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Why Primary Care Clinicians are Key to Identifying and Addressing Behavioral Health Stressors

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How can primary care physicians become more effective in recognizing, referring, and/or treating stress and common behavioral health conditions?

The ongoing pandemic has been stressful on patients and their families. A survey from this year shows that 4 in 10 adults report symptoms of anxiety or depression — versus only 1 in 10 pre-pandemic. Many of those needs are subclinical and are not being addressed by clinicians. The CDC’s Household Pulse Survey shows that between August 2020 and February 2021, the percentage of unmet mental health needs increased significantly from 9.2% to 11.7%. This is leading to mounting psychological distress and can contribute to increasing substance use issues.

Let’s face it: There are not enough psychiatrists to meet these needs now and there will continue to be a shortage over the next decade. An even larger problem is the amount of subclinical needs that have not yet been recognized or classified as anxiety or depression. Everyday stressors contributing to these needs, such as worry, sleep issues, relationship challenges, burnout at work, and life transitions, can have a profound impact on an individual’s overall health and well-being. For example, our group has found that these unaddressed factors lead to less control of hypertension, and others have found that behavioral health issues have impacts on common medical conditions like diabetes, CHF, and asthma.

Primary care physicians need to become more aware of these subclinical behavioral health needs to more proactively address them in daily practice. Systematic screening can help, via PHQ-2 questions and the broader PHQ-9 assessment when indicated. The latter calculators are available for use on handheld devices, and some EMRs have them embedded, ready for daily use. Importantly, stigma may make some patients hesitant to share mental health concerns — so practicing compassionate listening counts for a lot. We have been surprised at how often mild, moderate, or even severe depression is identified when the patient is systematically classified on a symptom calculator. Yet current studies show only 5% of patients are screened for depression in U.S. primary care visits.

Though calculators are useful, there are other patients with bothersome subclinical needs who will not score as being depressed. This is problematic, as unaddressed subclinical stress can progress to more serious behavioral health problems. In primary care, our colleagues have found that routinely asking an open-ended question such as “are you in good spirits these days?” at the start of a visit is useful in revealing some of these subclinical, as well as clinical, concerns. For patients you know, asking about their family members’ well-being is another easy way to get patients talking about these stressors.  

In addition, low-barrier support options such as coaching can help individuals develop coping skills and resilience to bounce back from life’s challenges — especially as we continue to wade through the COVID-19 pandemic and various natural disasters. Increasingly, there are digital apps and other self-help websites that may be a good fit for patients or their family members who need these types of subclinical support. 

Why do PCPs need to listen, lean in, and step in to this? Referring to behavioral health specialists is challenging in too many zip codes. A dearth of clinicians has created mental health deserts across the country where individuals can’t access care in a timely manner. Over 119 million Americans, or more than a third of the entire U.S. population, live in areas with mental health clinician shortages. In some of the largest U.S. cities, it takes an average of 25 days for new patients to see a psychiatrist. 

Outside of major U.S. cities, wait times are often much longer — if behavioral health clinicians are available at all. A study in the American Journal of Preventive Medicine found that 65% of non-metropolitan counties lacked a single psychiatrist, and 47% lacked a psychologist. Even before the pandemic, the National Institute of Mental Health reported that more than 20% of American adults experienced some form of mental illness, but fewer than half received treatment. Another study found that the average delay between the onset of mental illness symptoms and effective treatment is an astounding 11 years! For patients being treated by a psychiatrist for depression, a study found the odds of achieving response and of remission increase significantly as the time between appointments is reduced.

Many health systems, health plans, and employers have turned to virtual care visits to provide faster access to behavioral health specialists across the country, thus democratizing access. We find patients like ready access to a video visit for behavioral needs from the privacy of their bedroom, their car, or a quiet space during the workday. 

Over the past few years, our group has also emphasized national guidelines for referrals for possible bipolar disorders, suicidality, and treatment-refractory depression. Breaking down barriers between sharing of medical records is helpful in coordination of care and in avoiding potential medication interactions, which are many. 

Additionally, resources such as coaching, telephonic follow-ups, and deployment of self-help apps may be useful to patients and their family members. PCPs can utilize these as part of a preventive approach to subclinical behavioral health needs. 

The role that PCPs play is an increasingly important one. We believe that by leveraging continuing medical education, they can step in to help patients and their families in meaningful ways. 

What are other ways PCPs can help tackle patient stress and behavioral health issues? Share your thoughts in the comments below.

Nikole Benders-Hadi MD is a board-certified psychiatrist in New York State. She serves as Medical Director for Behavioral Health at Doctor On Demand.

Prentiss Taylor Jr., MD, FACP, is an Attending Physician with Advocate Christ Hospital in Metro Chicago. He is a graduate of Harvard Medical School, the Kellogg Business School, and is a Fellow of the American College of Physicians plus a Fellow of the American College of Preventive Medicine. He has been chosen by peers as a Top Doctor by Chicago Magazine or US News, multiple times, including in 2020. He also serves nationally as Vice President for Medical Affairs at Grand Rounds Health/ Doctor on Demand, a national health navigation service for patients.

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