• mental health;
  • primary care;
  • geriatric patients;
  • time use;
  • quality of care

OBJECTIVES: To assess how care is delivered for mental disorders using videotapes of office visits involving elderly patients.

DESIGN: Mixed-method observational analysis of the nature of the topics discussed, content of discussion, and the time spent on mental health.

SETTINGS: Three types of settings: an academic medical center, a managed care group, and fee-for-service solo practitioners.

PARTICIPANTS: Thirty-five primary care physicians and 366 of their elderly patients.

MEASUREMENTS: Videotapes of 385 visits covering 2,472 diverse topics were analyzed. Coding of the videotapes identified topics, determined talk time, and coded the dynamics of talk.

RESULTS: Mental health topics occurred in 22% of visits, although patient survey indicated that 50% of the patients were depressed. A typical mental health discussion lasted approximately 2 minutes. Qualitative analysis suggested wide variations in physician effort in providing mental health care. Referrals to mental health specialists were rare even for severely depressed and suicidal patients.

CONCLUSION: Little time is spent on mental health care for elderly patients despite heavy disease burdens. Standards of care based on a count of visits “during which a mental health problem is discussed” may need to be supplemented with guidelines about what should happen during the visit. System-level interventions are needed.