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Management of Patients With Depression by Rural Primary Care Practitioners
David Hartley, PhD;
Neil Korsen, MD;
Donna Bird, MS, MA;
Marc Agger, MPH
Arch Fam Med. 1998;7:139-145.
ABSTRACT
Objective To investigate the extent to which variations in treatment and referral patterns for adult patients with diagnosed symptoms of depression seen in primary care practices are explained by practitioner characteristics, such as training, years in primary practice, sex, and knowledge about depression; practice characteristics, such as size, patient volume, and payer mix; and service area characteristics, such as availability of specialty mental health services and rural location.
Design A 41-item telephone survey of primary care practitioners (PCPs) in Maine, including family and general practice doctors of medicine and doctors of osteopathy, general internists, nurse practitioners, and physician assistants (n=267).
Main Outcome Measure The degree to which PCPs treat patients with depression themselves, rather than refer them to a mental health specialist.
Results There is no significant (P=.10) urban-rural difference in the number of patients with depression seen as a percentage of total patient volume. Major barriers to referral to a mental health provider, as reported by the PCP, are long wait for an appointment, lack of available services, patients' unwillingness to use services, and reimbursement issues. Multivariate analyses indicate that PCP characteristics measuring knowledge and attitudes, as well as the lack of available services, are significantly related to treatment and referral patterns while practice characteristics and mental health provider supply are not.
Conclusion The treatment of rural patients with symptoms of depression is more likely to be improved by targeting PCPs' medical education than by efforts to increase the supply of specialty mental health providers in rural areas.
INTRODUCTION
INTEREST IN the management of major depression by primary care practitioners (PCPs) has increased since the release of guidelines for the treatment of depression by the Agency for Health Care Policy and Research.1-4 The treatment of depression in the primary care setting is especially relevant in rural areas. Primary care practitioners provide a substantial portion of mental health care in rural America.5-7 With few mental health specialists to whom they can refer patients, rural practitioners may treat more cases of depression on their own than their urban counterparts. While considerable attention has been directed toward the failure of primary care physicians to detect the presence of depression in their patients, with some notable exceptions,4, 8 little empirical research has investigated how rural PCPs deal with depression once they have identified it.9-12
In this study, we address this question, focusing on how PCPs (including primary care physicians, physician assistants, and nurse practitioners) manage adult patients with depression. Specifically, what proportion of patients do they refer to mental health specialty providers and what problems do they encounter in making such referrals? In addition, we seek to identify the determinants of these behaviors in practitioner characteristics, practice characteristics, and the availability of mental health specialty providers.
An estimated two thirds of US patients with clinical symptoms of mental illness receive no care at all for such symptoms.7 Of those who do receive formal treatment, approximately 40% receive care from a mental health specialist and 45% from the general medical sector. These national estimates have led to a suggestion that PCPs are a de facto mental health service system.7 While there is little question that some psychiatric disorders, such as schizophrenia, must be cared for by mental health specialists, others, including depression, can be treated in the primary care setting by PCPs who are knowledgeable. Unfortunately, several studies have indicated that primary care physicians fail to detect depression in 50% to 75% of patients with depression.8-9,13-14 While none of these studies reports an urban-rural difference in underdiagnosis, Rost et al4 found that rural family practice physicians detected only 24% of depressed cases that were independently identified by a diagnostic inventory.
Failure to record a diagnosis of depression is not necessarily an indication that the provider did not recognize it. With the use of a national sample, Jencks15 analyzed the relationship between diagnosis and treatment by either psychotropic medication or "therapeutic listening." He found that the rate of physician recognition of mental distress was substantially higher than the rate of diagnosis and that in 58% of cases in which a mental health treatment was provided, no mental health diagnosis was recorded. Simon and Von Korff16 found that patients with "unrecognized" depression had milder symptoms and were less disabled than those with recognized depression. A meta-analysis of unrecognized mental illness in the primary care setting found that improving the recognition of mental illness among primary care physicians made no difference in psychiatric symptoms at follow-up.12 With the use of in-depth interviews, Susman et al8 found that rural family physicians "found it easier to treat depression without a formal diagnosis."
