Introduction: Mental Health in Primary Care


Mental health disorders have been on the rise for years, multiplied by the effects of the COVID-19 pandemic. Forty percent of US adults reported struggling with mental health or substance use just 1 year ago, according to the CDC, and 11% had contemplated suicide.1 And yet, much like it takes decades to translate new research into clinical practice, this public health crisis has not yet found its place in everyday care.

A Word from the Editors

We – Psycom Pro and its sister consumer brand Psycom – are therefore making the bold and necessary proposal that mental health earn its rightful place in the annual battery of assessments undertaken by adults. In the coming months, Psycom Pro and Psycom, will be talking with clinicians in psychiatry, psychology, and primary care about the state of mental health screenings in the United States and what these experts envision an annual mental health exam could, and should, involve, including who would administer such an assessment and who would pay for it (eg, insurance payers, employers, the government). We’ll talk about what healthcare in the US might truly look like if it was put on an equal playing field with physical health, and how diagnoses and treatment plans – as well as patient outcomes – might change course. In alignment with Mental Health Awareness Month this May 2021, we begin with this report.

Our Expert Panel

Alison Huffstetler, MD

Alison Huffstetler, MD

W. Clay Jackson, MD

W. Clay Jackson, MD

Jean Kim, MD

Jean Kim, MD

Julie Kolzet, PhD

Julie Kolzet, PhD

David M. McCord, PhD

David M. McCord, PhD

Michael McGee, MD

Michael McGee, MD

Andrew Penn, NP

Andrew Penn, NP

Steven Starks, MD

Steven Starks, MD

 

  • Alison Huffstetler, MD, Assistant Professor of Family Medicine, Virginia Commonwealth University and Georgetown University School of Medicine, Washington, DC
  • Clay Jackson, MD, Clinical Assistant Professor of Family Medicine and Psychiatry, University of Tennessee College of Medicine, Memphis, TN; family practitioner; former president, Academy of Integrated Pain Management
  • Jean Kim, MD, Psychiatrist and Clinical Assistant Professor of Psychiatry at George Washington University, Washington, DC
  • Julie Kolzet, PhD, Licensed Clinical Psychologist and Consultant, New York, NY
  • David M. McCord, PhD, Professor of Clinical Psychology at Western Carolina University, Cullowhee, NC; president, Assessment Section of Division 12 (Clinical Psychology) of the American Psychological Association
  • Michael McGee, MD, Staff Psychiatrist, California Department of State Hospitals, Atascadero, CA; President, Well Mind, Inc; Book Author
  • Andrew Penn, NP, MS, PMHNP-BC, Psychiatric Nurse Practitioner; Associate Clinical Professor at the University of California San Francisco’s School of Nursing; Attending NP at the San Francisco Veterans Administration; Psychedelic-Assisted Therapy Researcher, San Francisco, CA
  • Steven Starks, MD, Clinical Assistant Professor, University of Houston College of Medicine, Houston, TX

 

Consider an adolescent visiting the pediatrician for an annual checkup. Once the child turns 13, a nurse practitioner will likely pull them aside, out of the parent’s or caregiver’s earshot, and ask them about their emotions, their feelings. The teen may be asked about bullying at school, sexual activity, and violence or anger at home. If any red flags arise, that clinician will carry out protocols to address the issues at stake, perhaps a referral, and follow-up at future visits.

Now, imagine an adult patient visiting her personal doctor for an annual exam. She fills out a pre-screen questionnaire in the waiting room, checking off feelings of depression and occasional suicidal thoughts. Who reviews this form? What are the protocols for follow-up? What if the provider doesn’t have the resources, or support, to provide adequate care or a referral? And more importantly, what if this patient chooses not to disclose any concerning issues on the form out of fear or discomfort? How is her mental health captured and treated? In many cases, it is not.

In fact, it was not until this spring (March 2021) that a screening tool for anxiety in teen girls and women to be used in primary or gynecological care was considered validated and covered by the Affordable Care Act, thanks to the work of the Women’s Preventive Services Initiative.2,3

Annual physicals and regular screenings are conducted for a reason. Bloodwork taken as part of a yearly physical can alert a clinician to a cardiovascular or metabolic disorder; annual pelvic exams and mammograms can help to identify potential cancers; annual dental and eye exams help to prevent long-term diseases such as periodontitis, glaucoma, and more. As we age, regular colonoscopies, electrocardiograms, dermatologic scans, and other tests shine a light on any potential problems or emerging risks so that care can be delivered and, ideally, prevent, more severe disease.

