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# (p. 579) The Role of Primary Care Physicians in Detection and Treatment of Adolescent Mental Health Problems

The Role of Primary Care Physicians in Detection and Treatment of Adolescent Mental Health Problems
Chapter:
The Role of Primary Care Physicians in Detection and Treatment of Adolescent Mental Health Problems
DOI:
10.1093/9780195173642.003.0031
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date: 08 December 2021

This chapter presents research conducted as part of the Sunnylands Adolescent Mental Health Initiative (SAMHI) to determine primary care provider practices in identifying and referring adolescents for treatment of mental health problems. It is estimated that over 70% of youth visit a primary care physician in an average year (Wells, Kataoka, & Asarnow, 2001), and with the advent of managed care, primary care physicians also serve as the gateway to obtaining specialist care, including mental health services (Glied & Neufield, 2001). However, research suggests that less than half of adolescents in the United States with a significant mental disorder are seen by an appropriate mental health service provider (Costello et al., 1998; Horwitz, Leaf, Leventhal, Borsyth, & Speechley, 1992; Sturm, Ringel, & Andreyeva, 2003).

Several explanations have been proposed for the poor treatment rate of adolescents with mental health problems. Most primary care providers are not extensively trained to identify or treat mental health problems (Wells et al., 2001), and their ability to screen patients for mental disorders is limited by time constraints per office visit (Chang, Warner, & Weissman, 1988) and restrictive reimbursement policies (Wells et al., 2001). Indeed, studies of primary care providers indicate that they recognize symptoms of mental disorder in only about 50% of adolescents reporting those symptoms prior to their visit (Horwitz et al., 1992; Kelleher et al., 1997). Even when symptoms are recognized, less than half of youth are referred for care to mental health specialists (Gardner et al., 2000; Rushton, Bruckman, & Kelleher, 2002). Although pediatric primary care providers increasingly recognize mental health problems in their patients (Kelleher, McInerny, Gardner, Childs, & Wasserman, 2000), it is clear that improving identification and referral practices represents a significant opportunity to increase appropriate treatment of adolescent mental disorders.

Despite long-standing weaknesses in the primary care system, recent changes in the delivery of mental health services may be influencing the treatment of adolescent mental disorders. Many managed care plans now contain dedicated services, or “carve-outs,” for mental health care that may encourage referral to specialists (Conti, Frank, & McGuire, 2004; Forrest et al., 1999; Glied & Neufield, 2001). Experience with these arrangements in adult managed care suggests that they may eliminate costly (and ineffective) inpatient mental health services, but very little is known about the effects of managed care on youth (Glied & Neufield, 2001; Scholle & Kelleher, 1998). Another development is the increase in public financing of children's health. More children are now covered by Medicaid and the State Children's Health Insurance Program, both of which may provide more comprehensive coverage than available through other mechanisms (Glied & Cuellar, 2003).

In addition to changes in the financing of health care, many initiatives have focused on the need for better mental health screening of children and adolescents, most notably the Report of the Surgeon General on Child Mental Health (U.S. Department of Health and Human Services, 2000) and the President's New Freedom Commission on Mental Health (2003). Furthermore, the American Academy of Pediatrics as part of its Bright Futures program (Jellinek, Patel, & Froehle, 2002) and the National Association of Pediatric Nurse Practitioners as part of its Keep Your Children/Yourself Safe and Secure initiative (KySS) (Melnyk, Brown, Jones, Kreipe, & Novak, 2003) now encourage primary care practitioners to screen their patients for common mental disorders and to refer those who meet diagnostic criteria to appropriate providers.

In this ever-changing policy environment, it is important to determine how well primary care physicians, especially those serving patients in managed care, are able to identify and refer adolescent patients with serious mental disorders. In particular, we were interested to determine if primary care physicians who treat adolescents view the mental health of their patients as their responsibility and, if so, whether their diagnostic skills and office practices enable them to identify a variety of mental health problems and to seek referrals for those in need of treatment. We were also interested in providers' views of stigma and beliefs about the efficacy of treatment in their decisions about mental health care.

To determine the status of current practices in adolescent primary care, the Annenberg Public Policy Center, with funding from SAMHI, com missioned Princeton Survey Research Associates to conduct a survey of over 700 primary care physicians who regularly treat adolescents ages 10 to 18 (pediatricians, family physicians, and general practitioners). The interviews were conducted by telephone between September 29, 2003, and January 23, 2004. The details of the methodology are provided in the Appendix to this chapter.

## SURVEY OF PRIMARY CARE PHYSICIANS WHO TREAT ADOLESCENTS

### Sample Characteristics

Table 30.1 shows the demographic composition of the sample in comparison to the universe of physicians from which it was drawn. The sample of 727 primary care providers closely mirrored the demographic characteristics of U.S. pediatricians, family practitioners, and general practitioners. The one exception was type of physician—pediatrician or family or general practitioners. Fewer family and general practitioners were willing to participate in the survey than were sampled. To compensate for their underrepresentation, the data were weighted to the proportions (80%/20%) originally sampled.

