The United States Preventive Services Task Force (USPSTF) is a public health organization that releases screening recommendations for significant health conditions such as cancer and more. These recommendations are often followed by primary care providers and insurance companies for reimbursement, for procedures including colonoscopies and mammograms. Recently, in September 2022, the USPSTF issued draft recommendations for the routine screening of adults under age 65 for anxiety disorders. This is the second major mental health screening recommendation by the organization, the first, in 2016, being a recommendation for depression screening in all age groups. The USPSTF also recommended counseling and/or medication referral for adult perinatal depression in 2019.
The USPSTF typically makes recommendations after a period of study and research on a particular health topic. They attempt to balance the benefits and risks of active screening versus routine ad hoc management of conditions with an eye toward preventive health, before making official recommendations including a letter rating. The ratings from A to X indicate how strongly the evidence favors the benefit of screening; at times they also give a rating of I, which indicates the evidence is inconclusive.
The recent mental health recommendations have been rated B, or moderate in terms of benefit. On the positive side, these recommendations indicate a sea change in terms of highlighting the importance of mental health as part of all other systems of health in medicine. This is sorely needed given the ongoing stigma, misunderstanding, and minimization of psychiatric issues within both the general public and medical communities. By emphasizing the importance of including a mental health assessment in a general list of preventive health concerns for people to monitor, the USPSTF has helped people recognize that mental health is just as routine and crucial to address as diabetes, cholesterol levels, or pap smears. The message of destigmatization and a shift toward inclusive mind-body health cannot be underestimated.
However, there remain many unaddressed concerns in this broad recommendation for anxiety screening, which mainly points to the ongoing limitations of primary care providers in conducting psychiatric care. Primary care physicians are not usually as fully trained in psychiatry; they are typically boarded in family medicine or internal medicine which only require limited behavioral health rotations at most. (Other primary care providers like nurse practitioners may have even more variable formal psychiatric training.) Yet they are the people who likely most frequently encounter routine psychiatric issues in their patients, many of whom tend not to seek out mental health specialists due to stigma, lack of awareness, and more. According to the American Academy of Family Physicians, up to a third of their patients have mental health diagnoses as one of their main presenting concerns.
With these new USPSTF recommendations, primary care physicians will become crucial in mental health treatment, but are they equipped to provide the best care to those patients? Primary care visits are notoriously brief and overbooked, due to low reimbursement rates by insurance companies, with onerous documentation requirements. Screening can aid in the efficiency of detecting people with mental health issues, but will a provider have enough time to follow up appropriately with patients on their concerns about depression or anxiety? Will they be able to adequately triage patients to the right level of care or give them appropriate treatment beyond a quick prescription? Will they give appropriate prescriptions as well? Routine antidepressants are one thing, but many may turn to quick fixes such as potentially addictive medications like benzodiazepines, without fully addressing the root causes of a person’s acute anxiety disorder.
Also making things worse is that the mental health care system in America is already woefully inadequate, with huge gaps in access and coverage. Long waiting lists for more specialized outpatient psychiatric care are the norm, and onerous battles with insurance companies over approval and coverage drain already stressed-out patients’ resources. Psychotherapy, which has good evidence for treating depression and anxiety, is more time-consuming and more difficult to access for many, especially those who cannot afford treatment. Due to low reimbursement and onerous paperwork requirements, many mental health providers do not accept insurance upfront.
So when primary care providers identify more people with mental health needs, without an adequate and rapid system of evaluation and treatment, especially for those with more serious or specialized psychiatric needs, what will actually happen then? Will those people be left without appropriate care? Will primary care providers be burdened with additional risks and stressors for identifying and treating these individuals without having the right systems of care to send them? Will the patients end up getting mediocre mental health care, and is that better than no care at all?
Follow-up data will be crucial in the coming years to see how these USPSTF initiatives influence patient outcomes and whether this data can help advocate for necessary changes in the existing health care system and coverage algorithms.