Primary care visits are increasingly addressing mental health concerns, a recent study found.
Researchers assessed temporal trends in outpatient primary care visits addressing a mental health concern using nationally representative serial cross-sectional data from the 2006-2018 National Ambulatory Medical Care Surveys (NAMCS), excluding 2017 data, which have not been publicly released due to data processing challenges. They restricted the sample to visits by adults ages 18 years and older to primary care physicians. For each visit, the NAMCS collects the primary and up to two additional diagnoses and up to three reasons for the visit. The researchers used ICD-9 diagnosis codes to identify whether a visit's primary diagnosis or any diagnosis or reason for visit was for a mental health concern. They categorized mental health concerns as mental health conditions influenced by physiologic conditions, disorders due to psychoactive substances, serious mental illness, depression, anxiety and stress, personality disorders, intellectual and developmental disorders, and mental health disorders arising during childhood. Results were published in the February Health Affairs.
The study sample included 109,898 visits, representing a weighted visit count of about 3.9 billion visits during the study period. Adjusted analyses showed significant increases in the rates of mental health concerns being addressed in primary care visits from 2006 to 2018. In 2006-2007, 3.4% of primary care visits had a mental health concern as a primary diagnosis. By 2016 and 2018, the proportion had increased to 6.3% (P<0.001). In 2006-2007, 10.7% of visits addressed a mental health concern within the visit, even if not as a primary diagnosis, and this percentage increased to 15.9% by 2016 and 2018 (P<0.001). Among primary care visits with a mental health concern addressed, anxiety and stress-related diagnoses were most common, representing between 29.4% (in 2008-2009) and 38.0% (in 2014-2015) of mental health primary care visits during the study period. While the proportion addressing anxiety and stress increased over time, the proportion of visits addressing depressive symptoms decreased (from 32.4% in 2006-2007 to 20.8% in 2016 and 2018). In adjusted analyses, younger age, payment through Medicare or Medicaid, female sex, and the physician at the visit being the patient's usual primary care physician were all associated with significantly greater odds of a mental health concern being addressed. Patients whose race was identified as Black (odds ratio [OR], 0.6) or other race (OR, 0.5) versus White and those identified as Hispanic (OR, 0.6) versus non-Hispanic were less likely to have a primary care visit with a mental health concern (P<0.001 for all).
Among other limitations, the NAMCS is based on visit-level data, which restricted the ability to track specific patients and assess patterns in mental health care over the course of a patient's disease, the study authors noted. They added that the sample only includes visits to the offices of non-federally employed physicians.
“These findings build on previous evidence that office-based primary care physicians have significantly increased their involvement in providing mental health care, despite the competing demands of primary care practice. … In the context of policy and care delivery changes, equipping primary care providers to address mental health needs is crucial,” the study authors wrote. ACP offers a compendium of resources to help integrate behavioral and mental health into primary care practice.