Welcome | Networking | Long Range Plan | Links | Membership Application

The Role of Rural Primary Care Providers in the Provision of Mental Health Services: Voices from the Plains

Letter to the Field No. 10

by Jack M. Geller, Ph.D., Marshfield Medical Research Foundation

Table of Contents
Introduction | Methodology | Role of Primary Care Providers | General Competencies | Relationship Between Rural MDs & MH Professionals | Summation and Limitations | References

Send Us Your Comments on this Document

Introduction

It has been twenty years since Regier, Goldberg, and Taube (1978) coined the phrase the "de facto mental health system," referring to the provision of mental health services by the general medical sector. At that time, using epidemiological methods, they estimated that approximately 60 percent of the total persons affected by mental disorders sought treatment in a primary care setting. Subsequent studies have continued to affirm the presence and importance of this de facto system (U.S. Department of Health and Human Services, 1984; National Rural Health Association [NRHA], 1992; Regier, Boyd, & Burke, 1988; U.S. Congress, 1990).

Physicians that practice in rural and frontier areas tend to play an even larger role in mental health care provision than their urban counterparts. This is in part due to the relative scarcity of mental health and other health care professionals in these outlying areas of the country. Other factors include the apparent preference rural residents have for primary care physicians (Johnson, 1995) and the stigma often associated with seeing a mental health professional. Unfortunately, sparsely populated areas without established mental health services (i.e., counseling) or providers (i.e., psychologists, social workers) also tend to have relatively few primary care physicians to act as substitutes. Nonmetro and frontier areas possess far less physician coverage than more urbanized areas even after controlling for population size. For example, Frenzen (1991) found that in 1988, the ratio of primary care physicians per 100,000 persons for remote rural areas was 38.2; for the more inclusive nonmetro areas it was 51.3. In comparison, metro areas had a ratio of 95.9.

Unfortunately, much has also been written about the deficiencies of primary care physicians in their treatment patterns (Anderson & Harthorn, 1989; Rost, Humphrey, & Kelleher 1994; Rost, Williams, Wherry, & Smith, 1995), referral patterns (Anderson & Harthorn, 1989; Farmer & Griffiths, 1992; Ozbayrak & Coskun, 1993), and training to treat people with mental disorders (U.S. Congress, 1990; Zimmerman & Wienckowski, 1991; NRHA, 1992). However, there is a growing realization that, regardless of shortcomings, primary care providers will continue to be sought out by patients for care of mental disorders, due to preference or lack of alternatives. Thus, a more recent focus has been on improving the link between primary care providers and mental health specialists. This may include integrated clinics, telecommunication links, or simply improving the competency of primary care providers through clinical practice guidelines, utilization of screening instruments, or greater contact with mental health professionals.

Conspicuously absent from most of these studies, commissioned reports, and policy papers, is the voice of the rural primary care provider. Perhaps due to their intense practice schedules, little has been written from their perspective. Accordingly, this paper presents the findings from a focus group held in early 1998, of a group of rural primary care providers who practice on the Western plains. While it would be far too presumptuous to suggest that this group of rural providers represent the thousands of physician, nurse practitioners, and physician assistants who treat rural and frontier residents every day, it does provide some insight into their perspective.

Methodology

As part of the Frontier Mental Health Services Resource Network, focus groups of providers and consumers were held in many rural locations throughout 1997 and 1998. The were held to better understand how people receive mental health services in the most remote areas of the country. This particular focus group was held during the winter of 1998 and consisted of six providers: three physicians, two nurse practitioners, and one physician assistant. All the providers practice in rural communities within a 30-40 mile range from each other.

All can be characterized as generalist providers who actively see and manage patients, many with serious mental disorders. Most of their patients have few or no other local choices, except for a visit from a mental health outreach worker from the nearest urban area (population 65,000, approximately 50 miles away). Three of the group members were male and three were female. The only unusual feature of this group of providers was their age. With the oldest group member being 49 years of age and the youngest being less than one year out of his internal medicine residency program, these providers are clearly younger than your average rural provider. On the other hand, these group members may represent "the new rural provider". Again, no claim is being made that this group represents anything beyond the views of the six members themselves.