Table 30.1 Sample Composition in Comparison to National Population Characteristics (N = 727)

Characteristic

Population

(%)

Unweighted

Sample

(%)

Weighted

Sample

(%)

Age

Under 45 years

40

33

32

45 years and older

60

63

65

Gender

Women

49

54

58

Men

51

46

42

Type

Pediatrician

80

92

80

Family or general practitioner

20

8

20

Urbanity

Urban

40

42

40

Suburban

46

42

43

Rural

14

11

12

Region

Northeast

26

32

30

Midwest

20

17

19

South

31

27

26

West

24

24

25

The sample of providers reported seeing an average of 27.4 adolescents in an average week (range, 1 to 200). Approximately 45% reported that the majority of their adolescent patients were enrolled in managed care, and about 50% reported that the majority of their patients were insured through public programs. Hence, this sample provides a unique look at the practices of providers who treat large numbers of adolescents in the United States within an ever-expanding universe of managed care and public reimbursement programs.

## FINDINGS

### Adolescent Mental Health Is a Strong Responsibility

Most primary care physicians believe that they have a responsibility to tend to both the physical and mental well-being of their adolescent patients (Table 30.2). When asked to what degree they believe it is their job to talk to adolescent patients about their mental health, more than 7 in 10 (76%) said it is their job to a great extent. Only a handful (3%) did not feel it is their job to ask about mental health issues.

Table 30.2 Physician Responsibilities in Regard to Mental Health Topicsa

Physician's Response

Topic

A Great Deal (%)

A Fair Amount (%)

Not Too Much/Not At All (%)

Mental health

76

21

3

Use of tobacco

80

18

2

School work and how things are going

79

20

1

Use of alcohol

78

19

2

Sexual activity

76

21

3

Use of other illegal drugs

76

20

3

Use of marijuana

74

22

3

Eating habits

73

25

2

Relationships with their family and friends

73

24

3

a According to response to the question, “In general, how much do you feel it is your job to talk to adolescent patients about their (Insert)?”

In addition to mental health issues, most physicians feel strongly that it is their job to ask about other aspects of their adolescent patients' lives. A large majority of physicians felt a great deal of responsibility to bring up risky behaviors such as use of tobacco (80%), alcohol (78%), marijuana (74%), and other illegal drugs (76%). As many physicians believed it is very much their job to ask how things are going at school (79%) and about sexual activity (76%). And nearly as many physicians believed it is very much a part of their job to ask about adolescents' eating habits (73%) and their relationships with family and friends (73%).

Physicians who felt it is their responsibility to ask adolescents about mental health issues were also more likely to strongly believe it is their job to ask about all of these other issues. This suggests that many physicians see their job as clearly encompassing much more than just the treatment of their patient's physical health.

### Mental Health Is Not Always a Priority During Physical Exams

Table 30.3 Frequency of Asking Questions on Various Mental Health Topics During Physical Exams in the Past Year

Physician's Response

Topic

A Great Deal (%)

A Fair Amount (%)

Not Too Much/Not At All

(%)

Mental health

48

43

9

School work and how things are going

84

15

1

Use of tobacco

74

21

4

Sexual activity (for those who have reached puberty)

66

29

5

Use of alcohol

65

30

4

Use of other illegal drugs

57

34

8

Use of marijuana

54

35

12

Physicians who say they always ask adolescents about their mental health tend to think that mental health is a big part of their job. We also found that female physicians are more likely to say they always ask about mental health than male physicians. And pediatricians make a point to always ask about mental health more often than family and general practitioners.

### Knowledge Is Good But Not Excellent

Despite their strong conviction that mental health is integral to their mission, primary care providers do not feel particularly qualified to treat mental health problems. Only 1 in 10 physicians (11%) said their knowledge of mental health issues is “excellent.” A slim majority said it is good (56%), while 33% said their knowledge is only somewhat good or weak.

We found no demographic differences be tween primary care physicians who say they have excellent knowledge of adolescent mental health and those who describe their knowledge as good. For example, female physicians were no more likely than male physicians to believe their knowledge level is excellent. And even though younger physicians were probably exposed to more information about mental health in medical school, physicians under age 50 described their knowledge base as excellent as often as older physicians. Furthermore, regardless of whether the physician practiced medicine in a rural, urban, or suburban location, there was no difference in their reported knowledge levels. Likewise, pediatricians were as likely as family and general practitioners to say they have excellent knowledge of mental health issues. The same conclusion applies to physicians whose patients are primarily enrolled in managed care or with private insurers.

Many physicians also report a lack of confidence in how to handle information they receive from adolescent patients about their mental status. Only half of physicians (50%) said they very often “know how to handle” this type of information. But 40% reported being less confident and said they only somewhat often rather than very often knew how to handle the information they get. At the same time, relatively few physicians (9%) said they are often unsure about how to handle the information they get on a patient's mental health.

Not surprisingly, physicians who said they have excellent knowledge about adolescent mental health were much more likely to say they very often know how to handle the information they get from patients about their mental health (86%) than those who describe their knowledge base as good (55%) or only somewhat good or weak (30%).

