Chapter 14

The Primary Care of Mental Disorders in the United States

Philip S. Wang, M.D., Dr. P.H.
Department of Health Care Policy, Harvard Medical School
Department of Psychiatry and Division of Pharmacoepidemiology and Pharmacoeconomics,
Brigham and Women’s Hospital, Harvard Medical School

Michael Lane, M.S.
Department of Health Care Policy, Harvard Medical School

Mark Olfson, M.D., M.P.H.
Department of Psychiatry, Columbia University

Harold A. Pincus, M.D.
Department of Psychiatry, University of Pittsburgh

Thomas L. Schwenk, M.D.
Department of Family Medicine, University of Michigan

Kenneth B. Wells, M.D., M.P.H.
Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles

Ronald C. Kessler, Ph.D.
Department of Health Care Policy, Harvard Medical School

Summary

Although the general medical sector traditionally has played an important role in the treatment of people with mental disorders, it has undergone dramatic changes during the past decade. For this reason, up-to-date information on the use of primary care for mental disorders in the United States is urgently needed.

In this chapter, we provide data on the patterns and predictors of 12-month mental health treatment in the general medical sector from the National Comorbidity Survey Replication (NCS-R). The NCS-R is a nationally representative face-to-face household survey of 9,282 English-speaking respondents ages 18 and older carried out between February 2001 and April 2003. Respondents were given a fully structured diagnostic interview, using the World Health Organization (WHO) World Mental Health (WMH) Survey Initiative version of the Composite International Diagnostic Interview (WMH-CIDI). The proportions of respondents with 12-month Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) anxiety, mood, impulse control, and substance abuse disorders who received treatment in the 12 months before the interview in the general medical sector were calculated. These proportions of respondents were compared with the proportions using other service sectors (specialty mental health, human services, and complementary-alternatives). The number of visits made in the prior year and the proportion of patients who received minimally adequate treatment were also assessed.

A larger proportion of respondents (9.3 percent), including those with (22.8 percent) and without (4.7 percent) 12-month DSM-IV disorders, received mental health services in the general medical sector in the prior year than in any other sector. However, the mean number of 12-month visits among those treated in the general medical sector (2.6) was considerably lower than in any other sector. Furthermore, only a third of treated cases in the general medical sector received minimally adequate treatment; even employing our broadest definition, this percentage was again lower than for cases treated in any other sector. Among those treated in the health care system, receiving specifically primary care for mental disorders was related to being older aged, female, less educated, not married, and living in rural areas.

Although the use of primary care to treat mental disorders in the United States has grown rapidly during the past decade, the intensity and adequacy of those treatments remain poor. We provide possible explanations for these findings, including the many structural and financial barriers primary care providers now face. We close by suggesting some new perspectives and policy directions that may be needed to improve the primary care of mental disorders in the United States.

Background

The primary care sector traditionally has played an important role in the treatment of people with mental disorders in the United States. In the Epidemiologic Catchment Area (ECA) study conducted in the 1980s, 12.7 percent of respondents with 12-month DSM-III (American Psychiatric Association, 1980) mental disorders received treatment in the general medical sector in the year before interview—a proportion equal to those receiving care in the mental health specialty sector (Regier et al., 1993). In the National Comorbidity Survey (NCS) conducted in the 1990s, the proportion of respondents with DSM-III-R (American Psychiatric Association, 1987) disorders receiving treatment in the general medical sector was 7.9 percent, a smaller proportion than those treated in the specialty sector (12.4 percent), but not dramatically so (Kessler & Wang, 1999).

Since then, there have been many important changes with potentially large impacts on the primary care of mental disorders in the United States. The recent Surgeon General’s Report (U.S. Department of Health and Human Services, 1999) and the President’s New Freedom Commission on Mental Health (2004) have emphasized detection of mental disorders and use of evidence-based treatments in general medical settings. Community campaigns promoting awareness, screening, and help-seeking for mental disorders largely in primary care have been launched (Hirschfeld et al., 1997; Jacobs, 1995). The introduction of newer, more tolerable pharmacologic treatments has made it easier for primary care providers to treat people with mental disorders (Leucht, Pitschel-Walz, Abraham, & Kissling, 1999; Olfson et al., 2002a; Schatzberg & Nemeroff, 2004). The era of managed care also has brought with it greater emphasis on the delivery of mental health treatments in primary care settings (Sturm & Klap, 1999; Weissman, Pettigrew, Sotsky, & Regier, 2000; Williams, 1998; Williams et al., 1999). The increasing "medicalization" of mental health care and direct-to-consumer advertising of pharmacological treatments have further increased consumer demand for general medical services (Relman, 1980; Rosenthal, Berndt, Donohue, Frank, & Epstein, 2002).

Up-to-date data are imperative to assess the impact of these changes and to identify the role that the general medical sector now plays in caring for people with mental disorders. Earlier research found that the recognition of mental disorders in primary care was poor, with as many as half of active cases not receiving correct diagnoses (Simon & Von Korff, 1995). Furthermore, rates of treatment initiation and the quality of treatments for mental disorders in primary care have been low, with only the minority of patients receiving care that meets minimal quality standards (Wang, Berglund, & Kessler, 2000; Wang, Demler, & Kessler, 2002; Wells, Schoenbaum, Unutzer, Lagomasino, & Rubenstein, 1999; Young, Klap, Sherbourne, & Wells, 2001). Up-to-date data on the intensity and adequacy of treatments received in primary care are crucial to guide future policy initiatives in this area.

The goals of this chapter are to provide basic descriptive data on the primary care of mental disorders from the NCS-R, conducted between 2001 and 2003 (Kessler et al., in press a). We first identify the proportions of cases with 12-month mental disorders who obtain any treatment in the general medical as well as other service sectors. We also calculate the typical number of visits made and the proportion receiving minimally adequate treatment for mental disorders in primary care and compare these numbers to other service sectors. Finally, we identify demographic correlates of seeking health care treatment for mental disorders in the general medical sector.