The group was convened at a central location away from their clinics to discuss the extent to which mental health services are a part of their practice. The participants discussed their treatment and referral patterns, their training and competencies, and their relationship with the formal mental health system. The entire focus group discussion was audio taped, with the permission of the group members, and subsequently transcribed. Below I have attempted to juxtapose the contemporary literature on the role of primary care providers with the comments from focus group members. As one will see, in some areas the comments of the focus group members mirror previous findings in the literature. However, in other areas, new data emerged.

A note about confidentiality; all members of the focus group were assured that their identities would be kept strictly confidential. As this group of providers would be easily identified if their practice locations were revealed, the fictitious town of "Plainville" was created to represent their practice location. Two additional communities are referenced in their comments. The first is the closest urban community, a college town of approximately 65,000, which I have named Collegeville. The second is the largest metropolitan city in the state (population over 1 million), where large tertiary centers are located. I refer to this city as "Metropolis".

The Role of Primary Care Providers

As mentioned above, it is clear from previous literature that primary care physicians provide a large percentage of the mental health services to patients with mental disorders. This was clearly true among our focus group participants. All viewed mental health as a significant part of their practice. When asked to estimate what percentage of their patient load is primarily mental health, most estimated 10 percent. When further asked what types of common disorders their patients' experience, the most common disorders were depression, anxiety/panic attacks, attention deficit disorder, and dementia among the elderly.

It is also important to recognize that, since these providers are virtually the only ones in Plainville, their patient load comes from a variety of sources. These providers not only have their private clinic and hospital practice, but they must provide care at nearby nursing homes and at the county jail. This diversity leads to providers always feeling inadequate with some of their patients. As one physician noted, "I have a pretty clear idea of how far I can go with a depressed patient ... but the place where I really get stuck all the time is with geriatrics. Particularly dementia, they're real tricky and they mask a lot of things. ...they tell you what you want to hear. They want to please you and then you find out from their family that, oh yeah, they're running around in their underwear out at 6:00 in the morning. You know, yeah, that kind of thing."

Another provider noted, "...what's been interesting since we've been covering the jail, that's another whole segment there, that population has a lot of significant mental health problems. ...they all fall between the cracks....they've been on medication, they come in, and it's been stopped. Then it's really a difficult thing ... you know, being confined and not having their medication, not having someone to send them to or try to find out what they were on. It really is an area that needs to be dealt with somehow."

As suggested, these providers take their role as mental health providers seriously. Unfortunately, they have few local specialized services to access for their patients and describe what can be best called a fragmented system. When asked to describe the mental health resources, one provider noted that, "maybe one psychiatrist comes out periodically." Another provider quickly noted that the psychiatrist covers three counties. Further discussions about another area psychiatrist quickly displayed the fragmentation. When asked if this second psychiatrist came from Collegeville, he noted, "I'm not sure where he comes from. I guess that's the whole idea is that we do not know!" Another focus group participant noted, "And another particular entity that I think we're missing are care planners, or what's that term, 'care coordinators'. We are desperately in need of those folks to just let everyone know what's going on with this patient."

When asked how they cope with such fragmentation, these providers displayed the same resourceful ingenuity found in all sectors of rural life. "But Plainville is a small enough town," one participant noted, "so we regularly ... discuss patients who are really difficult who - most of whom turn out to be people with a mental health diagnosis or substance abuse diagnosis. But what we have really done is we've developed kind of a, not just practice-wide, but community-wide approach to them, so that when my patient X shows up in the ER, everybody kind of knows what to tell her. And that's one of the advantages of this real small system."

