Psychosomatics 48:325-330, July-August
doi: 10.1176/appi.psy.48.4.325
© 2007 Academy of Psychosomatic Medicine
Psychotherapy by Primary-Care Providers: Results of a National Sample
Seth Himelhoch, M.D., M.P.H., and
Mark Ehrenreich, M.D.
Received September 20, 2005; revised December 29, 2005; accepted January 9, 2006. From the Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD. Send correspondence and reprint requests to Seth Himelhoch, M.D., M.P.H., Department of Psychiatry, Division of Services Research, 737 Lombard St., Room 516, Baltimore, MD 21201. e-mail: shimelho{at}psych.umaryland.edu
© 2007 The Academy of Psychosomatic Medicine
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ABSTRACT
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The authors used the National Ambulatory Medical Care Survey to examine visit characteristics associated with psychotherapy by primary-care physicians, as compared with psychiatrists. Chi-square tests and hierarchical logistic-regression models were developed to examine visit characteristics associated with receiving psychotherapy by primary-care physicians versus psychiatrists. Over 19% of all psychotherapy visits were reported by primary-care physicians. Visits to primary-care physicians, versus visits to psychiatrists, were significantly greater among those over age 65, in Hispanic patients, and those in rural areas. Primary-care physicians are reporting that they provide psychotherapy and may be filling a void for underserved populations.
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INTRODUCTION
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Psychiatric disorders are extremely common and disabling.1 Of those patients with psychiatric disorders who seek help in the healthcare system, nearly half receive their mental health care in the general-medical sector.1–3 Most research has focused on the identification and pharmacological treatment of psychiatric disorders by primary-care physicians. However, much less is known about primary-care physicians’ reporting of psychotherapy for psychiatric disorders. This is important as primary-care providers have reported increasing interest in providing psychotherapy,4 studies have demonstrated the efficacy of psychotherapeutic interventions in primary-care settings,5,6 effective programs to train primary-care residents in psychotherapy now exist,7 and primary-care patients may resist referral to mental health specialists and be less accepting of psychoactive medications.8 One study from the early 1980s investigating the provision of counseling services by non-psychiatrist physicians found, compared with visits for other reasons, visits to non-psychiatrist physicians during which mental health counseling services were provided were more likely to be with established patients, with female patients between the ages of 25 and 64, and be longer in duration.9 Over the past 2 decades, however, there have been many changes in both the practice of psychiatry and in the delivery of medical services. These changes have included the introduction of new classes of antidepressants (e.g., selective serotonin-reuptake inhibitors [SSRIs]), the advent of managed care, and the increased awareness of depression and other mental illnesses. It is unknown what effect these changes have had on primary-care providers’ reports of providing psychotherapy. The goal of our study is to describe the psychotherapeutic services that are currently being reported by primary-care providers in the United States and compare these services with psychotherapy services reported by psychiatrists.
Study Design and Population
Using the National Ambulatory Medical Care Survey (NAMCS; http://www.cdc.gov/nchs/about/major/ahcd/namcsdes.htm), the authors conducted a cross-sectional analysis of office-based physician visits for individuals 18 years of age and older during 1997–2002 to investigate the prevalence of psychotherapy visits provided by primary-care physicians. These years were specifically chosen to ensure consistency of choices under the heading Counseling/Education/Therapy from which our psychotherapy variable was drawn (see below). The NAMCS is a national probability-sample survey conducted by the National Center for Health Statistics (NCHS), which annually collects information on the use of ambulatory medical services provided by office-based physicians in the United States. Physicians complete a one-page form on a systematic sample of office visits occurring during a random 1-week period. The survey does not include physician visits in federally-based and hospital-based outpatient settings. For the years 1997–2002, the response rate for the survey ranged from 63% to 70%.
Psychotherapy
Psychotherapy was reported by specifically checking a box labeled Psychotherapy under the Counseling/Education/Therapy heading on the NAMCS patient record form. The NAMCS specifically defined psychotherapy as "all treatments involving the intentional use of verbal techniques to explore or alter the patient’s emotional life in order to effect symptom reduction or behavior change."