Methods

Sample

The NCS-R is a nationally representative face-to-face household survey of respondents ages 18 and older in the coterminous United States (Kessler et al., in press a; Kessler & Merikangas, in press). Interviews were carried out between February 2001 and April 2003 on 9,282 respondents. A core diagnostic assessment was administered to all respondents in Part I. Part II contained assessments of risk factors, correlates, service use, and additional disorders and was given to all Part I respondents with lifetime disorders plus a probability subsample of other respondents. Recruitment, consent, and field procedures used in the NCS-R were approved by the Human Subjects Committees of both Harvard Medical School and the University of Michigan. The overall NCS-R response rate was 70.9 percent.

Measures

WHO WMH-CIDI Survey: Diagnostic assessments of 12-month mental disorders were made using WHO’s WMH Survey Initiative version of the CIDI (Kessler & Ustun, in press). The WMH-CIDI is a fully structured lay-administered diagnostic interview that generates both ICD-10 (WHO, 1991) and DSM-IV (American Psychiatric Association, 1994) diagnoses. Twelve-month disorders considered here include mood (bipolar I and II disorders, major depressive disorder, and dysthymia), anxiety (panic disorder, agoraphobia without panic, specific phobia, social phobia, generalized anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and separation anxiety disorder), impulse-control (intermittent explosive disorder), and substance disorders (alcohol and drug abuse and dependence). Organic exclusions were employed with diagnostic hierarchy rules (except for substance disorders for which abuse is defined with or without dependence). The Structured Clinical Interview for DSM-IV (SCID) (First, Spitzer, & Williams, 1995) was used to conduct blind clinical reappraisals (Kessler et al., under review). These reappraisals showed generally good concordance between WMH-CIDI lifetime diagnoses and the SCID for anxiety, mood, and substance disorders (lifetime diagnoses of WMH-CIDI impulse-control disorders have not been validated). Evaluation of WMH-CIDI 12-month diagnoses is currently ongoing.

Mental Health Service Use in the Year Prior to Interview: Initial questions asked all Part II respondents whether they ever received treatment for "problems with your emotions or nerves or your use of alcohol or drugs." Respondent booklets were provided as visual recall aids and contained lists of the types of treatment providers. Assessments included different types of professionals, support groups, self-help groups, mental health crisis hotlines (assumed to be visits with nonpsychiatrist mental health specialists), complementary and alternative medicine (CAM) therapies, and use of treatment settings such as hospitals and other facilities (each day of admission was assumed to include a visit with a psychiatrist). Respondents were then asked followup questions about their age at first and most recent contacts as well as the number and duration of visits in the past 12 months.

Endorsements of 12-month service use were classified into the following categories: psychiatrist; nonpsychiatrist mental health specialist (psychologist or other nonpsychiatrist mental health professional in any setting, social worker or counselor in a mental health specialty setting, or use of a mental health hotline); general medical provider (primary care doctor, other general medical doctor, nurse, or any other health professional not previously mentioned); human services professional (religious or spiritual advisor, or social worker or counselor in any setting other than a specialty mental health setting); and CAM professional (any other type of healer, such as chiropractor, participation in an internet support group, or participation in a self-help group). Psychiatrist and nonpsychiatrist specialist categories were combined into a broader mental health specialty (MHS) category; MHS was also combined with general medical (GM) into an even broader health care (HC) category. Human Services (HS) and CAM providers were also combined into a Non-Health Care (NHC) category.

Definitions of Minimally Adequate Treatment: We initially created a broad definition of minimally adequate treatment to accommodate respondents who began treatments shortly before the NCS-R interview and therefore might not have had time to fulfill requirements, even if they were in the process of receiving adequate treatment. Furthermore, this broad definition of minimally adequate treatment was designed to accommodate the possibility that respondents may have been receiving very brief treatments that have been developed for certain disorders (Ballesteros, Duffy, Querejata, Arino, & Gonzales-Pinto, 2004; Ost, Ferebee, & Furmark, 1997). This broad definition of minimally adequate treatment consisted of receiving ≥ two visits to an appropriate treatment sector (i.e., one visit for presumptive evaluation/diagnosis and ≥ one visit for treatment) or being in ongoing treatment at interview.

We also attempted to construct a narrower definition of minimally adequate treatment based on available evidence-based guidelines (Agency for Health Care Policy and Research, 1993; American Psychiatric Association, 1998, 2000, 2002, 2004; Lehman & Steinwachs, 1998). This consisted of receiving either pharmacotherapy (≥ 2 months of an appropriate medication for the focal disorder plus ≥ four visits to any type of medical doctor) or psychotherapy (≥ eight visits with any health care or human services professional lasting an average of ≥ 30 minutes). We required ≥ four physician visits for pharmacotherapy based on the fact that ≥ four visits for medication evaluation, initiation, and monitoring are generally recommended during the acute and continuation phases of treatment in available guidelines (Agency for Health Care Policy and Research, 1993; American Psychiatric Association, 1998, 2000, 2002, 2004; Lehman & Steinwachs, 1998). Medications considered appropriate for disorders included antidepressants for depressive disorders; mood stabilizers or antipsychotics for bipolar disorders; antidepressants or anxiolytics for anxiety disorders; antagonists or agonists (e.g., disulfiram, naltrexone, or methodone) for alcohol and substance disorders; and any psychiatric drug for impulse control disorders (Schatzberg & Nemeroff, 2004). We required at least eight sessions for minimally adequate psychotherapy because clinical trials demonstrating effectiveness have generally included ≥ eight psychotherapy visits (Agency for Health Care Policy and Research, 1993; American Psychiatric Association, 1998, 2000, 2002, 2004; Lehman & Steinwachs, 1998). Self-help visits of any duration were counted as psychotherapy visits for alcohol and substance disorders.

For respondents with comorbid disorders, treatment adequacy was defined separately for each 12-month disorder (i.e., a respondent with comorbid disorders could be classified as receiving minimally adequate treatment for one disorder but not for another).