But where in this list of routine assessments does mental health lie? We know that depression, for example, just like physical diseases, can develop into more severe disease and even lead to suicide. We also know 1 in 5 Americans lives with a mental disorder – 50% of lifetime cases begin by age 14 – and that up to two-thirds of depression cases go undiagnosed, with primary care physicians potentially missing depression (especially among men) 50% of the time.4-7

We must simultaneously consider the massive disparities that exist in access to mental health care for Black, Indigenous, and People of Color (BIPOC), and the LGBTQ+ community. Add to this, the growing shortage of mental health professionals and the fact that, despite the example presented above, not every adolescent or teen has the ability to undergo an annual pediatric exam. The Kaiser Family Foundation reports that 13% of US adults (up to 21% among Hispanics) did not seek healthcare in the year prior due to cost, and 23% (nearly 40% among Hispanics) did not have a primary care physician.8

These are just some of the key challenges and questions we hope to address in this special project and to do so, we will focus on depression.


Depression and Mental Health Screening in the United States


We have elected to focus on depression in this special report, for the following reasons:

  • Affecting millions of adults each year in the US (see specific stats in Table I), depression is considered to be one of the leading mental health disorders that healthcare providers see in their patients on a regular basis
  • Major depressive disorder (MDD) has strong links to suicidal ideation and suicidal behavior: the most common underlying disorder of attempted suicide is depression; 30% to 70% of suicide victims suffer from MDD or bipolar disorder9
  • Depression has links to several other psychiatric disorders; research has shown that depression can lead to anxiety disorders, sleep disorders, and substance use disorders (SUDs) and can be misdiagnosed for bipolar disorder10-13
  • Depression has grown 3-fold since the beginning of the COVID-19 pandemic14
  • Depression is the primary screened psychiatric disorder in primary care (supported by CMS) usually conducted with the patient self-administered Patient Health Questionnaire or PHQ. Even so, this is a Grade B US Preventive Services Task Force (USPSTF) recommendation and the PHQ has not been formally adopted as standard practice15,16

Capturing the burden of this disorder on patients, providers, society, and healthcare systems is difficult given its many variables – including severity (mild, moderate, or severe), the frequency in which in occurs (episodic or chronic), its frequent overlap with other mental health disorders, as well as its common co-occurrence with other medical illnesses. Looking at the statistics can help.

TABLE I. THE IMPACT OF DEPRESSION IN THE UNITED STATES.

PREVALENCE

  • 3 million US adults (7.1% of all US adults) reported at least one major depressive symptom in the previous year1 (National Institute of Mental Health, 2017, latest survey)
  • 5% of adults in 2019 had symptoms of depression, of which 11.5% had mild symptoms, 4.2% moderate symptoms, and 2.8% severe symptoms.2

AS A COMORBIDITY3-5

  • 84% of people with irritable bowel syndrome (IBS); in turn, 30% of patients with a depressive disorder and 45% of patients with anxiety develop IBS
  • 50% of people with Parkinson’s disease
  • 25% of people living with cancer
  • 33% of people with diabetes
  • 20% of women with polycystic ovary syndrome
  • Further, depression often accompanies chronic pain conditions such as fibromyalgia, chronic fatigue syndrome, and rheumatoid arthritis; it remains challenging knowing whether the depression or the pain condition is the cause or effect.

AS THE RESULT OF THE COVID PANDEMIC

  • The prevalence of depression symptoms in the US increased from 8.5% before COVID-19 to 27.8% during COVID-19 –a more than 3-fold increase.6
  • Mood disorders among those with pre-existing psychiatric and neurological disorders substantially increased in patients 6 months after a COVID-19 diagnosis.7

AS AN ECONOMIC TOLL

  • The incremental burden of major depressive disorder (MDD) increased by 21.5% between 2005 and 2010 (from $173.2 billion to $210.5 billion) with 45% due to direct costs, 5% to suicide-related costs, and 50% to workplace costs.
  • Notably, comorbid conditions accounted for most of the growing economic burden, with only 38% of the total costs due to depression itself.