Providers Primary-care providers were identified using the NAMCS reclassification of the primary-care specialty group. This group included family practice, geriatric medicine, sports medicine (family practice or internal medicine), general practice, internal medicine, obstetrics/gynecology, adolescent medicine, and pediatrics. Because our sample was limited to adult patients, the authors excluded the pediatric and adolescent medicine categories. Psychiatrists were identified using the psychiatry specialty code taken from the physician recode variable provided by NAMCS.
Patient and Visit Characteristics
The NAMCS survey collects information about basic patient demographics, diagnoses, and treatment information. The authors used information on patient characteristics and practice-setting characteristics that the authors hypothesized might influence a practitioner’s decision to offer psychotherapy. Patient characteristics were age, gender, geographic region (northeast, south, midwest, or west), and payment source (private insurance, Medicaid/Medicare, or self-pay/no charge). Psychiatric diagnoses were based on International Classification of Diseases-9th Revision Clinical Modification (ICD-9-CM) codes and were categorized into Depressive Disorders and Other Psychiatric Disorders (bipolar affective disorder, psychotic disorders, anxiety disorders, personality disorders, and substance use disorders). Practice-setting characteristics were available for Metropolitan Statistical Areas (MSA; i.e., urban areas) versus Non-Metropolitan Statistical Areas (NMSA; i.e., rural and micrometropolitan areas) and continuity-visit versus new-patient visit.
Statistical Analysis
The NAMCS is based on a complex, multi-stage sampling design. We used the primary sampling units, stratum, and sample weights provided by the NAMCS survey in order to report weighted estimates as well as account for potential clustering. We performed chi-square tests and developed hierarchical logistic-regression models to examine visit characteristics associated with psychotherapy by a primary-care provider, as compared with psychiatry visits with psychotherapy.
From 1997 to 2002, there were 3,788 unweighted visits where psychotherapy was reported. Psychiatrists reported 3,520 unweighted visits, and primary-care providers reported 268 unweighted visits. The weighted population estimate for this sample was 12.1 million visits, broken down to 9.5 million visits to psychiatrists and 2.6 million visits to primary-care providers.
Because the visit duration variable (in minutes) was skewed to the right, we log-transformed this variable and then performed an ordinary least-squares regression to estimate the percent change in duration. All p values are two-sided.
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RESULTS
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Psychotherapy Outpatient Visits
Among all psychotherapy visits during the time period of 1997 to 2002, 73% of visits were to psychiatrists; 19.8% visits were to primary-care providers; and 7.2% of visits were to other physician providers. Among primary-care providers, psychotherapy visits accounted for about 0.9% of all visits. Among psychiatrists, psychotherapy visits accounted for 58% of all visits.
Patient and Practice Characteristics of Visits to Primary-Care Providers Reporting Psychotherapy
The mean age was 45.4 years (standard error [SE]: 0.52). Over 80% were under age 65 years. Over 63% of the visits were by women; 88.3% were White, and 9.4% were African American/Black. Over 14% of the visits were by Hispanic patients. Medicaid or Medicare insured 20.4% of visits.
The visits were divided between the following geographic regions: Northeast (47.0%), South (17.3%), Midwest (19.1%), and West (16.7%). Nearly 82% of the office visits were in metropolitan areas. Approximately 31% of the patient visits resulted in a diagnosis of depressive disorder; 17% were diagnosed with a psychiatric disorder other than depression; and approximately 52% did not receive a psychiatric diagnosis. Ninety-one percent of these visits were categorized as continuity-visits (return visits to the same physician; Table 1).
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TABLE 1. Percent and Adjusted Odds Ratios for Office Visits Reporting Psychotherapy, Comparing Primary-Care Providers (PCPs) With Psychiatrists
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Comparison With Psychiatry Visits Reporting Psychotherapy
As compared with psychiatry visits reporting psychotherapy, visits to primary-care providers reporting psychotherapy had more than 2 times the odds of occurring among those older than age 65 (adjusted odds ratio [AOR]: 2.04; 95% confidence interval [CI]: 1.39–3.00), and had nearly 3 times the probability among Hispanic patients as among non-Hispanics (AOR: 2.99; 95% CI: 1.98–4.49); the probability that psychotherapy was provided by a primary-care practitioner, rather than a psychiatrist, was more than 2 times greater in non-metropolitan areas than in metropolitan areas (AOR: 2.67; 95% CI: 1.06–6.71).
