America is running out of therapists. Here's how primary care might have to fill the gap.

America is running out of therapists. Here's how primary care might have to fill the gap.

137 million Americans now live in an area officially defined as a Mental Health Professional Shortage Area, accounting for 40% of the overall U.S. population, according to the Health Resources and Services Administration. The largest shortages appear among mental health counselors, psychologists, adult psychiatrists, addiction counselors, mental health and substance use disorder social workers, and psychiatric nurse practitioners. Several roles show particularly high unmet need, meaning projected supply is far below estimated demand. This means that 4 in 10 Americans simply cannot access support, regardless of insurance status or ability to pay.

Researchers have said for decades that primary care has become the country’s main mental health safety net, not because family doctors aim to become mental health providers, but because they are often the first place people turn to for help. They see patients over many years, know their history and are usually trusted. When someone finally feels ready to talk about what’s bothering them, they often bring it up with their doctor during a visit that was booked for a physical health issue.

This was confirmed by a 2024 survey by West Health and Gallup, which found that 70% of Americans would prefer their primary care provider to address both their physical and mental health in the same visit. This number did not come as a surprise to clinicians surveyed for the same report. The separation between physical and mental health has never mapped well onto how people experience being unwell, or how they ask for help. If primary care is already doing this work, the question now is whether it is properly equipped to do so.

Below, April Health examines this question in detail.

Identifying Mental Health Problems in a Primary Care Appointment

Consider how this works in practice. A patient goes in to have their persistently aching knee looked at by their doctor. They might be asked to complete a routine depression screening questionnaire while they are in the waiting room. If their score reaches a minimum threshold, the doctor may note it down. The patient might leave with a mental health referral, but might not if it didn’t come up during the appointment because of time restrictions. The depression goes unaddressed and is left to worsen. This is the exact gap the collaborative care model was designed to close.

Collaborative care was developed at the University of Washington in the mid-to-late 1990s. The model has been studied for more than two decades and is validated by more than 90 randomized controlled trials. Rather than referring patients to a third-party specialist, it gives them access to a behavioral health care manager alongside their existing doctor, overseen by a consulting psychiatrist. The care manager checks with patients, tracks symptoms using validated tools, and the psychiatrist regularly reviews decisions and helps guide the treatment plan, which is managed by the primary care doctor.

The evidence that collaborative care is effective is strong. The IMPACT trial, published in JAMA in 2002, followed patients aged 60 and older across primary care clinics and found that collaborative care more than doubled the effectiveness of depression treatment compared to usual care. A 2016 review of studies in JAMA Psychiatry confirmed that the benefits apply to patients coping with chronic physical conditions along with depression.

Uptake Has Been Slow

Despite the evidence and convenience, only a small fraction of primary care practices in the United States have implemented collaborative care. The obstacles are largely practical.

Reimbursement has been the biggest issue, historically; without clear billing pathways, primary care practices have had little financial incentive to invest in the staffing and infrastructure the model calls for. This is now changing significantly, with Medicare reimbursing collaborative care through billing codes and Medicaid coverage expanding across many states, according to the Meadows Mental Health Policy Institute and the American Psychiatric Association. Most major commercial insurers now cover the services as well.

A February 2026 report from Shatterproof and the Bowman Family Foundation found that the number of commercially insured patients billed for collaborative care grew 26-fold between 2018 and 2024, although that growth remains patchy, with some states seeing more than 1% of eligible individuals while others serve fewer than 0.05% of eligible people.

Building the care team itself has restricted adoption of the model. An in-house collaborative care team requires practices to recruit and train both care managers and psychiatrists, then make it financially viable. Practices are now addressing this by outsourcing to organizations that provide the model on their behalf. Even then, success depends on continued coordination between three people who have typically worked in separate systems, which takes time and investment that most practices have not previously had reason to make.

Designed for Everyday Stress

Collaborative care isn’t designed to replace the existing mental health system. People with complex needs, severe conditions, or multiple diagnoses need higher levels of care, and the broader shortage of mental health professionals needs its own mitigation policy. But for the millions of Americans living in mental health staff shortage areas, waiting for this to be solved would take too long. For patients with higher level needs who face long waits for specialist care, collaborative care can help in the meantime, supporting patients through the system and ensuring they are not left to manage alone.

Primary care has carried this load for many years without being properly set up to do it, and that is at last starting to change.

This story was produced by April Health and reviewed and distributed by Stacker.