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Each week, Health Affairs Editor-in-Chief Alan Weil brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
00;00;00;01 - 00;00;35;17
Alan Weil
Hello and welcome to “A Health Podyssey”. I'm your host, Alan Weil. As Americans needs for mental health services have grown. The limited capacity of the nation's mental health professionals to meet those needs is becoming more clear. Now, primary care clinicians have always played a role in identifying and treating mental health conditions. But as authors of a recent article published in Health Affairs Forefront note, primary care physicians are now literally the frontline workforce for the country's behavioral health crisis.
00;00;36;01 - 00;01;06;25
Alan Weil
So what role do primary care physicians play in meeting mental health needs? That's the topic of today's episode of “A Health Podyssey”. I'm here with Lisa Rotenstein, assistant professor at Harvard Medical School and medical director for Population Health at Brigham and Women's Hospital. Dr. Rotenstein and coauthors published a paper in the February 2023 issue of Health Affairs, examining the prevalence of mental health treatment during primary care physicians visits between 2006 and 2018.
00;01;07;01 - 00;01;19;15
Alan Weil
They found a significant increase in the role primary care plays in treating mental health concerns. We'll discuss these findings in more detail in today's episode. Dr. Rotenstein, welcome to the program.
00;01;20;12 - 00;01;21;18
Lisa Rotenstein
Thanks so much for having me.
00;01;22;07 - 00;01;50;16
Alan Weil
It's a really important topic and we tend to think a lot about mental health and mental health professionals. But as I noted in the introduction, people have always gone to their primary care physicians and been screened for and diagnosed with and treated for mental health conditions. So it would be really helpful if you could start by just stepping back from your paper and giving me and our listeners a sense of the prevalence of mental health concerns and mental health conditions in the United States.
00;01;50;16 - 00;01;54;26
Alan Weil
Are people getting treatment? We hear about mental health crisis. What does that mean?
00;01;55;12 - 00;02;20;27
Lisa Rotenstein
It's a really important question. We know that mental health conditions are common in the United States. And according to the National Institutes of Mental Health, one in five Americans, 20% of Americans, lived with a mental health condition in 2020. That's 53 million people. And yet only 46% of those adults received mental health services in the last year, and that was pre-pandemic.
00;02;21;09 - 00;02;45;03
Lisa Rotenstein
So the COVID pandemic has only accelerated the demand for mental health treatment. For example, there was a report from the World Health Organization that described a 25% increase in the prevalence of anxiety and depression. And then data from the U.S. suggests that one in four adults actually had anxiety or a depressive disorder in 2021. So the issue has only been magnified.
00;02;45;25 - 00;03;17;21
Lisa Rotenstein
And yet there aren't enough psychiatrists to meet this demand. Again, a study from before the pandemic projected a shortage of between 14,000 and 31,000 psychiatrists by 2024. And we only expect this shortage to be enhanced by the increase in demand for mental health care, given the trends we saw with the COVID 19 pandemic. The other issue is that patients may have limited access to specialty mental health care due to geography or insurance coverage.
00;03;18;02 - 00;03;23;17
Lisa Rotenstein
And as you noted, this results in primary care delivering a substantial portion of mental health care.
00;03;24;25 - 00;03;47;23
Alan Weil
Now, you mentioned anxiety and depression, and we're not going to go deep on the clinical side of this. But when you say something like one out of five people have a mental health condition, presumably that's a big range from what might be seen by some as smaller or more minor concerns all the way to very significant ones that affect people's ability to function on a daily basis.
00;03;47;27 - 00;03;56;24
Alan Weil
Can you just give us a little texture when you say 20% in mental health, what kinds of conditions are we talking about here?
00;03;57;12 - 00;04;30;08
Lisa Rotenstein
It's a great question. And yes, there definitely is a range. And so as we describe in the paper, there's ones that we might be more familiar with and which primary care physicians may be more familiar with treating and then others that may be less obvious. So a mental health condition could range from depression and affective disorders to anxiety and stress related diagnoses, to bipolar disorder, to serious mental illness and psychotic illnesses.