General Competencies

A number of articles have concluded that non-psychiatrist or primary care physicians are, by and large, inadequately prepared to recognize, refer, or treat mental disorders (Feldman, 1978; Pincus, Strain, Houpt & Gise, 1983; Jones, Badger, Ficken, Leeper & Anderson, 1988; Zimmerman & Wienckowski, 1991; Barrett, 1991; NRHA, 1992). Other possible reasons for this drawback, besides inadequate training in psychiatry/psychology, include:

Somewhat contrary to previous findings, Andersen and Harthorn (1989) found that primary care physicians recognized the presence of mental disorder essentially as well as mental health professionals (e.g., psychiatrists, psychologists). However, these physicians were less accurate in their diagnoses of affective, anxiety, somatic, and personality disorders. Generalist physicians were most accurate (81%) in recognizing organic disorders and least accurate (14%) in identifying personality disorders. Only about one-half of the physicians correctly identified anxiety (49%), somatic (49%), and affective (47%) disorders (Andersen & Harthorn, 1989).

There was significant consensus among the focus group participants that they do the best they can, but clearly were not adequately trained to provide a full range of mental health services. As one physician succinctly put it, "And I think that, just speaking freely, I don't think I'm adequately trained to do a lot of what I do. So I make a lot of phone calls to psychiatrists I know in Metropolis, and just ask- what would you do given the situation? ... Well, I just don't feel adequate doing a lot of what I do. A lot of hand holding." While another participant philosophically noted, "Well, I think - I've used this line many times, I hope I haven't seen more than I have. Because you don't know how much you miss. You always know that there is more out there that you don't know, and you're not recognizing. You just say, I'll take care of what I can identify. And that's why the relationship with the patient is so important."

Consequently, all the participants noted the need for better training in medical school and residency programs. As one of the older physicians noted, "I had to learn how to put in a chest tube, and that's true, you do have to know how to put in a chest tube. But how many times a year do you put in a chest tube when you are practicing in a small town? Once, maybe. How many people are you going to see with depression?"

At the same time, all the providers noted that while identifying depression, or other mental illness is sometimes illusive, there are more times when patients reveal mental health problems within the course of a routine office visit. As one of the nurse practitioners noted, "But you never know what you are going to get. They tell the front office that they only have this. Then they get in and they tell you they only have this. And then [at the end of the visit] your hand reaches for the door handle and they say, 'I've been using drugs for this period of time, and I'm thinking of killing myself.' And then you go, oh." While another physician noted, "...it's like they have been wanting to talk to you so they come in under the guise of insomnia or whatever, and then the mental health stuff starts surfacing."

It's reasonably clear that all of the participants were aware of their apparent deficits in recognizing mental disorders among their patients. At the same time they are quite honest and straightforward about it. As one physician mentioned, "...I think that sort of uncertainty is just one of the things you live with being a generalist."

The Relationship between Rural Physicians and Mental Health Professionals

When one reads the literature, one gets a clear impression that there is a strain between these two professional communities. Much of the literature is written by mental health professionals (primarily psychiatrists and psychologists) and suggests that generalist physicians do a poor job of recognizing mental illness in their patients, over-prescribe medication, under-dose, and do not refer patients frequently enough to mental health professionals.

This professional strain was quite apparent amongst the focus group participants. Interestingly however, these participants told a much different story than the literature suggests. For example, when first asked about the percentage of patients they refer to mental health professionals, instead of the relatively low percentages (10-30%) cited in the literature (Shapiro & Fink, 1963; Locke, Krantz, & Kramer, 1966; Fink, Goldensohn, Shapiro, & Daily, 1967; Orleans, George, Houpt, & Brodie, 1985), these providers responded with figures that ranged from 40 percent to 80 percent. Confused over this disparity, we discussed the definition of a referral.

Through this discussion several things became clear. All the providers in the group recognized the need for adjunctive therapy (primarily counseling) in addition to the medical management of their patients' medications. They were also acutely aware of the time constraints that exist in a primary care medical practice. Thus, they routinely seek out mental health counselors for their patients, which they define as a "referral". These counselors may be masters prepared counselors, or social workers, but rarely psychiatrists or psychologists. These rural providers speak highly of these counselors and rely on them to assist in the management of their patients with mental illness. However, when asked about referring their patient to a psychiatrist, they admit that this percentage is very small.