Predictor Variables: Demographic variables examined as potential predictors of service use included co-hort (defined by age at interview and categorized as 18–29, 30–44, 45–59, 60+); gender; race-ethnicity (Non-Hispanic White, Non-Hispanic Black, Hispanic, Other); completed years of education (0–11, 12, 13–15, and 16+); marital status (married-cohabitating, previously married, never married); family income in relation to the Federal poverty line (categorized as low [≤ 1.5 times the poverty line], low average [1.5+ to 3 times], high-average [3+ to 6 times], and high [6+ times]; urbanicity defined according to 2000 Census (U.S. Census Bureau, 2000) definitions (large and smaller Metropolitan Areas; Central Cities, Suburbs, and Adjacent Areas; and Rural Areas); and health insurance coverage (including private, public, or military sources).

Analyses: NCS-R data were first weighted to adjust for differences in probabilities of selection, differential nonresponse, residual differences between the sample and the U.S. population, and over-sampling in the Part II sample (Kessler et al., under review).

We examined basic patterns of service use by calculating the percentages receiving treatment in any and particular service sectors, the frequency of visits among those in treatment, and probabilities of treatments meeting criteria for our broad and narrow definitions of minimal adequacy. We examined the sociodemographic predictors of receiving any 12-month treatment in the total sample and treatment in the general medical sector among those receiving any health care treatment using logistic regression (Hosmer & Lemeshow, 1989) analysis.

The Taylor series method as implemented in SUDAAN (2002) was used to estimate standard errors. Statistical significance was evaluated using two-sided design-based tests and the .05 level of significance. Wald χ² tests were used to test significance in logistic regression analyses and were based on coefficient variance–covariance matrices adjusted for design effects using the Taylor series method.

Results

Twelve-Month Use of the General Medical Sector for Mental Health Services: In the total sample, 9.3 percent of respondents received mental health services in the general medical sector in the prior year, a percentage higher than for any other sector. The proportions using the general medical sector were also greater than for any other sector when the sample was broken down into those with 12-month mental disorders (22.8 percent) and without (4.7 percent). Among cases with specific 12-month DSM-IV disorders, the proportions receiving treatment in the general medical sector were highest for those with panic (43.7 percent), dysthymia (39.6 percent), bipolar (33.1 percent), or major depressive disorder (32.5 percent) and lowest for specific phobia (21.2 percent), alcohol dependence (19.3 percent), alcohol abuse (16.4 percent), or intermittent explosive disorder (12.6 percent) (table 14.1).

Mean Number of Visits in the General Medical Sector: The mean number of 12-month visits (table 14.2) among those receiving any treatment in the general medical sector was 2.6 and was considerably lower than the mean visits made in any other sector. The mean visits among those treated in the general medical sector were higher among those with disorders (2.9) than without (2.0), but not dramatically so. The mean visits in the general medical services sector among cases with specific disorders was highest for dysthymia (4.2) or panic disorder (4.1) and lowest for intermittent explosive disorder (2.2).

The median numbers of visits (not shown, but available upon request) were consistently lower than the means. For example, the median among patients receiving any treatment in the general medical sector was 1.6. The median visits to the general medical sector was 1.7 among patients with a 12-month disorder and 1.1 among those without. This greater magnitude of means than medians implies that a relatively small number of patients treated in the general medical sector receive a disproportionately higher share of all visits.

Proportions receiving minimally adequate treatment in the general medical sector: Table 14.3 shows the proportions of treated cases receiving minimally adequate treatment using our initial broad definition (i.e., receiving ≥ two visits to an appropriate sector or being in ongoing treatment at the time of interview). The percentage of treated cases receiving minimally adequate treatment in the general medical sector was only 33.2 percent; lower than in any other sector. Among cases with specific 12-month DSM-IV disorders, the proportions receiving minimally adequate treatment in the general medical sector were highest for those with separation anxiety disorder (63.7 percent), agoraphobia (60.6 percent), or dysthymia (46.1 percent) and lowest for drug abuse/dependence (18.0 percent), obsessive compulsive disorder (20.1 percent), or alcohol abuse/dependence (30.9 percent).

In analyses employing our narrower definition of minimally adequate treatment, only 12.7 percent of cases treated in the general medical sector qualified as receiving such care (not shown, but available upon request). Again, this proportion was lower than that observed for any other sector.

Predictors of Receiving Treatment in the General Medical Sector: After controlling for the presence of all individual 12-month mental disorders, the odds of receiving any 12-month mental health treatment are significantly related to being younger than age 60, female, non-Hispanic White, not having low-average family income, being previously married, and not living in a rural area (not shown, but available upon request). Among those who received any treatment, treatment in one of the health care sectors is significantly related to not being in the age range 18–29, not being non-Hispanic Black, living in rural areas, and having health insurance.

Among those who received health care treatment, receiving treatment specifically in the general medical sector was significantly related to being older aged, female, less educated, not married, and living in a rural area (see table 14.4).

Discussion

These results indicate that there has been a rapid rise in the use of primary care to treat mental disorders in the United States. Currently 22.8 percent of those with disorders receive treatment in the general medical sector, nearly triple the percentage observed in the NCS a decade ago (Kessler et al., 1999). Among treated cases, well over half now receive some form of primary care for their mental disorders—a proportion larger than for any other sector. General medical sector treatment is now the sole form of health care used by over one-third of cases accessing the health care system. This dramatically increased use of primary care for mental disorders in the NCS-R confirms the findings of other recent surveys. For example, the Healthcare for Communities (HCC) survey found that people with mental health needs are largely treated by primary care providers and that this trend increased over the period from 1997–8 to 2000–1 (Mechanic & Bilder, 2004). The National Medical Expenditure Survey and Medical Expenditure Panel Survey also found an increase in the use of physicians relative to mental health specialists during the 1990s (Olfson et al., 2002a).