### Ability to Identify Mental Health Problems

When asked about specific mental health conditions, most physicians felt at least somewhat capable of identifying these problems in adolescents (Table 30.4). However, physicians expressed more confidence in their ability to identify some conditions than others. Regardless of the condition they were asked about, only half or fewer felt very capable of identifying these disorders.

Table 30.4 Ability to Identify Various Mental Health Problems in Adolescents

Physician's Response

Mental Health Problem

Very Capable (%)

Somewhat Capable (%)

Not Too Capable

(%)

Not Capable

at All

(%)

Depression

50

48

2

Anxiety disorders such as panic disorder, social phobias, and obsessive/compulsive disorders

43

52

5

Eating disorders

39

55

5

1

Alcohol abuse

31

61

7

1

Drug abuse

25

65

8

Sexual abuse

22

59

16

2

Schizophrenia

21

51

23

4

Bipolar disorder

18

59

20

3

Physicians are most confident in their ability to identify depression. Still, only half (50%) said they feel very capable of identifying depression in adolescents. Almost all (98%), however, said they are at least somewhat capable of identifying adolescent depression.

In identifying anxiety and eating disorders, physicians are even less confident than they are for depression. Although over 9 in 10 said they are at least somewhat capable of identifying these conditions, only about 4 in 10 reported that they are very capable of identifying anxiety (43%) and eating disorders (39%). Next in order are drug and alcohol abuse. Only 3 in 10 or fewer said they are very capable of identifying alcohol (31%) and drug (25%) abuse. But again, 9 in 10 physicians said they are at least somewhat capable of identifying these behaviors.

When it comes to identifying victims of sexual abuse, quite a few physicians feel unsure. Only 22% said they are very capable of identifying victims of sexual abuse. Although 81% reported feeling at least somewhat capable, 18% seriously doubted their abilities to identify sexual abuse.

Physicians are most likely to express doubts about their capabilities when it comes to patients with either of two mental conditions—schizophrenia and bipolar disorders. Perhaps because of its low incidence, only 21% said they are very capable of identifying schizophrenia in adolescents. And although a solid majority (72%) reported feeling at least somewhat capable, 27% said they are not too or not at all capable of identifying this condition.

Bipolar disorder is another condition that quite a few express doubts about. Only 18% of physicians said they are very capable of identifying bipolar disorders. Although 77% reported feeling at least somewhat capable, 23% were less sure of their ability to identify this disorder in adolescents.

### Experience Matters

There is reason to believe that for at least some of these conditions, steps can be taken to increase physicians' confidence in diagnosing them. For example, by improving physicians' knowledge, they may be better able to diagnose depression, anxiety, and eating disorders. Solid majorities who described their knowledge base as excellent reported feeling very capable of identifying depression (85%), anxiety (76%), and eating disorders (71%). Knowledge may also help in identifying other conditions, although even among those with excellent knowledge, only half or fewer reported feeling very capable of identifying bipolar disorders (49%), sex abuse victims (47%), or schizophrenia (46%).

According to the physicians surveyed, they learn to diagnose mental health problems through a combination of patient care experiences and formal training. More than 4 in 10 attributed their diagnostic skills most to their patient care experience (43%), while almost as many referred to their medical training (40%).

Female physicians (50%) were more likely to attribute their skills to their patient care experience than male physicians (38%), and physicians over age 50 (21%) more often than their younger colleagues (7%) attributed their confidence to their personal experiences.

### (p. 585) Treatment Viewed as Effective

Physician competence in diagnosing and treating adolescent mental conditions obviously matters, but it is especially important because virtually all agree that with adequate care adolescents can be successfully treated for mental health conditions. Some physicians reported feeling more strongly about this than others: 71% strongly agreed that with adequate care adolescents can be successfully treated, whereas an additional 25% agreed somewhat. Very few physicians (3%) reported feeling that mental disorders cannot be successfully treated with adequate care.

### Screening for Mental Disorders

The most systematic way to learn about potential mental health problems is to screen patients for these conditions. According to physicians surveyed, not quite one in two adolescents will encounter such a test during an office visit.1 Roughly half of providers (48%) said that their office “routinely screens adolescent patients for mental health disorders.” However, slightly more physicians said their office does not routinely conduct a screening test (51%). Physicians who are more likely to screen are also more likely to be open and engaged and to be knowledgeable about mental health issues. Physicians who say they always ask about mental health issues, who strongly feel it is their responsibility to talk to adolescents about mental health issues, and who describe their knowledge as excellent are more likely to say they routinely screen their patients for mental disorders.

Physicians who reported screening patients tended to use either a screening instrument developed by the physician (36%) or a standard patient questionnaire that is administered to the adolescent (34%) (Table 30.5). Considerably fewer physicians reported using a standard questionnaire that is administered to the parent (4%) or do the screening themselves or have an associate do the screening (17%).

Table 30.5 Reported Method of Screeninga

Method

Physician's Response (%)

Use our own screening instrument

36

34

I or one of my associates does screening during the visit

17

Standard patient questionnaire administered to parent, such as the Pediatric Symptom Checklist

4

Other

7

a Among those saying they screen, N = 357.

