Is Mental Health Treatment Shifting to Primary Care Doctors?

May 05, 2016

A survey from the Centers for Disease Control and Prevention (CDC) has turned up a seeming paradox: More people with mental health problems have gained insurance coverage, but the percentage visiting mental health professionals has dropped off.

The new data raise the question of whether more of these patients are taking their troubles to primary care physicians instead.

The findings appear in a report issued yesterday by the CDC's National Center for Health Statistics (NCHS). Authors Robin Cohen, PhD, an NCHS statistician, and Emily Zammitti, MPH, an associate service fellow, analyzed data from the center's National Health Interview Survey on access and utilization for adults aged 18 to 64 years with and without serious psychological distress (SPD) in the past 30 days. SPD is a gauge of mental health problems severe enough to disrupt daily living and require treatment.

The survey uses the Kessler 6 nonspecific distress scale to identify individuals with SPD. The scale asks individuals how often in the past 30 days they felt:

  • So sad that nothing could cheer them up

  • Nervous

  • Restless or fidgety

  • Hopeless

  • That everything was an effort

  • Worthless

Individuals scoring 13 or higher on the 24-point scale were deemed to have SPD.

Dr Cohen and Zammitti found that the percentage of adults experiencing SPD in the previous 30 days has remained stable in recent years, nudging up from 3.2% in 2012 to 3.8% in 2015 through September. During that same time, the percentage of adults with SPD who lacked insurance coverage decreased from 28.1% to 19.5%, a not so surprisingly development, given the dramatic expansion of coverage under the Affordable Care Act (ACA) in 2014.

Likewise, the percentage of adults with SPD who needed mental healthcare in the previous 12 months, but could not afford it, declined from 33% in 2012 to 24.4% through September 2015. The problem of unaffordable prescriptions also shrank.

Increased access to insurance coverage did not translate into more crowded waiting rooms for psychiatrists, psychologists, licensed counselors, and other mental health professionals. The percentage of adults with SPD who reported seeing a mental health professional during the previous 12 months decreased from 41.8% to 34.2% during the study period.

However, the percentage of these adults visiting some kind of healthcare professional for whatever reason held steady — 87.7% in 2012 compared with 86.6% in 2015 through September. This rate was slightly higher than the roughly 80% for adults without SPD that prevailed during that period.

Shortage of Mental Health Professionals May Help Explain Trend

In their report, Dr Cohen and Zammitti said that the shrinking percentage of adults with SPD who have seen a mental health professional in the previous 12 months could stem from a number of factors, one being "an increasing trend in obtaining mental health care from primary care physicians." That possible explanation also came to mind for Joel Miller, executive director and CEO of the American Mental Health Counselors Association.

In an interview with Medscape Medical News, Miller said he wonders if patients are visiting primary care physicians for mental health conditions, but not taking the extra step of seeing a specialist. "Maybe the primary care doctors are struggling to find mental healthcare [providers] to refer to," Miller said. That can happen, he said, in an age of narrow provider networks fielded by health insurers as a cost-savings response to the ACA. If there's no good referral choice inside the network, patients are faced with going out of network for a mental health specialist, which may be unaffordable.

Another possible and interlocking reason for the fall-off in visits to mental health professionals is that there aren't enough of these practitioners, write Dr Cohen and Zammitti. The authors could have buttressed that theory by footnoting a Washington Post story from last fall. The newspaper quoted Thomas Insel, MD, then the director of the National Institute of Mental Health, as saying that more than half of counties in the United States lack any kind of mental health specialist.

One shorthanded field is psychiatry, according to the physician recruiting firm Merritt Hawkins. It reported last year that the number of searches it conducted for psychiatrists between April 2014 and March 2015 hit an all-time high in the company's 27-year history. The shortage will only get worse, Merritt Hawkins said, because 48% of psychiatrists are aged over 60 years and closing in on retirement.

The CDC report is available on the agency's website.

Follow me on Twitter @LowesRobert


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