Primary care is the front door for mental health concerns. These are the efforts to make integrated care more seamless

Sipra Laddha, MD was almost done with her psychiatry residency when she faced her own mental health crisis. While pregnant with twins, she developed pregnancy-related anxiety and then postpartum depression, and the experience underscored the need to better integrate mental health services into maternity care.

These days, Laddha specializes in reproductive psychiatry and is the co-founder of LunaJoy Health , a startup that works with ob-gyn practices to identify and provide outreach to patients who may be struggling with a behavioral health issue. 

Mental Health Awareness Month is almost over, but the work continues as more primary care practices aim to better serve the huge unmet need in behavioral health. They’re advocating for more reimbursement for providing mental health services, while a number of startups, LunaJoy among them, are popping up to help them manage the technical and logistical challenges. 

Integrating physical and mental health not only leads to better outcomes, but has become the norm amid a persistent clinician shortage. 

Eight out of 10 people already are accessing behavioral services from their primary care doctors, noted Jen Brull , president-elect of the American Academy of Family Physicians . And last year, for the first time, the U.S. Preventive Services Task Force even recommended anxiety screenings in primary care settings for all adults under the age of 65. 

The volume of patients with mental health concerns also is continuing to increase, especially among children and preteens. Even four years after the COVID-19 shutdowns, rates of anxiety, depression and suicidality are straining practices as young people continue to struggle with social isolation and the negative effects of social media, Brull noted. 

“The good news is that for the 15th straight year, the number of medical students choosing family medicine went up and we were able to offer more residency positions,” she said. “It’s probably not fast enough to keep up with what the United States needs, but at least we’re seeing that trend.”

The AAFP’s advocacy efforts are focused on a few fronts. The first is around securing insurance reimbursement for providing integrated care. It also wants to train more family medicine doctors, particularly in regions where there are shortages. The group is advocating, for instance, to expand the Teaching Health Center Graduate Medical Education Program, which funds residency spots in underserved areas. 

Despite the momentum around integrated care, barriers remain. Doctors need to feel comfortable prescribing psychotropic drugs, particularly those that are less commonly used in a primary care setting, said Matt Miclette, MPH MS RN , vice president of clinical operations at NeuroFlow , which develops software for integrated care delivery.

Then there are the startup costs. While insurance companies are increasingly willing to pay for integrated care, primary care practices still incur upfront costs related to hiring additional staff, like case managers, or investing in technology to help track outcomes. “The reimbursement only comes with your first patient,” Miclette said. 

NeuroFlow’s software allows practices to screen their entire patient roster to identify individuals who might benefit from mental health services. In that way, they can build a caseload of patients and immediately start implementing — and billing for — integrated care services.

At LunaJoy, the focus is on making sure that patients who screen positive for mental health issues — which affect one in five women during or after pregnancy — can get connected to resources. The company’s technology integrates with an ob-gyn’s electronic health record to identify women who might be struggling with a condition like anxiety or depression and then provides outreach to get them into treatment, which it provides.

“A lot of people think about this as a very finite period of time,” Laddha said. “But the evidence actually [suggests that] when we don’t treat these things aggressively during pregnancy … they tend to get worse.”

She points to data showing that mental health conditions are linked to 23% of preventable maternal deaths that occur within the first year after giving birth.

Of course, primary care practices can’t solve the mental health crisis alone. 

Across the country, groups that represent mental health professionals are pushing for changes that could attract more people to the field — particularly people of color, who are vastly underrepresented even as evidence mounts to support the value of receiving culturally-competent care. 

In California, which expects to have 50% fewer psychiatrists and 28% fewer mental health professionals than the population will need by the end of the decade, a number of initiatives are top of mind.

They include working with insurance companies to increase reimbursement, which would make the profession more attractive, noted Holly Daniels, PhD, LMFT , managing director of clinical affairs for the California Association of Marriage and Family Therapists.

“As the mental health needs of society increase, mental health clinicians are being overworked and overtaxed, and we do need to be able to make a good living and have good lives too,” she said, adding that student loan forgiveness could help here as well. Starting salaries are typically low while therapists complete the 3,000 hours of training required before they can get licensed.

The group also is holding events at universities and bolstering its social media presence to increase interest among students, Daniels noted. 

On the national level, a bill introduced this month aims to loosen licensing requirements for therapists who want to work with the Veterans Administration. And the American Association for Marriage and Family Therapy has made license portability across states a priority issue.

One of the challenges that Laddha points to is that mental health care is still very siloed: a patient might see one clinician for medication management and another for therapy. An interdisciplinary approach, she noted, includes making sure that all of that care is coordinated — something that LunaJoy is trying to foster.

“We're also expanding what each clinician is able to do with their skill set and their expertise,” she said. “We're in some ways creating the workforce that we need in order to deliver high quality care to women.”