The MHS beneficiary population among those aged 18–64 years in 2021 was 53.5% male, 31.1% active duty (AD), 15.5% dependents of AD, 20.9% retirees, and 32.5% other. These beneficiaries had 148 million total outpatient visits from 2017 to 2021 in DC and 217 million in PC. A total of 64.0 million DC visits were in primary care and 13.0 million were in behavioral health; 46.4 million PC visits were in primary care and 14.5 million in behavioral health (Fig. 1). Primary care visits in DC were more likely to be from younger and AD beneficiaries versus primary care visits in PC. The MHS has a codified priority to treat AD in DC, which likely explains why most of the AD remain in DC while most of the dependent care is PC. The prevalence of mental health disorders in AD service members has been reported to be around 15% based on relevant ICD codes from DC and PC visits including to behavioral health providers (U.S. Army Public Health Center 2020).

The total count of visits to behavioral health providers in DC decreased from 2,876,529 in 2017 to 2,337,271 in 2021, a 19% decrease over the 5-year period. In PC, this total count increased from 2,513,901 in 2017 to 3,538,712 in 2021, a 41% increase over the same period. For AD, the number of DC behavioral health visits in 2017 was 2,514,071, and in 2021 that number fell to 1,942,111 (a 22.8% decrease) while PC increased from 268,640 to 587,618 (a 119% increase). In 2017, 90.3% of AD BH care was provided by DC, while by 2021 the amount fell to 76.8% (Fig. 1).

The overall percentage of primary care visits in either DC or PC with a mental health diagnosis was 7.3% over the period 2017–2021 (Table 1). Annual percentages increased from 7.0% in 2017 to 7.9% in 2021. The overall percentage was 4.3% for AD, 6.1% for retirees, 11.9% for dependents, and 9.5% for all others, primarily including dependents of retirees; and 5.2% in men and 9.3% in women. For AD the percentages were similar across branches of service.

In DC, 5.7% of primary care visits had a mental health diagnosis in both 2017 and in 2021 (Fig. 2). The overall percentage over the study period was 3.9% for AD versus 11.6% for dependents (Table 1). In PC, 8.9% of primary care visits had a mental health diagnosis in 2017 versus 10.5% in 2021. The overall percentage was 8.4% for AD versus 12.4% for dependents.

Percent of primary care visits resulting in a mental health diagnosis

In Poisson regression models of prevalence ratios for mental health visits by year and military status or location of care, dependents of AD had 2.97 times higher percentage of DC and 1.48 times higher percentage of PC primary care visits with a mental health diagnosis, relative to AD, over the study period. Additionally, relative to DC primary care visits, PC primary care visits for AD had 2.14 times higher percentage and for dependents 1.06 times higher percentage of visits with a mental health diagnosis. All reported prevalence ratios were significantly different from 1 (p < 0.001 for each). Qualitative linear increases in the percentage of primary care visits with a mental health diagnosis were observed across study years in PC but not in direct care (Table 2).

Of PDTS prescriptions ordered in DC by a primary care provider, 9.6% of prescription fills had a mental health-related drug class in 2017 and 10.0% in 2021 (Fig. 3), with overall percentages of 7.7% for AD versus 15.5% for dependents. For AD this percentage increased from 7.6% in 2017 to 9.3% in 2021, and for dependents increased from 15.2% in 2017 to 16.7% in 2021. No qualitative linear trends in the percentages were apparent across study years.

Percent direct care psychotropic prescriptions