The Role of Rural Primary Care Physicians in the Provision of Mental
Health Services
Letter to the Field No. 5
by Jack M. Geller, Ph.D., Marshfield Medical Research Foundation and Kyle J. Muus,
Ph.D., The Center for Rural Health, University of North Dakota School of Medicine &
Health Sciences
Table of Contents
Introduction | Generalist Physicians as
Sources of Mental Health Care | Treatment Patterns | Mental Health Training and Primary Care Physicians | Referral Patterns | Future Outlook | References
Frontier rural areas suffer from a lack of mental health providers and inpatient
psychiatric services (Goldsmith, Wagenfeld, Manderscheid, Stiles & Longest, 1989;
Wagenfeld, Goldsmith, Stiles, Longest, & Manderscheid, 1990; Goldsmith et al., 1994).
A variety of reasons have been offered as to why mental health service delivery is
impaired in rural and frontier areas. In frontier areas, community mental health centers
cover vast service areas and the resultant distance from provider to consumer can impede
mental health service provision (Prue, Keane, Cornell, & Foy, 1979; Nease, 1993;
Sullivan, Jackson, & Spritzer, 1996). The ability to operate economically viable
mental health services in frontier areas is hindered by low population density (Corney,
1968; Bachrach, 1983; Loschen, 1986), higher per-unit costs (Gertz, Meider, &
Pluckhan, 1975; Loschen, 1986) and greater reliance on governmental and other outside
funding sources (Bachrach, 1983).
It is also generally believed that rural residents tend to under-utilize the mental health
services that are available (Bachrach, 1985; Watts, Scheffler & Jewell, 1986; Nease,
1993; Rost, Smith & Taylor, 1993). Some rural residents will not seek or utilize
mental health care because of a lack of anonymity in treatment, the stigma associated with
treatment, and clashes between treatment and traditional rural values such as independence
and privacy (Jeffrey & Reeve, 1978; Solomon, Hiesberger & Winer, 1981; Meyer,
1990; Rost, et al., 1993). Denial of mental illness by the individual or family also
impedes service utilization and can result in the future need for much more extensive care
and decreased likelihood of a positive response to treatment (Berry & Davis, 1978;
Loschen, 1986). Rural poverty is another, often overlooked factor affecting
under-utilization of mental health services. For instance, the economic downturn in the
1980s left farmers and other rural residents with fewer resources to be able to afford
adequate health insurance coverage or the out of pocket costs of such care. Compounding
the problem, this rural recession decreased employment opportunities in rural communities
and raised stress levels among residents (Meyer, 1990; National Rural Health Association,
1992; Nease, 1993).
The combination of fewer mental health providers and inpatient facilities, and low
utilization of traditional mental health services due to social factors and rural poverty
all point to a scenario where much of the burden of mental health care provision is placed
on primary care physicians.
Almost 20 years ago, Regier, Goldberg, and Taube (1978), in response to the 1977
President's Commission on Mental Health, used epidemiological methods to estimate the
number of persons in the US who had a mental disorder, as well as the sector of the health
care system where they sought treatment. They reported that approximately 21% of those
estimated to have a mental disorder in 1975 sought care from the specialty mental health
sector (approximately 7 million). However, over 60 percent of the total persons affected
by mental disorders (estimated at over 19 million) sought treatment in a primary care
setting. In a follow-up study in 1993 using Epidemiologic Catchment Area study data,
Regier et al. found that approximately 40% (9 million) of those who sought care for a
mental disorder in 1980 received care from the specialty mental health sector, and 43% (10
million) received care from the general medical health system.
Similarly, a 1984 report found that non-psychiatrist physicians provided 48% of the
patient visits resulting in the diagnosis of a mental disorder, and primary care
physicians (i.e., general practitioners; family physicians; and general internists)
accounted for 77% of these diagnoses (U.S. Department of Health & Human Services
[DHHS], 1984). The DHHS also found that 28% of primary care visits were for psychological
problems, and anxiety/nervousness accounted for 11% of the reasons people give to visit a
physician. More recent studies of this nature have purported that generalist physicians
provide up to 60% of the mental health services received by a population (Regier, Boyd
& Burke, 1988; U.S. Congress, 1990). Many other studies have also documented the
important role of primary care physicians in mental health care provision (Locke &
Gardner, 1969; Rosen, Locke, Goldberg, & Babigian, 1972; Lerner & Blackwell, 1975;
Fink, 1977; Goldberg, Babigian, Locke, & Rosen, 1978; Regier, Burke, Manderscheid,
& Burns, 1985; Schurman, Kramer, & Mitchell, 1985; National Rural Health
Association, 1992).
