Treating Anxiety and Depression in Primary Care: Reducing Barriers to Access


Colocating counseling and primary care services can help ensure that patients get the mental health care they need.

Fam Pract Manag. 2017 Jul-Aug;24(4):11-16.

Author disclosures: Jillian Vanselow disclosed that she is the president of the company that Dr. Nelson's practice contracted with to provide the mental health services described in the article. No other relevant financial affiliations disclosed.

An estimated 43.6 million U.S. adults, or 18.1 percent of the adult population, suffer from some form of mental illness, with anxiety and depressive disorders being the two most common. In a given year, an estimated 6.6 percent of adults (15.7 million) have at least one major depressive episode, and 4.3 percent of adults (10.2 million) have a major depressive episode with severe impairment. Unfortunately, less than half of people who experienced a mental illness in the past year received mental health care.1

Primary care physicians are often the first to identify, diagnose, and initiate treatment for mental health conditions. In fact, the two most common diagnoses in our family medicine clinic are anxiety and depression, and the most common type of referral is for mental health counseling. However, we know that despite the physician's recommendation to see a counselor, few patients actually follow through with scheduling an appointment. We asked patients why, and they described multiple barriers, including financial concerns, counselor availability, scheduling conflicts, inconvenient office location, and feelings of shame. It was clear that we needed to bridge this gap between referrals and counseling in order to improve the mental health of our patients.

Thinking differently about access

We (Dr. Nelson's practice) started thinking critically about how our patients accessed counseling services and the barriers they faced. Penchansky and Thomas first argued for a more precise definition of access to health care in the early 1980s.2 Their ideas are making a deserved comeback in the field of behavioral economics, given the inherent complexity of our modern health care system. Access, they argue, is more than just the ability or willingness to enter the health care system. They describe access as a concept of “fit” between the “client,” or patient, and the system. The concept of fit is further subdivided into five specific components:

  • Availability is about the adequacy of the supply of health care providers and programs.

  • Accessibility is the relationship between the service and the patient or the patient's transportation resources, including time, distance, or cost.

  • Accommodation is the patient's ability to adapt to the clinic's resources, such as its appointment system, hours of operation, or phone service.

  • Affordability is the relationship between prices and the patient's ability to pay, including health insurance, and how the patient perceives worth and value.

  • Acceptability is how well the patient and the provider can work together.

We used the Penchansky and Thomas framework to consider whether reducing barriers to access would increase patients' willingness to seek treatment for anxiety and depression in primary care. (See “Barriers to access for patients

About the Authors

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Dr. Colorafi is a health care technology consultant in Phoenix, an associate professor at Arizona State University's College of Nursing and Health Innovation in Tempe, Ariz., and an assistant professor at Washington State University's College of Nursing in Spokane, Wash....

Jillian Vanselow is president of Core Recovery, an outpatient behavioral health facility in Phoenix.

Dr. Nelson is a practicing family physician and chief executive officer of Desert Ridge Family Physicians in Phoenix.

The authors thank Ingrid Carlson-Wurpts and Thomas Canady for their contributions to the statistical analysis and Danielle Dibbern for her data entry services.

Author disclosures: Jillian Vanselow disclosed that she is the president of the company that Dr. Nelson's practice contracted with to provide the mental health services described in the article. No other relevant financial affiliations disclosed.



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1. Center for Behavioral Health Statistics and Quality. Behavioral Health Trends in the United States: Results From the 2014 National Survey on Drug Use and Health. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015. Accessed May 11, 2017....

2. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981;19(2):127–140.

3. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361–370.

4. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613.

5. France RD, Weddington WW, Houpt JL. Referral of patients from primary care physicians to a community mental health center. J Nerv Ment Dis. 1978;166(8):594–598.

6. National Priorities Partnership. Report from the National Quality Forum: National Priorities Partnership Quarterly Synthesis of Action In Support of the Partnership for Patients. Washington, DC: National Quality Forum; 2012.


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