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You may want to think twice before getting depression and anxiety care in primary care.

Generalists lack the focus, resources, and incentives to deliver care in the ways we know are most effective for depression and anxiety.

We love our primary care physicians (PCPs). These doctors are smart, hard-working, caring people who have dedicated themselves to providing a broad range of care to their community.

This includes being on the front lines of depression and anxiety care. About 1 in 41 primary care patients have symptoms of depression, and about 75%2 of people who seek medical care for depression go to primary care. In response, primary care physicians write about 80%3 of antidepressant prescriptions. In many ways, primary care is our mental health care system today.

Unfortunately, the reality is that, on average, people don’t get good depression care in primary care. A review published by the American Psychiatric Association summarized:

“Several studies have documented poor quality of depression care in the primary care sector, in the form of low rates of both disease recognition and appropriate treatment by primary care physicians.”4

Here’s what the studies show:

  • Depression is accurately diagnosed only 30-50% of the time in the primary care setting5
  • Fewer than 50% of people receive care consistent with treatment guidelines and best practices6

Millions of Americans need care for depression, and our healthcare system is letting them down.

Why is depression and anxiety care so broken?

The truth is that primary care was never designed for depression care. This isn’t an indictment of the hard-working primary care doctors, but of the mismatch between the needs of depression patients and the realities of the setting.

There are five core reasons why this is the case:

1. Broad, general responsibilities

As the “front door” of healthcare, primary care inherently has a broad focus. PCPs need to be ready to address hundreds of conditions, naturally limiting their ability to be expert and go deep with any of the more complex conditions supported by specialists.

2. Rushed appointments

The economics of primary care requires them to have short appointments, averaging about 18 minutes7, designed to identify and address routine medical issues quickly. A psychiatric evaluation for depression requires at least 30 minutes to evaluate the range of considerations and treatment options.

3. Limited referral options

In many cases, Primary Care Providers would love to refer patients to psychiatry and psychotherapy resources. But about ⅔ of them report that they can’t get outpatient mental health services for their patients.8 We have a shortage of mental health professionals. The Kaiser Family Foundation reports that only 27% of mental health provider need is met.9 PCPs have been left alone to do the best they can treating depression and anxiety patients without support from specialists.

4. Narrow prescribing practices

There are over 30 medications that can help people with depression and anxiety, each with multiple doses, and these can be used in hundreds of different combinations to get treatment right for a given patient’s needs. Yet an analysis of CMS prescribing data shows that PCPs commonly prescribe just 1-3 of these medications, treating depression more like a one size fits all condition.

5. Lack of tools and incentives for ongoing care

Depression is a daily struggle that requires ongoing care over time. It’s best supported by frequent communication between a patient and doctor and frequent measurement of symptoms and side effects to inform any necessary adjustments to care. Primary care doctors are only compensated for time spent face to face with a patient and lack the tools to remotely monitor and communicate with patients. As a result, 63% of patients stop treatment within six months.10

Most PCPs are very aware of these challenges and limitations.  A PCP commented in The New Yorker: “The problem is, I lack the time or training to diagnose and manage many psychiatric disorders…I’m probably not all that great at doing so.”11 PCPs have been doing the best they can for their patients even though they know they’re not well suited to deliver the best care. But they also know that if they don’t treat these patients, they’re unlikely to get any care at all. The system is set up to fail.

People with depression and anxiety deserve better care

Better care is not only possible, it’s available. Here’s what the evidence and best practice show works:

Easier access

Fewer than half of people with depression get care.12 Either they don’t have access to existing care, or don’t feel that their needs are met there. Enabling access from home via telemedicine, supported by simple, user-friendly experiences, means more people can access the care they need.

Unfortunately, a lot of telemedicine companies are also generalists and may offer to treat depression without any particular expertise or focus. This may improve access but often has the same quality issues as getting depression care in primary care.