00;04;30;20 - 00;04;41;12
Lisa Rotenstein
And then also disorders resulting from psychoactive substances. And again, these are just a sampling of the potential diagnoses. But as exactly as you note, there is a range.
00;04;41;25 - 00;05;09;15
Alan Weil
So given that spectrum and given what you said earlier about the shortage of psychiatrists and highly trained mental health specialists, when a person, when we think about a person receiving mental health treatment, what is the difference from a patient's, from a care perspective of getting that care potentially from a primary care physician or from a specialist?
00;05;09;28 - 00;05;37;24
Lisa Rotenstein
So in an ideal world, we'd have enough mental health professionals to provide all of the mental health care needed. And these professionals all just note they range from psychiatrists to psychologists to therapists to many others. But right now we have a real shortage of mental health professionals. So I will note that primary care doctors, especially with support from other members of the behavioral health team, can provide excellent and appropriate mental health care to their patients.
00;05;38;11 - 00;06;04;01
Lisa Rotenstein
For example, the impact study showed that a significantly greater proportion of older adults receiving care for depression in primary care as part of the collaborative care model, which involved a primary care physician and then a consulting psychiatrist and a depression case manager. So patients who received care through this model had a greater reduction in depressive symptoms than those receiving what we called usual care.
00;06;04;01 - 00;06;28;25
Lisa Rotenstein
And some of those patients receiving usual care received specialty care. But coming back to the question of mental health diagnoses and them having a broad distribution. So some diagnoses such as depression and anxiety are really the bread and butter of primary care and primary care doctors feel comfortable treating these diagnoses. That being said, specialized mental health providers can be really helpful.
00;06;28;25 - 00;06;52;02
Lisa Rotenstein
For example, in treatment of refractory cases or more complex cases. And then on the other hand, primary care physicians may have varying comfort levels with treating other diagnoses. So, for example, such as bipolar disorder or psychotic disorders. And in these cases, access to specialty mental health care is really valuable and truly important.
00;06;52;26 - 00;07;24;17
Alan Weil
I'll just simplify, and it sounds like you can get really good care from either place, but it has to be a fit from both the patients and the clinicians perspective. And sometimes the fit is real good and sometimes it's not going to be so great, which means that we really do need capacity in the primary care side, given both the limitations of capacity on the mental health clinician side as well as just accessibility of services.
00;07;24;18 - 00;07;42;28
Alan Weil
So let's turn to your study. You were looking at the prevalence of mental health concerns being addressed in the primary care setting. Just give us a sense, if you could, of the main findings about how often those concerns came up in primary care visits and how that's been changing over time.
00;07;43;20 - 00;08;09;28
Lisa Rotenstein
We found that the proportion of primary care visits that addressed a mental health concern as part of the visit increased by over 50% from 2006 to 2018. So visits involving a mental health concern comprised 10.7% of visits in the 2006 to 2007 timeframe. And this is in contrast to them comprising 15.9% of visits by 2016 to 2018.
00;08;10;08 - 00;08;25;18
Lisa Rotenstein
And we used a nationally representative dataset so our numbers and the proportions we are describing represent care delivered in a variety of settings across the United States.
00;08;26;12 - 00;08;50;12
Alan Weil
So this is a huge increase in the role of primary care. And your study looked at a number of dimensions of that increase. Maybe I'll start with this question that you focused on, which is people going to their regular primary care doctor as opposed to a primary care doctor who they don't typically see. And what's the difference between those two circumstances?
00;08;51;18 - 00;09;20;03
Lisa Rotenstein
We found that the proportion of visits that addressed a mental health concern was significantly higher. If the patient was seeing their usual primary care physician, their own primary care physician versus another primary care provider (PCP). So in 2006 to 2007, it was 11.2%. If the patient was seeing their own PCP versus 8.9% if they were not. And then by 2016, 2018, it was 16.8%.
00;09;20;09 - 00;09;50;16
Lisa Rotenstein
If they were seeing their usual PCP versus 12.4% if they were not. What does this tell us? It tells us that in a world of increasing on-demand health care options, there is still a real importance of having a usual primary care doctor and the relationship and the context that comes with that and the trust. And so it highlights the need for consistent primary care, continuous primary care and systems that support that.