When asked what criteria they use to decide when it is time to refer their patient's care to a psychiatrist, each provider had his or her own criteria. However, some of the more common criteria included: if the patient is acute (i.e., needing to be hospitalized); if they come into the emergency room with a mental disorder; if, after several attempts, their medication regimen fails; or if they routinely find that they cannot meet a patient's needs within the time constraints of a medical practice.

Another important factor influencing referral patterns was the expectation of the rural patient. Many of these physicians believe that their patients fully expect them to meet all their health needs regardless of origin. Consequently, some of these rural providers feel pressure to treat patients, even through all their uncertainty, due to this patient expectation. As one provider stated, referring to other rural physicians, "... these good old boys were there to deliver the babies, to fix the hernia, to take out the appendix, and they pulled them through all of these things. And now mental health is another thing he can fix because he fixed all these other things."

Overall, it is fair to say that referral to a psychiatrist is closer to a last resort that a first resort. Most of the focus group participants noted that because of past experiences they are uncomfortable referring any but the most acute patients to psychiatrists. One noted that by not referring patients she was "protecting them from the [mental health] system." Others recognized that this aversion to referring patients to psychiatrists further strains the relationship. As one physician noted, "And I think that creates a bad rapport between the folks (psychiatrists) that we do use because we send them our 'bombs'. And they think, 'here's someone else from Plainville!"

Another problem voiced by the group was the lack of communication between rural primary care providers and urban psychiatrists. This is often reflected in the amount of patient information received by the rural provider from the psychiatrist after a referred patient returns to the rural community. These providers feel that, unlike other medical specialists (e.g., cardiologists or oncologists) who provide feedback to the primary care provider regarding the diagnosis and treatment regimen of their patient, psychiatrists use the veil of confidentiality to keep information from them. This creates a great deal of frustration for the primary care provider who must now deal with the patient using incomplete information in their ongoing treatment after their return. In fact, as one provider related to the group his frustration about not getting even a discharge summary from a psychiatrist after one of his patient's inpatient episodes, none of the other providers seemed even remotely surprised. As one physician reflected, "... the mental health profession is now so scared of sharing information, much more than in any realm of medicine. So like this day-of-discharge summary thing you were talking about, they had to do a whole extra song and dance about sending any information back to you about the patient who you referred in with an acute problem. Because they are so worried about confidentiality, although you are the referring physician. ...But they're in a kind of legalistic mode rather than a serve-the-patient mode."

Further, some rural providers appear to be quite skeptical of the quality of service psychiatrists provide. One physician noted, "... but anymore, the psychiatrist is someone who calls himself or herself a psychopharmacologist, and they spend 15 minutes with a patient anyway and have a less clear idea than I do about what's going on and spend their time adjusting their medication, and that's all they do. ... and so the services are just really stinky."

However, the greatest display of animosity toward psychiatrists came from the most senior member of the focus group. A physician who has practiced in both urban and rural environments and has also taught in one of the state's residency program, he boldly stated, " I think psychiatrists are really; I hate to over-psychologize about psychiatrists, but I think they are at this time, they're a miserable bunch! You know, they feel their avenue, their professional venue being shrunk (you should excuse the expression). But what can they do, what can they make, what their view is, and I think they are just pretty miserable people. And that makes them hard to deal with as colleagues too. Because it is very hard to get them to do what you want, or what the patient needs, or to see you as a customer. Because it's like any other, it's like your unhappy waiter that throws food at you. That's how I feel. I practiced in Collegeville for nine years and I knew everybody. And I still know all the shrinks in Collegeville, but when you ask me who did I like to refer to there, it's still zero. I use them some, but there's nobody I really like."

While this remark was the boldest of all, none of the other focus group participants came to the defense of the psychiatric community. Clearly there is a significant gulf between these provider groups that needs to be addressed.

