In both medical and legislative arenas, there is growing awareness of the importance of mental health treatment. In 1996, Congress passed mental health parity legislation. In 1999, Surgeon General David Satcher reported that half of Americans who need mental health treatment do not receive it, either because they fear the stigma of mental illness or because they lack access to mental health services.
As family physicians, we receive mixed messages from the health care system about our role in managing mental health. On the one hand, we are accused of under-recognizing important mental health conditions such as depression and anxiety. On the other hand, we are prevented from treating those conditions, thanks to managed care systems that carve out mental health care from primary care.
Despite these mixed messages, one thing is clear: Patients with mental health issues often turn to their family doctor. But how common are these problems among our patients? How are they most likely to present? And how does emotional distress affect the outpatient visit? To answer these questions, we analyzed 1,269 directly observed adult outpatient visits to 138 family physicians.
Illuminating the ‘black box’ of primary care
This article continues our series offering practical lessons from the Direct Observation of Primary Care (DOPC) Study, which was funded by the National Institutes of Health and conducted by the Center for Research in Family Practice and Primary Care, with support from the AAFP. The study demonstrates the complexities of the patient visit, the demands of real-world practice and the value of primary care, issues that policymakers, the public and even clinicians have not fully understood. Researchers used a multi-method approach, including direct observation, to study 4,454 patient visits to 138 family physicians in 84 practice sites.
The study found that, according to self reports, 19 percent of adult patients experienced significant emotional distress during the previous four weeks. These patients were more likely to be visiting their family physicians for treatment of acute or chronic illnesses than for well care, and they were more likely to raise emotional issues during the visit. In addition, their visits were longer on average than those of other patients (11.5 minutes vs. 10 minutes), with more problems addressed during the visit. Recent emotional distress affected the content of the visit, even if the patient did not receive a mental health diagnosis. (For further information on visit content, see the original research paper.1)
Eighteen percent of patients who reported recent emotional distress received a diagnosis of depression or anxiety from their family physicians. These visits were longer on average (12.8 minutes in duration), and their content differed dramatically from that of other patient visits. More time was spent gathering family information, taking the patient's history and providing counseling, while much less time was spent on physical examination, chatting and preventive services.
Patients whose emotional distress resulted in a mental health diagnosis reported stronger relationships with their physicians than patients whose emotional distress was not diagnosed. Thus, although attention to patients' mental health concerns diverts time and energy away from other areas of medical care, it may have the added benefit of strengthening the doctor-patient relationship.
Emotional distress and its diagnosis, both common in family practice, can have a major impact on the patient visit, in terms of time spent, visit content and patient satisfaction. These benefits and trade-offs of integrating mental health care into family practice need to be recognized not only by family physicians deciding how best to spend their limited time with each patient, but also by health plans and legislators making policy decisions.