Physicians who routinely screen patients for mental disorders were more likely to do so during the office visit itself (81%) rather than while the patient is in the waiting room (13%) or at some other time (6%).

A majority of physicians who do not routinely screen patients reported being aware (64%) that there are screening instruments for common mental conditions that can be completed by adolescents while they wait to see the physician. At the same time, more than a third (36%) said they are not aware of these screening instruments.

### Treatment Decisions Are Quite Consistent

To find out more about physicians' actual treatment practices, we asked how they would proceed given a set of symptoms often associated with different mental health conditions—depression, anxiety disorders, bipolar disorders, eating disorders, alcohol abuse, and schizophrenia. (To reduce respondent burden, we only asked each physician about three of the disorders.) In particular, we asked if they would talk to the adolescent's parents about the symptoms, refer the patient to a mental health professional, or treat the patient themselves. We also asked physicians to estimate how many patients with each set of symptoms they actually referred in the last year and to what type of professional.

Physicians were remarkably consistent in their chosen course of treatment across different mental health conditions. Most physicians reported that they would talk to the adolescent's parents and would refer the adolescent to another professional. In a smaller percentage of cases, physicians claimed they would treat the patient themselves.

As seen in Table 30.6, physicians said they would be very likely to talk to parents of adolescents who presented symptoms of depression (91%) or schizophrenia (90%). A large majority also said they would be very likely to consult parents if an adolescent had symptoms of bipolar disorder (83%), eating disorder (81%), or an anxiety disorder (78%) or if an adolescent was showing signs of alcohol abuse (75%).

Table 30.6 Reported Likelihood of Talking to Parents About Adolescents Exhibiting Various Symptoms

Likelihood

Symptom

Very Likely (%)

Somewhat Likely

(%)

Not Too Likely (%)

Depression: lost interest in school and work, stopped getting together with friends, often refused to get out of bed in the morning

91

7

1

Schizophrenia: had trouble focusing on school work, no interest in hanging out with friends, convinced other people were reading their mind, suffered from disorganized speech

90

6

3

Bipolar disorder: displayed mood swings; very depressed at times and overexcited at other times

83

14

2

Eating disorder: lost weight even though did not need to, exercises rigorously, expressed concern about appearance

81

15

3

Anxiety: often intensely worried to the point that it disrupts daily life

78

19

1

Alcohol abuse: drunk at least once a week, consuming 5 or more drinks and sometimes would not remember what happened the night before

75

16

6

One group of respondents was randomly selected to receive questions about depression, schizophrenia, and eating disorders (N = 373), whereas the other group was asked about bipolar disorder, anxiety, and alcohol abuse (N = 355).

Very few among the physicians interviewed said they would not be likely to talk to the parent of an adolescent who had symptoms of one of these conditions.

In addition to talking to a parent, a majority of physicians said they would be very likely to refer an adolescent to a mental health professional for further testing or treatment (Table 30.7). Fewer than 1 in 10 physicians said they would not be likely to make a referral if a patient was showing symptoms associated with a mental disorder.

Table 30.7 Reported Likelihood of Referral to a Mental Health Professional for Further Diagnostic Tests and/or Counseling

Likelihood

Symptom

Very Likely (%)

Somewhat Likely

(%)

Not Too Likely (%)

Schizophrenia: had trouble focusing on school work, no interest in hanging out with friends, convinced other people were reading their mind, suffered from disorganized speech

94

5

1

Depression: lost interest in school and work, stopped getting together with friends, often refused to get out of bed in the morning

79

18

3

Anxiety: often intensely worried to the point that it disrupts daily life

76

18

5

Alcohol abuse: drunk at least once a week, consuming 5 or more drinks and sometimes would not remember what happened the night before

76

15

7

Bipolar disorder: displayed mood swings; very depressed at times and overexcited at other times

71

20

8

Eating disorder: lost weight even though did not need to, exercises rigorously, expressed concern about appearance

61

31

7

One group of respondents was randomly selected to receive questions about depression, schizophrenia, and eating disorders (N = 373), whereas the other group was asked about bipolar disorder, anxiety, and alcohol abuse (N = 355).

An adolescent presenting with symptoms of schizophrenia was most likely to be referred to a mental health professional (94%). A large majority of physicians also said they would be very likely to make a referral for symptoms associated with depression (79%), anxiety disorders (76%), alcohol abuse (76%), or bipolar disorders (71%). Somewhat fewer but still a solid majority said they would be very likely to refer an adolescent with symptoms of an eating disorder (61%) to a mental health professional.

Referring a patient to a mental health professional for further diagnostic tests does not mean that the physician will refrain from treating the patient in-house. Many physicians who said they are very likely to refer adolescents with symptoms of a specific disorder to another professional also said they would be likely to treat the patient themselves.

When asked about treating an adolescent with a mental health condition, roughly half said they are likely to treat these patients themselves, but relatively few said they are very likely to do so (Table 30.8).