The use of generalist physicians holds true for rural residents as well. They also tend to
utilize general medical resources for mental ailments more frequently than area mental
health centers (Fehr & Tyler, 1987) and actually prefer such primary care givers in
the treatment of such problems (Flaskerud & Kviz, 1982). Ordway (1976) found that
rural residents tended to first think of receiving mental health treatment from primary
care physicians and preferred consultation from a psychiatrist only in the case of serious
mental disorder. Equally important, other studies have also found that rural persons
afflicted with mental disorder prefer to initially consult a primary care physician
(Blackwell & Goldberg, 1968; Goldberg & Blackwell, 1970; Lerner & Blackwell,
1975).
Johnson (1995) recently explored this preference for seeking help from a primary care
physician in a statewide study of help seeking behavior among residents of Nebraska. In
that analysis, respondents were asked who they would turn to first in seeking help for a
mental health problem. Not surprisingly, a family physician was reported more frequently
than any other category of provider (40.9%), followed distantly by a private psychiatrist
(16.2%) and a minister (13.9%). Johnson also explored variations in help seeking behavior
by residential location. Using Beale codes, Johnson found an even greater propensity for
the most rural residents to seek help from a family physician (43% in the most isolated
rural areas as opposed to 37% in urban areas).
Johnson's analysis suggests that primary care physicians are the primary choice of all
residents when seeking help for a mental disorder, and that rural residents are even more
likely to seek help from a family physician than urban residents. Surprisingly, and of
some interest, is that less than one respondent in ten (7%) reported that they would first
seek help from a community mental health center. This preference for the family physician
can continue even after a person receives treatment from mental health providers. Lerner
and Blackwell (1975) surveyed 100 psychiatric inpatients and found that 38% planned to
have their family physician assist in aftercare.
Physicians that practice in rural and frontier areas tend to play an even larger role in
mental health care provision due, in part, to the relative scarcity of mental health and
other health care professionals in these outlying areas of the country. Unfortunately,
sparsely populated areas without established mental health services (i.e., counseling) or
providers (i.e., psychologists, social workers) also tend to have relatively few primary
care physicians to act as substitutes. Nonmetro and frontier areas possess far less
physician coverage than more urbanized areas even after controlling for population size.
For example, Frenzen (1994) found that in 1988, the ratio of primary care physicians per
100,000 persons for remote rural areas was 38.2; for the more inclusive nonmetro areas it
was 51.3. In comparison, metro areas had a ratio of 95.9.
If primary care physicians are providing a majority of the care for mental illness in
frontier areas, how well are they providing it? Much has been written about how primary
care physicians treat and manage patients presenting symptoms of mental disorder, and how
this differs from treatment provided by mental health professionals (e.g., psychiatrists
and psychologists). Several studies have documented the drug-dispensing behavior and use
of other treatments among non-psychiatrist physicians. One study (DHHS, 1984) found that
non-psychiatrists appeared to substitute drugs for time as their mental health-related
office visits lasted half as long as those of psychiatrists and were twice as likely to
result in a drug prescription. Gardiner, Peterson, and Hall (1974) also found that
generalist physicians placed heavy reliance on the use of psychotropic drugs and favored
their use as the sole treatment for the majority of their patients with mental disorders.
In fact, these physicians have been found to favor such drug treatment in many patient
visits even when no mental diagnosis is officially rendered (Jencks, 1985).
Not only do generalist physicians seem to use psychotropic drugs in treatment more
frequently, there is also evidence of inappropriate use of drug therapy among these
physicians. Fauman (1980) found that 59.2% of 72 surveyed general hospital physicians who
prescribed tricyclic antidepressants did not dispense sufficient doses to their patients.
In addition, 61.5% of 112 respondents were found to have inappropriately used tricyclic
treatment for such conditions as chronic pain, insomnia, enuresis, agitation, and anxiety.
Although there is an abundance of information that points to the generalist physicians'
higher propensity to use drug therapy, some studies have also documented their use of
counseling in concert with prescription drugs and have even found counseling to be the
most common treatment for mental disorders in the general practice setting. In one study
of primary care physicians, it was found that 31% of patients with emotional disorders
were provided with supportive therapy, 14% were given prescription drugs, and 35% were
given a combination of these treatments (Rosen, et al., 1972). Yet another study revealed
that a combination of drugs, advice, and reassurance was the most common method of mental
health treatment among a group of family practice physicians (Orleans, George, Houpt,
& Brodie, 1985).
