Social isolation, economic instability, and health uncertainty — not surprisingly, the COVID-19 pandemic has taken its toll on mental health in the U.S. The Centers for Disease Control and Prevention (CDC) found that 41% of more than 5,000 survey respondents in June 2020 reported at least one adverse mental or behavioral health condition as a result of COVID-19, including symptoms of depression or anxiety.¹ In October 2020, the International Committee of the Red Cross found that up to 51% of adults perceive that COVID-19 has negatively affected their mental health. The committee has labeled the psychological distress caused by the pandemic a “crisis within a crisis.”²

One could argue that the U.S. faced a mental health care crisis long before the pandemic. In 2017, the Substance Abuse and Mental Health Services Administration (SAMHSA) found that although nearly one in five U.S. adults face a mental health condition each year, only 43% receive services.³ Despite this relatively high prevalence of mental illness, the Health Resources and Services Administration (HRSA) projects that by 2030 there will be a shortage of 12,530 adult psychiatrists to meet the demand of behavioral health disorders.⁴ Family medicine doctors can help fill this gap.

WHY FAMILY PHYSICIANS SHOULD ADDRESS MENTAL HEALTH

There are four primary reasons you should incorporate mental health care into your practice.

1. Your patients need you. Family physicians are in the best position to address behavioral health. Up to 80% of people with a behavioral health disorder will visit a primary care physician or other primary care provider at least once a year.⁵ Moreover, some patients would rather seek help from their primary care physician than a specialty mental health provider.⁶ Similar outcomes are seen when antidepressant medications are prescribed in either the primary care setting or the specialty setting, as revealed in the largest randomized controlled trial focusing on depression to date (the Sequenced Treatment Alternative to Relieve Depression study).^7,8 Research has suggested that, in addition to pharmacotherapy, brief psychotherapy for depression can be delivered effectively in primary care.^8,9 Of course, there are times when primary care physicians should refer patients to a behavioral health specialist. However, up to 50% of patients referred to an outpatient behavioral health clinic will not make their first appointment.⁵

2. You will be a better doctor. After treating your patients' psychological illnesses, you shouldn't be surprised when their physical health improves as well. In 2019, the Lancet Psychiatry Commission released a landmark meta-review of almost 100 systematic reviews and meta-analyses summarizing the link between physical and mental health. The commission reported that the risk of cardio-metabolic disease is up to two times higher for individuals with a mental health disorder compared to individuals without one.¹⁰ Patients with depression have a 40% greater risk of developing cardiac disease, hypertension, stroke, diabetes, metabolic syndrome, or obesity than the general population.¹⁰ Additionally, most top-tier evidence identifies increased levels of physical inactivity, sleep disturbance, smoking, excessive alcohol consumption, and poor diets in many patients with mental illness diagnoses.¹⁰ By addressing your patients' mental health, you will likely help them improve their physical health as well.

3. You will save the system money. As one of the leading causes of disability in the U.S.,¹¹ mental illness was projected to account for $238 billion in health care spending in 2020.¹² Of the top five conditions driving overall health costs (including work-related productivity and medical and pharmaceutical expenses), depression is ranked number one.¹³ In 2014, an analysis commissioned by the American Psychiatric Association found that health care spending on persons with comorbid mental health or substance abuse problems can be 2.5 to 3.5 times higher than for those without such problems.¹⁴ When mental illness is adequately addressed, overall health care costs decrease.

4. You could reap financial benefits. The benefits may stem from the following:

• Value-based care: As the Centers for Medicare & Medicaid Services (CMS) shifts from fee-for-service to value-based payment models, primary care physicians will need to focus on quality of care over quantity. If improved mental health leads to improved physical health and helps patients avoid costly care, not only will your patients benefit, but you may be reimbursed more.

• Risk-adjustment models: CMS uses hierarchical condition category (HCC) codes to adjust for risk and predict costs for Medicare Advantage beneficiaries. This directly affects the reimbursement health care organizations receive. Payers map ICD-10 codes to HCC codes based on severity of illness, and higher HCC risk scores lead to higher capitated, per member per month payments.¹⁵ Of the 86 HCC codes, “Major Depressive, Bipolar, and Paranoid Disorders” (59) and “Personality Disorders” (60) were among the most-used in 2020.¹⁶

• Time-based billing: The evaluation and management (E/M) coding changes that took effect Jan. 1, 2021, simplified time-based billing, making it easier for physicians to be appropriately reimbursed for mental health visits. Because clinicians can now code office visits based on total time spent, they may use that time to prioritize a patient's depression or anxiety without the burden of documenting irrelevant exam or review of systems bullet points.

HOW FAMILY PHYSICIANS CAN ADDRESS MENTAL HEALTH

Here are four ideas for incorporating mental health care into your practice.

1. Use telemedicine to expand access to mental health care. During the COVID-19 public health crisis, CMS has loosened regulations for telemedicine services for Medicare beneficiaries, even allowing audio-only telehealth visits. (See “These Four Telehealth Changes Should Stay, Even After the Pandemic,” FPM, May/June 2021.) The American Academy of Family Physicians offers guidance on how to implement telemedicine services in a practice and get reimbursed properly (see https://www.aafp.org/family-physician/patient-care/current-hot-topics/recent-outbreaks/covid-19/covid-19-telehealth.html).

2. Screen for both mental health and physical health. Since 2016, the U.S. Preventive Services Task Force has recommended screening for depression in the general adult population.¹⁷ The Patient Health Questionnaire (PHQ) is used for adults, the Geriatric Depression Scale for older adults, and the Edinburgh Postnatal Depression Scale for pregnant and postpartum women. The Lancet Psychiatry Commission has further recommended screening for physical disorders and associated risk factors among patients with mental illness.¹⁰ As our patients suffer from increasing mental illnesses, it is incumbent upon us to prevent their physical health from being neglected. We need to continually screen all our patients appropriately on exercise, diet, obesity, substance abuse, sleep, and cancer.¹⁰

3. Pursue behavioral health integration. According to the Lancet Psychiatry Commission, “within the broad category of integrated care, collaborative care models are emerging as effective approaches that can simultaneously reduce costs and improve clinical outcomes and treatment adherence in the management of both mental illness and chronic physical condition.”¹⁰ Three trials supporting this are the TEAMcare,¹⁸ COINCIDE,¹⁹ and the RAINBOW20 trials. Many resources are available to assist with initiating integrated care, including the SAMHSA-HRSA Center for Integrated Health Solutions, the Collaborative Family Healthcare Association, and the Patient Centered Primary Care Institute.

4. Improve education. To ensure family physicians are prepared for the responsibility of providing mental health care, the Accreditation Council for Graduate Medical Education (ACGME) for Family Medicine requires graduating residents be able to independently diagnose, manage, and coordinate care for common mental illness in patients of all ages. However, a 2016 study found that a large percentage of residents reported a “lack of self-perceived competency in cognitive behavior therapy, psychopharmacology beyond basic antidepressants, and application of basic counseling skills.”²¹ Strategies to improve residents' behavioral health training include a greater emphasis on ACGME Family Medicine milestones related to behavioral skills or interventions,²² a more formal primary care behavioral health curriculum,²³ and increased individualized instruction with direct observation.²⁴

What makes primary care challenging but also rewarding is the unique privilege of providing comprehensive, whole-person care. Particularly now, with many patients' health care issues exacerbated by the stress of the pandemic, we have an unparalleled opportunity to address both their physical and mental health needs.