Table 30.8 Reported Likelihood of Personally Counseling or Treating the Adolescent

Likelihood

Symptom

Very likely (%)

Somewhat Likely

(%)

Not Too Likely (%)

Not Likely At All (%)

Depression: lost interest in school and work, stopped getting together with friends, often refused to get out of bed in the morning

25

32

27

16

Alcohol abuse: drunk at least once a week, consuming 5 or more drinks and sometimes would not remember what happened the night before

23

23

25

28

Eating disorder: lost weight even though did not need to, exercises rigorously, expressed concern about appearance

21

35

26

17

Bipolar disorder: displayed mood swings; very depressed at times and overexcited at other times

21

31

24

23

Anxiety: often intensely worried to the point that it disrupts daily life

21

30

28

21

One group of respondents was randomly selected to receive questions about depression, schizophrenia, and eating disorders (N = 373), whereas the other group was asked about bipolar disorder, anxiety, and alcohol abuse (N = 355).

Physicians were particularly cautious about treating patients with symptoms of schizophrenia. Only 9% said they would be very likely to treat the patient themselves. By contrast, a solid majority (72%) said they would not be too likely (34%) or not likely at all (38%) to treat an adolescent with these symptoms.

Physicians express greater willingness to treat adolescents with symptoms associated with other conditions. Even so, only a quarter or fewer said they would be very likely to treat any of these conditions themselves. Slim majorities, however, said they would be very or somewhat likely to treat adolescents with symptoms of depression (57%), eating disorders (56%), bipolar disorders (52%), or anxiety disorders (51%). Somewhat fewer said they would be somewhat or very likely to treat symptoms of alcohol abuse (46%).

Physicians who say they are very likely to treat a particular condition themselves are more likely to say they are very capable of identifying that disorder than those who say they are not likely to treat the condition themselves. This is true for all mental conditions except for schizophrenia, a condition which very few physicians, regardless of their confidence in their diagnostic skills, say they are very likely to treat themselves.

It is encouraging that physicians who feel less than total confidence in their diagnostic skills with regard to a particular disorder are less likely to treat that disorder themselves. At the same time, however, many physicians who said they are very likely to treat a condition themselves also said that they are only somewhat or not too confident in their ability to diagnose that condition. Of those physicians who said they are very likely to treat a condition, large proportions said they are less than very capable to identify alcohol abuse (47%), eating disorders (39%), and depression (37%). A majority of physicians (56%) who said they are very likely to treat bipolar disorders themselves said they are only somewhat confident in their diagnostic ability when it comes to identifying adolescents with this disorder.

### Psychiatrists Are Preferred

Providers who say they are likely to refer their adolescent patients are most likely to refer to a psychiatrist. More than half of physicians who reported being at least somewhat likely to refer, said they would refer an adolescent with symptoms of schizophrenia (63%), bipolar disorders (57%), or anxiety disorders (55%) to a psychiatrist.

Referrals to psychologists were second most likely, with nearly as many saying they would refer an adolescent showing signs of depression, eating disorders, or alcohol abuse to a psychologist as a psychiatrist. Substantially fewer said they would refer adolescents to a mental health worker or social worker. Alcohol abuse is an exception, with a sizable minority of physicians (28%) saying they would send adolescents showing signs of alcohol abuse to a mental health worker, such as a substance abuse counselor.

Providers talk to parents and make referrals to mental health professionals despite the fact that many of them worry about stigmatizing their adolescent patients with the diagnosis of a mental disorder. About one in two physicians (54%) said they very often (16%) or somewhat often (38%) worry that diagnosing an adolescent with a mental disorder will stigmatize the patient. Only 15% of physicians said they rarely worry about stigmatizing their patients.

A sizable minority of providers who said they often worried about the stigma of a mental health problem acknowledged that this makes them reluctant to actually diagnose an adolescent with a mental health disorder. Forty-three percent said that this concern causes them to be reluctant to a great (7%) or moderate extent (36%). Only about a quarter (24%) said that this concern plays no role in their diagnostic decision.

Based on responses to the two stigma questions, we created a single stigma score that reflected the degree to which physicians were concerned about diagnosing an adolescent with a mental disorder. Those who thought about stigma infrequently were given the two lowest scores (“not too often” and “not often at all”). Those who thought about stigma more often were given the highest score if they expressed either great or moderate reluctance to diagnose a patient with a mental disorder and an intermediate score if they only expressed a small or nonexistent reluctance to diagnose.

A regression analysis of this score indicated that providers with greater diagnostic knowledge about the disorders were less likely to be concerned about stigma than those with less knowledge. In addition, those with a patient population that contained high proportions of privately insured adolescents were less likely to be concerned about stigma. Belief in treatment efficacy was not related to concerns about stigma.

Most providers say they would refer adolescent patients with symptoms of a mental disorder to another health professional. But only 32% said that there are adequate mental health treatment resources in their community, whereas 67% reported that the treatment resources are inadequate. Indeed, 44% reported that they felt very strongly about this.