As compared with psychiatrist visits reporting psychotherapy, visits to primary-care providers reporting psychotherapy were less likely to include a specific psychiatric diagnosis. Specifically, there was a 75% lower probability of reporting a diagnosis of depressive disorder (AOR: 0.25; 95% CI: 0.19–0.34) and 86% less chance of reporting a diagnosis of any psychiatric disorder (AOR: 0.14; 95% CI: 0.08–0.25). Besides the variables listed above, the final multivariable model was also adjusted for gender, race, region, and payment type (Table 1).
Duration of Visits: Psychiatry Psychotherapy Visits Versus Primary-Care Provider Psychotherapy Visits
The mean length of time for a psychotherapy visit to a psychiatrist was approximately 40.6 minutes (95% CI: 38.1–43.1 minutes). The mean length of time for a psychotherapy visit to a primary-care physician was approximately 22.7 minutes (95% CI: 19.6–25.8 minutes). The duration of the visits to primary-care providers, after log-transformation of visit duration and least-squares regression analysis, was, on average, 60% shorter than visits to a psychiatrist (t = –11.68; p<0.0001). Adjusting for the presence or absence of a psychiatric diagnosis did not alter this result.
Duration of Visits: Psychotherapy Versus Non-Psychotherapy Visits to Primary-Care Provider
The mean length of time for a non-psychotherapy visit to a primary-care physician was approximately 18.1 minutes (95% CI: 17.6–18.6 minutes). As noted above, the mean length of time for a psychotherapy visit to a primary-care physician was approximately 22.5 minutes (95% CI: 19.9–25.2 minutes). After log-transforming the visit duration and performing a least-squares regression analysis, the duration of the visits to primary-care providers giving psychotherapy were, on average, 22.5% longer than non-psychotherapy visits (t = –4.40; p<0.0001).
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DISCUSSION
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We found that primary-care providers are reporting providing psychotherapy to an older, more Hispanic, and more rural population than psychiatrists. This finding is important in light of the fact that these populations are less likely to receive any mental health treatment, as confirmed by the National Comorbidity Survey Replication Study (NCS–R).11 Primary-care physicians may be filling a void for these underserved populations.
We also found that half of visits to primary-care providers where psychotherapy was reported had recorded a diagnosis of a psychiatric disorder; this compares with only 14.8% of visits that were reported to have a psychiatric diagnosis in the earlier NAMCS study. The marked increase in psychiatric diagnosis may reflect the increasing awareness of depression and the availability of the newer, safer, and easier-to-use antidepressants.10 This is also consistent with the recent finding that the largest increase in mental health service use over the past decade has been within the general-medical sector.11
Patients over age 65 had more than twice the odds of receiving psychotherapy from primary-care providers than from psychiatrists. Previous findings suggest that the majority of elderly individuals with depression are seen in the primary-care setting.12 Because depressed elderly individuals may also be more likely to endorse somatic symptoms, as opposed to psychological symptoms, and may be more concerned with the stigma associated with having a mental illness, they may, in fact, be more willing to be treated by a non-psychiatrist for these disorders. This may also be a result of physicians’ reluctance to refer elderly patients for psychotherapy.13
We also found that a larger percentage of patients were identified as Hispanic among those receiving psychotherapy from primary-care providers, versus patients with psychotherapy visits to psychiatrists. This is consistent with previous studies suggesting that ethnic minorities are less likely to receive psychotherapy from mental health practitioners and may preferentially rely on care from primary-care providers.14,15 Language, culture, and immigration status may all play a role in limiting access to mental health services.
Psychotherapy visits provided by primary-care providers had nearly 3 times the odds of occurring in a non-metropolitan area than psychotherapy visits provided by psychiatrists. Although physicians from rural areas may prefer to send their patients for specialty mental health care,16,17 barriers to that care, such as scarce referral sources, long travel times, or long waits for appointments may make such physicians the de-facto mental health providers in these areas.
