What drives referral from primary care physicians to mental health specialists? A randomized trial using actors portraying depressive symptoms

Richard L Kravitz, Peter Franks, Mitchell Feldman, Lisa S. Meredith, W Ladson Hinton, Carol Franz, Paul Duberstein, Ronald M. Epstein

Research output: Contribution to journalArticle

33 Citations (Scopus)

Abstract

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.

Original languageEnglish (US)
Pages (from-to)584-589
Number of pages6
JournalJournal of General Internal Medicine
Volume21
Issue number6
DOIs
StatePublished - Jun 2006

Fingerprint

Primary Care Physicians
Mental Health
Referral and Consultation
Depression
Physicians
Odds Ratio
Confidence Intervals
Primary Health Care
Adjustment Disorders
Aptitude
Drive
Life Change Events
Family Physicians
Psychotherapy
Antidepressive Agents
Randomized Controlled Trials
Health
Therapeutics
Research

Keywords

  • Health services research
  • Mental health
  • Primary care
  • Referral patterns
  • Specialty consultation

ASJC Scopus subject areas

  • Internal Medicine

Cite this

What drives referral from primary care physicians to mental health specialists? A randomized trial using actors portraying depressive symptoms. / Kravitz, Richard L; Franks, Peter; Feldman, Mitchell; Meredith, Lisa S.; Hinton, W Ladson; Franz, Carol; Duberstein, Paul; Epstein, Ronald M.

In: Journal of General Internal Medicine, Vol. 21, No. 6, 06.2006, p. 584-589.

Research output: Contribution to journalArticle

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abstract = "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.",
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