Table sources provided at end of reference list below.

What these numbers broadcast is the urgent need for better ways to address depression. They underscore the need for adequate initial assessment – which most often occurs in the primary care setting – and perhaps most importantly, the need for proper follow-up, including patient counseling and referral to a mental or behavioral health specialist when appropriate.

Current State of Depression Screening

As noted, Patient Health Questionnaire (PHQ-9), and its shortened version (PHQ-2), is the most widely used depression screening tool and seen by many experts as a sufficient and reliable way to identify symptoms of depression. Other tools cited by the USPSTF – an independent expert panel that reviews evidence-based medicine and makes clinical recommendations – for depression screening include: the Hospital Anxiety and Depression Scales in adults, the Geriatric Depression Scale in older adults, and the Edinburgh Postnatal Depression Scale in postpartum and pregnant women.

“We do a good job of identifying depression – if screening is done reliably and routinely,” says Alison Huffstetler, MD, an assistant professor of family medicine at Virginia Commonwealth University and Georgetown University School of Medicine. She points to the high sensitivity of the PHQ-2 to detect 97% of patients with depression. “Every primary care clinic should be screening people with the PHQ-2 at some point during the year,” she advises. But that’s not always the case.

Andrew Penn, RN, MS, PMHNP, a psychiatric nurse practitioner, associate clinical professor at the University of California San Francisco’s School of nursing, and attending NP at the San Francisco VA, cautioned that if primary care clinicians simply consider annual depression screening as “just another screening” they need to do to close a chart, that screening won’t be taken seriously. “We do annual suicide screening at the VA. One of the things we learned is that we must have a clear course of action to connect someone who screens positive to the mental health care that they need,” he says. Penn’s concern suggests gaps in the reliability of screening, particularly if such screening is considered perfunctory.

Furthermore, what is meant by “routine” is not widely agreed upon. The USPSTF currently advises depression screening for all adults (18 years and older) regardless of risk factors, including pregnant and postpartum women. Insufficient evidence is available, however, on the optimal timing and interval for screening. The task force, therefore, suggests using a pragmatic approach – this may include screening for all adults who have not been screened and using clinical judgment to assess whether additional screening should be done for those deemed at high risk for depression based on risk factors (see below), comorbid conditions, and life events.

Those at higher for depression include those with chronic illness and/or comorbid mental health disorders; a history of substance misuse; a family history of psychiatric disorders; complicated grief, chronic sleep problems, and loneliness; as well as older adults with disability and poor health status related to medical illness. Higher rates of depression also occur in women, young and middle-aged adults; BIPOC patient populations; and undereducated, previously unmarried, and unemployed persons.17,18

Clay Jackson, MD, a clinical assistant professor of family medicine at the University of Tennessee College of Medicine, Memphis, TN, says he screens all of his adult patients first with the PHQ-2 form followed by the longer PHQ-9 form when needed. He screens for other mental health disorders when indicated either by patient self-reporting or clinical assessment: these include ADHD (for adults and children), Bipolar Disorder, Alzheimer’s/Dementia, and Generalized Anxiety Disorder.

Psycom Pro Depression in the US Impact Infographic (Usama Zahoor)

How Can We Expand on Depression Screening?

Other experts would like to see a more comprehensive screening tool for depression. Michael McGee, MD, a staff psychiatrist with the California Department of State Hospitals and president of Well Mind, prefers to use a multisymptom behavioral health questionnaire (he points to this example from Sutter Health in Palo Alto, California). He notes that this wider-ranging form, which includes physical and somatic symptoms, may help to improve identifying patients with depressive symptoms, as well as symptoms that may indicate co-occurring health issues like anxiety, sleep problems, substance abuse, or other comorbidities.

