People with serious mental illnesses (SMIs) like schizophrenia have 2–3 times greater mortality than the overall population due to high rates of poorly controlled medical conditions including cardiovascular disease.1 Evidence shows sub-optimal care of medical conditions among many people with SMI.2 Primary care physicians have an important role to play in improving receipt of guideline-concordant physical healthcare for people with SMI.3 But little is known about PCPs’ views on caring for patients with SMI.

METHODS

We surveyed a nationally representative sample of 1000 US physicians identifying as family, internal, or general medicine practitioners using a tailored Dillman method.4 A simple random sample of physicians selected from the American Medical Association (AMA) Masterfile were mailed a questionnaire, $2 incentive, and postage-paid return envelope in February 2019. Non-respondents received identical packets in March, April, June, July, and August 2019. Eligible physicians were those in the original N = 1000 sample definitively identified as practicing primary care at the address on file for the entire field period. The instrument (Appendix in the Electronic Supplementary Material [ESM]) was developed by the study team. The four survey domains are italicized in Table 2 (see Table 2 and Appendix (ESM) for item wording/responses).

The response rate was 54% (361 returned surveys from 668 eligible physicians). Eligible physicians represented 50 states and responding physicians represented 49 states (WY absent). Twenty-five surveys with > 50% missing data were excluded from analyses. Response did not differ by specialty, age, sex, degree (MD/DO), or practice type. Chi-squared tests showed that more non-responders (37.2%) than responders (22.1%) were from the south; analyses incorporated weights adjusting for this difference. Data were analyzed descriptively. We used chi-squared tests to compare responses among physicians with versus without onsite mental health and care coordination services. This study was deemed exempt from review by the JHSPH Institutional Review Board.

RESULTS

Respondents’ demographic characteristics were similar to PCPs nationally (Table 1). Over 40% of practices did not perform population health tracking or care coordination; one-third had onsite mental healthcare. Fifty-two percent of PCPs thought that people with SMI want to change their health behaviors (Table 2). More than three-quarters reported ability to treat physical and mental health symptoms in SMI, but only 40.9% reported ability to treat substance use. Over 70% endorsed joint responsibility with specialty mental health providers for caring for people with SMI. Physicians at clinics with onsite mental health services reported greater ability to provide smoking cessation, mental health, and weight management services (p < 0.05; Appendix Table 1 in the ESM). Physicians at clinics with care coordination services were more likely to report need for a health educator and nurse to support care coordination and enhanced reimbursement (p < 0.05; Appendix Table 2 in the ESM).

Table 1 Characteristics of Primary Care Physician Survey Respondents, 2019 (N = 336)
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Table 2 US Primary Care Physicians’ Views Regarding Care for Patients with Serious Mental Illness (N = 336)
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DISCUSSION

The majority of US PCP respondents endorsed joint responsibility for caring for patients with SMI alongside specialty mental health providers, but the population health management and care coordination functions needed for integrated care5 were absent from more than 40% of practices. Only 52% of respondents believed that people with SMI wanted to make health behavior change, an attitude at odds with evidence showing people with SMI’s desire and ability to lose weight and quit smoking.6 Only 41% of PCPs reported that they were able to treat substance use, suggesting a need to bolster capacity to treat this common co-occurring issue in SMI. PCPs with onsite mental health services reported greater ability to deliver services (mental health, smoking cessation, and weight management) involving counseling. PCPs with onsite care coordination reported a higher need for additional coordination supports, perhaps suggesting that practices with care coordination serve high-need patient populations and/or recognition of the value of care coordination.

About one-third (N = 332) of physicians in the original sample had an incorrect practice status, specialty, or address and were deemed ineligible. While our sample was fairly small, with eligible physicians representing all 50 states but only 660 of 47,701 zip codes, respondents’ characteristics were similar to those of PCPs nationally. Our survey did not assess whether PCPs’ views on needed resources differed for SMI versus other chronic conditions.

A national sample of US PCPs viewed specialty mental healthcare providers and PCPs as jointly responsible for the health of people with SMI; financing and delivery models that effectively support such shared responsibility are needed.