Mental Health Care Services by Family Physicians (Position Paper)

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 also 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 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 Among diagnosed patients, 42 percent with clinical depression and 47 percent with generalized anxiety disorder (GAD) were first diagnosed by a primary care physician.¹² Estimates are that 11 percent to 36 percent of primary care patients have a psychiatric disorder, and research indicates that only one-half of those patients are diagnosed.^8,9,13-17

With increasing frequency, managed care organizations "carve out" mental health services from primary care and 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. 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 reimbursement mechanisms that create a disincentive to thorough and comprehensive mental health screening. The issue of appropriate reimbursement is critical when 32 percent of undiagnosed, asymptomatic adults indicate that they will first turn to their primary care physician for help with a mental health issue.¹² Only 4 percent would approach a psychiatric professional.¹² Denying or discounting reimbursement to family physicians and other primary care physicians is, in fact, denying access to care for a significant percentage of patients.

Among many Americans there is still a pervasive reluctance to seek care for mental health problems, just as there is still a public refusal to acknowledge the clinical basis of these problems and an archaic inclination to ascribe mental health problems to a "moral deficiency." The recent Surgeon General's report has even documented an increased tendency to associate mental health problems with the potential for violence, even though there is no evidence to support this association.¹⁸

Psychiatric problems are a major health issue. Globally, major depression ranks fourth in terms of disability-adjusted life years and may soon be the second leading cause of disability worldwide.^10,11,19 According to the Surgeon General, mental disorders collectively account for more than 15 percent of the overall burden of disease from all causes and slightly more than the burden associated with all forms of cancer.¹⁸ It is estimated that major depression in the United States is associated with 20,000 suicides and $47 billion in health care costs annually.¹⁹ Depression produces as much suffering and disability as does heart disease or diabetes.

There are numerous estimates concerning the incidence and prevalence of mental health disorders. The Surgeon General estimates that approximately 15 percent of the U.S. adult population use mental health services in any given year. It is estimated that 6 percent to 10 percent of patients in primary practice have major depression.^7,20 In other studies the frequency of mental disorders in general practice varies from 11 percent to 36 percent.¹³ The National Institute for Mental Health (NIMH) estimates that 12 percent of women and 7 percent of men are affected by a depressive illness each year.²⁰ The prevalence of major depressive disorder (MDD) in the primary care setting has been estimated at between 4.8 percent and 8.6 percent.⁵ Lifetime risk of major depression in women is 20 percent to 25 percent and 7 percent to 12 percent in men.⁵

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). During 1998 an estimated 829.3 million visits were made to physician offices, of which 24,496,000 were for psychiatric diagnoses.²¹ Psychiatric visits represented 3 percent of the total physician office visits.²¹ Based on an assumed need of 10 percent, there should have been almost 83 million psychiatric visits. The Surgeon General estimates that less than one-third of adults with a diagnosable mental disorder receives treatment in one year. The National Mental Health Association (NMHA) states that only 49 percent of patients with clinical depression and 52 percent of patients with GAD are receiving treatment.¹²

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 indicates that among elderly patients with high mean depressive scores, the risk of coronary heart disease increased 40 percent while the risk of death increased 60 percent compared with elderly patients with the lowest mean depressive scores.²² 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 percent more days of disability. In a comparison of patients with depressive disorders and patients with eight chronic medical disorders, only patients with chronic heart disease experienced more disability.⁴ Patients with mental disorders have higher utilization rates for general medical services and higher related medical costs compared with patients without mental disorders.⁶

In many respects family medicine represents the unification of the psychiatric and physical models of illness. Data published by the American Psychiatric Association on primary care training demonstrates that family medicine programs provide the most extensive psychiatric training.¹⁴ This includes clinical 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."

Multiple symptoms and problems are managed by family physicians.³ A visit to a psychiatric professional typically lasts at least 30 minutes and is focused on one clearly defined issue.⁵ In contrast, primary care visits last an average of 13 minutes and include an average of six patient problems.^4,5,11,19,20 Detecting and managing mental health problems compete with other priorities such as treating an acute physical illness, monitoring chronic illness, and providing preventive health services.^5,23

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 subthreshold or subsyndromal conditions. Unlike the psychiatric professional who sees patients who 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 percent of patients with major depression do not want or perceive the need for treatment.^19,11 Patients consistently underreport emotional issues to their physicians. One study demonstrated that only 20 percent to 30 percent 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.²⁴ 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.²⁵ 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.²⁵

There is no evidence, however, that an improved level of diagnosis without a concomitant improvement in therapy is beneficial.⁹ One study estimates that less than 10 percent of patients diagnosed with major depression receive demonstrably beneficial therapy. Enhanced diagnostic accuracy must be connected to structured programs that provide effective treatment.²⁴ 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 percent of family physicians indicated that it was their responsibility to treat depression, compared with 73 percent of general internists and 41 percent of obstetricians/gynecologists surveyed. Among family physicians, 35 percent were very confident and 48 percent were mostly confident about their overall ability to manage depression.²⁰ However, although primary care physicians prescribe 41 percent of antidepressants, the requisite follow-up visits are not always scheduled.^26,27 Studies demonstrate that patients treated with antidepressant medication have a visit frequency far below that recommended in the guidelines issued by the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality).²⁴

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. Convincing evidence in the medical literature supports the beneficial role of spirituality in the health of patients. A spiritual assessment performed during a medical or mental health encounter is a practical way to begin incorporating spirituality into primary care practice.²⁸ Unlike most other aspects of the medical history, simply taking a spiritual history is often sufficient and further intervention is not required.²⁹ An increasing number of family physicians are prepared to offer supportive counseling or referral for spiritual issues.³⁰

Reimbursement for office visits with a mental health diagnosis code is deeply discounted for Medicare patients. Many managed care plans do not reimburse 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 reimbursement is not the only reason for the documented failures in mental illness detection, the absence of reimbursement 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 percent of diagnosed patients and 61 percent of symptomatic but undiagnosed people want greater involvement by their primary care physician in their treatment.¹² 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 reimbursement issues, some family physicians have reported or coded the symptoms of mental illness rather than documenting the actual diagnosis.³¹ Failure to diagnose properly, whether a function of uncertainty or sensitivity to patient concerns or insurance coverage, has been estimated to range from 45 percent to 90 percent.^4,15 It does appear, however, that mental health problems are addressed more frequently than it appears from either billing or medical records.

Prevailing reimbursement structures are not only an impediment to the family physician's ability to maintain continuity of care, but they 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.³² 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.³² 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 that provided for other medical care.³³

The issue of comorbidity is ignored by many reimbursement mechanisms. Comorbidities involving mental illness imply the management of multiple problems, one of which may be causing, exacerbating, or may be independent of physical symptoms. In this situation, the family physician's position is compromised since carve-outs will necessitate an artificial separation of the issues and will result in fragmented care. The current system of carve-outs produces financial disincentives for integrated care since treatment of the two components is divided. Depending on how the risk is assigned, reimbursement mechanisms such as capitation may discourage referral, encourage retention, and create an excessive reliance on medication for treatment.

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 reimbursed for that care. Reimbursement 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.

(2001)