Views about treatment resources are apparently shaped in part by the type of patient being treated and the location the doctor practices in. Providers who treat predominantly low-income patients were more likely to say that treatment resources are inadequate (71%) than those who treat mostly middle-or high-income patients (57%). We also found that physicians who practice in rural communities (80%) were much more likely than those who practice in an urban (64%) or suburban setting (65%) to say that the treatment resources in their community are inadequate. Views about the adequacy of treatment resources were unrelated to beliefs about the potential efficacy of treatment.

### Collaborative Relationship with Mental Health Professionals

Despite inadequate resources, many primary care physicians often work closely with mental health care specialists. It is generally accepted that patients experience better outcomes when the referring physician works closely with the mental health specialist treating the patient. A solid majority of providers (68%) reported that they collaborate to a great (27%) or moderate (41%) extent with the mental health professionals to whom they refer their adolescent patients. An additional 27% reported collaborating to a small extent. Only a handful of doctors (5%) said they do not work with the mental health care professionals at all. Physicians who practiced in rural areas were much more likely to say they collaborate to a great extent (41%) than those who practice in suburban (26%) or urban areas (24%).

Physicians who claimed to collaborate with mental health specialists tended to view the experience in positive terms: 85% said they have a good relationship with these mental health professionals, and 42% said the relationship is very good.

## PREDICTORS OF IDENTIFICATION AND REFERRAL FOR CARE

The survey results suggest that primary care physicians agree about the importance of treating mental health problems in their adolescent patients and about referring those who are identified to a mental health specialist. The weak link in the process is the poor ability of physicians to identify patients who are in need of mental health services. Nevertheless, providers who report greater diagnostic skills should identify mental health conditions in their patients at a greater rate. If screening helps providers to recognize and diagnose mental disorder, we would also expect those who employ screening to report higher rates of mental health problems. In addition, if mental health carve-outs within managed care provide a ready link with mental health specialists, we would expect those with large proportions of patients in managed care to be more likely to refer patients for mental health care. We examined the role of these and other provider characteristics in reported prevalence of disorder and rates of referral.

### Prevalence of Mental Health Conditions Reported by Physicians

We asked physicians to estimate the percentage of adolescent patients they saw in the last year who had specific mental disorders. In addition to mental disorders, we asked about the percentage of adolescent patients who engaged in risky behaviors such as excessive alcohol use. The estimates given by the physicians roughly resemble the reported prevalence of these mental health conditions in the adolescent population (Table 30.9).

Table 30.9 Estimated Prevalence of Six Disorders in Annual Patient Load and Differences Attributable to Provider Characteristics (p < .05)

Diagnosis

Predictor

Anxiety

Depression

Bipolar Disorder

Schizophrenia

Eating Disorder

Alcohol Abuse

Mean prevalence (%)

10.84

16.46

4.75

1.81

9.20

10.86

Diagnostic knowledgea

3.89

4.32

1.49

0.65

3.50

Screening

1.28

0.26b

Stigmaa

−1.32

Managed care

−0.53

Private insurance

Family or general practice

3.58

5.49

1.60

3.36b

4.28

a Scored on a 1-to-4 scale.

b Significant only at the p < .10 level.

Depression was the most commonly seen mental disorder, followed by anxiety disorders and alcohol abuse. On average, physicians said that in the last year about 16% of their adolescent patients were depressed. Anxiety disorders and alcohol abuse were the next most commonly seen disorders, with physicians saying that, on average, about 10% of their patients had these conditions. About 9% of adolescent patients were thought to have an eating disorder. And physicians reported that about 5% of their patients, on average, were suffering from bipolar disorders and a little over 1% from schizophrenia.

These estimates are not far off from reported national prevalence of mental health conditions in adolescents. Approximately 10% to 15% of adolescents exhibit some signs of depression, although the percentage of adolescents who meet the criteria for a full-fledged diagnosis of depression is closer to 5% to 8%. Similarly, while only 1% of adolescents meet the full criteria for bipolar disorders, nearly 6% of adolescents present with many of the classic symptoms of the condition. Additionally, 13% of the adolescent population is thought to have an anxiety disorder, whereas 1% is believed to have schizophrenia (National Institutes of Mental Health, 2000a, 2000b); U.S. Department of Health and Human Services, 1999). Estimates of alcohol dependence are lower than the estimated rate found here; however, alcohol abuse is quite common among adolescents.

We conducted regression analyses to determine significant predictors of prevalence estimates. Table 30.9 shows the changes in prevalence rates attributable to several differences in provider characteristics with other differences held constant. Not shown are differences in provider gender, age, rural vs. urban location, reported weekly adolescent patient load, and income level of patient population. It is clear that the self-reported diagnostic skill of the provider is a consistent predictor of estimated prevalence. This was measured by taking the mean response to the questions concerning self-assessed diagnostic ability (Table 30.4) for the five mental disorders (alpha = .79). For alcohol abuse, we used the reported diagnostic knowledge for alcohol abuse. The only condition not predicted by self-assessed skill was the prevalence of eating disorders. Screening for mental disorders was also a predictor of anxiety and schizophrenia.

