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Mental health should be an extension of primary care

Article

Addressing the mental health crisis requires an integrated approach to physical and mental health

It’s clear that we need a new approach to address the country’s urgent mental health crisis. Nearly one in three U.S. adults experienced a mental health condition or substance use disorder in the past year. Since the pandemic began, we’ve seen concerning increases in the rates of anxiety and depression, as well as deaths resulting from alcohol, overd

Anisha Patel-Dunn, DO, chief medical officer at LifeStance. ©LifeStance

Anisha Patel-Dunn, DO, chief medical officer at LifeStance. ©LifeStance

ose, and suicide. The impact on children and teens is particularly alarming, with adolescent suicide rising 29% over the previous decade.

One major hurdle is the lack of access to mental health care. More than 150 million people live in an area with a shortage of mental health professionals, while only 56% of psychiatrists accept commercial insurance. This means many people don’t have access to the care they need, creating ripple effects across families and communities.

In my nearly two decades as a psychiatrist, I’ve seen firsthand the link between mental and physical health. Sleep, nutrition, accidents, and chronic illnesses all have major impacts on our mental health, yet it is often only the physical symptoms that are treated. Poor mental health is a proven risk factor for chronic physical conditions, and good mental health care helps us to effectively manage those conditions.

To address the urgent mental health crisis, we must take an integrated approach. Here are three ways we can begin to break down silos between mental and physical health care, arm health care workers with the tools they need to support mental health and, ultimately, deliver more effective patient care.

Make mental health an extension of primary care

Primary care physicians (PCPs) and pediatricians play an important role in recognizing when a patient is experiencing symptoms of a mental health condition. However, there are numerous roadblocks that may keep a patient from accessing mental health support at the suggestion of their PCP; for example, having to find a separate provider and wait weeks to be seen. This means patients can fall through the cracks and don’t receive the comprehensive care they need.

Without an integrated approach to care, there’s also a risk that underlying mental health conditions may be missed. I’ve seen this happen with adult patients suffering from panic attacks. They go to their doctor’s office or to the emergency room experiencing chest pain and shortness of breath, which require extensive workups to evaluate, and are not asked about key risk factors for anxiety disorders.

Integrating mental health into primary care could enable patients to consult with a mental health clinician right from their doctor’s office. Ideally, every primary care practice should have at least a part-time mental health clinician available as a member of the treatment team, either virtually or in-person.

In the above example, that patient would be asked about their psychological symptoms earlier on, leading to a more accurate diagnosis, earlier intervention and treatment, and cost savings. When PCPs identify a patient with underlying mental health symptoms, they can more quickly connect them with the right resources and facilitate effective treatments, ultimately improving the patient’s quality of life and decreasing the likelihood they’ll need more acute care down the road.

Invest in preventive mental health services

While prevention is a big focus of primary care, the dominant approach to mental health care continues to be reactive. Too few resources are dedicated to prevention, and a patient often isn’t connected to care until they’re experiencing a crisis, which can lead to serious consequences at work or home.

Known as the prevention paradox, the majority of illnesses and deaths that result from mental health and substance use disorders are attributable to those with mild or moderate symptoms, who make up a much larger percentage of the population than those with severe mental illnesses. A more upstream approach is needed to prevent these individuals from progressing.

There are critical touchpoints in primary care, such as prenatal visits, well child visits, and annual physicals, that provide an opportunity to identify, prevent or mitigate mental health and substance use conditions. One important step involves universal screening for these conditions within pediatric, primary care, and other opportunistic medical settings.

If patients are asked to complete mental health questionnaires while in their PCP’s waiting room, those providers can better identify early symptoms in patients who may not even recognize them in themselves. From there, PCPs can connect patients with the right resources to establish a collaborative care team that offers a whole-person approach to healthcare.

Another step is offering early intervention in school systems. Half of individuals who develop a mental health condition will show symptoms by the age of 14. Early intervention can make an impact, and research points to an urgent need to support teens and adolescents. Teen girls and LGBTQ+ teens in particular are facing increased mental health challenges. A similar screening process can be used in schools to identify early symptoms and connect individuals with the proper care. In fact, the U.S. Preventive Services Task Force has recommended that all 12-to-18-year-olds be screened for depression, and all 8-to-18-year-olds be screened for anxiety.

Address barriers to implementing integrated care

Comprehensive training in integrated mental healthcare is a necessary precursor to an improved health system. Mental health clinicians, who are often trained to work in lengthy sessions across long periods of time, need skills in brief, time-limited therapies that can fit within the scope of fast-paced medical settings.

Medical professionals also need training in integrated care, including skills in screening, assessment, brief intervention, and effective referral making. Unfortunately, despite an emphasis on the importance of integrated care in both mental health and medical training programs, and many government programs (such as federally qualified health centers that provide funding for care delivery that is contingent upon providing integrated care), there are still major gaps in our implementation of integrated care.

For example, although routine depression screening is recommended in primary care, fewer than 5% of primary care visits include depression screening, and rates are even lower among African American and elderly patients.

Many argue that the most effective strategy to promote implementation may be revamping the way health care is reimbursed. In most current models, mental and physical healthcare are reimbursed per service, which does nothing to encourage cooperation across different types of care providers. Value-based care, on the other hand, reimburses care providers based on specific patient outcomes that are known to reduce disease. This could include screening for, preventing, and treating mental health conditions.

To successfully execute their training and effectively support patients’ mental health needs, clinicians must be supported by the broader health care system, and this likely involves a paradigm shift in the financial systems that underlie it.

Prioritize mental health

Physical and mental health are inextricably linked. Embracing this fact is a crucial step in addressing the country’s mental health crisis. The healthcare system must treat mental health with the same urgency, level of resources and emphasis on prevention as physical conditions. This requires all health care providers, regardless of discipline, to commit to collaboration and advocacy.

There is no reason to wait until a patient has a trifecta of heart disease, diabetes, and depression to offer holistic care. By breaking down the silos between physical and mental health, clinicians can better identify a patient’s full care needs and get them proper treatment before a crisis occurs.

Anisha Patel-Dunn, DO, is the chief medical officer at LifeStance.

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