Several factors could help explain this increased use of primary care for mental disorders. Employing primary care physicians as "gatekeepers" has been one way that managed health plans have shifted mental health contacts to the general medical sector. While discontent has been growing over restricted access to specialists, formal gatekeeping continues to cover nearly 40 percent of patients, and higher cost alternatives allowing patients to self-refer to specialists remain poorly subscribed (Forrest, 2003; Forrest et al., 2001; Kaiser Family Foundation and Health Research Education Trust, 2000). Other developments, such as improved recognition of how mental disorders present and the design of primary care screening tools to detect mental disorders, have made it easier to deliver mental health care in general medical settings (Kessler & Wang, 1999; Kroenke, 2003; Simon, Von Korff, Piccinelli, Fullerton, & Ormell, 1999; Spitzer, Kroenke, & Williams, 1999). Pharmacologic treatments with improved safety profiles have made it easier for primary care providers to treat mental disorders, and direct-to-consumer advertising has spurred patient demand for such treatments (Gilbody, Wilson, & Watt, 2004; Leucht et al., 1999; Olfson et al., 2002a; Schatzberg & Nemeroff, 2004). There has also been a growing tendency for some primary care physicians to deliver psychotherapies themselves (Gallo et al., 2002; Hegel, Dietrich, Seville, & Jordan, 2004; Olfson, Marcus, Druss, & Pincus, 2002b).

While use of the general medical sector for mental health treatments clearly has grown, the intensity and quality of those treatments remain shallow and uneven. Cases treated in primary care received fewer visits in the prior year than those treated in any other sector. Even using our broadest definition of adequacy, only one-third of cases seen in the general medical sector received minimally adequate care—again, a proportion lower than for any other sector. These findings are consistent with earlier as well as more recent evidence. In the ECA study, respondents with mental disorders treated in the general medical sector received substantially fewer visits than those treated in specialty sectors (Narrow, Regier, Rae, Manderscheid, & Locke, 1993). Other studies conducted throughout the 1990s consistently found that only a minority of cases in primary care receive treatments that meet minimal standards for adequacy (Wang et al., 2000, 2002; Wells et al., 1999; Young et al., 2001). However, it is important to keep in mind that the quality of care received in mental health specialty settings was only moderately better in absolute terms, both in this study and others (Blanco, Laje, Olfson, Marcus, & Pincus, 2002; Simon, Von Korff, Rutter, & Peterson, 2001).

What explains the lower intensity and quality of mental health treatments in primary care? One possibility is that primary care patients with mental disorders, who typically present with somatic symptoms, may not believe that they have a mental disorder or need treatment, leading to lower compliance with recommended treatment regimens (Dietrich, Oxman, & Williams, 2003a; Kroenke, 2003; Mojtabai, Ofson, & Mechanic, 2002; Simon et al., 1999). Patients seeking help from general medical physicians have a less serious profile of disorders than those treated in other sectors (Kessler et al., 1999; Olfson & Pincus, 1996), which presumably impedes their unequivocal acceptance of physician formulations. Primary care patients also have been found to have less psychiatric comorbidity than patients seeking mental health specialty care (Kessler et al., 1999; Mojtabai et al., 2002). This lower severity could influence not only patient adherence, but also physician behavior, a possibility that is consistent with evidence that severity is related to treatment intensity (Mojtabai et al., 2002; Wells et al., 1999). However, some investigators have found only modest differences in severity or impairment between primary care and specialty samples (Simon et al., 2001), and others have found that the presence of even worrisome symptoms, such as suicidal ideation, does not lead to more intensive treatment in primary care (Wells et al., 1999). These latter findings suggest that higher quality treatments are as necessary and beneficial in primary care as in mental health specialty populations.

Some earlier studies have found that the ability of primary care physicians to correctly diagnose and treat mental disorders was lower than that of mental health specialists (Katon, Von Korff, Lin, Bush, & Ormel, 1992a; Simon & Von Korff, 1995; Simon, Von Korff, Wagner, & Barlow, 1993; Wells et al., 1989), and such findings have led to numerous educational and other training initiatives (Hirschfeld et al., 1997). Some recent data suggest that general medical physicians’ confidence in their abilities to treat mental disorders remains low despite additional didactic training (Dietrich et al., 2003b). Other data suggest that primary care physicians have improved rates of recognizing and treating mental disorders (Carney, Dietrich, Eliassen, Owen, & Badger, 1999), and in some treatment contexts primary care physicians and mental health specialists have similar levels of guideline-concordant care (Dietrich et al., 2003a; Simon et al., 2001).

Structural and financial barriers almost certainly play key roles in undermining the intensity and quality of mental health care in the general medical sector. Primary care physicians must deal with all of a patient’s health needs, including the considerable general medical comorbidity that afflicts primary care populations (Starfield et al., 2003). This situation frequently leads to "competing demands" on physicians’ limited time and resources (Jaen, Stange, & Nutting, 1994; Klinkman, 1997). Another important structural barrier primary care physicians face is the paucity of available mental health referrals (Trude & Stoddard, 2003). Capitated or bundled payments for primary care physicians and capitated referral systems, used in many managed care organizations, discourage maintenance treatment and referral to mental health specialists (Frank, Huskamp, & Pincus, 2003). Behavioral health carve-outs, now covering 50 to 70 percent of insured populations, can further erode general medical physicians’ financial incentives to adequately treat mental disorders as well as fragment and disorganize mental health care (Findlay, 1999; Frank et al., 2003; Frank & McGuire, 1998).

Use of the general medical sector varies across individual mental disorders. Panic disorder, which frequently presents with somatic symptoms, may prompt general medical attention; on the other hand, specific phobia, which often involves lower levels of subjective distress, may be less likely to prompt patients to seek primary care treatment (Brunello et al., 2001; Katerndahl & Realini, 1995; Katon, Von Korff, & Lin, 1992b; Leaf et al., 1985; Solomon & Gordon, 1988). Externalizing disorders (e.g., substance disorders and intermittent explosive disorder) may also be associated with lower perceived needs for treatment, as well as tendencies for patients and providers to view these problems as social or criminal rather than medical in nature (Kaskutas, Weisner, & Caetano, 1997; Mojtabai et al., 2002). Also, effective primary care treatments are just emerging, which may be another cause of lower treatment rates for impulse-control disorders (Fava, 1997; Olvera, 2002).