It is important to note that diagnostic skill was assessed on a four-point scale. The distribution of this scale was such that the difference between those who were most confident in their diagnostic skill (the top 15%) and those who were least confident (the lowest 15%) produced a difference of about 5 percentage points in reported prevalence of depression, anxiety, and alcohol abuse.

Concern about stigma was a predictor of diagnosis for alcohol abuse but was not systematically related to any of the other disorders. Belief in treatment efficacy (not shown) was also not related to any diagnosis rates. Family physicians and general practitioners also gave higher prevalence estimates for all the conditions but bipolar disorder. Prevalence estimates did not differ according to the proportion of the patient population that had private insurance or that was served by managed care.

We cannot confirm that the estimated prevalence rates are valid; however, the predictors are consistent with the hypothesis that providers with better diagnostic skills (or those who screen for disorder) are more likely to identify mental disorders. Furthermore, by holding constant other provider and practice characteristics that might affect prevalence rates, we can be more confident that the differences are a reflection of diagnostic skill and not patient populations.

### Rates of Referral for Treatment

We also asked providers to estimate the percentage of patients with symptoms of each mental condition they had referred to other professionals in the past year. Although referral rates did not differ dramatically across diagnoses (Table 30.10), the rates did differ considerably within each diagnosis. Roughly 30% to 45% of providers said they referred most adolescent patients with the given symptoms to other professionals. About 4 in 10 physicians said they referred most of their adolescent patients with symptoms of schizophrenia (44%) or alcohol abuse (38%). Somewhat fewer referred most of their patients with symptoms of bipolar disorders (35%), anxiety disorders (33%), depression (32%), or eating disorders (28%).

Table 30.10 Mean Estimated Rates of Referral for Treatment of Six Mental Health Problems in Past Year and Differences Attributable to Provider Characteristics (p < .05)

Diagnosis

Predictor

Anxiety

Depression

Bipolar Disorder

Schizophrenia

Eating Disorder

Alcohol Abuse

Mean referral rate (%)

51.20

52.70

52.49

54.59

43.84

48.37

Managed care

2.89

3.21

4.26

Private insurance

3.19

3.66

Screening

6.78

5.60

Respondents were randomly assigned to answer this question for one of two groups of conditions: depression, schizophrenia, and eating disorders (N = 373) or anxiety, bipolar disorder, and alcohol abuse (N = 355).

At the same time, many physicians referred 25% or fewer of their patients with symptoms of a mental health problem. Roughly 4 in 10 did not make a referral for most of their adolescent patients with signs of eating disorders (46%), alcohol abuse (46%), anxiety disorders (43%), schizophrenia (41%), bipolar disorders (40%), or depression (38%).

A regression analysis of referral rates indicated that types of practice and insurance were the major predictors (Table 30.10). Providers with most of their patients in managed care plans were more likely to refer patients with anxiety, bipolar, and alcohol problems. Providers with patients who were mostly privately insured were more likely to refer patients with schizophrenia and eating disorders. Providers who screened their patients for mental disorders were also more likely to refer them for treatment of depression and eating disorders. Diagnostic knowledge, stigma, belief in treatment efficacy, or type of provider were not significantly related to referral rates.

Although not shown in Table 30.10, our analysis also revealed that providers who were more likely to refer patients to mental health specialists were more likely to rate the treatment resources in their community as inadequate. This was especially true for the referral of anxiety disorders and bipolar disorder. Evaluations of treatment resources were not related to practice characteristics such as managed care or private insurance status.

## SUMMARY AND CONCLUSIONS

This survey of primary care providers who treat adolescents indicates that these physicians are concerned about the mental health of their adolescent patients and regard mental health as an important responsibility. In addition, the vast majority of primary care providers believe in the efficacy of treatment for mental disorders. However, primary care providers report only weak ability to diagnose mental health problems, and at best, only half employ any screening technique at all to detect mental health problems in their adolescent patients. Indeed, a separate survey of nonresponders to the survey indicated that the true rate of screening as well as diagnostic knowledge may well be lower.

### Weak Confidence in Detecting Disorders

The low levels of confidence in recognizing depression that were observed in this study are consistent with another recent survey of primary care pediatricians (Olson et al., 2001). Although the present survey indicates that providers feel most capable of identifying depression (about 50%), their confidence in identifying other disorders is even lower. For example, only 25% reported being very capable of identifying drug abuse in their adolescent patients. In the absence of effective screening procedures, primary care providers will continue to be unable to recognize mental and substance abuse disorders in their adolescent patients.

Providers' estimated prevalence of mental disorders in their patient populations indicated that although the rates are in line with national estimates, variation across providers was strongly related to diagnostic knowledge. Providers who were more confident in their ability to diagnose mental conditions reported higher prevalence of disorders in their patients. In addition, those who regularly screened for mental disorders were also more likely to recognize some of the conditions. The importance of appropriate diagnosis is also underlined in the finding that providers who screened their patients were more likely to refer them for treatment of depression and eating disorder.