David M. McCord, PhD, professor of clinical psychology at Western Carolina University in Cullowhee, NC, also would like to see a more comprehensive screening tool for depression than the PHQ. He and his colleagues developed the Multidimensional Behavioral Health Screen (MBHS), a 27-item questionnaire designed to screen every patient in the primary care setting on nine components of mental functioning (somatization, demoralization, anhedonia, anxiety, cognitive issues, activation, disconstraint, suicidality, and substance misuse). Built on a construct of assessing core psychopathology components as dimensions, rather than heterogeneous syndromes like the PHQ-9, the MBHS tool can provide a more precise measure and help clinicians rate the severity of dysfunction to improve their treatment decision-making.20 “Multiple scores help to separate somatic symptoms, anxiety, and anhedonia, separately from other more non-specific depressive symptoms,” explains Dr. McCord.

A recent study comparing the MBHS to the PHQ-9 for depression screening in adults seen in a family medical clinic serving both rural and urban populations across Appalachia found the MBHS to be a valid tool and alternative to the PHQ-9.21 Dr. McCord emphasizes that the enhanced specificity of the MBHS for depressive symptoms provides primary care physicians with more information and a clearer picture of next steps to take for a patient who screens positive for depression, such as whether a patient can be treated in the primary care setting or needs a referral for further evaluation. If remaining in the primary care setting, the tool can help guide the course of treatment – including possible medication and behavioral treatments.

In addition, Dr. McCord asserts that the tool may be better at assessing suicide risk as well. Unlike the PHQ-9, which provides often limited and inadequate information on suicide risk,22 the MBHS uses an algorithm to assess multiple risk factors for suicide – such as the number of suicide attempts, fearlessness of death, suicidal desire and ideation, and other risk factors. The algorithm points to a person’s level of suicide risk which gives primary care providers more information on the next steps to take.


Gaps in Mental Health Follow Up


USPSTF Recommendations for Mental Health Screening Systems

Whether current screening tools are sufficient as they are or more comprehensive assessments are needed to better identify depression – and other potential psychiatric disorders – can be debated. What few clinicians argue against, however, is the need for more robust follow-up after depression is identified in screened patients.

“Historically, only 50% of patients diagnosed with major depressive disorder will receive minimally adequate pharmacologic or psychologic treatment,” says Dr. Jackson.

USPSTF recommendations highlight the importance of further assessment in all patients with a positive score on depression screening to evaluate the severity of the depression, as well as to identify other comorbid psychological problems, medical conditions, or alternative diagnoses. To ensure appropriate follow-up after a depression screening, the task force states that adequate systems should be in place. “Systems” refer to a provider’s or practice’s ability to accurately diagnose and treat with evidence-based care, or refer for care – support can go as far as involving clinician and staff training, specialist assessments, medication adherence support, and more.17

These systems are where large gaps in mental health care make their ugly appearance. According to Dr. Jackson, the failure of the healthcare system to appropriately manage patients who screen positive for depression is tied to the lack – among other things – of bandwidth and systemic support in case management of these patients and making sure referrals are followed through on.

Penn voices the challenge this way: “The bigger issue is not, screening or not screening,” he says. “It’s the way the healthcare system interferes with developing a longstanding, trusted relationship between provider and patient.”

What a trusted relationship demands, and a healthcare system with sufficient resources to manage depression requires, is time. Specifically: time on the part of clinicians to conduct a reliable and sufficient assessment that is followed by appropriate care, and time on the part of patients to feel comfortable talking about symptoms and understanding the benefits of treatment compliance and follow-through.

Time Constraints: An Age-Old Barrier that has Long-Term Consequences

As is true throughout primary and increasingly specialty care, time constraints are a major barrier to delivering optimal depression management. Existing healthcare delivery models and reimbursement structures in primary care are largely not set up to effectively manage depression.

“[Insurers] don’t pay for the time it takes for counseling, and there aren’t sufficient resources to address mental health issues as part of the primary care visit,” explains Dr. McGee. If a patient scores positive on a depression screening during a primary care visit, that adds a further challenge to the busy clinician who is already often running behind schedule. Compounding the problem are disparities within the healthcare system that make it more difficult for some populations to access primary care in the first place, not to mention the specialty mental health services when needed.

