scores, the risk of coronary heart disease increased 40% while the risk of death increased 60% compared with elderly patients with the lowest mean depressive scores.30 The risk of disability in persons with major depression is 4 1/2 times the risk in asymptomatic persons.4 The risk is 1 1/2 times greater in persons with minor symptoms of depression, although because of its greater prevalence minor depression resulted in 50% more days of disability. Patients with mental disorders have higher utilization rates for general medical services and higher related medical costs than patients without mental disorders.6
In many respects family medicine represents the unification of the psychiatric and physical models of illness. Family medicine residency training includes clinical psychiatric rotations of one or more months in addition to mental health encounters generated by the continuity clinics. The Academy's recommended curriculum for human behavior and mental health was developed in cooperation with the American Psychological Association. An element of that curriculum is “that the family medicine resident should have sensitivity to, and knowledge of, the emotional aspects of organic illness. Family physicians must be able to recognize interrelationships among biologic, psychologic and social factors in all patients.” In a survey of directors of primary care training programs (family medicine, internal medicine, pediatrics, OB/GYN), only family medicine directors felt that their programs were “optimal to extensive” in terms of adequacy of psychiatric training.31
Family physicians typically manage multiple symptoms and problems.3 A visit to a psychiatric professional typically lasts at least 30 minutes and is focused on a clearly defined issue.5 In contrast, primary care visits last an average of 13 minutes and include an average of six patient problems.4,5,11,32,33 Detecting and managing mental health problems must compete with other priorities such as treating an acute physical illness, monitoring chronic illness, providing preventive health services, and assessing compliance to standards of care.5,34
Another important distinction between psychiatric practices and family medicine practices is that while patients who present for psychiatric treatment usually have severe symptoms that leave little doubt about the diagnosis, patients in the family physician's office typically present with vague somatic complaints such as “fatigue,” “feeling nervous,” etc., without an established psychiatric diagnosis. Unlike the psychiatric professional whose patients accept the diagnosis and the need for treatment, the family physician has to identify mental health problems that are frequently obscured by patient reluctance to acknowledge the problem or by physical symptoms that mask the underlying problem.
The general reluctance of patients to seek care for mental health problems complicates the diagnosis of mental illness. Survey results show that 40% of patients with major depression do not want or perceive the need for treatment.11,32 Patients consistently underreport emotional issues to their physicians. One study found that only 20% to 30% of patients with emotional/psychologic issues reported these to their primary care physicians.4 Many patients somatize their psychologic issues. One in three patients who go to the emergency department with acute chest pain is suffering from either panic disorder or depression.13 Eighty percent of patients with depression present initially with physical symptoms such as pain or fatigue or worsening symptoms of a chronic medical illness.35 Although this type of presentation creates a challenge for family physicians, these patients are not likely to seek care through the mental health system.
The major cause of mortality from mental illness is suicide, which may occur before a patient seeks care for a mental health related symptom. More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, influenza, and chronic lung disease combined.36 For adults ages 18 to 65, suicide ranked number 4 of the top 10 causes of death from the most recent death certificate data available (2007).24 Screening for suicide risk and access to lethal means, even in apparently asymptomatic patients, is a critically important part of the family physician's role in reducing mortality and morbidity from mental illness.36
There is no evidence, however, that an improved level of diagnosis without a concomitant improvement in therapy is beneficial.9 Enhanced diagnostic accuracy must be connected to structured programs that provide effective treatment.35 Research indicates that improving the treatment of mental health issues in primary care requires properly organized treatment programs, regular patient follow-up, monitoring of treatment adherence, and the use of mental health specialists for the more severely ill.4
In one survey, 87.5% of family physicians indicated that it was their responsibility to treat depression, compared with 73% of general internists and 41% of obstetricians/gynecologists surveyed. Among family physicians, 35% were very confident and 48% were mostly confident about their overall ability to manage depression.33 However, although primary care physicians prescribe 41% of antidepressants, the requisite follow-up visits do not always occur per guidelines, with national survey data revealing a median number of visits for general medical providers of 1.7 versus 7.4 for mental health specialty providers for those patients receiving treatment during the 12 month survey period.12,37,38 Studies demonstrate that patients treated with antidepressant medication have a visit frequency far below that recommended in the guidelines issued by the Agency for Healthcare Research and Quality.35
Evidence indicates that optimal treatment of depression includes interpersonal psychotherapy.4 Family physicians routinely provide encouragement and supportive therapy to their patients, and some provide more formal psychotherapy. However, not every physician needs to be proficient in the provision of psychotherapy. Referral to psychiatric nurses, counselors, psychologists, or psychiatrists either attached to the practice or in other organizations is also appropriate. Whatever the mechanism, however, every physician has an obligation to ensure that patients are made aware of psychotherapy as an option and assisted in accessing it.
