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Colleen McEvoy, MSN, C-PNP, moved to Bishop County, California, in 2007 with a passion for rural medicine and adolescent patients. Her new job as school-based primary care was a perfect combination of the two. She had big plans: sexual health resources on-site and comprehensive healthcare that teenagers could trust. But she had no idea how much of that work would be mental health care.
“I was totally inundated,” she told Medscape Medical News. With a population of less than 4000, Bishop lies just west of the Nevada border, 4 hours from any major healthcare center. “So many of the youth were coming in struggling [with mental health]”, she said. “And I didn’t have anywhere to refer.” The only way to get them better mental health care was to learn to provide it herself.
About Medscape Insights
Medscape continually surveys physicians and other medical professionals about key practice challenges and current issues, creating high-impact analyses. For example, Medscape’s Primary Care & Mental Health Treatment Report found that:
- 127 million Americans live in areas facing a shortage of mental health care professionals.
- 84% of primary care providers (PCPs) surveyed agreed they will need to play an essential role in providing mental healthcare.
- More than half of the surveyed PCPs reported their patients need help in mental/behavioral health treatment.
McEvoy’s predicament is ubiquitous across US primary care. PCPs are stepping up as the “de facto” mental health care providers in their communities. Amid a widespread shortage of mental health care, they wrote as many as 79% of prescriptions for depression and manage an estimated 60% of the total psychiatric cases (plus one third of severe persistent mental illness cases), sending only the most severe on to psychiatry.
To keep up, many PCPs, including McEvoy, are seeking additional training. They’re enrolling in courses, getting certifications, and contacting consult services to be able to offer patients more than just a standard serotonin reuptake inhibitor prescription. They’re getting more information not only on nuanced diseases but also a critical dose of confidence and community. These training programs surround PCPs with mental health support networks, so no one feels like they’re practicing in isolation.
When McEvoy started in Bishop County, there weren’t even good therapy options. Today, that’s improved, but there’s still only one option for a psychiatry referral: telehealth. Many Americans are in a similar predicament. Fewer live in areas with enough psychiatrists and mental health specialists. Most states employ fewer than 40% of the mental health care workers needed to meet demand.
Even where there are mental health care providers, the system can be hard to navigate. One study found that only 55% of psychiatrists accept private insurance compared with 89% of PCPs. Just 43% take new patients on Medicaid. And so primary care becomes the default. In troubled times, patients turn to the relationship they already have and can afford.
In 2019, more than half of the patients who talked to a doctor about a mental health condition of any kind spoke to a PCP. And patients don’t seem to mind. A 2024 Gallup survey found that 74% of patients are comfortable talking to PCPs about mental health, and 70% even want the doctor to bring up mental health concerns during their visits.
All PCPs fulfill mental health training during residency. “You can’t become a family physician without having been trained in behavioral health management and psychiatry,” said Russell W. Kohl, MD, a family physician and board member for the American Academy of Family Physicians. “We know almost 75% of what we do in primary care has a mental health component.”
“But 2 months of training during a 36-month residency is still not a lot,” said Petra Steinbuchel, MD, director of the California Child & Adolescent Mental Health Access Portal, a psychiatric consultation service for California PCPs. If they’re [PCPs] going to be the front lines of mental health care and handle the bulk of anxiety, depression, and Attention-deficit/ hyperactivity disorder without burning out, PCPs need more support.
How to Fill the Gap
There are now a variety of training programs designed to fill in the gap and better support PCPs. The REACH Institute, based in New York City, exists solely to equip PCPs to deliver high-quality mental health care. McEvoy completed their training in 2018.
She did a 3-day workshop on the East Coast. Then, for the following 6 months, she met regularly, sometimes monthly, sometimes bimonthly, with other providers to practice reviewing cases.
“There were a lot of little moments where I became more comfortable with assessment, diagnosis, and treatment,” she said. They dug deeper into diagnosing attention deficit disorder, how to evaluate an aggressive child, and a much broader range of medications and their use cases. The monthly meetings also helped alleviate her isolation. She found other providers doing the same work. There were experts she could consult. “You’re not practicing in a vacuum,” she said.
In Virginia, PCP Reina Blackwood, MD, wanted to expand her mental health care experience so she could better meet her patients where they were. She completed additional training in substance abuse disorder, Suboxone therapy, and pain reprocessing. “Mental health is fundamental to overall health, and being able to adequately manage someone’s mental health means I can also help them better manage their medical health,” she added.
The American Academy of Family Practice Physicians offers continuing medical education credits for behavioral health that allow physicians to go deeper. The organization also collaborated with seven other medical associations to create The Behavioral Health Integration Collaborative , which offers webinars, podcasts, and implementation tools for PCPs. And the US government’s Agency for Healthcare Research and Quality has the Academy for Integrated Behavioral Health and Primary Care.
These programs offer more nuanced information on behavioral health. But they also provide more information on referrals, billing codes, and implementing more behavioral health in the practice.
“The goal is not to say, ‘Oh, primary care, you don’t know about behavioral health,” Kohl said. It’s to help them better integrate the mental health care they are already doing, the cases they are already seeing, “in a way that makes it more efficient and effective for patients.”
Phone a Psych Expert
But even with additional training, it’s impossible for PCPs to navigate every mental health case on their own and manage a patient’s physical health.
This is where psychiatric consultation services for primary care doctors –– also called access programs –– can be a game changer. The first formal statewide program started in Massachusetts in 2005. As of 2025, 30 states have maternal psychiatric consultation services, and 49 states offer some form of a pediatric consultation hotline.
These programs provide real-time guidance on specific cases and advise on referrals, care coordination, insurance, and billing. It’s all about doctors “developing more confidence,” said Steinbuchel, who leads one of these programs.
The access programs field a range of requests. Older doctors may call in because they’ve never prescribed anti-anxiety meds before. Other doctors call in when trying to diagnose or help families manage autism for the first time. “We find that people use a program like this more heavily for maybe 1-3 years while they’re developing their skills and confidence,” Steinbuchel said.
At her REACH training, McEvoy learned about California’s statewide consultation service. She immediately became a regular user and encouraged her office to do the same. “It’s been game-changing for us,” she said of having someone to call who can give real-time advice.
The access programs are meant to be easily accessible. Providers register on a website and then request a consultation by phone or online form. Consulting specialists can join in on patient visits or offer guidance in debriefs.
And there’s data suggesting that this kind of primary care tele-mentoring can yield outcomes just as good as those achieved when patients travel to specialists. PCPs can fill this gap as well as anyone –– probably better. “But they need to know that they’re going to have some support,” Steinbuchel said.
The sources in this story reported having no relevant disclosures.
Donavyn Coffey is a Kentucky-based journalist reporting on healthcare, the environment, and anything that affects the way we eat. She has a master’s degree from New York University’s Arthur L. Carter Journalism Institute, New York City, and a master’s in molecular nutrition from Aarhus University in Aarhus, Denmark. You can see more of her work in WIRED, Teen Vogue, Scientific American, and elsewhere.
