BACKGROUND: Referral from primary care to the mental health specialty sector is important but poorly understood.
OBJECTIVE: Identify physician characteristics influencing mental health referral.
DESIGN: Randomized controlled trial using Standardized Patients (SPs).
SETTING: Offices of primary care physicians in 3 cities.
PARTICIPANTS: One hundred fifty-two family physicians and general internists recruited from 4 broad practice settings; 18 middle aged Caucasian female actors.
INTERVENTION: Two hundred and ninety-eight unannounced SP visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder.
MEASUREMENTS: Mental health referrals via SP written reports; physician and system characteristics through a self-administered physician questionnaire.
RESULTS: Among 298 SP visits, 107 (36%) resulted in mental health referral. Referrals were less likely among physicians with greater self-confidence in their ability to manage antidepressant therapy (adjusted odds ratio [AOR] 0.39, 95% confidence interval [CI] 0.17 to 0.86) and were more likely if physicians typically spent ≥10% of professional time on nonclinical activities (AOR 3.42, 95% CI 1.45 to 8.07), had personal life experience with psychotherapy for depression (AOR 2.74, 95% CI 1.15 to 6.52), or usually had access to mental health consultation within 2 weeks (AOR 2.94, 95% CI 1.26 to 6.92).
LIMITATION: The roles portrayed by SPs may not reflect the experience of a typical panel of primary care patients.
CONCLUSIONS: Controlling for patient and health system factors, physicians’ therapeutic confidence and personal experience were important influences on mental health referral. Research is needed to determine if addressing these factors can facilitate more appropriate care.
mental health primary care referral patterns specialty consultation health services research
This is a preview of subscription content, log in to check access.
Ackermann RT, Williams JW Jr. Rational treatment choices for nonmajor depressions in primary care: an evidence-based review. J Gen Intern Med. 2002;17:293–301.CrossRefPubMedGoogle Scholar
Churchill R, Hunot V, Corney R, et al. A systematic review of controlled trials of the effectiveness and cost-effectiveness of brief psychological treatments for depression. Health Technol Assess. 2001;5:1–173.PubMedGoogle Scholar
Lam RW, Kennedy SH. Evidence-based strategies for achieving and sustaining full remission in depression: focus on metaanalyses. Can J Psychiatry. 2004;49(3 Suppl 1):17S-26S.PubMedGoogle Scholar
Wampold BE, Minami T, Baskin TW, Callen Tierney S. A meta-(re)analysis of the effects of cognitive therapy versus ‘other therapies’ for depression. J Affect Disord. 2002;68:159–65.CrossRefPubMedGoogle Scholar
Kessler RC, Berglund P, Demler O, et al. The Epidemiology of Major Depressive Disorder: results from the national comorbidity survey replication (NCS-R). JAMA. 2003;289:3095–105.CrossRefPubMedGoogle Scholar
Sydney E, Hahn S. Depression. PIER: Physicians’ Information and Education Resource. Accessed October 27, 2005.Google Scholar
Grembowski DE, Martin D, Patrick DL, et al. Managed care, access to mental health specialists, and outcomes among primary care patients with depressive symptoms. J Gen Intern Med. 2002;17:258–69.CrossRefPubMedGoogle Scholar
Alegria M, McGuire T. Rethinking a universal framework in the psychiatric symptom-disorder relationship. J Health Soc Behav. 2003;44:257–74.CrossRefPubMedGoogle Scholar
Lin EH, Von Korff M, Katon W, et al. The role of the primary care physician in patients’ adherence to antidepressant therapy. Med Care. 1995;33:67–74.CrossRefPubMedGoogle Scholar
Miranda J, Munoz R. Intervention for minor depression in primary care patients. Psychosom Med. 1994;56:136–41.PubMedGoogle Scholar
Mitchell J, Baker M. Religious commitment and the construal of sources of help for emotional problems. Br J Med Psychol. 2000;73:289–301.CrossRefPubMedGoogle Scholar
Sadavoy J, Meier R, Ong AY. Barriers to access to mental health services for ethnic seniors: the Toronto study. Can J Psychiatry. 2004;49:192–9.PubMedGoogle Scholar
Arean PA, Miranda J. Do primary care patients accept psychological treatments? Gen Hosp Psychiatry. 1996;18:22–7.CrossRefPubMedGoogle Scholar
Olfson M. Primary care patients who refuse specialized mental health services. Arch Intern Med. 1991;151:129–32.CrossRefPubMedGoogle Scholar