Family physicians recognize the importance of understanding the patient's values when providing mental health care. By incorporating an assessment of those values into the overall diagnosis and treatment plan, family physicians are able to improve patient acceptance of a diagnosis of a mental health disorder and improve compliance to a treatment plan tailored to the patient’s understanding of that diagnosis.
Payment for office visits with a mental health diagnosis code has traditionally been discounted by Medicare for primary care. Many managed care plans do not pay family physicians for the provision of psychiatric care, even though family physicians are frequently in the position to diagnose and provide the care. While lack of payment is not the only reason for the documented failures in mental illness detection, the absence of payment has an impact on the lack of screening in primary care practices. This policy is also contradictory to the public's stated preference for care. A survey conducted for the NMHA indicated that 72% of diagnosed patients and 61% of symptomatic but undiagnosed people want greater involvement of their primary care physician in their treatment.29 This not only reflects the level of rapport between patients and family physicians, but it is also indicative of the level of apprehension caused by the potential stigma attached to mental illness and to accessing the formal mental health system.
Because of patient desires to avoid the stigma of mental illness or because of payment issues, many family physicians have reported or coded the symptoms of mental illness rather than documenting the actual diagnosis.39 Failure to diagnose properly, whether a function of uncertainty or sensitivity to patient concerns or insurance coverage, has been estimated to range from 45% to 90%.4,15 It does appear, however, that family physicians address mental health problems more frequently than it appears from either billing or medical records.
Prevailing payment structures are not only an impediment to the family physician's ability to maintain continuity of care but can result in greater overall health care costs. Recognition and management of mental health problems reduce the inappropriate use of medical and surgical care, thus reducing health care costs.6
This is an issue of particular significance for employers who require optimal employee productivity. According to the Kaiser Family Foundation Employer Health Benefits 2000 Survey, over the past several years there has been an appreciable decline in the level of mental health coverage provided by employers.40 Sharp decreases have occurred in the percentage of workers with unlimited outpatient mental health visits, and most plans also limit the number of inpatient mental health days.40 These payment limitations have an effect on the patient's ability to access mental health care. The American Academy of Family Physicians supports parity of health insurance coverage for patients, regardless of medical or mental health diagnosis. Health care plans should cover mental health care under the same terms and conditions as those governing coverage of other medical care.41
While psychiatric professionals are an essential element of the total health care continuum, the majority of patients with mental health issues will continue to access the health care system through primary care physicians. The desire of patients to receive treatment from their primary care physicians, or at least to have their primary care physicians more involved in their care has been repeatedly documented. Improving mental health treatment requires enhancing the ability of the primary care physician to treat and be appropriately paid for that care. Payment mechanisms should recognize the importance of the primary care physician in the treatment of mental illness as well as the significant issues of comorbidity that require nonpsychiatric care.
- American Academy of Family Physicians. Family physician, scope, philosophical statement." AAFP Reference Manual. Leawood, KS: AAFP, 1999.
- American Academy of Family Physicians. Mental Health, physician responsibility." AAFP Reference Manual. Leawood, KS: AAFP, 1999.
- Callahan EJ, Jaén CR, Crabtree BF, Zyzanski SJ, Goodwin MA, Stange KC. The impact of recent emotional distress and diagnosis of depression or anxiety on the physician-patient encounter in family practice. J Fam Pract. 1998;46(5):410-418.
- Eisenberg L. Treating depression and anxiety in primary care. Closing the gap between knowledge and practice. N Engl J Med. 1992;326(16):1080-1084.
- Klinkman MS. Competing demands in psychosocial care. A model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry. 1997;19(2):98-111.
- Saravay SM, Cole SA. Mental disorders in the primary care sector: a potential role for managed care. Am J Manag Care. 1998;4(9):1319-1322, quiz 1323-1324.
- Schulberg HC, Katon W, Simon GE, Rush AJ. Treating major depression in primary care practice: an update of the Agency for Health Care Policy and Research Practice Guidelines. Arch Gen Psychiatry. 1998;55(12):1121-1127.
- Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med. 1995;4(2):99-105.
- Tiemens BG, Ormel J, Simon GE. Occurrence, recognition, and outcome of psychological disorders in primary care. Am J Psychiatry. 1996;153(5):636-644.
- Gallo JJ, Coyne JC. The challenge of depression in late life: bridging science and service in primary care. JAMA. 2000;284(12):1570-1572.
