Primary care physicians face rising complexity of mental health concerns

Duke UniversitySep 19 2024

An examination of millions of patient visits to primary care physicians shows that mental health concerns are second only to musculoskeletal complaints in everyday care. One in nine patients was seeking care primarily because of a mental health concern.

These primary care physicians are the gatekeepers. The primary care physician data allows us to actually see people at their first contact with the healthcare system."

Avshalom Caspi, study leader, the Edward M. Arnett Professor of Psychology and Neuroscience at Duke University

Researchers examined more than 350 million primary care visits for 4.8 million people from January 2006 to December 2019, as recorded by the Norwegian government. Each visit's principal health concern was coded by the physicians, enabling the researchers to take a deep dive into what these doctors are seeing every day. The study appears Sept. 19 Nature Mental Health.

"The idea was basically to see what parts of the body are they treating," said Caspi, who has co-developed a measure for the pace of a person's aging process. "It turns out that 12% of all the encounters that primary care physicians have are for mental health problems. So of the 350 million encounters, they have over 40 million mental health encounters."

The data cover 14 years, ending in 2019 – pre-pandemic – and reflects a purely Norwegian population with socialized health care. Norway is one of the wealthiest nations on Earth, with effectively zero extreme poverty, and ranks seventh on a global measure of happiest countries, while the U.S. isn't even in the top 20.

But the insight into how much mental health figures into routine primary care is still valuable, Caspi said. "This is the complete record of people aged zero to 100, from all walks of life."

The prevalence of mental health concerns was about equal to the number coming in for respiratory and cardiovascular complaints, and more than coming in for infections, injuries, digestive, skin, urological or sensory issues.

Caspi said the most important takeaway is that the volume of mental health encounters being seen by primary physicians is second only to aches and pains. While it's mostly depression or anxiety, they are seeing "diverse and complicated conditions," including psychosis. "As I look at all this, I'm just staggered by the complexity of the mental health issues primary care physicians are having to contend with."

Depression, sleep disturbance, stress and anxiety, memory problems and substance abuse led the list. But concerns also included ADHD, learning problems, post-traumatic stress, eating disorders, sexual issues, psychosis and suicidal thoughts.

Caspi adds that it is also important to note "this isn't just happening at one point in the lifespan, it's happening everywhere, among all age groups," he said. Mental health concerns peaked in the 40s, when 1 out of every 5 visits to a primary-care physician was for a mental health issue.

"A primary care physician, on any given day, is going to encounter mental health issues in pediatric patients, in geriatric patients and among middle aged adults," Caspi said.

"This report underscores what has become increasingly evident in medicine: without targeted efforts to expand mental health services within the primary care setting, the medical system will not meet the mental health needs of those that it serves," said Dr. Damon Tweedy, a professor of psychiatry and behavioral sciences at Duke Health, who was not involved in this study.

Post-pandemic, this trend is also unavoidable in pediatric primary care, said Malinda Teague, an assistant clinical professor in the Duke School of Nursing, who was not involved with this study. "Even if it's a regular well-child visit, almost every child is coming in with some concern about behavior, anxiety, depression."

Caspi stops short of suggesting that primary care physicians need to become more educated in mental health, but he would like to see mental health professionals better integrated into the primary care model. "You go to see your GP and you've got a mental health problem. And they say 'let's go right down the hall and get you set up.' That's called a warm handoff, and the VA has been good about that."

Teague agrees and notes that Duke pediatric primary care already has a similar model, but she says it is not enough. "These embedded mental health clinicians are quickly at capacity and can't see all the patients that are in need. Primary care providers must be competent and confident in handling common mental health conditions to provide this access to care for their patients."

"The American Academy of Pediatrics made a recommendation a few years ago that every child 12 and up should be screened for depression at every visit," Teague said. "I can tell you though, that doesn't happen. You've got someone coming in for an ear infection, or coming in for a cough. Who's screening them for depression? Because of our fee-for-service model, the time limits on patient visits don't really support that very well," she said. "As a result, these screenings are only happening at yearly check-ups and we are missing enormous opportunities to help."

Regardless, Caspi encouraged patients to share their mental health concerns with their doctors. "Don't be shy," he said. "Because they are seeing this a lot."