Who Americans Turn to for Mental Health Care

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Overall, more Americans are visiting psychiatrists for mental health care than primary care physicians, according to a report released this week by the Centers for Disease Control and Prevention (CDC)—but there are distinct geographic differences.

Adults visited medical offices for mental health reasons an average of 30 million times each year between 2012 and 2014, according to data from the National Ambulatory Medical Care Survey. Psychiatrists delivered care for 55 percent of those visits, while primary care physicians delivered care for 32 percent of visits. That gap was pronounced in large cities, where 63 percent of mental health-related physician office visits were to psychiatrists. Yet in medium-sized metropolitan areas, the percentage of visits to psychiatrists and primary care physicians were not significantly different. In rural places, 29 percent of office visits were to psychiatrists while roughly half were to primary care doctors.

“The findings point to an issue of supply and demand,” says Donald Cherry, the report’s lead author and a researcher at the National Center for Health Statistics. “There may be more opportunities to access a psychiatrist in urban areas, but it may not be an option in rural areas.”

Having options is important because the type of provider patients visit can impact the quality of care they receive, says Mark Olfson, an expert in mental health care delivery at Columbia University Medical Center. A psychiatrist at a mental health clinic is specifically trained to treat complex mental health conditions and prescribe the relevant medications like antipsychotics. The clinic team provides a comprehensive assessment of the patient and addresses the various ways the condition affects the patient’s life. They might help the person maintain employment, manage finances, or cultivate a social network.

Every doctor is different, but primary care physicians are generally comfortable treating conditions such as depression, anxiety, and sleeping problems, Olfson says. However, more complex psychiatric conditions—including schizophrenia, bipolar disorder, or post-traumatic stress disorder—may strain a primary care physician’s time, resources, and abilities.

“Very few primary care physicians are comfortable managing more serious conditions," he says. "In rural areas of the country, where there isn’t ready access to psychiatrists, people with these conditions are at real risk.”

The field has been aware of the divide between urban and rural psychiatric care. Olfson recalls looking at a map of psychiatry practices across the United States and noticing the dense clusters in large cities. But the new findings were striking, he says, because they demonstrate how that concentration relates to where patients seek care. (Since the National Ambulatory Medical Care Survey focuses on visits to medical offices, the data do not capture the role of professionals who are not medical doctors, such as psychologists, social workers, nurse practitioners, or others who provide mental health care.)

A central reason for the prevalence of psychiatrists in large cities is that they earn more in urban and suburban areas; further, psychiatrists typically take on a large debt burden from medical school.

There are a few ways to address the divide from a policy perspective, Olfson says. One is to improve and increase programs that offer debt relief in exchange for working in rural areas for a set period of time. Others include instituting programs at medical schools that focus on rural mental health care. And mitigating stigma around mental health conditions might make people in smaller communities more comfortable visiting a psychiatrist.

“This data is really important to have for people making policy decisions,” Olfson says. “These are nationally representative numbers, so they really are telling us how care is distributed out there in our country.”