The inability to detect mental disorders in adolescents is a serious flaw in the primary care system. No matter how well intentioned providers may be, there is little that can be done to help adolescents in need of treatment if they are not first identified. Although providers recognize the importance of referring their patients to mental health specialists and of including parents in the treatment of mental disorders, these intentions do not come into play without adequate resources and abilities to detect patients at risk for mental and substance abuse disorders.

Pediatricians as a group were even less likely to report mental health problems in their pa tients than family doctors or general practitioners. In view of the much higher representation of pediatricians in the adolescent primary care system, there is a large opportunity to increase the ability to detect mental disorders in primary care. The Bright Futures and KySS programs already recommend screening and referral for adolescent mental disorders and have materials in place that could advance the adoption of better screening practices. Research would also be valuable to determine if computer-assisted screening mechanisms such as that developed by the Columbia Teen Screen program (McGuire & Flynn, 2003) could be adopted in primary care.

Increased knowledge and ability to diagnose mental health problems may also reduce concerns about stigma, a factor that could also impede appropriate referral and treatment. Providers with greater confidence in their understanding of mental disorders were also less likely to express concerns about the stigma of mental disorder. Although concerns about stigma were only related to the estimated prevalence of alcohol abuse, substance abuse is highly comorbid with other disorders and its association with stigma is likely to reflect a failure to identify these disorders as well (American Academy of Pediatrics, 2000).

### Rates of Referral for Mental Health Problems

Recognition of mental disorder is only a first step in delivering appropriate care. Providers must also make decisions about appropriate treatment. Estimates of rates of treatment referral indicated that about half of patients with major mental disorders are referred on average. It is difficult to evaluate the optimal level of referral without greater knowledge of the diagnostic criteria used by providers. However, given these reported rates of referral, it is not surprising that less than half of adolescents with serious mental conditions are estimated to receive appropriate mental health services (Costello et al., 1998; Horwitz et al., 1992; Sturm et al., 2003).

Practice characteristics were the strongest predictors of reported referral rates. In particular, providers whose patient population was primarily served by managed care were more likely to refer those patients for anxiety disorder, bipolar disorder, and alcohol abuse. This finding may reflect the influence of increased deployment of mental health carve-outs in managed care. This approach is designed to contain costs for mental health treatment, but it could also encourage referral for those who are appropriately diagnosed with mental conditions (Conti et al., 2004). Unfortunately, the present research could not assess the quality of the referrals that are being made in managed care. There is evidence to suggest that the barriers to successful referral are actually greater in pediatric managed-care systems (Walders, Childs, Comer, Kelleher, & Drotar, 2003). Hence, many have expressed concerns that mental health carve-outs will encourage referral to less than optimal care providers (Glied & Neufield, 2001; Jellinek & Little, 1998; Kelleher, Scholle, Feldman, & Nace, 1999). Research to determine the fate of adolescents with mental disorders in managed care is clearly a high priority.

Providers whose patient population was primarily served by private insurance were more likely to refer them for treatment of some disorders (schizophrenia and eating disorder). This finding suggests that patients in the public sector may be receiving even less appropriate treatment for these conditions.

### Treatment Resources Are Often Inadequate

An important concern in the findings is the unfavorable evaluation that most providers report of treatment resources in their communities. Indeed, providers who were more likely to refer patients to mental health specialists were also more likely to evaluate those services as inadequate. This finding suggests that better screening will only solve a part of the mental health service delivery problem for adolescents. Better treatment resources will also be needed (cf. Walders et al., 2003). In sum, this survey indicates that appropriate screening and diagnosis of adolescents in primary care is a critical step in advancing the mental health of youth. At the same time, how ever, increased referral to mental health specialists may have the potential to make providers even more aware of the limitations in the mental health treatment system for adolescents.

## Appendix Design and Data Collection Procedures

As part of its Sunnylands Adolescent Mental Health Initiative, the Annenberg Public Policy Center commissioned Princeton Survey Research Associates International (PSRAI) to conduct the survey. The fieldwork was conducted by Princeton Data Source, LLC, and Braun Research, Inc., from September 29, 2003, to January 23, 2004. In total, 727 interviews were conducted with a nationally representative sample of pediatricians, family practitioners, and general practitioners who regularly treat adolescents between the ages of 10 and 18. The interviews took approximately 25 min to complete. The maximum margin of sampling error for results based on the full sample is ±4%.

# SAMPLE DESIGN

A nationally representative sample of 5,000 pediatricians, family practitioners, and general practitioners was drawn from the American Medical Association's (AMA) Physician Masterfile. The AMA Physician Masterfile is the nation's largest repository of primary-source physician data and includes both members and nonmembers in the United States and all of its foreign territories. Since the population of interest was physicians who are currently practicing medicine, we drew our sample from a prescreened list provided by SK&A Information Services, Inc., that had removed fellows, residents, students, and retired doctors.

The sample was drawn among the three main types of primary care physicians who are likely to treat adolescents—pediatricians, family practitioners, and general practitioners. The composition of the sample reflects the fact that most adolescents are treated by pediatricians rather than by family and general practitioners, who tend to have a broader patient base. On the basis of this information, the sample was drawn so that it comprised 80% pediatricians and 20% family and general practitioners.