00;09;50;17 - 00;10;21;11
Lisa Rotenstein
It's notable that periodic health exams have actually been associated with establishing a relationship with the PCP, in addition to helping to identify chronic diseases and management of those chronic diseases. But what our data suggests is that situations where there is an opportunity to develop a relationship that can persist over time, also create the opportunity to raise mental health concerns.
00;10;21;26 - 00;10;58;04
Alan Weil
That just makes so much sense as a patient that higher levels of trust and knowledge and comfort with your clinician would make it easier to move into these areas. I'd like to talk to you about some of the other dimensions of differences you found. We'll have time to cover some more topics after we take a short break. And we're back.
00;10;58;05 - 00;11;24;02
Alan Weil
I'm speaking with Dr. Lisa Rotenstein about the increasing role of primary care visits, covering mental health topics as opposed to people going just to mental health specialists. Before the break, we discussed the importance of a long standing relationship that people are more likely to turn to mental health issues if they're seeing their usual primary care physician.
00;11;24;17 - 00;11;37;07
Alan Weil
There are some other dimensions that you looked at in the paper. One had to do with shifts in which disorders patients were seeking treatment for. I thought this was really interesting. Could you say a little bit about how that's changed?
00;11;38;14 - 00;12;14;20
Lisa Rotenstein
So in the paper you'll see that we were able to describe changes in diagnoses addressed within the context of primary care over time across multiple categories. And what I would say is most notable is that we saw a significant increase in anxiety and stress related diagnoses addressed in primary care visits over time. So they started at about 29.9% of the primary care visits in 2006, 2007 and then increased to 34.5% by 2016, 2018.
00;12;14;21 - 00;12;50;12
Lisa Rotenstein
They peaked at 38% in 2014 to 2015. Interestingly, at the same time, we saw that the proportion of visits addressing depressive symptoms decreased. So they started out at 32.4% in 2006 to 2007 and they were 20.8% by 2016, 2018. It's notable because depression and anxiety often occur together, and it's possible that our findings actually reflect physicians becoming more comfortable over time with diagnosing and treating anxiety in the primary care setting.
00;12;50;12 - 00;13;06;19
Lisa Rotenstein
And so perhaps symptoms that may have been categorized as depressive symptoms earlier on in the course of our study were now being categorized as anxiety or stress related diagnoses. And this has been shown in other research as well.
00;13;06;24 - 00;13;24;23
Alan Weil
And I know you said this earlier, but we should just remember this is all before COVID. And so some of these numbers could have changed significantly in the wake of COVID as well. You also looked at the race and ethnicity of patients, and I wonder if you could say a little bit about the differences you observed across that dimension.
00;13;25;10 - 00;13;54;16
Lisa Rotenstein
So we found that black patients were 40% less likely than white patients to have a mental health concern addressed during a primary care visit. And Hispanic patients were 40% less likely than non-Hispanic patients to have a mental health concern addressed during a primary care visit. And this is despite the fact that a nationally representative surveys we do see similar or slightly lower rates of mental health conditions such as depression among Hispanic and nonwhite individuals.
00;13;55;26 - 00;14;31;22
Lisa Rotenstein
So we wouldn't expect to see such stark differences in the data just based on prevalence alone. What our data does not tell us is why and I think that is the key question. So further work really is needed to identify what are the process disparities, perhaps different screening rates or structural barriers, whether it's access to care or insurance coverage or reimbursement of mental health services or communication barriers that actually have been shown to contribute to less common treatment of mental health conditions in primary care.
00;14;32;05 - 00;14;39;08
Lisa Rotenstein
What are these contributing factors for racial and ethnic minority patients? And then how do we act on these factors?
00;14;39;24 - 00;15;03;13
Alan Weil
So your work here goes into a lot of detail on what's going on. But the overall picture, as we started with, is just this increasing role and important role for primary care. Given that you say in the paper, I'll read a little quote here that, “We need to be equipping primary care providers to address mental health needs.”
