Family physicians provide much of the frontline mental health care in the United States, and mental health diagnoses now account for approximately 16% of all primary care visits.1 Family physicians are increasingly tasked with identifying, diagnosing, and managing psychiatric symptoms in an environment where time constraints, multimorbidity, and limited access to specialty care shape clinical decision-making.
Although recognition of mental illness has clear benefits, concern is growing about overdiagnosis—assigning psychiatric diagnoses that may not represent disorders causing persistent functional impairment or giving a diagnosis for symptoms that would resolve without diagnosis-specific treatment. For more than a decade, American Family Physician has shed light on the harms of overdiagnosis and overtreatment, with recent emphasis on common mental health symptoms such as depression and anxiety.2–4
With mental health, overdiagnosis carries unique risks. Diagnostic labels influence the patient's concept of self, expectations of chronic illness, medication exposure, and long-term health care use.5 Longitudinal studies suggest that many subthreshold depressive and anxiety symptoms remit over time, particularly when contextual factors improve.6 Premature diagnostic labeling may medicalize normal emotional responses and expose patients to unnecessary treatment, particularly pharmacotherapy. Family physicians, who often establish diagnoses early and maintain long-term relationships with patients, are uniquely positioned to mitigate these risks.
In a nationally representative sample of 896 primary care physicians and 312 psychiatrists, 67% of the former and 62% of the latter agreed that physicians overtreat normal sadness, stress, and worry.7 It has long been recognized that subthreshold psychiatric symptoms, such as grief, developmental variations in attention and social behavior, or stress-mediated worry or sadness, are more prevalent than those meeting complete criteria for a diagnosis.8
Clinicians should pay attention to drivers of mental health overdiagnosis in primary care. These include subthreshold diagnoses (eg, conflation of depression as a symptom, which merits only supportive therapy, with the diagnosis of major depressive disorder); misuse of screening tools as diagnostic instruments (eg, treating Patient Health Questionnaire or Generalized Anxiety Disorder-7 cutoff scores as diagnostic rather than supporting further evaluation); and system-level incentives that favor diagnostic labeling to optimize coding and address quality measures. For example, in an effort to use precise billing codes, there is a tendency to diagnose specific conditions instead of describing psychosocial symptoms. The approach to mental health symptoms is different than other subthreshold diagnoses. Although clinicians may code chest pain as unspecified chest pain (R07.9), they would not start chronic treatment until the diagnosis was clarified. This is not true for depression, for which selective serotonin reuptake inhibitors are often initiated before diagnostic clarification.9–11
In the primary care setting, where patients present with undifferentiated symptoms and complex social and physical realities, it is critical to establish persistent, functional impairment for diagnosis.12 Indeed, the Future Diagnostic and Statistical Manual of Mental Disorders Strategic Committee has emphasized function as an essential element of complete psychiatric diagnosis.13
Evidence-based care does not necessitate applying an immediate diagnosis, however. Stepped-care trials show that watchful waiting with support is noninferior to antidepressants for mild and subthreshold depressive symptoms and may reduce unnecessary use of medication.14 Practical, transdiagnostic strategies (ie, addressing symptoms common to multiple mental health conditions rather than diagnosing and treating one disease) exist to help family physicians validate patient distress in the setting of subthreshold psychiatric symptoms.15,16
Acceptance and commitment therapy is a brief cognitive behavior therapy and model of human functioning that differs from other methods because the primary focus is to improve patients' psychological flexibility (ie, the ability to remain present despite distress) instead of symptom elimination.17 Acceptance and commitment therapy has demonstrated effectiveness across various conditions in the primary care setting, including anxiety and depression, and can be delivered by clinicians who are not psychotherapists.17,18 Family physicians can apply principles informed by acceptance and commitment therapy during a routine appointment to approach patients with subthreshold psychiatric symptoms.
The acceptance and commitment therapy framework argues that the core of human suffering is psychological inflexibility and that suffering can be mitigated through evidence-based mindfulness practices and values-driven behavior change 19 (Table 1).
TABLE 1. Acceptance and Commitment Therapy for Primary Care
| Component | Description | Example language |
|---|---|---|
| Values clarification | Identify what matters most to the patient | What matters most to you right now in your life? |
| Cognitive defusion | Create distance from distressing thoughts | Can we notice that thought rather than treat it as a fact? |
| Acceptance | Normalize distress as part of the human experience | These feelings are difficult, but they are understandable given what you're facing. |
| Committed action | Encourage small, values-based steps | What is one small step you could take this week toward that? |
| Awareness of present moment | Increase attention to current experience | What are you noticing right now as we talk about this? |
Continuity of care allows the evolution of symptoms to be seen in context and improves diagnostic accuracy. Scheduling follow-up as part of the treatment plan reframes time as an intervention. Longitudinal relationships are among family medicine's most effective tools for balancing access to interventions with diagnostic restraint.
Understandably, patients can experience distress when symptoms are not given a formal label or are not the primary focus of treatment. Clear communication can validate these symptoms and reframe the conversation to promote values-congruent committed action despite a patient's distress. For example, a clinician might reflect, “I hear that you are feeling anxious, and it has been hard to focus. If these feelings weren't in the way, what would you be doing differently in your life with your work, hobbies, relationships, and health?” This way, the physician is focused on what matters most to the patient and helps identify a preferred life direction.
After clarification of values, the clinician can shift the conversation to promote practical behavior change. An example might sound like “You mentioned you felt disconnected from your children. What's one thing you could do this week that would move you toward connecting with them? Not to feel better, but because it matters deeply to you.” A values-guided approach aims to respect the whole of the human experience without pathologizing symptoms. By emphasizing that the focus is values-guided behavior and not symptom elimination, the physician acknowledges that discomfort may persist in the pursuit of behavior change. The goal is to help patients align their behavior with deeply held values and not to withhold other forms of treatment for patients who need it. If symptoms and functional impairment worsen, medication or other intervention may be necessary. Table 2 illustrates two approaches to treating an example patient and what the outcomes might be.
TABLE 2. Examples of Mental Health Treatment in Primary Care
| A 52-year-old man presents 2 weeks after the sudden death of his son. He has insomnia, low mood, and poor concentration (Patient Health Questionnaire-9 score = 12). Two different approaches to this scenario could be used, each yielding a different outcome. They are discussed below. |
| Diagnostic labeling |
| He is diagnosed with major depressive disorder and prescribed a low-dose selective serotonin reuptake inhibitor, with follow-up recommended. |
| After 2 weeks, he stops the medication due to lack of perceived benefit and does not return to his primary care physician. He assumes his situation is hopeless. Over the next few months, his symptoms gradually improve, but he can't help but feel flawed or broken due to his diagnosis of depression. |
| Transdiagnostic approach Informed by acceptance and commitment therapy |
| The physician acknowledges the patient's distress as a response to loss and documents bereavement (Z63.4), without assigning a more formal psychiatric symptom or diagnosis. |
| The visit focuses on what matters most to the patient and identifying small, values-consistent steps. Follow-up is scheduled in 3 weeks. |
| At follow-up, he reports ongoing sadness but improved function. He describes feeling more able to navigate his grief and understands that his experience is a normal response to loss. |
Family physicians can counter the drivers of mental health overdiagnosis by validating symptoms without reflexive labeling, treating distress and symptoms rather than focusing on a diagnosis (transdiagnostic approach), leveraging values clarification and committed actions, and prioritizing longitudinal follow-up to clarify diagnosis. These approaches preserve access to care while reducing harms from unnecessary diagnoses and treatments.
Disclaimer: The views expressed are those of the authors and do not necessarily represent those of the US government or the Indian Health Service.
