Management of patients with depression by rural primary care practitioners

Objective: To investigate the extent to which variations in treatment and referral patterns for adult patients with diagnosed symptoms of depression seen in primary care practices are explained by practitioner characteristics, such as training, years in primary practice, sex, and knowledge about depression; practice characteristics, such as size, patient volume, and payer mix; and service area characteristics, such as availability of specialty mental health services and rural location. Design: A 41-item telephone survey of primary care practitioners (PCPs) in Maine, including family and general practice doctors of medicine and doctors of osteopathy, general internists, nurse practitioners, and physician assistants (n=267). Main Outcome Measure: The degree to which PCPs treat patients with depression themselves, rather than refer them to a mental health specialist. Results: There is no significant (P=.10) urban-rural difference in the number of patients with depression seen as a percentage of total patient volume. Major barriers to referral to a mental health provider, as reported by the PCP, are long wait for an appointment, lack of available services, patients' unwillingness to use services, and reimbursement issues. Multivariate analyses indicate that PCP characteristics measuring knowledge and attitudes, as well as the lack of available services, are significantly related to treatment and referral patterns while practice characteristics and mental health provider supply are not. Conclusion: The treatment of rural patients with symptoms of depression is more likely to be improved by targeting PCPs' medical education than by efforts to increase the supply of specialty mental health providers in rural areas.