A survey of millions of patient visits to primary care physicians found that mental health concerns were second only to musculoskeletal symptoms in routine care, with one in nine patients seeking care primarily for a mental health concern.
“These primary care physicians are the gatekeepers. Primary care physician data allows us to really see people as they come into contact with the health care system for the first time.”
Avshalom Caspi, study leader and professor of psychology and neuroscience at Duke University
The researchers looked at more than 350 million primary care visits involving 4.8 million people recorded by the Norwegian government between January 2006 and December 2019. The main health concerns during the visits were coded by doctors, allowing the researchers to dig deeper into what doctors see every day. The study appears September 19 in Nature Mental Health.
“Basically, our goal was to understand what parts of the body doctors were treating,” says Caspi, who co-developed an index to measure how quickly people age. “And we found that 12 percent of all visits to primary care physicians are for mental health issues. So, of the 350 million visits, over 40 million are for mental health issues.”
The data covers a 14-year period up to 2019, before the pandemic, and reflects only the population of Norway, which has a social security system. Norway is one of the wealthiest countries on earth with virtually zero extreme poverty, and it ranks seventh in an index of the happiest countries in the world, while the United States isn’t even in the top 20.
But the insight into the extent to which mental health is involved in everyday primary care is still valuable, Caspi says: “This is a complete record of people from age 0 to 100, from all walks of life.”
The prevalence of mental health concerns was nearly as high as the number of patient visits with respiratory or cardiovascular symptoms, and exceeded the number of patient visits with infections, injuries, gastrointestinal, skin, urinary, and sensory problems.
Most importantly, Caspi said, primary care physicians are seeing more mental health-related patients than any other group of patients for pain and suffering. Most are depression and anxiety disorders, but they also see “a wide variety of complex conditions” including psychosis. “When you look at all of this, it just blows my mind how complex the mental health issues are that primary care physicians have to deal with.”
Depression, sleep disorders, stress and anxiety, memory problems and substance abuse topped the list, but ADHD, learning disabilities, post-traumatic stress, eating disorders, sexual problems, mental illness and suicidal thoughts were also included as concerns.
Caspi added that it’s also important to note that “this isn’t just something that happens at one point in life, it’s happening everywhere, at all ages.” Mental health concerns peak in people in their 40s, with one in five visits to their doctor being due to a mental health issue.
“Family doctors encounter mental health issues every day in pediatric patients, geriatric patients and middle-aged adults,” Caspi said.
“This report highlights what is increasingly clear in the health care world: without targeted efforts to expand mental health services in primary care settings, the health care system will not be able to meet the mental health needs of patients,” said Dr. Damon Tweedie, a professor of psychiatry and behavioral sciences at Duke Health, who was not involved in the study.
Post-pandemic, this trend is inevitable in pediatric primary care, says Malinda Teague, a clinical assistant professor at Duke University’s School of Nursing, who was not involved in the study: “Even for routine checkups, almost every child is coming in with some concern about behavior, anxiety or depression.”
While Caspi doesn’t say primary care physicians need to become more knowledgeable about mental health, he would like to see mental health professionals better integrated into the primary care model. “You go to your family doctor with a mental health issue, and they say, ‘Let me just go right down the hall and start treating you.’ It’s called a warm handoff, and the VA has done it well.”
Teague agrees, noting that a similar model already exists at Duke Children’s Primary Care, but it’s not enough: “These full-time mental health clinicians are quickly reaching capacity and are unable to see all the patients who need them. Primary care providers must have the ability and confidence to treat common mental health illnesses in order to provide patients with access to care.”
“The American Academy of Pediatrics recommended several years ago that children over the age of 12 should be screened for depression at every visit,” Teague says. “But that’s not happening. We have people coming in with ear infections and coughs. Who is screening for depression? Our reimbursement model doesn’t help us much with time restrictions on patient visits,” Teague says. “As a result, these tests are only done once a year during wellness visits, and we’re missing a huge opportunity to help.”
Either way, Caspi encouraged patients to talk to their doctors about their mental health concerns: “Don’t be embarrassed, because doctors see this all the time,” he said.
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Journal References:
Caspi, A., et al. (2024). Nationwide analysis of 350 million patient encounters reveals prevalence of mental illness in primary care. Nature Mental Health. doi.org/10.1038/s44220-024-00310-5.
