Visits for Depression to Physician Assistants and Nurse Practitioners in the USA

  • Abiola O. Keller
  • Roderick S. Hooker
  • Elizabeth A. Jacobs


Major depression is a major public health problem. In 2015, approximately 16 million US adults experienced a major depressive episode.1 Depression adversely affects physical health2 and functioning.3,4 The disease is recognized globally as a leading cause of disability.5 Available research has shown that existing pharmacotherapy and psychotherapy treatments can effectively treat symptoms for many adults with depression.6,7 However, a large proportion of adults are undertreated8 or overtreated9 for depression. Moreover, racial and ethnic disparities in the undertreatment of depression persist.10,11 One strategy for improving the quality and equity of depression care is by ensuring access to a consistent source of care for individuals with depression. Having a usual source of care is associated with an increased likelihood of receiving adequate depression treatment12 and timely preventive services.13A worsening physician shortage, coupled with the increased demand for...



We would like to acknowledge the contribution of Lisa E. Rein, MS, Aniko Szabo, PhD, and Tom Chelius, MS, for their assistance with the statistical analyses for earlier versions of this paper.

Work was conducted at Marquette University, Milwaukee, WI.

Funding Information

The project described was supported by the Robert Wood Johnson Foundation New Connections Program. Abiola O. Keller received support from the NIH Loan Repayment Program for Health Disparities Research (LRP-HDR) (grant number L60 MD008863; PI: A. Keller). Additional support was provided by the National Centers for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through grant number UL1TR001436. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.