Because of the stigma associated with mental health problems, many residents of rural areas are unwilling to use specialty mental health services because of concerns about confidentiality.17-20 A survey of 350 family practice physicians found that patient resistance was a major barrier to effective specialty care treatment.21 Believing that the patient will not follow through on a referral because of stigma and confidentiality concerns, PCPs may underdiagnose a patient or choose not to refer a patient to a mental health provider. As Susman et al8 reported, "they hesitate to diagnose this condition because of diagnostic uncertainty, perceived stigma, the desire to preserve the physician-patient relationship, time and financial pressures, and a lack of supporting resources."
The recognition of mental illness and a determination to treat or refer patients exhibiting symptoms of mental illness may be determined, in part, by clinician training, attitudes, and beliefs. With the use of primary data from primary care physicians, physician assistants, and nurse practitioners (n=178), Main et al2 concluded that training in depression and beliefs about self-efficacy in treating depression may profoundly influence the degree to which clinicians recognize depression in primary care.
On the other hand, if a mental health provider is located on-site, travel time and patient resistance because of stigma or confidentiality concerns may be diminished and the likelihood of referral may increase. Because it may be difficult to find mental health providers who will accept Medicaid-insured patients, PCPs in practices that accept notable numbers of Medicaid patients may be less likely to refer and more likely to treat patients.
As previously mentioned, the lack of mental health specialty providers in many rural areas may pose a barrier to referrals. Lambert and Agger22 found that most urban-rural differences in use of mental health services by Aid to Family and Dependent Children–eligible Medicaid enrollees were explained by the supply of mental health specialty providers in the area. While a lack of local providers does not prohibit use of mental health specialty services, it adds distance and travel time as barriers to access.
While PCPs who choose to treat depression themselves may not be concerned about the availability of mental health specialty providers locally, they may want to consult with a psychiatrist. Telephone consultations are not as geographically bound as referrals but neither are they readily available in remote areas. Poor access to such consultation may limit a PCP's ability to treat depression.
In some cases, there may seem to be an adequate supply of mental health providers, but policy and reimbursement issues limit many patients' access to these providers. Community mental health centers, by virtue of their mission and funding streams, may be required to devote most of their resources to severely mentally ill individuals, resulting in long waiting lists for patients with less severe mental health problems.23-24 While private mental health providers may have shorter waiting lists, they often refuse to accept, or are ineligible for, Medicaid or other forms of insurance, thus posing an additional barrier.25
This study determines the extent to which PCPs are treating depression themselves and the extent to which the factors previously described affect referrals to mental health specialty providers. Our analytic model is focused on the outcome of the conflict between opposing incentives, to treat or to refer, and the determinants of that outcome in characteristics of the provider, the practice, or the service area.
Appropriate policy strategies for improving access to quality care for depression will differ dramatically, depending on which groups of characteristics are found to be significant influences. Provider characteristics may be influenced through medical education, local supply of mental health services may be influenced by policy strategies that address incentives for mental health providers to locate in underserved areas, and practice characteristics may be affected by accelerating the growth of managed care and provider networks.
We hypothesize that PCPs in regions with few mental health providers will encounter more cases of depression, provide more treatment themselves, and make fewer referrals than PCPs in regions with a greater supply of mental health providers. Primary care practitioners who report long waiting times for an appointment with a mental health provider and patient resistance to receiving treatment in a mental health setting are also more likely to treat patients with depression themselves. In cases in which the mental health services are available on-site (colocated), we expect PCPs to provide less treatment themselves. We also hypothesize that PCPs with a greater patient volume will provide less treatment themselves, referring patients earlier and more frequently.
We expect that PCPs with specific training and knowledge about depression will be treating more cases of depression themselves, rather than referring these cases to mental health specialists. Similarly, those who believe that depression is a notable problem in primary care are likely to be more knowledgeable about the diagnosis and treatment of depression. Believing that they can be effective treating it themselves, such PCPs are likely to treat more cases themselves.
We acknowledge that the structure of the mental health services provision system in a region affects the balance between the incentives to treat patients and the incentives to refer patients. For example, while there may be a community mental health center nearby, if that center has a reputation for treating only persons with chronic or severe mental illness, PCPs may not refer patients to it. On the other hand, a history of information exchange may exist between primary care and mental health providers. These historical and structural circumstances may influence PCPs to refer patients to a more distant provider or to treat most patients with depression themselves. While a detailed investigation of these regional characteristics is needed, such an analysis is beyond the scope of this article.
