National analysis reveals mental health issues are a significant part of primary care practice

A study of millions of patient consultations with general practitioners shows that mental health problems are second only to musculoskeletal disorders in daily care. One in nine patients consults primarily because of a mental health problem.

“These primary care physicians are the gatekeepers of the study,” said study leader Avshalom Caspi, the Edward M. Arnett Professor of Psychology and Neuroscience at Duke University. “Data from primary care physicians allows us to see people from their first encounter with the health care system.”

The researchers examined more than 350 million primary care visits for 4.8 million people between January 2006 and December 2019, according to Norwegian government data. The primary health problem of each visit was coded by the doctors, allowing the researchers to take a deep look at what these doctors see every day. The study is published in Nature Mental Health.

“The idea was to see what parts of the body they were treating,” says Caspi, who helped develop a tool to measure the rate of a person’s aging. “It turns out that 12% of all GP consultations are for mental health issues. So out of 350 million consultations, over 40 million are for mental health issues.”

The data covers 14 years, up to 2019, before the pandemic, and reflects a purely Norwegian population with a socialized health system. Norway is one of the richest countries on the planet, with virtually no extreme poverty, and ranks seventh in a global measure of the happiest countries, while the United States does not even make the top 20.

But it’s still useful to know how mental health is being addressed in primary health care, Caspi said. “This is the complete record of people from 0 to 100, from all walks of life.”

The prevalence of mental health problems was roughly equal to the number of consultations for respiratory and cardiovascular problems, and higher than that of consultations for infections, injuries, digestive, skin, urological or sensory problems.

Caspi said the most important takeaway is that the number of mental health visits primary care physicians make is second only to pain and aches. While it’s mostly depression or anxiety, they see “diverse and complex conditions,” including psychosis. “Looking at all of this, I’m just amazed at the complexity of the mental health issues that primary care physicians have to deal with,” Caspi said.

Depression, sleep disorders, stress and anxiety, memory problems and substance abuse top the list. But other concerns include ADHD, learning disabilities, post-traumatic stress, eating disorders, sexual problems, psychosis and suicidal thoughts.

Caspi adds that it’s also important to note that “this doesn’t just happen at one point in life, but everywhere, in every age group,” he said. Mental health issues peaked in the 1940s, when one in five visits to a primary care physician was related to a mental health issue.

“A primary care physician, on any given day, is going to encounter mental health issues in pediatric patients, in geriatric patients and in middle-aged adults,” Caspi said.

“This report underscores what has become increasingly clear in medicine: Without targeted efforts to expand mental health services in primary care, the medical system will not meet the mental health needs of those it serves,” said Dr. Damon Tweedy, professor of psychiatry and behavioral sciences at Duke Health, who was not involved in the study.

Post-pandemic, this trend is also inevitable in pediatric primary care, said Malinda Teague, a clinical assistant professor at the Duke School of Nursing who was not involved in this study. “Even if it’s a routine visit for a well-child, almost all children come in with concerns about their behavior, anxiety or depression.”

Caspi isn’t suggesting that primary care physicians need to be better trained in mental health, but he would like to see mental health professionals better integrated into the primary care model. “You go to your primary care physician and you have a mental health issue. And they say, ‘Let’s go down the hall and we’ll help you.’ That’s called a warm handoff, and the VA has done a good job of that.”

Teague agrees, noting that Duke’s pediatric primary care already has a similar model, but it’s not enough. “These embedded mental health clinicians quickly reach capacity and can’t see all the patients who need them. Primary care providers need to be skilled and confident in managing common mental health issues to provide that access to care for their patients.”

“The American Academy of Pediatrics recommended a few years ago that every child 12 and older be screened for depression at every visit,” Teague said.

“I can tell you that this doesn’t happen. Someone comes in with an ear infection or a cough. Who screens them for depression? Because of our fee-for-service model, the patient consultation times aren’t really geared toward that,” she said. “So these screenings are only happening at annual visits, and we’re missing out on huge opportunities to help.”

Regardless, Caspi encouraged patients to share their mental health issues with their doctors. “Don’t be shy,” he said. “Because they see this a lot.”