Van Voorhees BW, Cooper LA, Rost KM, et al. Primary care patients with depression are less accepting of treatment than those seen by mental health specialists. J Gen Intern Med. 2003;18:991–1000.CrossRefPubMedGoogle Scholar
Kushner K, Diamond R, Beasley JW, Mundt M, Plane MB, Robbins K. Primary care physicians’ experience with mental health consultation. Psychiatr Serv. 2001;52:838–40.CrossRefPubMedGoogle Scholar
Meredith LS, Rubenstein LV, Rost K, et al. Treating depression in staff-model versus network-model managed care organizations. J Gen Intern Med. 1999;14:39–48.CrossRefPubMedGoogle Scholar
Trude S, Stoddard JJ. Referral gridlock: primary care physicians and mental health services. J Gen Intern Med. 2003;18:442–9.CrossRefPubMedGoogle Scholar
Valenstein M, Klinkman M, Becker S, et al. Concurrent treatment of patients with depression in the community: provider practices, attitudes, and barriers to collaboration. J Fam Pract. 1999;48:180–7.PubMedGoogle Scholar
Van Voorhees BW, Wang NY, Ford DE. Managed care organizational complexity and access to high-quality mental health services: perspective of U.S. primary care physicians. Gen Hosp Psychiatry. 2003;25:149–57.CrossRefPubMedGoogle Scholar
Simon GE, Fleck M, Lucas R, Bushnell DM. Prevalence and predictors of depression treatment in an international primary care study. Am J Psychiatry. 2004;161:1626–34.CrossRefPubMedGoogle Scholar
Glied S. Too little time? The recognition and treatment of mental health problems in primary care. Health Serv Res. 1998;33(4 Part 1):891–910.PubMedGoogle Scholar
Alvidrez J, Arean PA. Physician willingness to refer older depressed patients for psychotherapy. Int J Psychiatry Med. 2002;32:21–35.CrossRefPubMedGoogle Scholar
Williams JW Jr, Rost K., Dietrich AJ, Ciotti MC, Zyzanski SJ, Cornell J. Primary care physicians’ approach to depressive disorders. Effects of physician specialty and practice structure. Arch Fam Med. 1999;8:58–67.CrossRefPubMedGoogle Scholar
Kravitz RL, Epstein RM, Feldman MD, et al. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. JAMA. 2005;293:1995–2002.CrossRefPubMedGoogle Scholar
The American Association for Public Opinion Research. Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. Lenexa, KS: AAPOR; 2000.Google Scholar
Kravitz RL, Bell RA, Azari R, Kelly-Reif S, Krupat E, Thom DH. Direct observation of requests for clinical services in office practice: what do patients want and do they get it? Arch Intern Med. 2003;163:1673–81.CrossRefPubMedGoogle Scholar
Mintzes B, Barer ML, Kravitz RL, et al. How does direct-to-consumer advertising (DTCA) affect prescribing? A survey in primary care environments with and without legal DTCA. Can Med Assoc J. 2003;169:405–12.Google Scholar
Weissman JS, Blumenthal D, Silk AJ, et al. Physicians report on patient encounters involving direct-to-consumer advertising. Health Aff (Millwood). 2004;Suppl Web Exclusives:W4:219–33.Google Scholar
Franz CE, Epstein RM, Miller K, et al. Caught in the act? Prevalence, predictors, and consequences of detection in a study using standardized patients. Health Serv Res. In press.Google Scholar
Funder DC. Toward a social psychology of person judgments: implications for person perception accuracy and self-knowledge. In: Forgas JP, Williams KD, eds. Social Judgments: Implicit and Explicit Processes. New York: Cambridge University Press; 2003:115–33.Google Scholar
Borowsky SJ, Rubenstein LV, Skootsky SA, Shapiro MF. Referrals by general internists and internal medicine trainees in an academic medicine practice. Am J Manage Care. 1997;3:1679–87.Google Scholar
Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138:273–87.PubMedGoogle Scholar
Roland M, Morris R. Are referrals by general practitioners influenced by the availability of consultants? BMJ. 1988;297:599–600.CrossRefPubMedGoogle Scholar
Calman N, Hyman R, Licht W. Variability in consultation rates and practitioner level of diagnostic certainty. J Fam Pract. 1992;35:31–8.PubMedGoogle Scholar
Reynolds G, Chitnis J, Roland M. General practitioner outpatient referrals: do good doctors refer more patients to hospital. BMJ. 1991;25:1250–2.CrossRefGoogle Scholar
Franks P, Williams G, Zwanziger J, Mooney C, Sorbero M. Why do physicians vary so widely in their referral rates? J Gen Intern Med. 2000;15:163–8.CrossRefPubMedGoogle Scholar
Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall; 1986.Google Scholar