Access to Healthcare: Barriers Facing BIPOC Communities

“If you can’t see your doctor, a screening tool won’t be helpful,” says Steven Starks, MD, a clinical assistant professor at the University of Houston College of Medicine, “and follow-up will not even be part of the equation.” He notes that poverty and insurance gaps disproportionately affect patients in BIPOC communities.

According to the American Psychiatric Association, people in racial and ethnic minority groups are less likely to seek or receive care for mental health issues. Data from 2015 show that, compared to 48% of whites receiving mental health services, only 31% of Blacks and Hispanics and 22% of Asians received these services. Barriers to care included lack of insurance or being underinsured, lack of diversity among mental health care providers and culturally competent providers, language barriers, and distrust in the healthcare system.23

Dr. Starks cites evidence suggesting that clinicians of the same racial, ethnic, and cultural background achieve better health outcomes in their patients.24 “The key is that BIPOC doctors spend more time listening, relating, and engaging,” he says. “All physicians and mental health professionals have the capacity to promote change; they simply need to master cultural humility.”

He further underscores that once screened for depression, people in these population groups may not receive culturally and linguistically appropriate services for depression treatment. “Given the lack of diversity in the mental health workforce, we need all of our professionals to understand the disparities that exist for BIPOC communities, to take a closer look at their own biases, and to implement anti-racist practices that are sensitive to the needs of the communities they serve,” he says.

Also crucial, adds Dr. Starks, is to meet these populations where they are, which may mean delivery of treatments, services, and support outside of the clinical setting. “Health systems should think of partnering with community-based organizations that focus on mental health and wellness to find innovative ways to serve their communities,” he notes, encouraging health professionals to learn as much as they can about and engage with the communities they serve.


Balancing Mental Health Care with Physical Health Care


Adequate Mental Health Screenings: Integrated Care as a Potential Solution

Given the close and highly acknowledged association between mental and physical health, one potential solution to better integrate depression (and other psychiatric disorders) into primary care is to place a stronger focus on mental health during annual health checkups and routine clinical visits.

As Dr. McGee noted, mental health is well recognized in chronic disease care, including chronic pain management – but perhaps less so in acute or initial patient presentations. Continuing to unfold the old paradigm, where the psychiatric and somatic are largely siloed, toward integrated approaches could be a way forward. The key is to look at both mental and physical health at the same time as the mental influences the physical and vice versa, says Dr. McGee, and obtain “a total mind/body assessment.”

Jean Kim, MD, a psychiatrist and clinical assistant professor of psychiatry at George Washington University, cautions, however, that understanding the connections between physical and mental health can be challenging for physicians. “There are issues where genuine physical ailments are dismissed by physicians/providers because the patient has a psychiatric history, unfortunately,” she says. “Even among physicians, the understanding of the crossover between mental health and physical symptoms can be poorly understood and unfairly stigmatized.”

Another potential way to help primary care clinicians take a more thorough assessment of depression and improve triage to and compliance with treatment management (either in the primary care clinic or by referral) is to include a mental or behavioral health specialist within their clinic.

Integrated behavioral health – in which a behavioral health specialist is embedded into a primary care practice – has been around for a while, but its plausibility as a model of care has become more recognized since the passing of the Affordable Care Act. The healthcare system’s growing focus on alternative financing models (eg, value-based) and principles behind integrated care (eg, population health, patient-centered, team-based, coordinated care) are helping as well.25-28

“Integrative behavioral health within primary care is really key,” says Dr. Huffstetler, who also specializes in population health. “I may have 8 or 9 minutes with a patient, but if I had a social worker or psychologist, or any kind of counselor, who was in my clinic that I could provide a ‘warm handoff’ to, that would be such an incredible asset,” she says.

Having that extra set of hands, eyes, and ears is a big bonus, according to Julie Kolzet, PhD, a licensed psychologist and consultant based in New York. Primary care psychology – a term used by the American Psychological Association for integrated care – “allows for a more thorough assessment of patients for mental health when clinicians are pressed for time” says Dr. Kolzet, noting that it is important for patients who screen positive for a mental health condition such as depression to be offered treatment expediently. “You need to get patients in the moment because it is hard for patients with depression, for example, to make extra steps to get the care they need,” she says, pointing out that patients can face numerous hurdles to accessing care such as locating a clinician within their network, lack of internet access for telehealth or teletherapy, and finding the motivation to pursue and comply with treatment amidst experiencing negative emotions.

