Mental illness is a general term for a range of mental health conditions that affect one’s mood, thinking and behavior. The prevalence has important public health ramifications. It is one of the leading causes of disability in the United States,1 affecting roughly 23% of all adults and 17% of youth.2 While mental illness is common in all parts of society, prevalence differs among racial and ethnic groups. For example, rates of mental illness are higher among American Indian or Alaska Native adults (26.6%) than among white (23.9%), Black (21.4%), Hispanic (20.7%) or Asian (16.4%) adults.2 Expenditures for treatment of mental illness in U.S. adults totaled approximately $106.5 billion in 2019, and nearly one-third of the total amount ($33.9 billion) was paid by private insurance.3 Approximately one-quarter of spending on mental health treatment was paid by Medicaid, the second largest payer.3,4
The fragmented nature of medical and mental health care in the United States has created a number of challenges to providing high-quality mental health care services.5 Mental health services are not distributed evenly nationwide, and many communities lack access to these services.6 Roughly two-thirds of primary care physicians are unable to connect their patients to outpatient mental health services.7 As a result, primary care physicians must assume a leading role in the management of mental illness.
The AAFP also recognizes that institutional racism within the U.S. health care delivery system historically led to the systematic segregation and discrimination of patients based on race and ethnicity, the effects of which persist to this day.8 The experience of racism and discrimination has been shown to increase the risk for mental illness.9 In addition, lack of access to mental health treatments due to no insurance or inadequate insurance coverage and lack of access to culturally competent clinicians can make it difficult for persons of color to access the mental health system. These issues, combined with increased stigma in communities of color, can result in increased risk of mental illness and decreased access to treatment.
Family medicine, which promotes integration of the behavioral and physical models of illness, serves a vital role in providing mental and behavioral health care services. Approximately 40% of office visits for mental health concerns (e.g., depression, anxiety) occur in primary care offices, and 47% of prescriptions for any mental illness are written by primary care physicians.10 The established relationship that exists between a patient and their family physician creates a greater opportunity for continued support and care when navigating mental health concerns. Through this connection, primary care physicians may be able to recognize the onset of mental illness in their patients and have better preexisting knowledge of any relevant social, emotional and environmental factors, as well as comorbidities and other considerations that can contribute to overall mental health.10
Transformations within primary care have called for reintegration of mental health care into routine comprehensive care through a team-based approach.6,11,12 Integration can take place across a continuum, including collaboration and partnerships, colocation of services or full integration within one single care plan.13 The current lack of integration is a barrier to improving the quality of care, health outcomes and efficiency of care delivery for patients who are dealing with both mental and physical illness. 14,15
This paper explores various issues family physicians face regarding mental health and mental and behavioral health care services, clarifies the family physician’s role and highlights the direction of the American Academy of Family Physicians’ efforts to advocate for a better system for addressing mental health in the United States. In addition, it covers the following topics: incorporation of mental and behavioral health services in primary care; health inequities and populations placed at increased risk, including people who use drugs and other substances; and payment.
Family physicians are one of the primary sources for behavioral health care in the United States and are well equipped to provide mental and behavioral health services for their patients across the lifespan. The United States has significant gaps in the provision of mental and behavioral health care services, and mental health concerns that occur throughout the different phases of life continue to be prevalent.16 Family physicians are ideally suited to provide behavioral health care and act as advocates and champions for improving health care systems and increasing access to mental and behavioral health care services.
The AAFP calls for action in the following areas:
Physician Level
Practice Level
Community/Leadership Level
Educational/Advocacy Level
While psychiatric and other mental health professionals can play an important role in the provision of high-quality mental health care services, primary care physicians provide the majority of care for patients in the United States. Most people with mental health conditions will be diagnosed and treated in the primary care setting.19 Mental illness also complicates other medical conditions, making them more challenging and expensive to manage.19 Together, these factors make mental health an important issue for family medicine practices.
