Navigating the mental health masquerade

By Kristen Fuller, MD | Fact-checked by Barbara Bekiesz

Published February 17, 2023

Key Takeaways

A 28-year-old female came into my office complaining of "digestive problems." She had abdominal pain and irregular bowel movements. I ruled out the run-of-the mill infectious GI bugs, and she did not fit the picture for inflammatory bowel syndrome. I asked about her diet, fluid intake, and daily stressors—and then started diving deeper into her personal life.

I found out she was in an abusive intimate partner relationship, and she was experiencing severe symptoms of depression associated with trauma.

Her physical symptoms were a reflection of her internal stressors and emotions. This was not a GI case, but rather a mental health case.

I took the appropriate steps, referred her to my colleague in behavioral health, and provided her with a plethora of resources, including women's shelters, crisis hotlines, and domestic violence support groups.

Mental health masquerade

I have lost count of the number of patients complaining of physical ailments such as abdominal pain, headaches, and insomnia, who are struggling with mental health ailments.

Once I start to inquire about their daily habits, lifestyle, stressors, substance use, and mood and mental health, I find that most of these physical ailments are directly linked to an underlying mental health disorder such as depression or anxiety.

A simple Google search of "behavioral health in the primary care setting" returns an impressive number of high-quality studies and articles highlighting the importance of incorporating mental healthcare into primary care office visits. After all, behavioral health issues are significant contributors to medical morbidity, mortality, and elevated costs.

What does the research say?

Research shows that up to 70% of patients who visit their primary care provider do so because of mental health problems, including depression, anxiety, stress, and burnout, according to an article published by the American Psychological Association.^[]

In addition, 40% of patients who die from suicide visited their primary care provider within the month before their death.

There is also a plethora of evidence-based research that shows the bidirectional relationship between mental health disorders and chronic medical conditions such as diabetes, cardiovascular disease, obesity, asthma, epilepsy, and cancer. In addition, psychological distress has been found to weaken the immune system. ^[]

In an article in Family Practice Management, Sarina Schrager, MD, explains the benefits of integrating mental health into primary care outpatient medicine, noting that 75% of primary care visits include mental or behavioral health components.^[]

After all, how many of our patients come to us for tips on weight loss, stress management, and smoking cessation? And how often do we see patients severely struggling with depression or substance misuse?

Yet, many of us struggle with finding clear-cut solutions for these patients because referrals to psych could take upwards of 3 months, and 3 months is often too long to wait for individuals in dire need of mental health treatment—not to mention their inability to access mental health or substance abuse treatment due to lack of insurance coverage.

"I work in Wisconsin,” stated Dr. Schrager, “where we have a relatively low percentage of uninsured patients. Still, I frequently find myself prescribing antipsychotic medications that I don't feel comfortable managing, at least until my patient can see a psychiatrist (in three months)."

Integrating behavioral health

One model for integrated behavioral healthcare includes having a mental health consultant—a psychologist, licensed clinical social worker, or other behavioral health professional—on the healthcare team.

Rather than being a handoff of care, it's a team-based approach lending support to the primary care physician. The acronym GATHER sums it up: Generalist, Accessible, Team-based, High productivity, Education, and Routine.

"Fully integrating behavioral health in primary care is the gold standard for care. "

— Sarah Schrager, MD

There are numerous benefits of integrated behavioral health:^[]

Better outcomes for patients
Less money spent on emergency room visits
Improved patient and physician experiences
Better chance that patients will cope with, and treat, their chronic medical disorders when their mental health disorders are addressed

Nevertheless, integrating behavioral health into primary care practice has certain pitfalls, such as billing and coding challenges.

Physicians, mid-level staff, and behavioral health professionals must all learn to code and bill appropriately so they can receive payment and keep their practice afloat. This may require outsourcing the integrated behavioral health and primary care billing to an outside entity with deep expertise in this area.

So, yes, we should integrate mental healthcare into our primary care office visits. Even if we are not set up for a fully integrated behavioral health and primary care practice, we can at least talk with our patients about their mental health and substance use.

We should ask them screening questions about their mood, stress levels, relationships, and sleep. We should ask them about their daily coping strategies. We should ask them about alcohol and drug use. We should ask them about any dangerous or intrusive thoughts.

And we should ask them these questions in the most empathetic manner because we want honest answers from our patients to help them navigate any mental health struggles they are experiencing.