The primary care system is the default mental health system: Now what?

In the U.S., primary care has been the de facto mental health system for years. It's the first, and usually only, place many patients turn for behavioral health issues. Primary care physicians (PCP) provide most of the care for depression, anxiety and mental illness in general, and roughly a third of care for severe mental illness.1

Primary care's role is growing: PCPs provide more health services and treat more patients with a broader array of diagnoses. They're also prescribing more, and more types of, psychotropic meds.2

There's a good reason for this: Patients trust their PCPs, and PCPs are far more accessible than behavioral health specialists both financially and geographically. Limited health insurance coverage and narrow networks mean many patients must pay for mental health services out of pocket. Moreover, in many communities, especially rural ones, specialty behavioral health services are unavailable.

Offering such services through primary care offices not only improves accessibility, but it also can mitigate the perceived stigma of visiting a psychiatrist or therapist.

Finally, there's the simple fact that we can't segregate the mind from the body. Artificial distinctions between physical and mental or emotional health benefit no one.

So yes, addressing behavioral health in the primary care setting makes sense. But so long as we put the entire burden on the PCP, the situation is unsustainable — and often not reimbursable.

PCPs need support

A 2019 survey found that PCPs don't feel adequately prepared to screen patients for substance use or mental health disorders, nor do they feel equipped to educate them about these issues. And the challenge will only grow as the COVID-driven mental health crisis continues.

PCPs often lack the appropriate expertise and training, especially for more serious mental health conditions. Some patients want, or need, more than PCPs alone can provide.

An interesting 2022 study suggests patients who tried but were unable to access specialty mental health care were less satisfied with the quality of their PCP-provided mental health care. One of the biggest concerns was the lack of availability of counseling through their PCP. Of those who received mental health care only from their PCP, 73% received medication only.

We know that medication,  especially medication alone, isn't always the optimal treatment. But PCPs aren't routinely trained in talk therapy techniques, and they really don't have the time to spend on them given the time constraints of a typical visit.3

And so, we have a dilemma. Because physical health and mental health are so closely intertwined, primary care is the ideal place to treat both. And practically, it's the only place many patients can receive mental health services. But we also know that many PCPs are poorly equipped to manage behavioral health issues. Further, insurers continue to carve out mental health services, making reimbursement a very real concern for the PCP.

Integrated, collaborated and patient-centered

The solution is collaboration and integration.

There are various approaches to integrated care. Here are two that are gaining significant traction and, in some cases, reimbursement.

  • The Primary Care Behavioral Health (PCBH) model: A behavioral health consultant (BHC) — a psychologist or clinical social worker — works onsite with the PCP. BHCs can support mental health issues as well as the management of conditions such as diabetes and hypertension. If the PCP determines a patient may benefit, they call in the BHC. The patient doesn't go anywhere; the consultant comes to them.
  • The Collaborative Care Model (CoCM): Based on a chronic care management approach, this model has a strong body of evidence supporting its effectiveness.[vii] It involves psychiatric services for a defined group of patients diagnosed with chronic mental illness (typically, depression and/or anxiety). A care manager tracks patients via a registry and coordinates care with other team members, including a consulting psychiatrist, The registry enables the care manager to measure and track outcomes — a key element of this model.4

Empower PCPs to engage patients

To deliver comprehensive, patient-centered, coordinated care, we cannot separate the mental from the physical. Care must be integrated. We must empower PCPs to deliver whole-person care that engages the full range of physical, psychological and social factors required for health and wellbeing. That means having the right tools and the right support.

Total Brain can help. We offer a SaaS-based mental health platform that supports behavioral health integration. With digital neuroscience, brain capacities and mental health risks can be measured, improved and managed — just like physical health.

1. Jetty A, Petterson S, Westfall JM, Jabbarpour Y. Assessing Primary Care Contributions to Behavioral Health: A Cross-sectional Study Using Medical Expenditure Panel Survey. Journal of Primary Care & Community Health. January 2021. doi:10.1177/21501327211023871

2. Kyanko, Kelly A., et al. “Does Primary Care Fill the Gap in Access to Specialty Mental Health Care? A Mixed Methods Study.” J. Gen. Intern. Med., vol. 37, no. 7, May. 2022, p. 1641, doi:10.1007/s11606-021-072

3. Kyanko, op. cit.

4.  “Evidence Base for CoCM | University of Washington AIMS Center.” 2 Jan. 2021,

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