Family physicians are well positioned to address their patients’ mental health issues. The behavioral sciences and mental health are central tenets of the specialty of family medicine,20 and family physicians receive high-quality training in these areas. The Review Committee for Family Medicine of the Accreditation Council for Graduate Medical Education has stringent standards for mental and behavioral health education in family medicine residencies.21
Screening for Mental Illness
Mental health screening is not new to family medicine. Recently, due to the amplifying effects of mental health diagnoses on chronic conditions, screening for mental health has been linked to quality metrics and payment. Universal screening allows clinicians to better identify mental health needs and interventions for their patients. It can be an important strategy for decreasing morbidity in adults, supporting long-term mental wellness in children and adolescents, and preventing adverse maternal and child health outcomes associated with perinatal depressive symptoms, postpartum depression or maternal suicide.22-27 Although screening for mental health may seem overwhelming for busy clinicians, leveraging technology, empowering staff and utilizing wellness visits can help practices complete this important task.28
Identification of mental health issues is integral to ensuring appropriate treatment and reducing complications. Family physicians should be aware of up-to-date screening recommendations for adult and child/adolescent patients,29 including screening for anxiety in children and adolescents ages 8 to 18 years and adults and screening for depression and suicide risk in adolescents ages 12 to 18 years and adults.22,23,30,31 It is also important to approach screening in a culturally and linguistically appropriate manner, understanding that mental health conditions may manifest differently in various cultural contexts. The AAFP has developed or endorsed a number of mental health clinical recommendations and guidelines for family physicians.
Behavioral Health Integration
Mental and behavioral health care services are out of reach for a significant number of Americans. In 2022, nearly a quarter of all adults with any mental illness reported being unable to access needed treatment.32 Barriers to accessing these services include the following32:
In addition to expected barriers that prevent access to mental health care,33 all U.S. states have a shortage of child and adolescent psychiatrists.34 Approximately 17% of children ages 2 to 8 years in the United States have been diagnosed with a mental, behavioral or developmental disorder,35 and at least 20% of people ages 9 to 17 years have a diagnosable mental illness or will develop one at some point in their life.36,37 The behavioral health needs of adolescents differ from those of adults due to children’s continuing development and the environments in which they live. This highlights the distinct importance of a mental and behavioral health care plan that is individualized for each patient.
In a joint report on the dissemination of integrated care, the American Psychiatric Association and Academy of Psychosomatic Medicine state, “Integrating mental health into primary care settings, as well as the blending of primary and preventive medicine into traditional mental health settings, represents a more holistic approach to treatment than the traditional consultative and referral models.”38 This more unified approach increases access for patients by making mental and behavioral health services available in their regular primary care practice.39 Continued integration of these services helps family physicians meet the immediate mental and behavioral health needs of the children, adolescents and adults in their practice. It allows for continued support and monitoring of mental well-being across the patient’s lifespan as their physical health needs are also being addressed.
When integrated into primary care, mental and behavioral health specialists can impact the care of more patients than they can in the specialty mental health referral sector.40 They typically have shorter and more problem-focused encounters in the primary care setting, taking on a more consultative and team-based role and focusing on helping primary care physicians treat mental health concerns. Utilization of an integrated intervention setting is evidence based and has demonstrated improved access, better quality of patient care, lower utilization of more restricted resources and reduced total cost of care.38
Family physicians should feel comfortable screening, initiating treatment and following patients for general mental health diagnoses, and they should develop a robust matrix of support within their clinic and community settings. A multidisciplinary approach to mental health management has demonstrated better overall health and wellness outcomes in patients.41 Additionally, a team-driven, population-focused, evidence-based and measurement-guided approach helps family physicians identify cost-effective and scalable interventions within a clinical setting.38
Telemedicine and Telepsychiatry