  1. 1.
    National Institute of Mental Health. Major Depression among Adults. Available online at Accessed on September 14, 2015.
  2. 2.
    National Institute for Health Care Management (NIHCM) Foundation. Identifying and Treating Maternal Depression: Strategies & Considerations for Health Plans. Washington, DC: National Institute for Health Care Management (NIHCM) Foundation. Available online at Accessed on November 26, 2015.
  3. 3.
    Greenberg PE, Birnbaum HG. The Economic Burden of Depression in the US: Societal and Patient Perspectives. Expert Opinion on Pharmacotherapy. 2005;6(3):369–376.CrossRefPubMedGoogle Scholar
  4. 4.
    Wang PS, Beck AL, Berglund P, et al. Effects of Major Depression on Moment-in-Time Work Performance. The American Journal of Psychiatry. 2004;161(10):1885–1891.CrossRefPubMedGoogle Scholar
  5. 5.
    World Health Organization. Health Statistics and Information Systems: Global Health Estimates 2015. Available online at Accessed on September 14, 2015.
  6. 6.
    Work Group on Major Depressive Disorder. Practice Guidelines for Treatment of Patients with Major Depressive Disorder. Washington, DC: APA; 2000.Google Scholar
  7. 7.
    Cuijpers P, Berking M, Andersson G, et al. A Meta-Analysis of Cognitive-Behavioural Therapy for Adult Depression, Alone and in Comparison with Other Treatments. Canadian Journal of Psychiatry Revue Canadienne de Psychiatrie. 2013;58(7):376–385.CrossRefPubMedGoogle Scholar
  8. 8.
    Young AS, Klap R, Sherbourne CD, et al. The Quality of Care for Depressive and Anxiety Disorders in the United States. Archives of General Psychiatry. 2001;58(1):55–61.CrossRefPubMedGoogle Scholar
  9. 9.
    Mojtabai R. Clinician-identified Depression in Community Settings: Concordance with Structured-Interview Diagnoses. Psychotherapy and Psychosomatics. 2013;82(3):161–169.CrossRefPubMedGoogle Scholar
  10. 10.
    González HM, Vega WA, Williams DR, et al. Depression Care in the United States: Too Little for Too Few. Archives of General Psychiatry. 2010;67(1):37–46.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Witt WP, Keller A, Gottlieb C, et al. Access to Adequate Outpatient Depression Care for Mothers in the USA: A Nationally Representative Population-Based Study. Journal of Behavioral Health Services & Research. 2011;38(2):191–204.CrossRefGoogle Scholar
  12. 12.
    Keller AO, Gangnon R, Witt WP. The Impact of Patient–Provider Communication and Language Spoken on Adequacy of Depression Treatment for U.S. Women. Health Communication. 2014;29(7):646–655.CrossRefPubMedGoogle Scholar
  13. 13.
    Witt WP, Kahn R, Fortuna L, et al. Psychological Distress as a Barrier to Preventive Healthcare among U.S. Women. Journal of Primary Prevention. 2009;30(5):531–547.CrossRefPubMedGoogle Scholar
  14. 14.
    IHS Inc. The Complexities of Physician Supply and Demand: Projections from 2014 to 2025. Available online at 2016. Accessed on May 17, 2017.
  15. 15.
    Stange K. How Does Provider Supply and Regulation Influence Health Care Markets? Evidence From Nurse Practitioners and Physician Assistants. Journal of Health Economics. 2014;33:1–27.CrossRefPubMedGoogle Scholar
  16. 16.
    United States Bureau of Labor Statistics. Occupational Employment and Wages, May 2016; 29–1171 Nurse Practitioners. Available online at Accessed on May 18, 2017.
  17. 17.
    United States Bureau of Labor Statistics. Occupational Employment and Wages, May 2016; 29–1071 Physician Assistants. Available online at Accessed om May 18, 2017.
  18. 18.
    Hooker RS, Everett CM. The Contributions of Physician Assistants in Primary Care Systems. Health and Social Care in the Community. 2012;20(1):20–31.CrossRefPubMedGoogle Scholar
  19. 19.
    Everett CM, Schumacher JR, Wright A, et al. Physician Assistants and Nurse Practitioners as a Usual Source of Care. Journal of Rural Health. 2009;25(4):407–414.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Hing E, Hooker RS, Ashman JJ. Primary Health Care in Community Health Centers and Comparison with Office-Based Practice. Journal of Community Health. 2011;36(3):406–413.CrossRefPubMedGoogle Scholar
  21. 21.
    Benitez J, Coplan B, Dehn RW, et al. Payment Source and Provider Type in the US Healthcare System. Journal of the American Academy of Physician Assistants. 2015;28(3):46–53.CrossRefPubMedGoogle Scholar
  22. 22.
    Hooker RS, McCaig LF. Use of Physician Assistants and Nurse Practitioners in Primary Care, 1995–1999. Health Affairs (Millwood). 2001;20(4):231–238.CrossRefGoogle Scholar
  23. 23.
    Hooker RS, Benitez JA, Coplan BH, et al. Ambulatory and Chronic Disease Care by Physician Assistants and Nurse Practitioners. Journal of Ambulatory Care Management. 2013;36(4):293–301.CrossRefPubMedGoogle Scholar
  24. 24.