Specialized, focused care for depression and anxiety

Depression and anxiety are complex, heterogeneous conditions. A provider’s ability to focus and become expert on the nuances of diagnosis and treatment supports better outcomes. For example, one national study found that 19% of people visiting primary care got appropriate care for depression while 90% visiting mental health specialists did.13

Data driven prescribing

With 250+ different depression manifestations and 300+ different medication and dose combinations, choosing which is most likely to work for a given patient is a huge challenge. A 2016 Yale study14 highlighted how data can be used to help predict how a certain patient will respond to a given medication. By using technology to gather relevant data, evaluate it against clinical research and guidelines, and suggest the best treatment for each patient, we can help every provider make informed and sophisticated prescribing decisions, leading to better outcomes. 

Measurement-based care

Every person responds to antidepressant medication differently, and it’s common to need to adjust treatment based on how an individual responds. While this has traditionally been a pure trial and error approach, the process is made much more effective by precision prescribing (see above) and frequently measuring symptoms and side effects during treatment to enable data-driven adjustment decisions. This approach is known as measurement-based care and has shown to lead to better and more lasting treatment outcomes.15

Comprehensive care

Depression and anxiety have biological, psychological, and social contributors, and the best treatments address them comprehensively. Research shows that treating with medication and therapy together leads to a 60% better chance of recovery than either treatment alone. And everyone should get support with healthy lifestyle changes.

Brightside was built for this

We developed Brightside to offer evidence-based, best-practice, personalized depression and anxiety care to everyone who needs it, all from the comfort of home.

Every Brightside member receives a comprehensive evaluation from a dedicated doctor, who uses the Brightside PrecisionRx tool to analyze over 100 unique data points about the member and analyze the evidence to determine the treatment plan most likely to work for them.

Brightside delivers medication to the member’s door each month, eliminating the need for pharmacy pickups. The Brightside doctor closely monitors and tracks member progress at every step, evaluating symptom check-ins and making any necessary medication adjustments until it’s just right. Members seamlessly communicate with their doctor at any time, all from the comfort of home.

Every Brightside member can choose to complete self-paced therapy lessons or can work with a licensed Brightside Therapist to complete a personalized program based on approaches that are proven to work. Additionally, every member receives self-care resources related to diet, sleep, exercise, stress management, and relationships for a healthy lifestyle.

The Brightside approach is working. 83% of members experience a clinically significant symptom reduction, and 60% achieve remission levels within 12 weeks. While 52% of Brightside members start with suicidal ideation, only 15% report this after 12 weeks.

Primary care doctors have been asked to stretch themselves and treat depression and anxiety without proper resources for too long. They finally have a reliable place to refer all of their depression and anxiety patients, allowing them to continue to deliver great care to their communities.

Sources

  1. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a6.htm,
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3670434/
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3670434/
  4. https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.54.5.682?trendmd_shared=1
  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3670434/, https://www.ahrq.gov/sites/default/files/publications/files/mentalhth.pdf, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3184591/
  6. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/210536, https://www.ahrq.gov/sites/default/files/publications/files/mentalhth.pdf, https://www.americanprogress.org/wp-content/uploads/issues/2010/10/pdf/mentalhealth.pdf, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495452/, https://www.ncbi.nlm.nih.gov/pubmed/11146758
  7. https://journals.stfm.org/familymedicine/2018/february/young-2017-0121/
  8. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.28.3.w490,
  9. https://www.kff.org/other/state-indicator/mental-health-care-health-professional-shortage-areas-hpsas/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
  10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169979/
  11. https://www.newyorker.com/tech/annals-of-technology/should-mental-health-be-a-primary-care-doctors-job
  12. https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf
  13. https://www.ncbi.nlm.nih.gov/pubmed/11146758
  14. https://memlab.yale.edu/sites/default/files/files/2016_Chekroud_etal_Lancet(1).pdf
  15. https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.2015.15070928?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&, https://thekennedyforum-dot-org.s3.amazonaws.com/documents/KennedyForum-MeasurementBasedCare_2.pdf
  16. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1897300
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