Somewhat contrary to previous findings, Andersen and Harthorn (1989) found that primary
care physicians did recognize the presence of mental disorder essentially as well
as mental health professionals (e.g., psychiatrists, psychologists). However, these
physicians were less accurate in their diagnoses of affective, anxiety, somatic, and
personality disorders. Generalist physicians were most accurate (81%) in recognizing
organic disorders and least accurate (14%) in identifying personality disorders. Only
about one-half of the physicians correctly identified anxiety (49%), somatic (49%), and
affective (47%) disorders (Andersen & Harthorn, 1989).
In one of the more recent and rural studies, Rost, Williams, Wherry, and Smith (1995)
examined the relationship between process and outcome for patients with major depression
in 21 rural primary care practices in Arkansas. After screening over 600 patients, 47
meeting DSM-III-R criteria for major depression were recruited into the study. Findings
from the study are significant: only 24 percent of the cases meeting the diagnosis
criteria were found to have "depression" noted in the patient's medical record
at the initial visit. Although 63 percent of those diagnosed received pharmacologic
treatment, only 29 percent received a sufficient dosage for a long enough period of time
to meet the AHCPR clinical practice guidelines. Further, while it was inconsistently noted
in the record, it appeared that few patients received psychotherapy from a mental health
professional. Most importantly, only one-third (32%) of the patients followed were in
remission after 5 months (a rate of less than half that found in other practice settings).
Rost, Humphrey, and Kelleher (1994) examined the barriers rural primary care physicians
face in the treatment of patients with depression. In that study, the lack of physician
time and the inability of rural patients to recognize their problem were found to be the
most often reported barriers. Other barriers such as the unavailability of mental health
specialists and the inability of the patients to afford specialty care were also reported
at somewhat lesser percentages.
In sum, the literature appears to be mixed regarding the appropriateness of generalist
physicians' handling of mentally ill patients. This uncertainty raises questions
concerning the extent of their mental health training and the degree to which they are
prepared to adequately manage such patients. Both of these issues will now be addressed by
examining the literature of the past 20 years in these areas.
Although primary care physicians provide a significant volume of mental health
services, their training in mental health diagnosis and treatment appears to be limited.
The time allotted to clinical psychiatric clerkships has gradually declined in most
medical schools (Callen & Davis, 1978). In fact, the six-week clerkship in psychiatry
for all third-year students is the briefest among the five standard third-year clinical
rounds, and course work in behavioral sciences amounts to about 5% of the medical school
in-class curriculum (U.S. Congress, 1990).
In addition, it appears that students have little direct contact with psychiatrists during
this training. Jones, Badger, Parlour, and Coggins (1982) studied family practice
residency programs and found that training was typically provided by part-time or
volunteer faculty and that less than 5% of faculty members were full-time psychiatrists.
Strain, Pincus, Houpt, Gise, and Taintor (1987) also noted a general under-utilization of
psychiatrists in medical school-based mental health training. In some cases, programs were
found to bypass psychiatry departments entirely to hire less expensive nonmedical
behavioral scientists to teach mental health content. Pincus, Strain, Houpt, and Gise
(1983) concluded that some family medicine programs don't adequately train students to
carefully diagnose and treat psychiatric disorders. This lack of training can also be
found in internal medicine, the major U.S. primary care field. For board certification in
internal medicine there is no required test for competence in patient interviewing or
psychiatric diagnosis (Fogel, 1993). Similarly, Pincus et al. (1983) found that little
attention was given to psychosocial concerns in most internal medicine programs.
Several articles have addressed how generalist physicians themselves feel about their
preparation in the provision of mental health care. In an early study, Castelnuovo-Tedesco
(1967) polled a group of recent medical school graduates and found that one-third said
their graduate training in psychiatry was indifferent or poor and one-half felt they had
not learned enough psychiatry for their current general practice. Further, respondents
felt psychiatry was one of the worst-taught subjects among their medical school
experiences (Castelnuovo-Tedesco, 1967). Werkman, Mallory, and Harris (1976) found that
family physicians rated marital discord and alcoholism as the most common psychiatric
matters, and many felt they needed additional training to adequately manage these
patients. Fisher, Fowler, and Fabrega (1973) found that the majority of family physicians
under study felt they needed and desired additional postgraduate training in psychiatry to
better serve their patients. Similarly, Cassata and Kirkman-Liff (1981) report that a
group of family physicians they studied, in response to increasing demand for mental
health care provision in their practices, expressed an interest in taking additional
continuing education courses in psychiatry covering such topics as
individual/marital/parental counseling and psychopharmacology. Finally, about one-third of
polled U.S. family physicians indicated a need for further training in treating emotional
and psychiatric disorders (Orleans et al., 1985).