PARTICIPANTS AND METHODS
SAMPLE
Lists of all family practice and general internal medicine doctors of medicine and doctors of osteopathy, general practice nurse practitioners, and physician assistants were obtained from the Maine licensing authorities and from professional organizations. When multiple lists were obtained, systematic cross-checking against telephone directories and provider staff rosters was used to arrive at a single list for each group that seemed to be the most current and accurate. In all, we identified 964 PCPs practicing in Maine. Project funds did not allow surveying all of them, so a sampling strategy was used. Because characterizing referral patterns in local areas was to be part of the analysis, we chose to survey all PCPs in selected geographic areas.
At the time of the survey, Maine was divided into 62 primary care analysis areas (PCAAs) and 6 mental health service areas. Because referrals were expected to follow predictable geographic patterns, with most referrals made within a PCAA, to adjacent PCAAs, or to an urban area, a random selection of PCAAs would leave gaps in our understanding of referral patterns. We chose to limit our survey to PCPs in the 38 PCAAs in central Maine, eliminating 2 southern mental health service areas and 1 northern mental health service area. In addition to the advantage of assuring that the entire area surveyed was contiguous, this strategy eliminated the southern Maine regions in which managed care penetration is greatest, based on enrollment figures. We assumed that greater managed care penetration would affect referral patterns and might also affect how much mental health care is provided by PCPs. Elimination of the northern region, which consists solely of Aroostook County, Maine, also seemed justified by the dramatically different geography of that region. Most of the PCAAs in Aroostook County are adjacent to Canada to the east and north and adjacent to unorganized territories to the west and south. This pattern is likely to restrict the options for referrals. Moreover, travel distances in Aroostook County are longer and roads are generally poorer than in many other areas of the state. For these reasons, we believe that our ability to generalize our findings might be compromised if our sample included Aroostook County.
After eliminating individuals who had died, retired, left the area, or no longer practiced primary care, a list of 229 doctors of medicine, 50 doctors of osteopathy, 59 physician assistants, and 30 nurse practitioners was developed. Of the 368 PCPs contacted, 267 completed the survey, for a response rate of 73%. Telephone surveys were completed during the spring and summer of 1995.
MEASURES
Survey respondents were asked to report on personal and practice characteristics, as well as on details about how they treat and refer patients with symptoms of depression. Specific training in the treatment of depression is defined by an algorithm using 6 survey questions that were previously used by Main et al.2 If the respondent had experience diagnosing and treating depression during training "about as much as for a common disease" or "more than that spent on other common diseases," this was considered specific training. Similarly, if the respondent had continuing medical education experiences "about as much as for other diseases or problems" or "more than that for other diseases or problems," this was also considered notable training.
In addition to a question about familiarity with the Agency for Health Care Policy and Research's guidelines for the treatment of depression, respondents were asked if they routinely screen for depression and if they use a screening instrument.
The total number of patients with depression seen per week was calculated from survey responses (self-report) as the sum of those patients for whom a diagnosis of depression was recorded and those who exhibited symptoms of depression but for whom a diagnosis of depression was not recorded. This approach acknowledges that many cases of depression are not formally diagnosed for various reasons, including stigma, reimbursement, and inability to follow up the diagnosis with a referral to a mental health specialty provider.26 To quantify how much of a PCP's practice is devoted to the care of patients with depression, we divided the total number of patients with depression seen per week, as previously defined, by the total number of patients seen per week. Elsewhere in the literature, this ratio has been estimated at from 9.0% to 20.9%.12, 27-28
Respondents were asked a series of questions about factors that hindered their ability to treat patients with depression and factors that hindered their ability to refer such patients to specialty mental health services. A 3-point scale indicated whether each factor hindered the PCP not at all, somewhat, or a great deal.
Because the unit of analysis is the practitioner, no data are available regarding patient characteristics. However, 1 variable that captures the practitioner's perception of his or her patients' characteristics was investigated: the extent to which patient unwillingness to be treated in the mental health setting hinders the PCP's ability to make a referral.