The sociodemographic predictors of general medical sector use are generally consistent with prior research. The greater use of primary care for mental disorders by older people may be due to the stigma of mental disorders in the elderly, the unacceptability of mental health specialty treatments, and high rates of general medical care use for medical problems in the age group (Fischer, Wei, Solberg, Rush, & Heinrich, 2003; Klap, Unroe, & Unutzer, 2003; Leaf et al., 1985). The fact that female patients are more likely than male patients to use the general medical sector may be due to primary care physicians’ greater willingness to treat women, while referring men to mental health specialists (Kessler, 1986; Shapiro et al., 1984). Because we adjusted for income, the inverse relationship between education and general medical sector use is not just due to education serving as a proxy for greater financial resources to pay for mental health specialty services; instead, these results could reflect the greater emphasis on knowledge and cognitive processes in many specialty psychotherapies (Wells, Manning, Duan, Newhouse, & Ware, 1986). The diminished use of primary care among those separated, widowed, or divorced may indicate that those experiencing relationship loss or strife often seek out counseling (Leaf et al., 1985). Greater use of primary care for mental health needs in rural areas may reflect the structural reality that mental health specialty resources are scarce outside of urban and suburban areas (Rost, Fortney, Fischer, & Smith, 2002).

There are, of course, several sets of potential limitations to keep in mind when interpreting these results. The WMH-CIDI did not assess all DSM-IV disorders. The most important consequence of this frame exclusion is that some respondents classified as not having a mental disorder may actually have met criteria for a DSM-IV disorder that was not assessed. People who were homeless or institutionalized were also excluded. However, the results reported here should still apply to a large majority of the population because the homeless and institutionalized make up a small percentage of the U.S. population.

People with mental disorders may also have had higher survey refusal rates (i.e., systematic survey nonresponse) or rates of recall failure, conscious nonreporting, and errors in the diagnostic evaluation (i.e., systematic nonreporting) than those without disorders. A likely consequence of such errors is that unmet needs for treatment have been underestimated (Allgulander, 1989; Cannell, Marquis, & Laurent, 1977; Eaton, Anthony, Tepper, & Dryman, 1992; Kessler et al., in press a; Kessler et al., under review; Turner et al., 1998).

Another potential limitation concerns the validity of self-reports of treatment use. Some investigators have found that self-reports of mental health service use overestimate treatment records (Rhodes & Fung 2004; Rhodes, Lin, & Mustard, 2002). Questions designed to measure a subject’s commitment to the survey (i.e., commitment probes) and exclusion of the < 1 percent of respondents who failed to endorse that they would think carefully and answer honestly were employed in the NCS-R to minimize such inaccuracies. However, to the extent that they occurred, they are likely to have caused us to underestimate unmet needs for treatment.

The validity of our definitions of minimally adequate treatment is another potential limitation. For example, brief treatments have been described for certain phobias (Ost et al., 1997) and alcohol disorders (Ballesteros et al., 2004). Furthermore, those diagnosed shortly before interview may not have had enough time to meet our criteria for minimally adequate treatment. However, our broader definition (≥ two visits to an appropriate sector or being in ongoing treatment at the time of interview) should have taken these possibilities into account.

Finally, we did not attempt to determine needs for treatment based on the seriousness of disorders, as doing so was beyond the scope of this initial descriptive report. It therefore remains possible that respondents with untreated or inadequately treated disorders are disproportionately made up of mild or self-limiting cases.

Despite these potential limitations, the results reveal that improvements in the primary care of mental disorders are warranted. Even though there has been a large increase in the proportion of people with mental disorders receiving treatment, particularly in the general medical sector, many active cases still go untreated. Additional outreach efforts are clearly still needed to promote recognition of disorders and timely initiation of treatments. Concentrating these efforts in general medical settings seems indicated given, that they are increasingly the de facto portals of entry into the service delivery system for most people with mental health needs. Expanding awareness programs and use of tools to screen for mental disorders in primary care practices may be effective ways to achieve these goals (Hirschfeld et al., 1997; Jacobs, 1995; Spitzer et al., 1999).

Efforts to improve the quality of treatments are also sorely needed in light of the widespread low intensity and inadequacy of existing primary care for mental disorders. Simply introducing treatment guidelines and other simple educational approaches have not proven to be successful. However, a range of multifaceted primary care interventions that include elements of clinician and patient education, care management, and greater integration of primary and specialty care have proven to be effective and in some cases cost-effective (Gilbody, Whitty, Grimshaw, & Thomas, 2003; Katon et al., 1995; Katon, Roy-Byrne, Russo, & Cowley, 2002; Wells et al., 2000). Establishing performance standards, such as the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Center for Mental Health Services Consumer-Oriented Mental Health Report Card or the new National Committee for Quality Assurance standards, could further help enhance the quality of primary care treatments and monitor the impact of future primary care interventions (National Committee for Quality Assurance, 1997; Substance Abuse and Mental Health Services Administration, 1996).