    Morgan PA, Shah ND, Kaufman JS, et al. Impact of Physician Assistant Care on Office Visit Resource Use in the United States. Health Services Research. 2008;43(5 Pt 2):1906–1922.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Chang ET, Magnabosco JL, Chaney E, et al. Predictors of Primary Care Management of Depression in the Veterans Affairs Healthcare System. Journal of General Internal Medicine. 2014;29(7):1017–1025.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Ganz DA, Koretz BK, Bail JK, et al. Nurse Practitioner Comanagement for Patients in an Academic Geriatric Practice. American Journal of Managed Care. 2010;16(12):e343–355.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Reuben DB, Ganz DA, Roth CP, et al. Effect of Nurse Practitioner Comanagement on the Care of Geriatric Conditions. Journal of the American Geriatrics Society. 2013;61(6):857–867.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Morgan PA, Strand J, Ostbye T, et al. Missing in Action: Care by Physician Assistants and Nurse Practitioners in National Health Surveys. Health Services Research. 2007;42(5):2022–2037.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Lau DT, McCaig LF, Hing E. Toward a More Complete Picture of Outpatient, Office-Based Health Care in the U.S. American Journal of Preventive Medicine. 2016;51(3):403–409.CrossRefPubMedGoogle Scholar
  30. 30.
    Ference EH, Min JY, Chandra RK, et al. Antibiotic Prescribing by Physicians Versus Nurse Practitioners for Pediatric Upper Respiratory Infections. Annals of Otology Rhinology & Laryngology. 2016;125(12):982–991.CrossRefGoogle Scholar
  31. 31.
    Asao K, McEwen LN, Lee JM, et al. Ascertainment of Outpatient Visits by Patients with Diabetes: The National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS). Journal of Diabetes and Its Complications. 2015;29(5):650–658.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Centers for Disease Control and Prevention/National Center for Health Statistics. Ambulatory Health Care Data. Available online at Accessed on September 2, 2016.
  33. 33.
    National Center for Health Statistics. National Ambulatory Medical Care Survey 2015 Patient Record. Available online at Accessed on September 2, 2016.
  34. 34.
    Kurtzman ET, Barnow BS. A Comparison of Nurse Practitioners, Physician Assistants, and Primary Care Physicians’ Patterns of Practice and Quality of Care in Health Centers. Medical Care. 2017;55(6):615–622.CrossRefPubMedGoogle Scholar
  35. 35.
    Everett C, Thorpe C, Palta M, et al. Physician Assistants and Nurse Practitioners Perform Effective Roles on Teams Caring for Medicare Patients with Diabetes. Health Affairs (Millwood). 2013;32(11):1942–1948.CrossRefGoogle Scholar
  36. 36.
    Andersen RM. Revisiting The Behavioral Model and Access to Medical Care: Does it Matter? Journal of Health and Social Behavior. 1995;36(1):1–10.CrossRefPubMedGoogle Scholar
  37. 37.
    SAS Institute Inc. SAS/STAT® 9.3 User’s Guide. Cary, NC: SAS Institute Inc.;2011.Google Scholar
  38. 38.
    Stata, Release 13 (Statistical Software) [computer program]. College Station, TX: StataCorp LP; 2013.Google Scholar
  39. 39.
    National Center for Health Statistics. Reliability of Estimates. Available online at Accessed on September 21, 2016.
  40. 40.
    Lichtenstein BJ, Reuben DB, Karlamangla AS, et al. Effect of Physician Delegation to Other Healthcare Providers on the Quality of Care for Geriatric Conditions. Journal of the American Geriatrics Society. 2015;63(10):2164–2170.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Archer J, Bower P, Gilbody S, et al. Collaborative Care for Depression and Anxiety Problems. The Cochrane Database of Systematic Reviews. 2012;10:Cd006525.PubMedGoogle Scholar
  42. 42.
    Unutzer J, Katon W, Callahan CM, et al. Collaborative Care Management of Late-Life Depression in the Primary Care Setting: A Randomized Controlled Trial. Journal of the American Medical Association. 2002;288(22):2836–2845.CrossRefPubMedGoogle Scholar
  43. 43.
    Gilbody S, Bower P, Fletcher J, et al. Collaborative Care for Depression: A Cumulative Meta-Analysis and Review of Longer-Term Outcomes. Archives of Internal Medicine. 2006;166(21):2314–2321.CrossRefPubMedGoogle Scholar
  44. 44.
    Katon W, Rutter C, Ludman EJ, et al. A Randomized Trial of Relapse Prevention of Depression in Primary Care. Archives of General Psychiatry. 2001;58(3):241–247.CrossRefPubMedGoogle Scholar
  45. 45.
    Badger L, Robinson H, Farley T. Management of Mental Disorders in Rural Primary Care: A Proposal for Integrated Psychosocial Services. Journal of Family Practice. 1999;48(10):813–818.PubMedGoogle Scholar
  46. 46.
    Colon-Gonzalez MC, McCall-Hosenfeld JS, Weisman CS, et al. “Someone’s Got to Do it” - Primary Care Providers (PCPs) Describe Caring for Rural Women with Mental Health Problems. Mental Health and Family Medicine. 2013;10(4):191–202.Google Scholar
  47. 47.
    Hing E, Hsiao CJ. In Which States are Physician Assistants or Nurse Practitioners More Likely to Work in Primary Care? Journal of the American Academy of Physician Assistants. 2015;28(9):46–53.CrossRefPubMedGoogle Scholar

Copyright information

© National Council for Behavioral Health 2017

Authors and Affiliations

  • Abiola O. Keller
    • 1
  • Roderick S. Hooker
    • 2
  • Elizabeth A. Jacobs
    • 3
  1. 1.College of NursingMarquette UniversityMilwaukeeUSA
  2. 2.Physician Assistant ProgramNorthern Arizona UniversityPhoenixUSA
  3. 3.Departments of Population Health and Internal Medicine, Dell Medical SchoolThe University of Texas at AustinAustinUSA

Personalised recommendations