Telemedicine is defined as “the process of providing health care from a distance using technology.”42 Telepsychiatry is a subset of telemedicine that may involve a psychiatrist supporting primary care physicians and other health care specialists through direct or indirect interaction with patients. The COVID-19 pandemic triggered an unprecedented expansion in the use of telemedicine as physicians and other health care professionals heavily utilized the telecommunications infrastructure to remain engaged with their patients. Telehealth technologies can increase access to care, enhance patient-physician collaboration, decrease costs and improve health outcomes.18
Telemedicine for mental health is a growing interest in primary care, and telehealth initiatives for behavioral care are expanding rapidly. Researchers continue to assess the benefits and positive outcomes of using telemedicine and compare the effectiveness and cost of telemedicine visits with face-to-face visits.43,44 Family physicians who want to integrate mental health care services into their practice but have limited local access to mental health professionals should consider utilizing telemedicine to offer these services to their patients.45-47 When telehealth and telemedicine are conducted within the context of appropriate standards of care, the AAFP supports expanded use of these services as an appropriate and efficient means of improving health.18
Trauma-Informed Care
Trauma is a significant health problem in the United States. An estimated 62% to 75% of people experience at least one traumatic event in their lifetime.48 Exposure to trauma (e.g., intimate partner violence, sexual abuse, rape, neglect, terrorism, war, natural disasters, street violence) predisposes those affected to poor physical and mental health outcomes.49-51 Further, the more adverse childhood experiences, or ACEs, a patient has, the greater their risk of poor health outcomes, health risk behaviors and socioeconomic outcomes as an adult.52
Trauma-informed care and trauma-informed practices have become areas of active study in health care settings. These approaches to engaging people who have a history of trauma recognize the effect of traumatic experiences or ACEs on their lives.53 Trauma-informed care is the standard of care to facilitate healing and help prevent the consequences of exposure to trauma.54 The trauma-informed care framework includes the following elements: realizing the high prevalence of trauma and its serious effects on health and behavior; recognizing the signs and symptoms of trauma; responding to the high prevalence of trauma by integrating knowledge about it into practices, procedures and policies; and using best practices for screening and history taking to avoid retraumatizing patients.53
Trauma-informed care is a growing area of focus in the medical community, and further research is needed to examine how training primary care physicians to provide trauma-informed care affects health outcomes and quality of care.48 In its policy on trauma-informed care, the AAFP urges its members to understand and incorporate trauma-informed care into clinical practice.17
Health Inequities
While mental health conditions can affect anyone, regardless of culture, race, ethnicity, gender or sexual orientation, the prevalence of these conditions is higher in some populations. People from racial and ethnic minority groups bear a disproportionately high burden of disability due to mental illness. Despite lower rates of depression in Black people (24.6%) and Hispanic people (19.6%) compared with white people (34.7%), depression is more persistent in Black and Hispanic people.55 Higher rates of posttraumatic stress disorder and alcohol dependence are reported by American Indians/Alaska Natives compared with other racial and ethnic groups.56 In addition, the mental health of people from racial and ethnic minority groups has worsened since 2019, and these populations experienced disproportionate loss and illness during the COVID-19 pandemic.57
Many people from racial and ethnic minority groups may face obstacles to obtaining mental and behavioral health care, including racism/bias, lack of health insurance or insufficient health insurance, lack of culturally sensitive clinicians, language barriers, discrimination in treatment settings, financial strain and stigma.58 Lack of racial and ethnic diversity among mental health specialists may also limit access to care. For example, while people in racial and ethnic minority groups represent approximately 30% of the U.S. population, approximately 90% of mental health professionals identify as non-Hispanic white.59
Children and Adolescents
According to the American Psychological Association Working Group for Addressing Racial and Ethnic Disparities in Youth Mental Health, up to half of the people in the United States will develop a mental health disorder in their lifetime, and most of these disorders begin in childhood and adolescence.59 Among racial and ethnic minority youth, other identities (e.g., identities related to socioeconomic status, sexual orientation, gender or cognitive and physical ability status) may intersect with their racial and ethnic identity in ways that create mental health challenges. For example, approximately 39% of African American children, 32% of Latino children and 36% of American Indian children live in poverty, which is more than twice the percentage of Asian children (14%) and non-Latino white children (14%) who live in poverty.59 Children living in poverty are exposed to a greater number of stressors and ACEs. Early and chronic ACEs have been associated with poor emotional and behavioral regulation in adulthood, which impacts not only mental health but overall well-being.