- Williams JW Jr. Competing demands: Does care for depression fit in primary care? J Gen Intern Med. 1998;13(2):137-139.
- Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):629-640.
- American Psychiatric Association. Collaboration between psychiatrists, primary docs vital to ensuring more people get MH care. Psychiatr News. 1998;(November):20.
- American Psychiatric Association. Primary care residents need better training in psychiatry, says Wiener. Psychiatr News. 1997;(December):5.
- Carlat DJ. The psychiatric review of symptoms: a screening tool for family physicians. Am Fam Physician. 1998;58(7):1617-1624.
- Klinkman MS, Coyne JC, Gallo S, Schwenk TL. False positives, false negatives, and the validity of the diagnosis of major depression in primary care. Arch Fam Med. 1998;7(5):451-461.
- Schwenk TL. Screening for depression in primary care. JAMA. 2000;284(11):1379-1380.
- Fogarty, CT., Sharma, S., Chetty, V., Culpepper, L. “Mental health conditions are associated with increased health care utilization among urban family medicine patients” JABFM. 2008; Sept-Oct;21(5):398-407.
- 2008 statistical data from World Health Organization, Global Health Observatory database, Avenue Appia 20, 1211 Geneva 27, Switzerland.
- 2008 statistical data from Substance Abuse and Mental Health Services Administration’s “National Expenditures for Mental Health Services and Substance Abuse Treatment Report”.
- Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602.
- Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-627.
- Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication—Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49(10):980-989.
- Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006;295(9):1023-1032.
- Kang HK, Bullman TA. Risk of suicide among US veterans after returning from the Iraq or Afghanistan war zones. JAMA. 2008;300(6):652-653.
- Data from the “Survey of Inmates in State and Federal Correctional Facilities” (2004), Department of Justice, 950 Pennsylvania Avenue, NW, Washington, DC. 20530-0001.
- Data from the “Survey of Inmates in Local Jails” (2002), Department of Justice, 950 Pennsylvania Avenue, NW, Washington, DC 20530-0001.
- Data from the National Vital Statistics System, Center for Disease Control, 4770 Buford Hwy, NE MS K-51, Atlanta, Ga. 30341-3717.
- National Mental Health Association. America's mental health survey, May 2000. Conducted by Roper Starch Worldwide, Inc. www.roper.com/Newsroom/content/news189.htm.
- Ariyo AA, Haan M, Tangen CM, et al.; Cardiovascular Health Study Collaborative Research Group. Depressive symptoms and risks of coronary heart disease and mortality in elderly Americans. Circulation. 2000;102(15):1773-1779.
- Leigh, H., Mallios, R., Stewart, D. “Teaching psychiatry in primary care residencies: do training directors of primary care and psychiatry see eye to eye? Acad Psychiatry 2008; Nov;32:504-509.
- Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283(2):212-220.
- Williams JW Jr, Rost K, Dietrich AJ, Ciotti MC, Zyzanski SJ, Cornell J. Primary care physicians’ approach to depressive disorders. Effects of physician specialty and practice structure. Arch Fam Med. 1999;8(1):58-67.
- Rost K, Nutting P, Smith J, Coyne JC, Cooper-Patrick L, Rubenstein L. The role of competing demands in the treatment provided primary care patients with major depression. Arch Fam Med. 2000;9(2):150-154.
- Katon W, Von Korff M, Lin E, et al. Population-based care of depression: effective disease management strategies to decrease prevalence. Gen Hosp Psychiatry. 1997;19(3):169-178.
- McCanse C. Surgeon general announces national strategy. FPReport. 2001;7(6):1-2.
- American Psychiatric Association. Prescriptions for antidepressants, stimulants increase dramatically. Psychiatr News. 1998;(March):17.
- Pincus HA, Tanielian TL, Marcus SC, et al. Prescribing trends in psychotropic medications: primary care, psychiatry, and other medical specialties. JAMA. 1998;279(7):526-531.
- Rost K, Smith R, Matthews DB, Guise B. The deliberate misdiagnosis of major depression in primary care. Arch Fam Med. 1994;3(4):333-337.
- The Kaiser Family Foundation and Health Research and Education Trust. Employer Health Benefits 2000 Annual Survey. Mento Park, CA: Henry J. Kaiser Family Foundation, 2000.
- American Academy of Family Physicians. "Mental health, parity in mental health coverage for patients." AAFP Reference Manual. Leawood, KS: AAFP,1999.
- National Ambulatory Medical Survey 2008 Survey Tables; Center for Disease Control, Mental Health Work Group, 4770 Buford Hwy, NE MS K-51, Atlanta, Ga. 30341-3717.
(2001) (2011 COD)