Mental health disorders are so common that 1 in 5 adults in the U.S. experienced mental illness in 2018. But only 43 percent of adults with mental illness received treatment.
Why is that? There are several possible reasons. Though attitudes are improving, there is still a stigma associated with mental illness, and for that reason some people are reluctant to seek help. But often the problem is supply not meeting demand: Many communities, especially in rural areas, have few mental health care providers—or none. Even in areas with providers, people may have to wait a long time to get an appointment.
Screening and Treating Depression in Primary Care
Primary care providers, such as family doctors and internists, play an important role in providing mental health services. According to CDC data published last year, an annual average of 30 million mental health-related physician office visits were made by adults between 2012 and 2014. Psychiatrists provided care at 55 percent of these visits, while primary care physicians covered 32 percent.
Even when a patient ends up seeing a mental health professional, his or her treatment often begins at their primary care provider’s office. In fact, says Dana M. Neutze, MD, PhD, associate medical director of the UNC Family Medicine Center at Chapel Hill, “the majority of psychiatric care now starts in the primary care setting.”
Since 2002, the U.S. Preventive Services Task Force (USPSTF) has recommended screening in primary care of the general adult population for depression. In 2016, the USPSTF updated its recommendation to specifically mention both pregnant women and postpartum women (those who have recently given birth).
As a result of that recommendation, many primary care providers now include depression screening as part of a patient’s annual visit. A simple two-question form, called the Patient Health Questionnaire-2 or PHQ-2, is often the starting point. It asks how often, over the last two weeks, a person (1) has had little interest or pleasure in doing things, or (2) was feeling down, depressed or hopeless.
The PHQ-2 results in a score that ranges from 0 to 6. If a person’s score on the PHQ-2 is 3 or higher, that indicates depression is likely, and then he or she is given a longer, nine-question form, the Patient Health Questionnaire-9, or PHQ-9. It is used to provide a more detailed assessment of the person’s mental state and produces a score ranging from 0 to 27.
Depending on the patient’s score and symptoms, they may be prescribed antidepressants, referred for psychotherapy or both.
Dr. Neutze estimates that at her practice, as many as 20 percent of adult patients receive mental health services.
“In primary care, there are several antidepressants we can choose from and safely start a patient on,” she says. For many people, antidepressants and several follow-up visits may be all they need. But if a patient fails to show improvement after a few months, medications may need to be changed or it may be helpful to start psychotherapy if it wasn’t part of the initial plan. Patients with resistant depression who have tried multiple therapies may need to see a psychiatrist, Dr. Neutze says.
Depression, anxiety and emotional distress related to grief are the mental health issues that are most commonly treated by primary care providers, Dr. Neutze says. A person who has a condition that is more difficult to treat, such as bipolar disorder or schizophrenia, will typically need to see a psychiatrist. But once the person’s condition is stable, a primary care provider can often take over the role of prescribing medication refills.
The Difference Between Primary Care and Psychotherapy
It’s important to know that primary care visits tend to be much shorter than a therapy session and most general physicians won’t have training in psychotherapies such as cognitive behavioral therapy. If it’s determined that a patient needs to see a psychotherapist, the primary care provider can help with finding a provider, though a referral usually isn’t needed.
It’s important to bring up any concerns about your mental or emotional health with your primary care provider, Dr. Neutze says.
“I really want people to know,” she says, “that it’s OK for you to talk with your primary care provider if you are feeling depressed, anxious or have any other concerns about your mental health. You don’t have to wait for an appointment with a psychiatrist.”
A primary care provider can screen you for depression and begin mental health treatment if needed. Find a primary care provider near you.