It is important to note that although the duration for psychotherapy visits to psychiatrists was 60% longer than psychotherapy visits to primary-care physicians, we found that the visit duration to primary-care providers reporting psychotherapy was 23% longer than visits to primary-care providers who did not provide psychotherapy. This appears to offer some support to the idea that primary-care providers were actually providing additional time-sensitive services such as psychotherapy during their office visits. However, the mean duration of these psychotherapy visits to primary-care providers was 22.5 minutes, which is less than the 30-minute minimum for psychotherapy visits used by the National Comorbidity Survey Replication Study (NCS–R) to define minimally-adequate treatment.11
This study has a number of limitations. The definition of psychotherapy used by NAMCS is very broad and inclusive, and, as a result, we are unable to evaluate or describe any specific techniques that were used during these patient visits. Given the differences in training and the length of time spent with patients, it is likely that the type of psychotherapy provided by primary-care physicians is significantly different from that provided by psychiatrists.
Another potential limitation relates to an uncertainty introduced by the format of the patient record instrument utilized by the NAMCS. The area on the survey instrument for recording Counseling/Education/Therapy services includes the instruction to mark all those services "ordered or provided." It is therefore possible that our study included some patient visits during which psychotherapy was ordered for the patient, rather than being provided by the primary-care doctor or by the psychiatrist. Although this is a clear limitation of the study, we believe that our assumption that psychotherapy was actually provided during the majority of these visits is a reasonable one. "Psychotherapy" and "Mental Health/Stress Management" are both among the services that are included in the Counseling/Education/Therapy section. The definition of Mental Health/Stress Management used by NAMCS is "General advice and counseling about mental health issues and education about mental disorders. Includes referrals to other mental health professionals for mental health counseling. Also includes information intended to help patients reduce stress through exercise, biofeedback, yoga, etc. Includes referrals to other health professionals for the purpose of coping with stress" (italics ours). This is in contrast to the definition of psychotherapy used by NAMCS: "all treatments involving the intentional use of verbal techniques to explore or alter the patient’s emotional life in order to effect symptom-reduction or behavior change." Since the definition of psychotherapy does not specifically mention the referral to mental health professionals, but the mental health counseling section does, we believe that it is reasonable to assume that when psychotherapy was checked off, it was actually provided. It also does not make sense to "order psychotherapy." We believe that given the educational backgrounds of most physicians, this semantic irregularity would be noted. The longer time spent with patients by primary-care physicians during the psychotherapy visits also supports this assumption. Finally, a recent finding that 21% of primary-care physicians would conduct office-based counseling themselves for their depressed patients further supports the idea that these services were not just "ordered."18 Two other limitations of the study are related to the cross-sectional nature of the NAMCS data. We are unable to investigate the effect of visit acuity on receipt of psychotherapy or say whether or not psychotherapy was offered at previous visits. We also are only able to identify associations, and not causations, between provision of psychotherapy and visit characteristics.
The Hispanic-ethnicity variable was not imputed for missing data, and, therefore, there may be reporting bias, such that the Hispanic-ethnicity variable either undercodes or overcodes for this characteristic in the general population. As such, we would advise caution in interpreting our result. Although the NAMCS data are adjusted to account for the sample of physicians who did not participate in the study, it is possible that a non-response bias may still exist.
Finally, although a significant proportion of psychotherapy visits are provided by non-physicians (e.g. psychologists, social workers), the purpose of this article was to investigate trends in psychotherapy provided by non-psychiatric physicians. Because NAMCS only captures medical visits, we are unable to comment on how well our findings describe non-physician mental health providers.
Implications
Many patients with psychiatric disorders, particularly those with depression, receive their mental health care from their primary-care physicians. Both antidepressant and psychotherapeutic treatment have been found to be effective in treating depressed primary-care patients.18 Research has generally found that the combination of antidepressant treatment with psychotherapy is more effective than either alone. Therefore, if patients are receiving their mental health care from their primary-care physician, it is good to know that these physicians are providing psychotherapy. What we do not know is the type of psychotherapy being provided, the psychotherapy training of the physicians providing this care, the reasons why these physicians are providing this care instead of referring to the specialty mental health system, or the effectiveness of this therapy. These questions need to be answered by further research.
