What Drives Referral from Primary Care Physicians to Mental Health Specialists? A Randomized Trial Using Actors Portraying Depressive Symptoms


  • The authors have no conflicts of interest to declare.

Address correspondence and requests for reprints to Dr. Kravitz: Center for Health Services Research in Primary Care and Department of Internal Medicine, University of California Davis, 2103 Stockton Blvd., Grange Building, Suite 2224, Sacramento, CA 95817 (e-mail: rlkravitz@ucdavis.edu).


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 geqslant R: gt-or-equal, slanted10% 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.