To quantify the local supply of mental health services, we use the number of persons per mental health practitioner. Counties were not chosen as the geographic unit because counties in Maine are large and tend to encompass mixed urban and rural populations. Instead, we used PCAAs. These are smaller geographic units developed by the Bureau of Primary Care for designating primary care shortages. The ratio of persons to practitioners is adjusted to account for the supply in adjacent PCAAs. Because the urban areas within the region surveyed are among the smallest metropolitan statistical areas in the United States, we expected urban-rural differences among the variables of interest to be small.
Although the area surveyed includes metropolitan statistical area and non–metropolitan statistical area regions, the supply of mental health specialty providers is highly correlated with the urban-rural variable, when urban is defined as all PCAAs falling within a metropolitan statistical area. In a previous study, our colleagues found that urban-rural differences were explained by the supply of mental health providers.22 Our hypotheses and analysis will focus, therefore, on the supply variable rather than on the urban-rural variable.
For this analysis, the term "consultation" is used for advice to the PCP to use in his or her own treatment of the patient. The term "referral" is used when the PCP refers the patient to the mental health provider for treatment. Thus, a consultation implies that the PCP personally is treating the patient.
ANALYTIC APPROACH
While variations between urban and rural areas for some of the key variables are of interest, the focus of our analysis is on the question of whether PCPs provide treatment themselves or refer the patient to a mental health provider. The variable that best captures this question is measured by the question, "What percentage of your patients with depression do you treat yourself without referring?" Our multivariate analysis is focused on this variable.
RESULTS
SAMPLE CHARACTERISTICS
Table 1 provides descriptive characteristics of the 267 PCPs who responded to the survey. In general, approximately two thirds of our respondents indicated that they had specific training in depression. The notable exception is nurse practitioners, only one third of whom had such training. Primary care practitioners reported that 16.3% of their patients exhibited symptoms of depression. For primary care physicians, the reported prevalence rate was 17.3%, clearly in the upper range of prevalence rates reported in previous studies.12, 27-28 The high prevalence may be due to the inclusion of patients with symptoms for whom a diagnosis is not recorded. On average, the respondents in our sample entered a diagnosis for about 65% of the patients they saw with symptoms of depression.
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Table 1. Characteristics of Primary Care Physicians, Physician Assistants, and Nurse Practitioners*
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One group of questions was designed to assess whether PCPs are familiar with the Agency for Health Care Policy and Research's guidelines for the treatment of depression and whether they follow them. Although only 15% of our respondents use the Agency for Health Care Policy and Research's guidelines and only 45% have ever seen them, we found that most respondents (64.8%) reported some sort of screening for depression. Although our survey did not assess whether medications were used according to the guidelines, 82% of our respondents reported seeing patients with depression 2 to 4 times per month as recommended by the guidelines.
Bivariate statistics comparing urban with rural areas, and comparing areas with a low supply of mental health providers with those with a high supply of mental health providers (not shown), indicate that PCPs in rural or low-supply areas do not differ from those in urban or high-supply areas by any relevant indicators other than practice size (8.4 urban vs 3.8 rural, P<.001) and percentage who use a consultant (66.2% in high-supply areas vs 77.6% in low-supply areas, P<.05). No significant differences between urban and rural respondents or between those in high-supply and those in low-supply areas are observed in number of patients with depression, use of medications, or percentage of patients treated without a referral (eg, 44.7% vs 41.6%, urban vs rural; P=.32), indicating that the key service area characteristic (supply) does not explain differences in treatment and referral.
The greater use of consultants for advice regarding medications administered by PCPs in low-supply areas is surprising. After discussing several possible explanations with rural providers, the most plausible explanation begins with the assumption that patients seeking treatment for mental health problems from PCPs in areas of high mental health service supply are less severely distressed than those seeking such care in areas of low supply. In high-supply areas, those with more severe symptoms, comorbidities, or both may find their way directly to mental health providers, while in low-supply areas, they do not. Thus, seeing more severe cases, PCPs in low-supply areas have a greater need for consultation.
