With too few mental health providers, more patients turn to primary care

While primary care is experiencing its own workforce shortage, the profession is shouldering more mental health screenings to help bridge the behavioral health provider gap.

It took one cancer patient 15 years ago to convince Barbara Chapman that the model of mental health treatment needed some serious work.

It was 2009, and she was an advanced practice nurse working in a Dallas primary care practice when she met a female patient diagnosed with breast and lung cancer. The same woman had also been diagnosed with schizophrenia.

The woman didn’t have health insurance, but Chapman was determined to help her navigate the medical system for both cancer and mental health treatment. After several weeks, Chapman was able to find a place that would treat her physical and mental illnesses.

“I made a promise to her that I would do everything in my power to make sure nobody had to go through that again,” Chapman said.

That seminal experience is why Chapman, who now serves as an assistant clinical professor for the family nurse practitioner and psychiatric mental health nurse practitioner programs at the University of Texas at Tyler, has been an advocate for a better, collaborative care model for mental and medical health fields.

“There is not a diagnosis that doesn’t have a mental health component. I am doing everything in my power to promote that message to my students and others because we can work together to solve this crisis we find ourselves in,” Chapman said. “This means we can be the front line to total treatment.”

Behavioral health has historically been structured, researched, financed, and regulated differently than general health care, and mental health and substance use disorders are typically treated as a specialty.

Even the way people pay for mental health and medical treatment has been vastly different.

“A lot of people don’t have psychiatric services in their health insurance, or if they do, it might only cover three visits or something to that effect, and then the rest of it is out of pocket,” Chapman said. “While in medical, the way insurance is set up is pretty straightforward. It’s one of the obstacles we haven’t gotten past.”

Keeping mental health a separate field has contributed to the workforce shortage Americans are now experiencing. Mental health services are not distributed evenly nationwide, as providers can’t keep their doors open in most rural or lower-income areas because reimbursement from health insurance plans is so low.

In Texas, 98% of the 254 counties are designated as mental health professional shortage areas. Texas ranks last in the nation for access to mental health care. In rural Texas, the shortage can be even more problematic because patients earn less than in cities, may not have health insurance, and then there’s the added cost of transportation to larger towns and cities that do have therapists or psychiatrists.

Experts say the best way to solve this crisis is by early diagnosing mental illness before it reaches a point where medical treatment, hospitalization, or other intensive services are needed. However, studies have found primary care physicians are often the first point of contact when it comes to mental illness, not behavioral health providers.

“I have had people come into my office for a blood pressure check or routine blood work, and all of a sudden, they break down in tears and start telling me all the other things that are going on with their life,” Chapman, who volunteers her time with mobile health services around the state, said.

This is why people like Chapman believe the answer to the mental health crisis might be in the medical field, starting with the collaborative care model, where every routine primary care check-up can include a screening for behavioral health issues like depression, anxiety, and substance use, similar to what primary care doctors do for blood sugar and cholesterol levels. This gives the primary care provider the responsibility of early detection before a mental health concern turns into a crisis.

Chapman said primary care providers have understandably been slow to adopt this model mainly because some may lack confidence in making a mental health diagnosis and are combating workforce issues of their own.

The federal government estimates that the United States will be short some 68,020 have a primary care physicians by 2036.

“Yes, they’re already overwhelmed. And so taking on mental health care issues while dealing with an already very busy primary care practice will be a difficult thing to do,” Chapman said. “But I tell all my students, you have to understand that you are the first line of defense. We are the first to hear about someone being a little depressed or that they are going through a divorce or that a mom died.”

Dr. Zachary Sartor, a family medicine faculty physician at Waco Family Medicine who treats the underserved residents of McLennan and Bell counties, said the collaborative care model has become an essential part of the medical field. He said his clinic has taken a unique approach to collaborative care by having mental health providers work alongside primary care to ease the burden on both fields.

“The collaborative model can take a lot of time and can limit our ability to do this, so having those providers working beside us in the clinic makes that time limit feasible. If I see someone for hypertension, they can also see someone for depression, allowing us to see more people without putting an additional burden on the clinician,” he said.

Sartor believes primary care is well-positioned to impact the mental health crisis in Texas. He said patients usually prefer to meet with their primary care doctor about mental health, which allows them to be treated for everything under one roof, which is key for rural areas of the state.

“I believe most mental illness can be treated in primary care with the right training,” Sartor said. “There will always be a need for specialists in mental health, but primary care has a broad scope of practice, and this will allow us to treat most of these effectively.”

Chapman, at UT-Tyler, believes that if primary care providers are only tasked with handling low-level mental illnesses like ADHD, anxiety, and low-scale depression, then the medical field can help mental health providers without overwhelming themselves in the process.

“There are things primary care providers can’t handle like schizophrenia or bipolar disorder and higher level diagnosis like that. But we are in an all-boots-on-the-ground situation. None of us are doing well,” she said.

A new approach

In Austin, Dr. Roshni Koli, is one voice primary care physicians turn to when they need help with a mental health diagnosis for a child.

As a psychiatrist and assistant professor of psychiatry at Dell Medical School, Koli has been answering primary care doctors’ questions as part of the state’s Child Psychiatry Access Network, which provides telehealth mental health consultations.

The questions she takes range from “What kind of diagnosis goes with these symptoms?” to “What kind of medication is needed for anxiety?” to “Where should I refer someone with suicidal thoughts?”

“I just got off a call where a primary care physician was asking about a plan for anxiety for one of his patients. They had already figured out the diagnosis but just needed some help with medication. Most people call me with some idea already,” Koli said.

The Texas Legislature created CPAN in 2019 as part of a larger group of programs designed to improve psychiatric care for young people. These include the Perinatal Psychiatry Access Network, which allows reproductive care providers to call a mental health provider for assistance with their patients.

“Mental health and physical health are inextricably intertwined. Both are essential for good health, but oftentimes, those notes collected by primary care doctors and psychologists are not shared with each other,” Koli said. “We are starting to see that change.”

Koli said that ever since the COVID-19 pandemic, she has seen a strong willingness from primary care providers to start getting involved with the program.

Since 2019, CPAN has enrolled more than 12,700 providers and nearly 2,500 clinics and completed over 34,000 calls either for consultation with a psychiatrist or for specialized resources and referrals.

“It kind of just makes sense for primary care to take this on. Physicians are already monitoring if you have high blood pressure, or high cholesterol and do follow-ups based on those reports. We can apply those same principles to mental health,” Koli said.

The Meadows Mental Health Institute released a study in 2020 that suggested if every Texan with major depression had access to the Collaborative Care Model, between 725 and 1,100 lives could be saved every year.

Texas Health and Human Services also has its own model called the Healthy Community Collaborative, which promotes partnerships between public and private sectors to integrate services for people experiencing homelessness and mental illness and/or substance use disorders.

“We have seen once you treat someone's mental illness, their physical health improves as well,” Koli said.

Chapman said these state-sponsored collaborative care programs show Texas is moving in the right direction. However, she said these programs currently only cater to very specific populations, and the state has a dire need for overall adult mental health services.

“We need to set up something with the same model for adult care. I think it’s a good model that needs to be implemented in all other areas,” she said. “We need this for everyone.”

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