Integrated behavioral health is already implemented in a number of healthcare systems, such as the VA (called Primary Care – Mental Health Integration) but lags behind in most primary care clinics nationwide.

“There are some academic integrated care models along with a good evidence base for integrated behavioral health within primary care,” says Dr. McGee, but he doesn’t see this model implemented widely yet. Implementation of such a model, he suggests, would help primary care providers better address the myriad of barriers to improving depression and other mental health treatments.

Dr. Jackson also highlights the need to utilize quality improvement techniques and metrics to improve mental health care assessments. “Just as we measure blood pressure for hypertension patients and adjust medications accordingly or refer accordingly if they are not receiving adequate management goals, we need to do the same with depression and make sure that we change from a qualitative management of strategy to a quantitative management of strategy,” he says.

(More on how metrics and big data may play a role in the future of psychiatry with Daniel Barron, MD, PhD)

Mental Health Assessments In Conclusion – For Now

Depression exacts a tremendous burden on individual and societal health. Primary care providers play a key role in screening, assessing, and managing depression in patients, many of whom often have co-occurring medical illnesses. If done routinely and reliably, current screening with the PHQ-2 and PHQ-9 is a good way to identify patients with depression symptoms. Other more comprehensive screening tools could offer much-needed additional support for making treatment decisions and capturing warning signs of other psychiatric disorders. Integrated practice models have the potential to greatly expand care access and reduce the number of undiagnosed depression cases.

But crucial gaps remain. How reliable are the screening tools if done in a perfunctory way without adequate follow-through for patients screened as positive? How is “routine” screening defined and whose responsibility is it to screen? How many primary care providers have the ability to bring on a behavioral or mental health specialist? As Dr. Huffstettler noted, these models are not yet widely implemented. In addition, they often come with a higher price tag to the patient or insurance payer. For Dr. Huffstetler, however, an integrative behavioral health model within primary care would greatly help with follow-up needed for patients who screen positive for depression.

Along with closer scrutiny at the screening tools used and how they are used, needed is a vastly improved way to follow up with patients who screen positive for depression. As Dr. Jackson noted, only about 50% of patients diagnosed with major depressive disorder (MDD) receive minimally adequate treatment. This doesn’t include the many patients without a diagnosis. In addition, Dr. Jackson notes that of patients referred by their primary care providers for treatment, only 50% of them actually make the referral appointment.

“I think if it were easy to refer a positive depression screen to treatment, and if the person were able to get into the kind of care they would like with a minimum of barriers, that too might help to improve the state of depression care,” said Penn.

Even when a referral is made and that patient wants to see it through, as noted, they may have a hard time getting sufficient care. “Our mental health system remains underpaid, understaffed, and overburdened,” says Penn, citing long wait times to see a mental health specialist and weak reimbursement rates for mental health relative to other medical specialties as examples of impediments to better depression care. “We still need a great deal of work on our mental health system in terms of access, training, and insurance coverage and management to properly care for the many people with depression that screening will detect.”

Perhaps it all does come back to having adequate systems. “We are not quite there yet,” says Dr. Kolzet, who emphasizes that while primary care is both the gateway and important overseer – there is a lot of room for others at the table. “In terms of best practices by way of integrated care, we need to think about what’s realistic and judicious for all parties involved and that is likely to evolve over time,” she said, noting the roles of the patient, the clinician, the care clinic (virtual or otherwise), third-party payers, institutions, pharma, government agencies, and other stakeholders. “We have to focus on the development of systems rather than single-use solutions.”

 


What’s Next?


This summer, our expert panelists will share more specific thoughts on how true integrated care models and comprehensive mental health screenings – including in primary care and specialty care – could actually work if put into practice.

Back to our full report package, directed by Psycom Pro Executive Editor Angie Drakulich, with related articles on Mental Health Treatment in the Context of Chronic Pain, The Interplay Between Physical and Mental Health Conditions, Mental Health Policies Set to Improve Access to Care, and Data as the Driver of Future Psychiatry.

References
Last Updated: Jun 10, 2021