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.

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 > 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).

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.