00;15;03;21 - 00;15;25;19
Alan Weil
So that sounds right. They have a bigger role here and therefore they should be ready for it. I'm going to ask you to move a little bit from your researcher hat to your clinician hat and say, what does that mean? What kind of equipping is needed? What would help make sure that when people turn to their primary care physician, they get what they need?
00;15;26;23 - 00;15;52;29
Lisa Rotenstein
I'll start off by saying that I do think that primary care providers are a great starting point for diagnosing and addressing mental health concerns. And this is the right work and this is the work that many primary care physicians are in a great place to do. That being said, they often would benefit from extra skills and extra supports around them in order to deliver care that is right for even more people.
00;15;53;07 - 00;16;22;26
Lisa Rotenstein
And then additionally, under the current reimbursement system, primary care is not adequately compensated for the work necessarily involved in managing mental health conditions or for the teams that are involved in effectively treating mental health conditions. And I'll just underscore that to deliver mental health care effectively really requires a multidisciplinary approach that can take a variety of formats. It could include co-located therapy or psychiatry resources.
00;16;23;04 - 00;16;50;08
Lisa Rotenstein
It could include e-consultation services that help PCPs manage medication regimens. Longer visit lengths that provide time to address patient's physical needs and their mental health needs. And similarly, documentation systems that facilitate addressing both those sets of needs. And there's multiple models that have been studied over time from co-location, such as there have been studies actually published in Health Affairs
00;16;50;08 - 00;17;24;02
Lisa Rotenstein
looking at that in the Veterans Health Administration or collaborative care, which I lead at my own institution, in which a care manager conducts telephonic check-ins with patients and they provide self-management support and motivational interviewing, and they work as part of a team with the PCP and a consulting psychiatrist. But all of these models require additional supports with for primary care practices, whether it's explicit relationships with mental health providers or adding new members to the team, and then having the financial resources to do so.
00;17;24;15 - 00;17;47;13
Lisa Rotenstein
And so ultimately, this requires a funding structure that supports these extra resources or a kind of reimbursement structure that incentivizes providers and systems to take care of the whole patient rather than focusing on visit based care. And that ultimately, I think, will enable us to provide the mental health care that that we want to provide and can provide.
00;17;48;05 - 00;18;06;23
Alan Weil
So that sounds like a heavy lift, but an important one. But it also makes me wonder. You talk about these things to equip primary care. It sounds to me like a lot of the infrastructure you describe there would also be helpful for the mental health specialists when they're providing care, too. So this isn't really sort of an either/or.
00;18;07;00 - 00;18;12;24
Alan Weil
This is, as you say, it takes a team based approach. Is that a fair observation?
00;18;13;13 - 00;18;42;07
Lisa Rotenstein
I would agree with that. It takes a team based approach. And I think, though, that that approach is particularly important in primary care where, you know, we get a broad range of training. And so in some instances, as I mentioned, certain diagnoses are bread and butter, and certain diagnoses may have us leaning on the expertise of other members of the team relatively more heavily.
00;18;42;26 - 00;19;04;22
Alan Weil
That makes a lot of sense to me. So as we're finishing up, I'm just curious, this is a really important trend you're documenting here and you've talked a little bit about what it's going to take to support primary care. Putting your research hat back on, what questions come out of this work and your practice that maybe you'll take a look at next?
00;19;05;18 - 00;19;36;00
Lisa Rotenstein
I think, well, there's many interesting questions that arise from this and a few that I am particularly interested in have to do with the reimbursement systems and payment structures that most effectively allow us to deliver the integrated behavioral health we know is right. So that's a first one. I think that there are interesting questions around patterns of mental health delivery in primary care based on the physician and the patient gender.
00;19;36;09 - 00;19;54;24
Lisa Rotenstein
And then as we talked about earlier, I think it's crucially important for us to understand in more detail the why behind the racial and ethnic disparities we identified, because that's really not an acceptable trend. And so we should be working to address that.
00;19;55;09 - 00;20;09;24
Alan Weil
Well, Dr. Rotenstein, thank you for the research and for explaining it so clearly, for continuing to improve our understanding of not just what we have, but where we need to go. And thank you for being my guest today on “A Health Podyssey”.
00;20;10;21 - 00;20;13;11
Lisa Rotenstein
Thank you so much.