A national analysis shows that mental health problems are a large part of primary care practice

A study of millions of patient visits to general practitioners shows that mental health problems in daily care come second after musculoskeletal complaints. One in nine patients sought care primarily for mental health problems.

“These primary care physicians are the gatekeepers,” says study leader Avshalom Caspi, Edward M. Arnett Professor of Psychology and Neuroscience at Duke University. “The GP data allows us to actually see people at their first contact with the healthcare system.”

Researchers examined more than 350 million primary care visits for 4.8 million people between January 2006 and December 2019, as recorded by the Norwegian government. The top health issue of each visit was coded by the doctors, allowing the researchers to dive deep into what these doctors see every day. The study appears in Nature mental health.

“The idea was really to see which parts of the body they were treating,” says Caspi, who helped develop a measure of the speed of a person’s aging process. “It turns out that 12% of all encounters that GPs have are for mental health issues. So out of 350 million encounters, they have more than 40 million mental health encounters.”

The data covers 14 years ending in 2019 – before the pandemic – and reflects a purely Norwegian population with socialized healthcare. Norway is one of the richest countries in the world, with essentially zero extreme poverty, and ranks seventh in the global rankings of happiest countries, while the US isn’t even in the top 20.

But understanding how much mental health care plays a role in regular primary care is still valuable, Caspi said. “This is the complete overview of people between zero and a hundred years old, from all walks of life.”

The prevalence of mental health problems was approximately equal to the number coming in for respiratory and cardiovascular complaints, and more than the number coming in for infections, injuries, digestive, skin, urological or sensory problems.

Caspi said the key finding is that the number of mental health contacts seen by GPs is second only to aches and pains. While it’s usually depression or anxiety, they see “diverse and complicated conditions,” including psychosis. “Looking at all of this, I am simply stunned by the complexity of the mental health issues that GPs deal with,” says Caspi.

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

Caspi adds that it’s also important to note: “This doesn’t just happen at one point in the lifespan, it happens everywhere, among all age groups,” he said. Concerns about mental health reached their peak in the 1940s, when 1 in 5 visits to a GP was for a mental health problem.

“On any given day, a primary care physician will 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 focused efforts to expand mental health care within primary care, the medical system will not meet the mental health care needs of those it serves,” said Dr. Damon Tweedy, a professor of psychiatry and behavioral sciences at Duke Health, who was not involved in this study.

Post-pandemic, this trend is also inevitable in pediatric primary care, says Malinda Teague, an assistant clinical professor at the Duke School of Nursing, who was not involved in this study. “Even if it is a regular visit with a child, almost every child comes in with some concern about behavior, anxiety and depression.”

Caspi is not suggesting that primary care physicians need to be better trained in mental health care, but he would like to see mental health professionals become better integrated into the primary care model. “You go to your doctor and you have a mental health problem. And they say, ‘Let’s go down the hall and sort everything out.’ That’s called a warm transfer, and the VA has been good at that.”

Teague agrees, noting that Duke pediatric primary care already has a similar model, but she says it’s not enough. “These embedded mental health clinicians move quickly and cannot see all patients in need. Primary care providers must be competent and confident in managing common mental health issues to provide this access to care for their patients.”

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

“I can tell you that doesn’t happen. Someone comes in with an ear infection, or someone has a cough. Who screens him or her for depression? Because of our fee-for-service model, time becomes patient visits don’t really support that very well,” she said. “As a result, these screenings only occur during annual checkups and we miss tremendous opportunities to help.”

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