AAFP white paper on the provision of mental health care services by family physicians

AAFP white paper on the provision of mental health care services by family physicians – American Academy of Family Physicians Commission on Health Care Services

Family physicians are trained specifically to provide mental health services, which are an essential component of comprehensive primary medical care. Patients frequently seek care from their primary care physician for symptomatic complaints (e.g., headaches) with underlying psychosocial problems (e.g., stress). Patients may suffer negative consequences if they are denied access to receiving mental health services from their primary care physician. The continuity of patient care may be disrupted and the overall costs of health care escalated.

The American Academy of Family Physicians sees as unfortunate the trend within the public and private insurance and purchaser communities to manage the costs of mental health care either by the elimination or limitation of benefits to the insured population. This takes one of several forms. Reimbursement to physicians may be discounted. Medicare, for example, pays physicians only 60 percent of the fee schedule amount for visits with a psychiatric diagnosis. Alternatively, a self-contained behavioral health entity, such as one of the so-called “carve out” companies, is named the exclusive provider of mental health care services. Such companies can–and do–apply “specialty-specific” reimbursement rules, which exclude coverage for mental health treatment provided by that patient’s personal physician, often a family physician.

In this “carve out” model, patients with certain diagnoses are transferred from the care of the family physician into another system, managed strictly by physician and nonphysician mental health care providers. At times, such exclusive contracts prohibit the family physician from providing any primary care service, including prescribing of psychotropic drugs. This insurance and industry driven trend might reduce the immediate cost of mental health care services. However, we may surmise the long-term effects of any trend which ignores the need for primary care-based detection, treatment and management of mental illness. These include, most likely, an eventual, significant increase in the financial cost of caring for the mentally ill, an increase in the utilization and cost of medical services and a future incalculable social cost as millions of Americans do not seek out specialty mental health care services.

This white paper demonstrates the necessity of including basic mental health care services in a uniform benefits package and shows, as well, the need to recognize in that benefits package the critical role played by the family physician in the delivery of primary mental health services. This will be accomplished by documenting: (1) the prevalence of mental disorders seen within general medical settings, thereby establishing the central role of the primary care physician in the delivery of mental health services nationwide; (2) the cost-effectiveness of primary care physician-provided mental health services, and (3) the extent to which their education equips family physicians to provide such services. Finally, this white paper briefly describes a collaborative delivery system model, in which the family physician, as the primary case manager, collaborates with mental health professionals in an integrated system.

Prevalence and Cost of Mental Health Disorders

Numerous studies point to the prevalence of patients presenting with mental disorders in general medical practice. It is known, for instance, that, as of 1988, patients with diagnosable mental disorders constitute between 11 and 35 percent of all general medical visits.[1] That not all of these patients present with mental health complaints is noteworthy Indeed, many present to the health care system with physical complaints. In the event that the patient’s underlying mental health disorder goes unrecognized (and therefore untreated), the patient continues to seek medical attention, often undergoing expensive diagnostic and surgical procedures.

Failure to treat mental disorders in the general medical setting results in undesirable patient outcomes. The depressed patient’s ability to function differs little from that of the patient with end-stage coronary artery disease.[2] A large number of high medical care utilizers are patients with mental disorders, particularly depression[3] and somatization.[4] Conectively, they consume outpatient health care resources at two to three times that of the overall population, and their consumption of inpatient hospitalization/specialty care resources is 10 times that of the overall population.

The two-year Hawaii Medicaid Project provides stark evidence of potential cost savings when mental health care services are integrated into general medical care. In 1990, a large group of “at-risk” Medicaid recipients were divided randomly into two groups. One group received targeted psychotherapy; the other received usual medical care. The group receiving psychotherapy integrated around their medical care reduced by 38 percent its medical utilization.[5] In another instance, providing the elderly with mental health services reduced their inpatient medical expense by as much as 70 percent.[6]

The evidence suggests strongly that providing mental health services to medical patients either can reduce or offset subsequent medical utilization. Considering the medical utilization of all medical patients who either present with depression, anxiety disorders or somatization (an estimated 20 to 30 percent of the primary care population), the accrued cost saving resulting from the inclusion of mental health services into any delivery system is impressive.