What subjects are important for someone who will set up a rural, primary care practice?
Johnson and Snibbe (1975) studied a group of psychiatrists, psychologists and
nonpsychiatrist physicians and determined the most important psychiatric topics for their
practices. Topics included: interviewing, suicide evaluation, psychopharmacology,
chronically ill or dying patients, psychophysiologic disorders, psychiatric referral, the
doctor-patient relationship, drug and alcohol abuse, differential diagnosis, and sexual
problems. Callen and Davis (1978) conducted a similar study using only rural primary care
physicians and found that this group deemed many of the same topics to be the most
pertinent to their practice. This rural list also included treatment of depression,
psychosomatic disorders, and geriatric psychiatry.
A number of articles have concluded that non-psychiatrist or primary care physicians are,
by and large, inadequately prepared to recognize, refer, or treat mental disorders
(Feldman, 1978; Pincus, et al., 1983; Jones, Badger, Ficken, Leeper & Anderson, 1988;
Zimmerman & Wienckowski, 1991; Barrett, 1991; National Rural Health Association,
1992). Other possible reasons for this drawback, aside from inadequate training in
psychiatry/psychology, included heavy patient load and time constraints on patient visits,
expectations of authority and peers, medical school selection process, and students'
experiences in medical school (Feldman, 1978; Orleans et al., 1985; Fogel, 1993).
Some research has also alluded to generalist physicians' referral behavior and its
appropriateness. Although there is no reason to suppose that every patient presenting
symptoms of mental disorder in a primary health care setting should see a psychiatrist, it
is commonly believed (at least by psychiatrists) that the proportion referred is too
small.
Kessel (1960) was one of the first to look at this issue and found that only 10% of
patients in general practice considered suitable for referral were actually referred to a
psychiatrist. Twenty-four years later, the U.S. Department of Health and Human Services
(1984) found that primary care physicians referred mental health patients to mental health
professionals of any kind in only 5% of the episodes. Others have found that primary care
physicians referred patients with psychiatric diagnoses at rates of 17-30% (Shapiro &
Fink, 1963; Locke, Krantz & Kramer, 1966; Fink, Goldensohn, Shapiro, & Daily,
1967; Orleans et al., 1985).
The type of disorder present appears to influence referral patterns. Andersen and Harthorn
(1989) found that both primary care physicians and mental health professionals (i.e.,
psychologists) favored psychiatric referral over on-site treatment for most mental
disorders, but physicians favored treatment in primary care settings for certain anxiety
and somatic disorders. Hull (1979), surveying a group of nonpsychiatrist physicians, found
that most tended to refer psychosis cases to psychiatrists but preferred to treat
alcoholic and neurotic cases themselves. In a similar vein, Fauman (1983) found that among
polled internists, more than one-half said they normally forgo referral and prefer to
treat depression, anxiety, and psychosomatic and organic brain disorders themselves.
Research has also been conducted on other factors associated with the likelihood of
referral. Patient characteristics such as being male, higher socioeconomic status, younger
age and presence of a psychiatric label have been found to be positively correlated with
referral rate (Shepherd, Cooper, Brown, & Kalton, 1966; Wilkinson, 1989; Farmer &
Griffiths, 1992). Physicians with longer practice tenure and positive feelings toward
psychiatrists tended to refer more frequently (Shortell & Daniels, 1974; Gardiner, et
al., 1974; Wilkinson, 1989; Ozbayrak & Coskun, 1993). Also, attributes of the
disorder, specifically issues of its type, severity and chronicity, and inadequate
response to physician treatment have been found to be positively related to referral
(Shepherd, et al., 1966; Fink, et al., 1967; Fink, Shapiro, Goldensohn, & Daily, 1969;
Hopkins & Cooper, 1969; Wilkinson, 1989; Andersen & Harthorn, 1989).