Clinicians’ implicit bias and limited cultural humility can contribute to inequities in mental and behavioral health care quality and outcomes for children and adolescents from racial and ethnic minority groups. These factors can also lead to misdiagnosis or underdiagnosis of mental health disorders. For example, studies have shown that some behaviors consistent with mental illness are attributed to conduct disorder in children from racial and ethnic minority groups.59 Instead of being appropriately diagnosed and treated, these children are often subject to disciplinary action, which may ultimately lead to excessive placement in the prison pipeline. In fact, 50% to 75% of youth in the juvenile justice system meet criteria for mental health disorders.60
Incarcerated People
The United States is home to only 5% of the world's population but holds almost 25% of the world’s incarcerated people.61 Rates of mental illness are much higher among incarcerated people than in the general population. In the United States, 64% of people in jails and over 33% of people in prisons have been diagnosed with a mental illness.62 Many people with treatable mental health concerns get caught up in the criminal justice system when they should be working within the mental health system. Often, incarcerated people are not having their mental health needs met, and incarceration can result in worsening mental health.63
The AAFP’s position paper on incarceration and health highlights positive actions that family physicians can take, including identifying ways to reduce negative health outcomes for people in
correctional facilities, supporting interventions that could improve the health of incarcerated people, and advocating to prevent unnecessary incarceration by diverting people from the justice system into appropriate mental health treatment.64
LGBTQ+ People
While the full spectrum of LGBTQ+ identities is often underrepresented in research on mental and behavioral health, there is compelling evidence that members of the LGBTQ+ community are at increased risk for experiencing mental health challenges. They are more likely to experience trauma and discrimination. A majority of LGBTQ+ people report being harassed or experiencing violence or other negative social interactions,65 which can include unequal treatment within the health care system.66 Members of the LGBTQ+ community are more likely to report experiencing negative, challenging interactions with a health care professional, such as having their health concerns dismissed, being blamed for a health problem or being subject to a clinician’s assumptions.67 However, in spite of this increased risk, LGBTQ+ people are more likely to talk with a clinician about their mental health than non-LGBTQ+ people.67
Compared with heterosexual adults, lesbian, gay and bisexual adults are more than twice as likely to have a mental health disorder in their lifetime,68 and LGBTQ+ people are 2.5 times more likely to experience depression, anxiety and substance misuse.69 Lesbian and bisexual women are approximately twice as likely to report heavy alcohol drinking in the past month compared with heterosexual women.70 Compared with the rate of suicide attempts for heterosexual youth, suicide attempt rates are two times greater for questioning youth and four times greater for lesbian, gay and bisexual youth.71 Moreover, among LGBTQ+ older adults, approximately 31% report depressive symptoms and 39% report suicidal ideation.72
The AAFP advocates for equal health rights for LGBTQ+ patients and recognizes that gender-affirming health care, including access to supportive behavioral health care, is part of comprehensive primary care for many gender-diverse patients of all ages.73
Rural Populations
Rural areas in the United States have a significant lack of access to specialty mental health care, and this contributes to disparities. More than 60% of rural Americans live in designated shortage areas of mental health specialists,74 and an estimated 65% of nonmetropolitan counties do not have any psychiatrists.75 Telehealth services can provide increased access to qualified mental health services for patients in rural areas, offering more opportunities to be assessed and treated by experts who are culturally sensitive and familiar with these special populations.
Pregnant People
Fifty-three percent of pregnancy-related deaths occur within the first 365 days after giving birth.76 Mental health conditions are the underlying cause of 23% of reported pregnancy-related deaths, making them the most common complication during pregnancy and delivery. One in five pregnant or postpartum people are diagnosed with perinatal mood and anxiety disorder,77 and one in eight report experiencing symptoms of postpartum depression in the first 12 months after giving birth.78 However, approximately 75% of people experiencing maternal mental health conditions do not receive treatment.79
Primary care physicians can collaborate with the patient and other clinicians involved in their obstetric care to develop a postpartum care plan that addresses the transition to parenthood and social-emotional well-being. Crucial steps that family physicians can take to ensure the mental and physical well-being of their patients before, during and after pregnancy include the following: screen for postpartum depression and anxiety, provide appropriate external resources for support and mentoring, screen for tobacco and substance use, and follow up on any preexisting mental health disorders or concerns.80
Older Adults
As people age, they face physical, psychological and social changes that challenge their overall health and well-being. Many older adults experience depression and loneliness as a result of losing friends and loved ones, coping with serious illnesses and dealing with other stressors late in life.81 During the COVID-19 pandemic, older adults were more adversely affected, experiencing more severe complications, higher mortality rates and difficulty adapting to telemedicine and other technologies.82 In addition to growing concerns about the overall well-being of older adults, there were concerns that isolation could exacerbate mental health conditions in this population. According to the 2020 National Health Interview Survey, older adults (ages 65 and older) were the least likely to have received any mental health treatment in the past year (18.7%) when compared with adults ages 45 to 64 (20.5%) and adults ages 18 to 44 (20.9%).83
The long-term relationship that often develops between a patient and their family physician creates a greater opportunity for continued support throughout the life cycle, provides continuity of care and helps navigate mental health concerns. Additionally, primary care physicians are best equipped to take comorbid conditions and polypharmacy concerns into account when managing mental illnesses such as depression and anxiety in older adults.