On the other hand, eliminating coverage for basic treatment of mental health disorders from the benefits package promises–at the least–two undesirable effects: the inappropriate utilization of expensive health care resources will continue, as will the human suffering of those Americans with diagnosed but untreated mental health disorders.

The Role of Primary Care in Mental Health

The provision of mental health services is a major component of family medicine. An estimated 30 percent of family practice visits involve counseling for psychologic stressors.[7] Frequently, though, patients with mental health disorders present with physical complaints. A recent survey of 75,858 office visits by patients to primary care physicians revealed that 20.9 percent of the patients had clinically significant depression, yet only 1.2 percent cited depression as a reason for their visit.[8] A study made of the 1980-81 National Ambulatory Medical Care Survey data base discloses that 50 percent of the office visits resulting in a mental health diagnosis were made to nonpsychiatrist physicians.[9] In 1988, general medical physicians wrote approximately two-thirds of all the prescriptions for psychotropic medications.[10] (Psychiatrists accounted for less than 18 percent of those prescriptions.) The Epidemiological Catchment Area project, the most important study to date of primary care mental health, examined the help-seeking patterns of persons with mental disorders and found little difference between the percentage of patients who received treatment in primary care settings and the percentage of those who received treatment in specialty mental health settings.[11]

Existing evidence has established that primary care physicians treat approximately half of all patients with mental health diagnoses. Family physicians perform a mental health assessment as part of the routine medical history and examination and provide anticipatory guidance and supportive counseling as appropriate. Commonly, the family physician provides the diagnosis and treatment of uncomplicated anxiety and depression. Reimbursement rules that discriminate against the appropriate use of mental health diagnoses are a disservice to patients and physicians alike.

Finally, benefit and delivery system design and reimbursement policies should not inhibit individuals’ access to appropriate mental health services provided by their primary care physicians. Examples include patients being referred to a separate delivery system to receive mental health services and services not being reimbursed if a mental health diagnosis is recorded. Likewise, primary care capitation rates should include a portion of the dollars allotted for mental health coverage.

Family Physician Training in Mental Health

Instruction in the prevention, diagnosis and management of mental health disorders is an integral part of family medicine residency training and continuing medical education. During a three-year residency, family physicians participate in a program which integrates psychiatry and behavioral science to assure they develop the required expertise in the following areas: (1) the diagnosis and management of the psychologic components of illness; (2) family dynamics, the physician-patient relationship, patient counseling and interviewing skills, and human sexuality; (3) normal and abnormal psychologic growth and development, including family life cycle; (4) the recognition, diagnosis and management of psychiatric disorders, including psychopharmacology, and (5) physician well-being and impairment. Furthermore, “Recommended Core Curriculum Guidelines on Psychiatry for Family Practice Residents” have been developed and endorsed by the AAFP and the American Psychiatric Association.

Family physicians engage in professional lifelong learning. Every six years, a board-certified family physician must be recertified. The identical number of hours (300) of continuing medical education is required for membership in the AAFP. Many continuing medical education courses and publications deal directly with the treatment of mental health problems. Thus, throughout their career, family physicians hone the mental health care skills acquired in their residency training.

A Collaborative Mental Health Care Model

A restructuring of health care delivery systems provides an opportunity to develop a collaborative model for the delivery of mental health services. The collaborative model proposed herein can rationalize the delivery of mental health care by integrating medical and specialty mental health services, thereby reducing overall cost and improving outcome.

The movement today toward managed care emphasizes the role of the family physician as case manager, and this emphasis is integral to the proposed collaborative model. As the case manager, the family physician makes the critical decisions regarding treatment capitalizing on the physician’s long-term relationship with the patient. The model also acknowledges that many mental health problems require no treatment beyond that provided by the family physician.

Primary care-based mental health services (e.g., clinical psychologists and social workers) must be available to assist the family physician, however. A consultation might address one of several issues. For instance, at one time, the consultation may assist the physician in developing either a short- or long-term medication and/or behavioral treatment plan. On another occasion, a consultation may involve advising the patient on short-term problem solving or the necessity of compliance with medical treatment. In the proposed collaborative model, the provision of primary mental health services is coordinated by the physician, who remains in charge of the overall process of care for the patient.