Beyond developing outreach and quality improvement initiatives, the longer term task of achieving sustainable improvement in the primary care of mental disorders remains. Primary care providers continue to face daunting financial and structural barriers to delivering quality mental health care. These same financial and structural barriers also deter the uptake of even effective model approaches in primary care (Frank et al., 2003; Klinkman, 1997; Pincus, Hough, Houtsinger, Rollman, & Frank, 2003; Williams, 1998; Williams et al., 1999). Widespread dissemination of quality improvement programs may ultimately depend on removing financial disincentives and redesigning current systems of care (Frank et al., 2003; Williams et al., 1999). The Robert Wood Johnson Depression in Primary Care Program is one ongoing initiative that seeks to align primary care providers’ incentives to promote sustainable evidence-based practice (Pincus et al., 2003). Finally, employer and governmental purchasers currently hesitate to pay for even proven interventions because they lack metrics for assessing return on investment (Wang, Simon, & Kessler, 2003). The National Institute of Mental Health (NIMH)-sponsored Work Outcomes Research and Cost-Effectiveness Study (WORCS) is an ongoing initiative that will calculate returns on investment to purchasers for investing in enhanced care of mental disorders (Wang et al., 2003).

New Perspectives and Directions

Taken together, the results described above and in related studies lead to what might be considered the fourth major stage in the development of an effective and efficient approach to the care of mental illness. The first stage was characterized by describing the volume of patients treated by the "hidden mental health sector" and by characterizing the extent to which these services were disorganized, inefficient, uncontrolled, and poorly reimbursed.

The second stage was characterized by the first of two very different approaches to remedying these deficiencies. The first approach was based on brute force or the "retail approach" to educational interventions to improve what was assumed to be a knowledge and skill deficiency in primary care physicians. This approach was taken so that mental health care could be controlled by, and to a considerable extent limited to, primary care physicians through gatekeeping and other means of limiting access to specialty mental health providers. While promoted by many health care plans as a way to "strengthen" the primary care physician’s role in comprehensive health care, it was viewed by most primary care physicians as a crude cost-containment mechanism to limit services that many employers and payers perceived to have relatively little value by. Despite a wide range of creative, intensive, and theoretically sound approaches to education and professional development, including studies based on intense, multifaceted educational interventions involving both didactic and active experiences and case-based exercises, outcome studies showed that the detection, accurate diagnosis, and effective treatment of depression and other mental illnesses improved little. Knowledge was a necessary but not sufficient condition to improve mental health care in the primary care setting.

Attempts to restrict most mental health care to the primary care setting occurred during the same period as the expansion of mental health "carve-outs." These carve-outs required all mental health care to be provided in mental health care settings, usually without adequate or sometimes any communication with the patient’s pri-ary care physician. Mental health carve-outs were an effective approach for patients who actively sought specialty services. However, this organizational structure did not well serve the large portion of the primary care population who could not, would not, or did not seek such care. Most important, capturing and confining all mental health care in a single system, often organized through commercial contracts with outside provider organizations, limited care through restricted formularies and limits on the availability of outpatient counseling and inpatient admission. Both the carving out and confinement of services to a single provider group and the restrictions on access to services stood in distinct contrast to the relatively open access to therapies and providers for most other chronic medical conditions. The net effect of this approach was to restrict access to mental health care for a large portion of the population who resisted being carved out, as well as to limit mental health services to those who actively sought such care.

The third phase of this evolution was the design and evaluation of stratified approaches to allocating care based on severity and treatment response. In these models, psychiatrists are available to primary care physicians for direct (to patient) or indirect (to primary care physician) consultation; case managers follow patients closely and provide support, counseling, and education; and patients receive a variety of additional support and monitoring services. These approaches show significant benefit in adherence to medication regimens, treatment response, and functional outcomes but are unsustainable financially. Almost universally, these studies showed positive results while receiving support and funding but left no enduring legacy when the research funding ended. Care reverted to baseline levels.

The net effect of these three phases was to raise the consciousness of primary care physicians and their patients regarding the importance and legitimacy of effective treatment for mental illness. This experience also demonstrated new approaches that led to markedly improved outcomes, but without providing new resources or access to the incremental reimbursement necessary to support the required intensity of care to achieve such outcomes. Little evidence existed that a multifaceted, structured, and stratified approach to mental illness care could be supported through usual practice revenues, or that most payers were willing to make the necessary investment in such programs—despite evidence of significant cost savings through reduced utilization of inappropriate medical care, decreased attrition, decreased disability, improved performance, and decreased absenteeism.

In combination with the data described above, these lessons lead naturally to a fourth stage characterized by the following critical questions that are worthy of attention by health services investigators, payers, employers, and health policy experts.

1. To what degree is the considerable mental illness care provided in the non-mental health care sector inevitable, because of a shortage of mental health care professionals (particularly psychiatrists), or desirable?

2. What financial structures and payer mechanisms are necessary to support the case management, stratified care, and structured consultation–liaison relationships that have been shown to be feasible and effective but unsustainable in the current health care system?

3. How could the treatment of mental illness be rationally allocated between the service sectors to result in higher levels of treatment to remission and more effective care of psychiatric comorbidity?

4. Is it possible for the treatment of mental illnesses to become a model for how a highly prevalent and expensive set of persistent conditions could be addressed by primary care and specialty sectors in a "both/and," rather than an "either/or" paradigm?

The current model of chronic disease care, and particularly the care of patients with multiple chronic diseases, is fragmented, inefficient, ineffective, and expensive. Health policy experts and national organizations have made several calls for new models for the population-based care of chronic disease. The new models would be required to allocate resources rationally; stratify care according to severity and complexity; and ensure that medical care information is structured, organized, and shared in sophisticated ways among a team of providers, including both primary care physicians and specialty consultants. Such calls have, in general, not yet led to substantial changes. The care of mental illness could become the paradigm for such a systemic change.