Summation and Limitations

As noted earlier, no attempt has been made to suggest that this group of rural providers is representative of any larger group or constituency. However, their attitudes and opinions can provide us with some insight into the perspective of the rural primary care provider. With that said, I have attempted to juxtapose salient findings in the literature regarding this "de facto" mental health system with the knowledge, attitudes, and opinions of this small group of providers.

In general, one could conclude that many of the findings in the literature have been confirmed. Generalist providers do seem to provide a large percentage of the mental health services in rural areas. Additionally, while, as the literature suggests and the focus group confirms, these providers do the best they can, they often feel uncertain and less than fully prepared to serve the mental health needs of their patients. Yet as one provider noted, uncertainty is a phenomenon all too familiar to the generalist provider.

What was surprising was the extent to which these providers recognize this deficit and seek out "mid-level" mental health workers to provide adjunctive therapy for their patients experiencing mental illness. Focus group participants noted that somewhere between 40-80% of their patients with mental disorders are referred to these mental health workers. This number far exceeds the literature that suggests as few as 10-30% of eligible patients are ever referred to a mental health professional.

Of course, the difference appears to be in the definition of a referral. The literature usually defines referral as a change in the provider who supervises the medical and psychological management of the patient experiencing a mental disorder. These providers defined a referral as the act of seeking adjunctive counseling in addition to their medical and supervisory management of the patient. If this differential definition is common, then it may be quite fallacious to assume that primary care providers who choose to manage patients with mental disorders are inadequately providing or ignoring the counseling needs of these patients.

Another problem highlighted by the focus group was rural providers apparent inability to get patient information back from the urban psychiatrist after they refer patients to them. The frustrations expressed by these rural providers appear to be a function of two differing standards of patient confidentiality. Where in other sectors of medicine the routine sharing of patient information between the primary care provider and medical specialist is the norm, psychiatrists appear to use a different standard. Consequently, rural providers often have to treat patients returning home from psychiatric treatment with incomplete information on what occurred during hospital stays and without other vital information. This not only frustrates primary care providers, but it further compounds the referral problem by decreasing the probability that the rural provider would ever refer future patients, except for the most acute. One would think that a reasonable compromise could be achieved to ensure that patient confidentiality is upheld and necessary information is shared amongst all appropriate providers.

Finally, it was surprising to find the extent to which these rural providers felt animosity toward the psychiatric community. Throughout the focus group, few if any kind words were spoken about psychiatrists. These rural providers were wary of the way they have been treated by the psychiatrists they refer to and were equally concerned about the quality of care their patients receive. This feeling is apparently so common among these providers that their tendency is to try everything they can to avoid referring the patient. As one provider noted, "...to protect them from the [mental health] system." It is unclear whether it is fully realized at this time how great the gulf is between these professional communities. However, until this gulf is truly recognized, it is hard to imagine how one might initiate a process that will begin to close it.

Lastly, it is important to note again that the data for this paper comes from a very small sample of rural providers in one location. Therefore, it would be extremely risky to suggest that these views are truly representative of all rural providers. However, they do provide some interesting insights and raise some long standing issues. Further, there is little doubt that the voice of the rural primary care provider in this discussion is long overdue. Consequently, further data collection from other primary care providers in other rural locations is sorely needed to help us better understand the dynamic relationship between these two important provider groups.

Send Us Your Comments on this Document

References

 

Andersen, S.M., & Harthorn, B.H. (1989). The recognition, diagnosis, and treatment of mental disorders by primary care physicians. Medical Care, 27, 869-885.

Barrett J. (1991). Treatment practices in primary care: Setting directions for health outcome research. Journal of Family Practice, 33, 19-21.

Farmer, A., & Griffiths, H. (1992). Labeling and illness in primary care: Comparing factors influencing general practitioners' and psychiatrists' decisions regarding patient referral to mental illness services. Psychological Medicine, 22, 717-723.

Feldman, A. (1978). The family practitioner as psychiatrist. American Journal of Psychiatry, 134,126-129.

Fink, R., Goldensohn, S.S., Shapiro S., & Daily E.F. (1967). Treatment of patients designated by family doctors as having emotional problems. American Journal of Public Health, 57, 1550-1564.

