What drives referral from primary care physicians to mental health specialists? A randomized trial using actors portraying depressive symptoms.
BACKGROUND
Referral from primary care to the mental health specialty sector is important but poorly understood.


OBJECTIVE
Identify physician characteristics influencing mental health referral.


METHODS
Randomized controlled trial using Standardized Patients (SPs).


METHODS
Offices of primary care physicians in 3 cities.


METHODS
One hundred fifty-two family physicians and general internists recruited from 4 broad practice settings; 18 middle aged Caucasian female actors.


METHODS
Two hundred and ninety-eight unannounced SP visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder.


METHODS
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 > or =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).


CONCLUSIONS
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.
Kravitz
Richard L
RL
Center for Health Services Research in Primary Care and Department of Internal Medicine, University of California Davis, Sacramento, CA 95817, USA. rlkravitz@ucdavis.edu
Franks
Peter
P
Feldman
Mitchell
M
Meredith
Lisa S
LS
Hinton
Ladson
L
Franz
Carol
C
Duberstein
Paul
P
Epstein
Ronald M
RM
D000328:Adult; D000368:Aged; D003863:Depression / Q000628:therapy; D003866:Depressive Disorder / Q000628:therapy*; D004324:Drama; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008605:Mental Health Services; D008875:Middle Aged; D010817:Physician-Patient Relations; D010821:Physicians, Family; D012017:Referral and Consultation