People Who Use Drugs and Other Substances
Many people experiencing mental illness also have substance use disorders, and the converse is true as well.84 Mental illness and substance use often occur together due to shared genetic risk factors, environmental influences such as early exposure to stress or trauma and the use of substances as a form of self-medication.85 The 2021 National Survey on Drug Use and Health found that adults with any mental illness (39.7%) or serious mental illness (50.2%) were significantly more likely to have used illicit substances in the past year compared with those who reported no mental illness (17.7%).86 The common comorbidity of substance use disorders and mental health disorders emphasizes the need for an integrated approach to behavioral health care interventions in order to identify the disorders concurrently and provide appropriate treatment for each.87
Tobacco use is also prevalent among people living with mental illness. Twenty-three percent of adults with any mental illness report that they smoke cigarettes compared with 13.6% of adults with no mental illness.88 Despite only representing 25% of the U.S. adult population, people who have a mental illness or a substance use disorder consume 40% of all cigarettes sold.89 Although tobacco use among U.S. adults has decreased in recent years, the reduction rate among people with a mental health disorder is much lower. People who have any mental illness are only half as likely to quit smoking compared to people without a mental illness.90 Therefore, addressing tobacco addiction among people living with mental illness is an important strategy for decreasing preventable morbidity and mortality. The AAFP’s Behavioral Health and Tobacco Cessation resource provides a comprehensive overview of this issue and highlights opportunities for family physicians to make a significant impact on reducing tobacco use by their patients, including those who have behavioral health disorders.91
The AAFP has long advocated for equitable access to health care for all and continues to do so.92 Mental and behavioral health care should be affordable and nondiscriminatory,93 and all clinically effective treatments appropriate to the needs of people with mental illness should be covered. Further, payment for mental and behavioral health care should be equal in scope to payment for the care of other illnesses.
Historically, primary care physicians have not been appropriately paid for screening, treatment and care coordination for mental health concerns. Lack of adequate payment for these services and an insufficient mental health workforce have interfered with family physicians’ ability to offer comprehensive care and management of mental health conditions, as well as their ability to integrate behavioral health services into family medicine practice. The expansion of telehealth payment during the COVID-19 public health emergency improved access to care for patients, particularly those with limited access to care and services.
Behavioral Health Integration Services
Behavioral health integration, or BHI, services provide payment for the additional care management services patients with mental, behavioral health or psychiatric conditions receive from their primary care team.94 Under traditional fee-for-service payment, practices can bill for two types of BHI services:
General BHI and CoCM are covered by Medicare and many private payers. They are monthly, time-based services that include the following94:
CoCM requires that a psychiatric consultant is a member of the behavioral health team, while GBHI services can be provided by a psychologist or social worker. Payment and time requirements for GBHI and CoCM codes are often challenging for physicians to meet and do not represent the broad range of BHI in primary care practices. Practices may also use a variety of CPT codes to report additional behavioral health services, such as screening, although payment for these codes is typically low.
Outside of FFS payment, practices may also benefit by transitioning to value-based payment. Value-based payment offers practices more flexibility to provide additional services — like BHI services — that are tailored to factors including their patient population, locality and practice type. However, under both FFS and value-based payment, primary care practices may face challenges integrating care due to the lack of up-front funding needed to hire additional staff and update electronic health record systems and other health information technology components.
Family physicians are well trained to provide many types of mental and behavioral health care services, and they play an important role in providing these services. A variety of models and resources exist to help them fill existing gaps in the provision of mental and behavioral health care services in the United States, especially for populations that have been made vulnerable. It is imperative for family physicians to integrate mental and behavioral health care professionals into their practice when possible. In this manner, family physicians can better meet both the physical and mental health care needs of their patients.
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