ACKNOWLEDGEMENTS

The National Comorbidity Survey Replication (NCS-R) is supported by NIMH (U01-MH60220) with supplemental support from the National Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Robert Wood Johnson Foundation (RWJF; Grant 044708), and the John W. Alden Trust. Collaborating NCS-R investigators include Ronald C. Kessler (Principal Investigator, Harvard Medical School), Kathleen Merikangas (Co-Principal Investigator, NIMH), James Anthony (Michigan State University), William Eaton (The Johns Hopkins University), Meyer Glantz (NIDA), Doreen Koretz (Harvard University), Jane McLeod (Indiana University), Mark Olfson (New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University), Harold Pincus (University of Pittsburgh), Greg Simon (Group Health Cooperative), Michael Von Korff (Group Health Cooperative), Philip Wang (Harvard Medical School), Kenneth Wells (UCLA), Elaine Wethington (Cornell University), and Hans-Ulrich Wittchen (Max Planck Institute of Psychiatry; Technical University of Dresden). The views and opinions expressed in this chapter are those of the authors and should not be construed to represent the views of any of the sponsoring organizations, agencies, or U.S. Government. A complete list of NCS publications and the full text of all NCS-R instruments can be found at http://www.hcp.med.harvard.edu/ncs. Send correspondence to ncs@hcp.med.harvard.edu.

The NCS-R is carried out in conjunction with the World Health Organization World Mental Health (WMH) Survey Initiative. We thank the staff of the WMH Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on data analysis. These activities were supported by the National Institute of Mental Health (R01-MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the U.S. Public Health Service (R13-MH066849, R01-MH069864, and R01-DA016558), the Fogarty International Center (FIRCA R01-TW006481), the Pan American Health Organization, Eli Lilly and Company, Ortho-McNeil Pharmaceutical, Inc., GlaxoSmithKline, and Bristol-Myers Squibb. A complete list of WMH publications can be found at http://www.hcp.med.harvard.edu/wmh/.

References

Agency for Health Care Policy and Research. (1993). Depression Guideline Panel, Vol. 2: Treatment of major depression. Clinical Practice Guideline No. 5. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research.

Allgulander, C. (1989). Psychoactive drug use in a general population sample, Sweden: Correlates with perceived health, psychiatric diagnoses, and mortality in an automated record-linkage study. American Journal of Public Health, 79, 1006–1010.

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders: DSM-III. (3rd ed.). Washington, DC: Author.

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders: DSM-III-R (Rev. 3rd ed.). Washington, DC: Author.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders: DSM-IV-R.(Rev. 4th ed.). Washington, DC: Author.

American Psychiatric Association. (1998). Practice guideline for the treatment of patients with panic disorder. Washington, DC: Author.

American Psychiatric Association. (2000). Practice guideline for treatment of patients with major depressive disorder (2nd ed.). Washington, DC: Author.

American Psychiatric Association. (2002). Practice guideline for treatment of patients with bipolar disorder (2nd ed.). Washington, DC: Author.

American Psychiatric Association. (2004). Practice guideline for treatment of patients with schizophrenia (2nd ed.). Washington, DC: Author.

Ballesteros, J., Duffy, J. C., Querejeta, I., Arino, J., & Gonzalez-Pinto, A. (2004). Efficacy of brief interventions for hazardous drinkers in primary care: Systematic review and meta-analyses. Alcoholism, Clinical and Experimental Research, 28, 608–618.

Blanco, C., Laje, G., Olfson, M., Marcus, S. C., & Pincus, H. A. (2002). Trends in the treatment of bipolar disorder by outpatient psychiatrists. American Journal of Psychiatry, 159, 1005–1010.

Brunello, N., Davidson, J. R., Deahl, M., Kessler, R. C., Mendlewicz, J., Racagni, G., et al. (2001). Posttraumatic stress disorder: Diagnosis and epidemiology, comorbidity and social consequences, biology and treatment. Neuropsychobiology, 43, 150–162.

Cannell, C. F., Marquis, K. H., & Laurent, A. (1977). A summary of studies of interviewing methodology: 1959–1970. Vital Health Statistics, 2.

Carney, P. A., Dietrich, A. J., Eliassen, M. S., Owen, M., & Badger, L. W. (1999). Recognizing and managing depression in primary care: A standardized patient study. Journal of Family Practice, 48, 965–972.

Dietrich, A. J., Oxman, T. E., & Williams, J. W., Jr. (2003a). Treatment of depression by mental health specialists and primary care physicians. JAMA, 290, 1991; author reply 1992–1993.

Dietrich, A. J., Williams, J. W., Jr., Ciotti, M. C., Schulkin, J., Stotland, N., Rost, K., et al. (2003b). Depression care attitudes and practices of newer obstetrician-gynecologists: A national survey. American Journal of Obstetrics and Gynecology, 189, 267–273.

Eaton, W. W., Anthony, J. C., Tepper, S., & Dryman, A. (1992). Psychopathology and attrition in the epidemiologic catchment area surveys. American Journal of Epidemiology, 135, 1051–1059.

Fava, M. (1997). Psychopharmacologic treatment of pathologic aggression. Psychiatric Clinics of North America, 20, 427–451.

Findlay, S. (1999). Managed behavioral health care in 1999: An industry at a crossroads. Health Affairs (Millwood), 18, 116–124.

First, M. B., Spitzer, R. L., & Williams, J. B. (1995). Structured clinical interview for DSM-IV (SCID-I). New York: Biometrics Research, New York State Psychiatric Institute.

Fischer, L. R., Wei, F., Solberg, L. I., Rush, W. A., & Heinrich, R. L. (2003). Treatment of elderly and other adult patients for depression in primary care. Journal of the American Geriatrics Society, 51, 1554–1562.

Forrest, C. B. (2003). Primary care in the United States. Primary care gatekeeping and referrals: Effective filter or failed experiment? British Medical Journal, 326, 692–695.

Forrest, C. B., Weiner, J. P., Fowles, J., Vogeli, C., Frick, K. D., Lemke, K. W., et al. (2001). Self-referral in point-of-service health plans. JAMA, 285, 2223–2231.

Frank, R. G., Huskamp, H. A., & Pincus, H. A. (2003). Aligning incentives in the treatment of depression in primary care with evidence-based practice. Psychiatric Services, 54, 682–687.

Frank, R. G., & McGuire, T. G. (1998). The economic functions of carve outs in managed care. American Journal of Managed Care, 4 Supplement, SP31–39.