Although further research is needed on ways to reduce barriers to care for the large number of patients with mental health needs, one potential avenue to address the needs of underserved patients is via primary-care providers, who appear to be helping to fill a void for some of these underserved patient populations. However, before this solution can be advocated, further research is needed into the content, quality, and effectiveness of the treatments given by these providers. Because of the frequency and importance of these services, this is an area in need of further inquiry.
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ACKNOWLEDGMENTS
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This work was supported by NIDA Grant K-23 DA019820, to Dr. Himelhoch.
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REFERENCES
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- U.S. Department of Health and Human Services: Mental Health: A Report of the Surgeon General: Executive Summary, 1999. Rockville, MD, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999
- Regier DA, Narrow W, Rae DS, et al: The de facto U.S. mental and addictive disorders service system: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry 1993; 50:85–94[Abstract/Free Full Text]
- Kessler RC, Zhao S, Katz SJ, et al: Past-year use of outpatient services for psychiatric problems in the National Comorbidity Survey. Am J Psychiatry 1999; 156:115–123[Abstract/Free Full Text]
- Judd F, Weissman M, Davis J, et al: Interpersonal counseling in general practice. Aust Fam Physician 2004; 33:323–337
- Bower P, Rowland N, Hardy R: The clinical effectiveness of counseling in primary care: a systematic review and meta-analysis. Psychol Med 2003; 33:203–215[CrossRef][Medline]
- Ludman E, Katon W, Bush T, et al: Behavioral factors associated with symptom outcomes in a primary care-based depression-prevention intervention trial. Fam Med 2004; 36:204–208[Medline]
- Hegel MT, Dietrich AJ, Seville JL, et al: Training residents in problem-solving treatment of depression: a pilot feasibility and impact study. Fam Med 2004; 36:204–208[Medline]
- Van Voorhees BW, Cooper LA, Rost KM, et al: Primary-care patients with depression are less accepting of treatment than those seen by mental health specialists. J Gen Intern Med 2003; 18:991–1000[CrossRef][Medline]
- Schurman RA, Mitchell JB, Kramer PD: When doctors listen: counseling patterns of non-psychiatrist physicians. Am J Psychiatry 1985; 142:934–938[Abstract/Free Full Text]
- Wang PS, Lane M, Olfson M, et al: Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey replication. Arch Gen Psychiatry 2005; 62:629–640[Abstract/Free Full Text]
- Harman JS, Crystal S, Walkup J, et al: Trends in Elderly Patients’ Office Visits for the Treatment of Depression According to Physician Specialty: 1985-1999. J Behav Health Serv Res 2003; 30:332–341[CrossRef][Medline]
- Alvidrez J, Areán PA: Physician willingness to refer older depressed patients for psychotherapy. Int J Psychiatry Med 2003; 32:21–35[CrossRef]
- Miranda J, Cooper L: Disparities in care for depression among primary-care patients. J Gen Intern Med 2004; 19:120–126[CrossRef][Medline]
- Miranda J, Azocar F, Organista KC, et al: Treatment of depression among impoverished primary-care patients from ethnic minority groups. Psychiatr Serv 2003; 54:219–225[Abstract/Free Full Text]
- Ng B, Bardwell WA, Camacho A: Depression treatment in rural California: preliminary survey of nonpsychiatric physicians. J Rural Health 2002; 18:556–562[Medline]
- Rost K, Humphrey J, Kelleher K: Physician management preferences and barriers to caring for rural patients with depression. Arch Fam Med 1994; 3:409–414[Abstract/Free Full Text]
- Epstein SA, Hooper LM, Weinfurt K, et al: The use of simulated patients to assess primary-care physicians’ treatment of depression. Academy of Psychosomatic Medicine Meeting, Marco Island, FL, 2004
- Schulberg HC, Block MR, Madonia MJ, et al: Treating major depression in primary-care practice: eight-month clinical outcomes. Arch Gen Psychiatry 1996; 53:913–919[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
