© iStock/iStock Barriers to mental health services are being lowered by offering services at primary care clinics.
The appointment started out routine enough: a patient in need of help for high blood pressure. Then, said Kristen James, a family medicine doctor-in-training, the patient started crying, and it turned into a mental health visit.
It wasn’t the first time that happened in the South Los Angeles clinic where James works as a third-year resident physician — and it won’t be the last.
Primary care providers are at the forefront of the nation’s deepening behavioral health crisis because when patients walk into a doctor’s office, they bring all their needs with them. Asthma. Anxiety. Diabetes. Depression. Sniffles. Stress.
“We artificially separate ‘this is a mental health issue’ and ‘this is a physical health issue,’” said Lisa Barkley, a doctor and director of the family medicine residency program at Charles R. Drew University of Medicine and Science, where James is training. “But really, people are just coming in for their issues.”
A growing number of providers — like those at Charles Drew — are integrating behavioral health and primary care to improve the continuity of treatment and lower barriers to access.
Now, the federal government is trying to bring down those barriers, too, by awarding 24 medical schools and hospitals a total of $60 million to train the next generation of primary care physicians — family medicine doctors, pediatricians, internists — to address behavioral health needs.
“Primary care physicians — or providers — are the front line. They know the patients. They know the families. They know when someone is struggling,” said Sarah Abdelsayed, a family medicine and addiction medicine physician at the University of Buffalo. “Some people might not be comfortable going to a therapist’s office. They might not be comfortable hearing the word [therapy].”
Although behavioral and physical health are deeply intertwined, the two forms of care are often siloed in a poorly coordinated system. And patients often fall through the cracks of the disjointed system when they are referred to an outside specialist.
The barriers to care are many: provider shortages, high out-of-pocket costs, gaps in insurance coverage, stigma and shame. For marginalized communities, the obstacle course to access includes additional hurdles added by centuries of racial animus, class resentments and geographic isolation.
Sometimes, patients are so focused on their physical ailments — things like feeling run down or headaches — that if “the first thing out of your mouth is, ‘well, this is from your depression,’ they’re not going to trust you,” Abdelsayed said. “They’re going to think you’re writing them off or being dismissive.”
This can be especially true when working in communities where trust of the medical profession is tenuous, she said. So, Abdelsayed addresses physical complaints first, then introduces concerns about patients’ mental well-being in a more open-ended fashion by asking, “Could this potentially be from all the stress going on at home? I’m not saying it’s only that, but I’m worried that might be making it worse. What do you think?”
The goal is to give people the space to share and to ensure they’re heard, she said, noting that it was common for appointments to last about an hour in her Buffalo offices after a racially motivated mass killing at a supermarket in a predominantly Black neighborhood in the city.
If patients need support beyond what primary care providers can offer, they don’t have to go somewhere else to get it with an integrated care model, often on-site. In such a setting, there’s a behavioral health team, social workers, therapists or psychiatrists often. Experts say this helps foster discretion and dignity, because people could be sitting in a waiting room for myriad reasons.
“We’ve grown comfortable with colleagues having diabetes, having serious things like cancer, but if they say they have a behavioral or substance use issue,” that same grace often is not extended, said Millard Collins, a family medicine physician who is a professor and chair of the family and community medicine department at Meharry Medical College in Nashville. “If I’m suffering, especially in the day of the cellphone, I don’t want to walk into a place that shouts my business.”
Using money from the federal grant, family medicine residents at Charles Drew — which is a historically Black college and university in Los Angeles — will do more mobile outreach, caring for young people in homeless encampments and at community organizations. At Meharry, doctors training in family and preventive medicine will work on motivational interviewing skills, learning to skip stern lectures and scare tactics when talking to patients and to instead uncover their motivation for change. And family medicine residents at the University of Buffalo will deepen their understanding of how to use medication treatment for opioid use disorder.
At the Montana Family Medicine Residency, the grant will help improve technology at six remote locations.
“Montana only has 1 million people total, but if you look corner-to-corner across the state, it’s the same distance from Chicago to Washington, D.C.,” said Julie Kelso, a psychiatrist and faculty member with the Montana Family Medicine Residency, which is based at an integrated primary care clinic where she is a staff member. “If we can get technology connectivity, we can have residents out at those clinics and they can get precepting — supervision — from attending physicians remotely.”
If the nation is going through a provider shortage, then Montana is in famine. A 2018 study in Psychiatric Services, which is published monthly by the American Psychiatric Association, estimates there will be 14 psychiatrists for every 100,000 adults nationally in 2024. In Montana, a state with one of the highest suicide rates, Kelso said, the ratio is about half the national average.
“Kids are really worried about climate change. They have active shooter drills, so they’re worried about school shootings. They are kids who experienced isolation during covid — so much loss during covid,” Kelso said. “That doesn’t take into account social media and cyberbullying and high rates of child poverty.”
As of September, researchers said the coronavirus pandemic left more than 310,000 of the nation’s children without their primary or secondary caretaker, or put another way: One out of every 79 Native American children. One out of every 148 Black children. One out of every 206 Latino children. One out of every 308 White children. One out of every 386 Asian children.
In October, the U.S. Preventive Services Task Force recommended all 12-to-18-year-olds be screened for depression and 8-to-18-year-olds for anxiety, noting that a constellation of factors, such as the trauma of losing a parent, increases risk.
“It is never going to be the case that we’re going to meet all children’s mental health needs and adolescents’ mental health needs if we just say it has to be the work of psychiatrists and social workers,” Carole Johnson, administrator of the Health Resources and Services Administration, said while visiting Charles Drew in January.
While the federal grant helps address the physician shortage in communities most in need, Johnson said she worries about another obstacle to access, including for mental health services: patients who will lose health insurance when Medicaid recipients are once again subject to reviews of who should be on the rolls starting in April. That’s because of the end of the coronavirus-related public health emergency, which prohibits states from kicking people off Medicaid during the federal disaster.
“That’s going to be a complicated moment for everyone we serve,” Johnson said. “That is our front-burner concern.”
The uncertainty about the months ahead extends across the country as massive coverage losses loom, which can only exacerbate existing mental health challenges.
Before the pandemic, nearly 40 percent of young people reported experiencing persistent feelings of sadness and hopelessness, and depression was one of the nation’s most debilitating conditions, according to a Centers for Disease Control and Prevention study. But research shows less than 20 percent of patients with depression are seen by psychiatrists or psychologists, and most of the nearly 14 million patients who experience a major depressive episode were seen in primary care settings.
“For me as a family physician, at least 65 percent of what we deal with is influenced by behavioral health and mental health,” Collins said.
Chronic diseases have associated conditions and adjustment periods, Collins said, noting that he sees a lot of patients with end-stage renal disease resulting from diabetes and requiring dialysis. And it’s not just a matter of physical ailments.
“It is an incredible, life-altering adjustment having to go and plug yourself in for four to six hours a week. It can be depressing,” Collins said. Then, he added, there are the patients who come in distraught from trying to “extrapolate things from insurance” or understand aftercare instructions they received when leaving the emergency room.
“Mental health must be assessed every time they come,” Collins said. “I don’t treat just one organ.”
