Who Is at Risk of Nondetection of Mental Health Problems in Primary Care?


  • Presented in part at the annual national meeting of the Society of General Internal Medicine, May 1995.

  • The views expressed in this article are those of the author and do not necessarily represent the views of the Department of Veterans Affairs.

Address correspondence and reprint requests to Dr. Borowsky: Section of General Internal Medicine (111-0),1 Veterans Dr., Minneapolis, MN 55417 (e-mail: borow003@gold.tc.umn.edu).


OBJECTIVE: To determine patient and provider characteristics associated with increased risk of nondetection of mental health problems by primary care physicians.

DESIGN: Cross-sectional patient and physician surveys conducted as part of the Medical Outcomes Study.

PARTICIPANTS: We studied 19,309 patients and 349 internists and family physicians.

MEASUREMENTS AND MAIN RESULTS: We counted “detection” of a mental health problem whenever physicians reported, in a postvisit survey, that they thought the patient had a mental health problem or that they had counseled or referred the patient for mental health. Key independent variables included patient self-reported demographic characteristics, health-related quality of life (HRQOL), depression diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders, and physician demographics and proclivity to provide counseling for depression. Logistic regression analysis, adjusted for HRQOL, revealed physicians were less likely to detect mental health problems in African Americans (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.46 to 0.86), men (OR, 0.64; 95% CI, 0.54 to 0.75), and patients younger than 35 years (OR, 0.61; 95% CI, 0.44 to 0.84), and more likely to detect them in patients with diabetes (OR, 1.4; 95% CI, 1.0 to 1.8) or hypertension (OR, 1.3; 95% CI, 1.1 to 1.6). In a model that included DSM-III diagnoses, odds of detection remained reduced for African Americans as well as for Hispanics (OR, 0.29; 95% CI, 0.11 to 0.71), and patients with more-severe DSM-III diagnoses were more likely to be detected. Physician proclivity toward providing counseling for depression influenced the likelihood of detection.

CONCLUSIONS: Patients' race, gender, and coexisting medical conditions affected physician awareness of mental health problems. Strategies to improve detection of mental health problems among African Americans, Hispanics, and men should be explored and evaluated.