The Importance of Screening for Mental Health Symptoms in the Primary Care Setting
Mental health problems affect approximately 45 million adults in the United States alone1, with more than 25% of the population afflicted with some form of mental illness at any given time2. Despite these figures, for many people, their mental health problems persist undiagnosed and untreated. Even in affluent countries like the United States, nearly 50% of people with clinical depression are untreated3. Given national and global shortages of mental health providers and the stigma associated with receiving treatment, many people with mental health conditions do not seek specialty mental health services. Primary care providers (PCP’s) have thus become the de facto mental health providers worldwide, diagnosing and treating some 70% of all patients seeking help for common mental health conditions like depressive, anxious, and substance use disorders4. This figure is even more pronounced in rural areas, where mental health specialists are particularly hard to find.
In addition to identifying and treating many mental health conditions directly, PCP’s work closely with patients to manage various health conditions with significant behavioral components. Examples of conditions that require substantial lifestyle modifications on the part of the patient include obesity, diabetes, chronic pain, and insomnia. The connections among behaviors, emotions, and physical health are so pronounced that in any given day, approximately three-quarters of a PCP’s schedule will consist of patients with clinical problems involving a significant behavioral or psychological component5.
These data underscore the importance of identifying and addressing mental health problems in the primary care setting. The first step toward this objective is to develop and implement an effective screening process. A robust mental health evaluation is multi-modal and involves gathering data from various sources including clinical observation, self-report, assessment instruments, and extensive records review. Given significant time constraints, competing objectives, and other barriers in the primary care setting, however, such an evaluation is impractical. As a result, many clinics and providers have eschewed the process entirely. Research suggests that less than five percent of patients in the United States are screened for depression in the primary care setting6. That figure is even lower for non-White and elderly patients, exacerbating existing health disparities in these groups. Screening of other mental health and chemical dependency conditions is similarly lacking, despite recommendations from the U.S. Preventive Services Task Force and other national organizations.
Even in clinics that do regularly screen for mental health and chemical dependency issues, the scope of these screenings is typically limited. First, it is often restricted to one or two conditions (e.g., depression, anxiety). Because many symptoms of mental health conditions are non-specific, misdiagnosis is likely to occur when the screening process is too narrow. For example, inattention is a common complaint across various conditions (e.g., insomnia, anxiety, depression, post-traumatic stress disorder, attention deficit-hyperactivity disorder, substance use disorders). In the same way a physician would be expected to complete a thorough work-up of a fever to consider various differential diagnoses (e.g., influenza, bacterial pneumonia, rheumatoid arthritis) before prescribing a treatment, an analogous process should be employed for inattention before a potentially addictive stimulant is prescribed. Likewise, if a PCP misdiagnoses unipolar depression based on the symptom of sadness in a patient with bipolar disorder, the PCP may inadvertently induce a manic episode by prescribing an antidepressant medication. These examples highlight how jumping to diagnostic conclusions prematurely by failing to screen for other conditions can result in harmful consequences for treatable conditions that simply require a different intervention.
A related problem associated with overly restrictive mental health screenings is that co-morbidities may be overlooked. A significant body of research highlights the prevalence of co-morbidities in mental health. Roughly 50% of individuals with a mental health diagnosis meet criteria for more than one such diagnosis over their lifetime, often simultaneously7. Similarly, nearly half of all people diagnosed with a substance use disorder also have a diagnosable mood or anxiety disorder. Although the mechanisms that underlie co-morbid psychological and substance use disorders are complex, there is general consensus that these conditions are not siloed. Rather, symptoms of one condition can, and usually do, impact another. As such, it is imperative that treatment is based on a comprehensive and accurate diagnostic impression that considers all relevant mental health and chemical dependency issues. This requires adequate screening mechanisms and triage processes in the primary care setting.
1Centers for Disease Control and Prevention (CDC). (2018, June). Mental Health-related Physician Office Visits by Adults Aged 18 and Over: United States, 2012–2014. https://www.cdc.gov/nchs/products/databriefs/db311.htm
2Kessler, R. C., & Wang, P. S. (2008). The descriptive epidemiology of commonly occurring mental disorders in the United States. Annual review of public health, 29, 115–129.
3Thornicroft, G., Chatterji, S., Evans-Lacko, S., Gruber, M., Sampson, N., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Andrade, L., Borges, G., Bruffaerts, R., Bunting, B., de Almeida, J. M., Florescu, S., de Girolamo, G., Gureje, O., Haro, J. M., He, Y., Hinkov, H., Karam, E., … Kessler, R. C. (2017). Undertreatment of people with major depressive disorder in 21 countries. The British journal of psychiatry: the journal of mental science, 210(2), 119–124. https://doi.org/10.1192/bjp.bp.116.188078
4Wang, P. S., Aguilar-Gaxiola, S., Alonso, J., Angermeyer, M. C., Borges, G., Bromet, E. J., Bruffaerts, R., de Girolamo, G., de Graaf, R., Gureje, O., Haro, J. M., Karam, E. G., Kessler, R. C., Kovess, V., Lane, M. C., Lee, S., Levinson, D., Ono, Y., Petukhova, M., Posada-Villa, J., … Wells, J. E. (2007). Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet (London, England), 370(9590), 841–850. https://doi.org/10.1016/S0140-6736(07)61414-7
5Robinson, P.J. & Reiter, J.T. Behavioral Consultation and Primary Care: A Guide to Integrating Services. (2007). New York, NY: Springer.
6Akincigil, A., & Matthews, E. B. (2017). National Rates and Patterns of Depression Screening in Primary Care: Results From 2012 and 2013. Psychiatric Services, 68(7), 660-666. doi:10.1176/appi.ps.201600096
7Plana-Ripoll, O., Pedersen, C. B., Holtz, Y., Benros, M. E., Dalsgaard, S., de Jonge, P., Fan, C. C., Degenhardt, L., Ganna, A., Greve, A. N., Gunn, J., Iburg, K. M., Kessing, L. V., Lee, B. K., Lim, C., Mors, O., Nordentoft, M., Prior, A., Roest, A. M., Saha, S., … McGrath, J. J. (2019). Exploring Comorbidity Within Mental Disorders Among a Danish National Population. JAMA psychiatry, 76(3), 259–270. https://doi.org/10.1001/jamapsychiatry.2018.3658 (link no longer valid)