BARRIERS TO TREATMENT AND REFERRAL
Responses to survey questions regarding factors that hinder the PCP's ability to treat depression and those that hinder the PCP's ability to refer patients with depression indicate that some patients are not only unwilling to be seen by a mental health specialist but resist mental health treatment in the primary care setting as well (Table 2). The unavailability of a consultant seems to hinder many PCPs' ability to treat depression themselves. In addition, the lack of available services and long waiting times seem to be major factors hindering referrals for many of those surveyed.
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Table 2. Factors That Hinder Treatment for and Referral of 267 Patients With Depression Seen by Primary Care Practitioners (PCPs)*
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MULTIVARIATE ANALYSIS
The multivariate analysis of factors associated with treatment and referral patterns uses the continuous dependent variable, "What percentage of your patients with depression do you treat yourself without referring?" Table 3 provides findings from ordinary least squares regression using all variables needed to test for hypothesized effects.
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Table 3. Ordinary Least Squares Regression: Percentage of 227 Patients With Depression Treated Without Referral*
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Variables indicating the characteristics of the practice setting are not significant, while variables describing characteristics of the practitioner are significant. The effect of availability of mental health services is uncertain, as our supply measure is not significant, while the respondents' perception that lack of available services hinders referrals is significant. We chose to use a continuous variable, the ratio of population to mental health specialty providers in the local PCAA, adjusted for the supply in adjacent PCAAs, as a measure of the availability of specialty mental health services. (Because of a skewed distribution, the natural logarithm of this ratio was used in the analysis.) Because this variable was closely associated with the urban-rural variable, we did not include both in the multivariate model. (When a dichotomous urban-rural variable was substituted for the supply ratio variable, it was similarly nonsignificant [P=.86].)
Patient volume, availability of mental health counseling on site, and Medicaid reimbursement mix are not significant in the multivariate analysis. In general, it seems that practice characteristics do not play a major role in determining treatment and referral behavior.
Assuming that the PCP's perceptions of the availability of mental health services might differ from our measure of mental health provider supply, we included a variable in the analysis derived from the question, "How much does lack of services hinder your ability to refer?" While lack of services may be interpreted to mean that services are too far away or that waiting times are too long, it is a general indicator of whether the PCPs have difficulty finding providers to whom they can refer patients. That this variable was significant suggests that the mere presence of mental health providers in the area may not mean that such services are available.
Several variables are included in the multivariate model as indicators of physicians' attitudes toward depression. Respondents who believe that depression is a notable problem in the primary care setting, and those who believe that PCPs are effective in treating depression, treat a greater proportion of their patients with depression themselves. In a separate analysis, we found that these variables were also significantly (P<.001) associated with recognizing symptoms of depression in a higher percentage of patients. This pattern suggests that some PCPs are predisposed to look for symptoms of depression, find them, and treat them. Surprisingly, this pattern was not associated with our algorithm-generated measure of training.
Our measure of training credited the respondent for training directly related to depression whether it was obtained in medical school, during residency, or by continuing medical education. Those with meaningful training by this measure differed marginally from those without such training in the percentage of patients with depression who they treated themselves without referral (45.8% vs 39.0%, P=.09). In the multivariate model, training was not found to be related to treatment patterns. The practitioner's perception of his or her own knowledge, however, was significant. This perception, as measured by the 3-point scale described in the "Measures" subsection of the "Participants and Methods" section, is a significant predictor of the percentage of patients treated without referral. This finding suggests that the practitioner's own perception about his or her level of knowledge is a better predictor of treatment patterns than a more direct indicator of training.
Lacking a direct measure of patient characteristics, we included the PCP's perception of patient unwillingness to be treated in the mental health sector as an independent variable. The regression coefficient for this varable had a t value of 1.927, with a probability of .06. While this is not statistically significant, neither does it convincingly embrace the null hypothesis. We conclude that patient reluctance to use mental health providers probably plays a secondary role in the PCP's decision about management of depression, as suggested by Susman et al,8 who report that stigma and patient resistance to being identified as mentally ill affect how rural practitioners manage this condition.
COMMENT
Individual practitioner characteristics are a major determinant of a PCP's decision to treat or refer a patient. Primary care practitioners who see depression as a major problem in primary practice, and who believe themselves capable of treating depression effectively, are those most likely to treat it, regardless of the availability of mental health specialty providers.