Fogel, B. (1993). Mental health services and outcome-driven health care. American Journal of Public Health, 83, 319-321.

Frenzen, P.D. (1991). The increasing supply of physicians in US urban and rural areas, 1975 to 1988. American Journal of Public Health, 81, 1141-1147.

Johnson, P. (1995). Analysis of population preferences for mental health providers among urban and rural Nebraskans. Unpublished manuscript, Department of Sociology, University of Nebraska, Lincoln.

Jones, L.R., Badger, L.W., Ficken, R.P., Leeper, J.D., & Anderson, R.L. (1988). Mental health training of primary care physicians: An outcome study. International Journal of Psychiatry in Medicine, 18, 107-121.

Kelleher, K., Holmes, T.M., & Williams, C. (1994). Major recent trends in mental health in primary care. In R.W. Manderscheid & Sonnenschein, M.A. (Eds.), Mental Health, United States, 1994. Rockville, MD: U.S. Department of Health and Human Services.

Locke, B.Z., Krantz, G., & Kramer, M. (1966). Psychiatric need and demand in a prepaid group practice program. American Journal of Public Health, 56, 895-904.

National Institute of Mental Health. (1986). Overview of health practices in primary care settings, with recommendations for further research (Series DN No. 7). Washington, DC: U.S. Government Printing Office.

National Rural Health Association. (1992). Study of models to meet rural health care needs through mobilization of health professions education and services resources (Volume I). Kansas City, MO: National Rural Health Association.

Orleans, C.T., George, L.K., Houpt, J.L., & Brodie, H.K.H. (1985). How primary physicians treat psychiatric disorders: A national survey of family practitioners. American Journal of Psychiatry, 142, 52-57.

Ozbayrak, K.R., & Coskun, A. (1993). Attitudes of pediatricians toward psychiatric consultations. General Hospital Psychiatry, 15, 334-338.

Pincus, H.A., Strain, J.J, Houpt, J.L., & Gise, L.H. (1983). Models of mental health training in primary care. Journal of the American Medical Association, 249, 3065-3068.

Regier, D.A., Goldberg, I.D., & Taube, C.A. (1978). The de facto U.S. mental health services system. Archives of General Psychiatry, 35, 685-693.

Regier, D.A., Boyd, J.H., & Burke, J.D. (1988). One-month prevalence of mental disorders in the United States. Archives of General Psychiatry, 45, 977-986.

Rost, K., Humphrey, J., & Kelleher, K. (1994, May). Physician management preferences and barriers to care for rural patients with depression. Archives of Family Medicine, 3, 409-414.

Rost, K., Williams, C., Wherry, J., & Smith G.R. (1995). The process and outcomes of care for major depression in rural family practice settings. Journal of Rural Health, 11, 114-120.

Shapiro, S., & Fink, R. (1963). Methodological considerations in studying patterns of medical care related to mental illness. Milbank Memorial Fund Quarterly, 41, 371-399.

U.S. Congress, Office of Technology Assessment. (1990). Health Care in Rural America (OTA-H-113), Washington, DC: U.S. Congress.

U.S. Department of Health and Human Services, Office of Data Analysis and Management. (1984). The hidden mental health network: Provision of mental health services by non-psychiatrist physicians. Rockville, MD: Department of Health and Human Services.

Zimmerman, M.A., & Wienckowski, L.A. (1991). Revisiting health and mental health linkages: A policy whose time has come...again. Journal of Public Health Policy, 12, 510-524.

Zung, W.W.K., Magill, M., Moore, J.T., & George, D.T. (1983). Recognition and treatment of depression in a family medicine practice. Journal of Clinical Psychiatry, 44, 3-6. 10



Write us with comments on our site
James A. Ciarlo, Ph.D., Project Director
This project is supported by the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration
Contract No. 280-94-0014

URL: http://www.du.edu/frontier-mh/letter10.html

Last Updated: July 21, 1998

General

| Welcome | About this web site

Young Family Network

| Introduction | Tips