Mezey and Kellett (1971) found the most common reasons why nonpsychiatrist physicians did
not refer patients to psychiatrists were the patients' dislike for such referral,
physician concerns about labeling the patient, and feeling that the treatment of neurotic
patients was every physician's responsibility. Steinberg, Torem and Saravay (1980) found
that physician opposition to consultation was involved in more than 50% of non-referred
cases. Specifically, physicians felt that there was either no psychiatric problem or that
psychiatry could not help the patient. Less frequently cited was physicians' feeling that
the patient might become upset with such suggestions of referral. Orleans et al. (1985)
also found, while studying a group of family physicians, that they tended to treat most
psychiatric disorders themselves. Most felt, however, that this care was incomplete due to
patient opposition, time restrictions, limited third-party payment for mental health care,
lack of coordination between primary and mental health care providers, and inadequate
psychosocial training.
As populations in frontier areas continue to dwindle, it will probably
become less and less feasible to recruit additional local mental health specialists
(psychiatrists, psychologists, psychiatric nurses, and psychiatric social workers) to
these regions. Nurses, social workers, and occasionally family therapists or ministers
with some mental health training are currently working in rural and frontier areas, but
primary care physicians are still the most numerous service provider in these areas
(Holzer, Mohatt, Goldsmith, & Nguyen, 1997). Thus, in the immediate future, rural as
well as frontier mental health services are most likely to continue to be in the hands of
primary care physicians. Therefore, a premium must be placed not on rural recruitment of
psychiatric care givers, but on developing rural networks of care between primary care
providers, mental health professionals, and nonphysician providers. It will also be
necessary to improve medical and continuing medical education to better inform primary
care physicians on mental health care issues. Interestingly, that was the exactly what
Regier, et al. (1978) concluded almost 20 years ago when they wrote, "Hence, there is
a need for both further integration of the general health and mental health care sectors
and for a greater attention to an appropriate division of responsibility that will
maximize the availability and appropriateness of services for persons with mental
disorder." (Regier, et al., 1978, p. 693).
There have been some innovative approaches to educating primary care providers on mental
health issues. For example, the National Institute on Mental Health (NIMH) provides
programs that teach primary care physicians how to recognize and treat mental conditions.
The Depression Awareness, Recognition, and Treatment (DART) Program was developed in 1988
to educate primary care physicians and other health professionals around the country about
the signs of and treatment for depressive disorders (Meyer, 1990; Hunter & Windle,
1991). In addition, the NIMH provides funding for various forms of mental health-related
continuing education programs.
One of the most effective tools available to rural primary care physicians, however,
appears to be the development and dissemination of the AHCPR Clinical Practice Guidelines
for Depression in Primary Care (1993). In a small, but significant study, Rost, et al.,
(1995) reported that depressed patients who received treatment in concordance with the
guidelines were significantly more likely to be in remission after 5 months, than patients
who received pharmacologic treatment, but not in concordance with the guidelines. Further,
since that study, computer assisted versions of the guidelines have been developed, and
are currently being tested.
Further efforts must also be made to explore ways in which primary care providers can
successfully link with mental health care providers to improve efficiency and quality of
care. Strides should be made in developing alternative means to strengthen the linkages
between primary care physicians in frontier and rural areas and urban-based mental health
specialists. One successful strategy to link primary care providers with mental health
providers is the integration of practices in rural medical clinics (Bird, et al., 1995).
Probably the most successful models of this type are the federally-funded Community Health
Centers. These centers, many of which are located in rural areas, are required under
federal law to offer a wide range of services to patients, including mental health
services. Consequently, it is not uncommon to find patients requiring medical, mental
health, or dental services sitting side-by-side in the waiting rooms of these centers. In
addition, Bird, et al., (1995) found that similar rural models in the private sector
exist, although the majority are still in the public sector.
Another area that holds considerable promise is telemedicine. The use of two-way
interactive video is slowly becoming an important bridge between rural primary care
physicians and urban specialists and sub-specialists. Similar connectivity between rural
physicians and urban based mental health specialists could considerably improve access to
urban-based consultation. This would allow rural primary care physicians to consult about
the diagnosis and treatment of various mental afflictions they encounter in the course of
their practice. Just as important is the hope that as these linkages develop, and mental
health and primary care providers establish stronger ties, that referral rates among
primary care physicians will increase, to the benefit of both providers and patients.
The success of these emerging networks and training initiatives is likely to be directly
linked to the ability of rural residents to access quality mental health services. Such
networks will utilize local primary care providers (both physician and nonphysician) as
the local point of contact, but offer the patient access to an expansive array of more
urban-based professional mental health resources. The establishment of such emerging
networks is critical, if rural mental health care is not to be synonymous with substandard
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