Our failure to find that the supply of mental health specialty providers is significantly related to treatment patterns of PCPs does not exclude the possibility that the structure of the local mental health services provision system plays a role in determining treatment and referral patterns. Our indicator of supply does not account for several factors that might affect such patterns. For example, local mental health providers may not be reimbursable by some payers, may limit their practices to certain types of clients, or may work part-time. Respondents reporting that a lack of available services hinders referrals may have had such factors in mind.
Thus, while local or anecdotal factors may support our initial hypothesis that the supply of mental health specialty providers is associated with treatment and referral practices of PCPs, the multivariate analysis suggests that, in general, this relationship is nonsignificant. This finding is corroborated by a related study in which Medicaid data were used to examine service use of Medicaid enrollees with depression.29 While that study found that the supply of specialty mental health providers explains use of mental health services, it also found that, in areas of low mental health provider supply, PCPs did not act as substitutes for mental health providers. As in this study, the supply of mental health providers did not affect how much treatment was provided in the primary care setting.
This finding has implications for cost and quality of treatment for depression and, indirectly, for access to that treatment. The treatment of depression in the primary care setting has been shown to be less costly than treatment in the specialty setting, but doubts have been raised about its long-term effectiveness.3 Recent studies have not addressed whether PCPs with specific training, knowledge, and confidence in their ability to treat depression achieve better outcomes than other PCPs. The pattern revealed in our analysis suggests that such factors are important in explaining how PCPs manage depression and may lead some PCPs to achieve better clinical outcomes than others. Thus, we may be able to improve the outcomes of treatment for depression by PCPs through improvements in medical education and through postresidency training approaches, such as continuing medical education or the kinds of outreach associated with area health education centers. Our finding that midlevel practitioners (physician assistants and nurse practitioners) treat significantly fewer cases of depression than primary care physicians suggests that education targeted to these providers may be a good investment. If we are able, through such interventions, to improve PCPs' knowledge and confidence regarding the treatment of depression, and thereby improve their competence in such treatment, then the lack of mental health specialty providers in rural areas need not mean a lack of access to treatment for depression. On the other hand, our marginal finding regarding patient unwillingness to use mental health services suggests that patient education regarding mental health problems and the appropriate use of mental health services may also be needed.
This study is limited to 1 state, and caution should be used in generalizing our findings to other rural states. Specifically, Maine has a large proportion of solo practitioners, as well as many community health centers. Primary care practitioners in states in which group practice is more common may exhibit different behaviors. The study is also limited by the fact that all primary data were obtained by self-report. The volume of patients and of patients with depression may be underreported or overreported, although we know of no evidence to suggest that these reporting variations would not be random. Our failure to find the supply of mental health providers to be significantly related to PCPs' behavior may be explained, in part, by the simplicity of our supply indicator (Table 3). In this and our previous studies,22, 29 we have used a simple sum of provider full-time equivalencies as an indicator of the geographic availability of specialty mental health providers. This approach makes use of existing provider listings but fails to account for the varying scope of practice among different mental health professions; it also does not account for the reimbursement policies of various insurers regarding these professions. Further research is needed to determine a cost-effective method of estimating geographic availability with greater sensitivity. In addition, detailed qualitative studies of specific regions, based on observed regional referral patterns, are needed to specify availability more accurately. We also recommend that future research addressing the clinical outcomes of treatment for depression by PCPs acknowledge that PCPs vary in training, knowledge, and attitudes. Research that has not controlled for these variables may have done a disservice to those PCPs who are more effective in treating depression.
AUTHOR INFORMATION
Accepted for publication April 10, 1997.
This study was supported by grant 000004-02 from the Office of Rural Health Policy, Health Resources and Services Administration, US Department of Health and Human Services, Rockville, Md.
We thank James Barrett, MD, Robert Fried, MD, Daniel Meyer, PhD, and Drew Travers, PA, for helping with the design of the survey instrument.
Reprints: David Hartley, PhD, Maine Rural Health Research Center, University of Southern Maine, Box 9300, Portland, ME 04104-9300.
From the Maine Rural Health Research Center, Edmund S. Muskie School of Public Service, University of Southern Maine, Portland.
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