A referral for specialty mental health care is indicated when it becomes apparent that a patient is nonresponsive to primary care-based treatment. The defining feature of specialty mental health care is that once referred, the specialist assumes responsibility for the patient until he/she is stabilized. At that point, the primary care physician resumes responsibility for the patient’s overall care.

This collaborative model maximizes the effectiveness of mental health services. It recognizes the time constraints of primary care practice and supports a team approach to medical and mental health care.

The collaborative model makes cost-effective use of both primary care and specialty mental health resources. The results of a recent demonstration project offers a case in point. After replacing its managed care firm (i.e., a “carve-out” model) with a collaborative mental health care model, a large health care delivery system reduced by 33 percent its overall medical and mental health costs, while retaining high consumer and provider satisfaction.[12]


A uniform benefits package must include coverage for mental health care services. The prevalence of mental health disorders and the health care needs of our patients, together with the high societal cost of failure to provide treatment, make such an inclusion mandatory. A collaborative model that integrates both primary care and specialty mental health services can best meet the needs of our patients and introduce substantial cost savings into a benefits package. Third-party payment policies should encourage the provision of mental health services through a primary care-based collaborative model.


[1.] Barrett JE, Barrett JA, Oxman TE, Gerber PD. The prevalence of psychiatric disorders in a primary care practice. Arch Gen Psychiatry 1988;45:1100-6. [2.] Wells KB, Stewart A, Hays RD, Burnam MA, Rogers W, Daniels M, et al. The functioning and well-being of depressed patients. Results from the Medical Outcomes Study. JAMA 1989;262:914-9. [3.] Katon W, Von Korff M, Lin E, Bush T, Russo J, Lipscomb P, et al. A randomized trial of psychiatric consultation with distressed high utilizers. Gen Hosp Psychiatry 1992;14:86-98. [4.] Smith GR Jr, Monson RA, Ray DC. Patients with multiple unexplained symptoms. Their characteristics, functional health, and health care utilization. Arch Intern Med 1986;146:69-72. [5.] Cumming NA, et al., eds. The impact of psychological intervention on healthcare utilization and costs. San Francisco: Biodyne Institute, 1990. [6.] Mumford E, Schlesinger HJ, Glass GV, Patrick C, Cuerdon T. A new look at evidence about reduced cost of medical utilization following mental health treatment. Am J Psychiatry 1984;141:1145-58. [7.] Stewart MA, McWhinney IR, Buck CW. How illness presents: a study of patient behavior. J Fam Pract 1975;2(6):411-4. [8.] Zung WW, Broadhead WE, Roth ME. Prevalence of depressive symptoms in primary care. J Fam Pract 1993;37(4):337-44. [9.] Schurman RA, Kramer PD, Mitchell JB. The hidden mental health network. Treatment of mental illness by nonpsychiatrist physicians. Arch Gen Psychiatry 1985;42:89-94. [10.] Beardsley RS, Gardocki GJ, Larson DB, Hidalgo J. Prescribing of psychotropic medication by primary care physicians and psychiatrists. Arch Gen Psychiatry 1988;45:1117-9. [11.] Narrow WE, Regier DA, Rae DS, Manderscheid RW, Locke BZ. Use of services by persons with mental and addictive disorders. Findings from the National Institute of Mental Health Epidemiologic Catchment Area Program. Arch Gen Psychiatry 1993;50:95-107. [12.] German M. Effective case management in managed mental health care: conditions, methods and outcomes. HMO Pract 1994;8:34-40.

The AAFP Commission on Health Care Services has been studying the issue of mental health care services by family physicians. A culmination of their work is the “White Paper on the Provision of Mental Health Care Services by Family Physicians.” The white paper was approved by the AAFP Board of Directors at their November 1994 meeting. Copies may be obtained by calling the AAFP Order Department at 800-944-0000.

COPYRIGHT 1995 American Academy of Family Physicians

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