The probability of referring to a mental health provider in this study was higher for physicians who devoted more time to nonclinical activities, perceived mental health consultation to be more readily available, had less confidence in their ability to manage antidepressants, and had personal life experience with psychotherapy for depression.
The idea that physicians with academic or administrative responsibilities practice differently than full-time clinicians is consistent with the work of Borowsky et al. 34
who found that mental health referrals are extremely common in academic generalist practices
The association between availability of health care services availability and utilization is a time-honored theme in health services research. 35, 36
Physician-reported availability of mental health consultation within a 2-week window varied 4-fold across study sites and was, after adjustment, associated with a 3-fold increase in the odds of recommending care from a mental health professional.
Increased knowledge in a particular clinical domain usually increases referrals, 37, 38
possibly because more knowledgeable doctors are more attuned to clinical complexities. 39
However, consistent with Williams et al. 26
we found that physicians with greater confidence in their ability to manage antidepressant therapy were substantially less
likely to recommend consultation with a mental health provider. Perhaps therapeutic self-efficacy 40
operates differently than diagnostic sophistication, in which recognition of the complexities of a topic might lead to greater appreciation of the value of consultation.
Seventy percent of participating physicians reported that they (or a close friend or relative) had been treated for depression, and nearly half had direct or vicarious experience with psychotherapy. Physicians reporting such experience were more likely to offer patients a mental health referral. The association does not owe to enhanced outcomes expectancies, 41
because referral rates were high regardless of perceived effectiveness. Although these observational results do not prove that exposing health professional students to psychotherapy would alter their propensity to make mental health referrals once in practice, the hypothesis deserves further exploration. Alternatively, a common predisposing factor (such as a tendency toward self-reflection) 42
may bring physicians to acquire greater familiarity with psychotherapy and to recommend it to patients.
Taken as a whole, relatively stable physician characteristics (age, gender, race/ethnicity, and primary care specialty) have little influence on mental health referral while more mutable conditions of practice, self-efficacy, and life experiences carry greater weight. Curiously, referral decisions were associated with chart-recorded diagnosis when SPs portrayed major depression but not adjustment disorder. This suggests that physicians view the basis for referral differently in the 2 conditions, perhaps seeking specific management assistance in major depression and diagnostic validation or general psychosocial support in adjustment disorder.
Apart from identifying factors influencing referral, our study highlights important aspects of the referral process. Psychiatrists were rarely consulted, perhaps reflecting the “occupational transformation of the mental health system.” 43, 44
In addition, except in the CA-HMO (fully integrated) system, a minority of patients were given meaningful assistance with making an appointment. Most were told to call a toll-free number, call their health plan, or use the phone book.
This study has several limitations. The SP roles represent a narrow spectrum of primary care practice. Only first visits were studied, precluding conclusions about referral behavior over time. Future therapeutic decision making (including whether to refer) would ordinarily hinge on the patients' response to initial therapy, among other factors. Furthermore, referral is a process that extends far beyond the primary care physician's recommendation. We only examined the most proximal part of the procedure, so our estimated referral rates represent an upper bound on actual referral. Finally, the small number of sites limits generalizability to other geographic regions and conditions of practice.
In summary, this study indicates that primary care physicians' perceptions of mental health services availability, personal life experiences, and therapeutic self-confidence are important influences on mental health referral in depression. Further research is needed to determine whether interventions designed to enhance the referral process can lead to better outcomes, especially for patients with more severe depression, in whom the need for combined therapy with medication and psychotherapy might be most compelling.