Gallo, J. J., Meredith, L. S., Gonzales, J., Cooper, L. A., Nutting, P., Ford, D. E., et al. (2002). Do family physicians and internists differ in knowledge, attitudes, and self-reported approaches for depression? International Journal of Psychiatry in Medicine, 32, 1–20.

Gilbody, S., Whitty, P., Grimshaw, J., & Thomas, R. (2003). Educational and organizational interventions to improve the management of depression in primary care: a systematic review. JAMA, 289, 3145–3151.

Gilbody, S., Wilson, P., & Watt, I. (2004). Direct-to-consumer advertising of psychotropics. An emerging and evolving form of pharmaceutical company influence. British Journal of Psychiatry, 185, 1–2.

Hegel, M. T., Dietrich, A. J., Seville, J. L., & Jordan, C. B. (2004). Training residents in problem-solving treatment of depression: A pilot feasibility and impact study. Family Medicine, 36, 204–208.

Hirschfeld, R. M., Keller, M. B., Panico, S., Arons, B. S., Barlow, D., Davidoff, F., et al. (1997). The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA, 277, 333–340.

Hosmer, D. W., & Lemeshow, S. (1989). Applied logistic regression. New York: Wiley & Sons.

Jacobs, D. G., (1995). National Depression Screening Day: Educating the public, reaching those in need of treatment, and broadening professional understanding. Harvard Review of Psychiatry, 3, 156–159.

Jaen, C. R., Stange, K. C., & Nutting, P. A. (1994). Competing demands of primary care: A model for the delivery of clinical preventive services. Journal of Family Practice, 38, 166–171.

Kaiser Family Foundation and Health Research Education Trust. (2000). Employer Health Benefits. 2000 annual survey. http://www.kff.org/insurance/index.cfm. Accessed July 12, 2005.

Kaskutas, L. A., Weisner, C., & Caetano, R. (1997). Predictors of help seeking among a longitudinal sample of the general population, 1984–1992. Journal of Studies on Alcohol, 58, 155–161.

Katerndahl, D. A., & Realini, J. P. (1995). Where do panic attack sufferers seek care? Journal of Family Practice, 40, 237–243.

Katon, W., Von Korff, M., Lin, E., Bush, T., & Ormel, J. (1992a). Adequacy and duration of antidepressant treatment in primary care. Medical Care, 30, 67–76.

Katon, W., Von Korff, M., Lin, E., Walker, E., Simon, G. E., Bush, T., et al. (1995). Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA, 273, 1026–1031.

Katon, W. J., Roy-Byrne, P., Russo, J., & Cowley, D. (2002). Cost-effectiveness and cost offset of a collaborative care intervention for primary care patients with panic disorder. Archives of General Psychiatry, 59, 1098–1104.

Katon, W. J., Von Korff, M., & Lin, E. (1992b). Panic disorder: Relationship to high medical utilization. American Journal of Medicine, 92, 7S–11S.

Kessler, R. C. (1986). Sex differences in the use of health services. In S. McHugh & T. M. Vallis (Eds.), Illness behavior: A multidisciplinary model (pp. 135–148). New York: Plenum.

Kessler, R. C., Berglund, P., Chiu, W.T., et al. (in press a). The US National Comorbidity Survey Replication (NCS-R): An overview of design and field procedures. International Journal of Methods in Psychiatric Research.

Kessler, R. C., Berglund, P., Demler, O., et al. (under review). The National Comorbidity Survey Replication (NCS-R): An overview of methods.

Kessler, R. C., & Merikangas, K. R. (in press). The National Comorbidity Survey Replication (NCS-R). International Journal of Methods in Psychiatric Research.

Kessler, R. C., & Ustun, T. B. (in press). The World Mental Health (WMH) survey initiative version of the World Health Organization Composite International Diagnostic Interview (CIDI). International Journal of Methods in Psychiatric Research.

Kessler, R. C., & Wang, P. S. (1999). Screening measures for behavioral health assessment. In G. Hyner, K. Peterson, J. Travis, J. Dewey, J. Foerster, & E. Framer (Eds.), SPM handbook of health assessment tools (pp. 33–40). Pittsburgh, PA: Society for Prospective Medicine.

Kessler, R. C., Zhao, S., Katz, S. J., Kouzis, A. C., Frank, R. G., Edlund, M., et al. (1999). Past-year use of outpatient services for psychiatric problems in the National Comorbidity Survey. American Journal of Psychiatry, 156, 115–123.

Klap, R., Unroe, K. T., & Unutzer, J. (2003). Caring for mental illness in the United States: A focus on older adults. American Journal of Geriatric Psychiatry, 11, 517–524.

Klinkman, M. S. (1997). Competing demands in psychosocial care. A model for the identification and treatment of depressive disorders in primary care. General Hospital Psychiatry, 19, 98–111.

Kroenke, K. (2003). Patients presenting with somatic complaints: Epidemiology, psychiatric comorbidity and management. International Journal of Methods in Psychiatric Research, 12, 34–43.

Leaf, P. J., Livingston, M. M., Tischler, G. L., Weissman, M. M., Holzer, C. E., III, & Myers, J. K. (1985). Contact with health professionals for the treatment of psychiatric and emotional problems. Medical Care, 23, 1322–1337.

Lehman, A. F., & Steinwachs, D. M. (1998). Translating research into practice: The Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophrenia Bulletin, 24, 1–10.

Leucht, S., Pitschel-Walz, G., Abraham, D., & Kissling, W. (1999). Efficacy and extrapyramidal side-effects of the new antipsychotics olanzapine, quetiapine, risperidone, and sertindole compared to conventional antipsychotics and placebo. A meta-analysis of randomized controlled trials. Schizophrenia Research, 35, 51–68.

Mechanic, D., & Bilder, S. (2004). Treatment of people with mental illness: A decade-long perspective. Health Affairs (Millwood,) 23, 84–95.

Mojtabai, R., Olfson, M., & Mechanic, D. (2002). Perceived need and help-seeking in adults with mood, anxiety, or substance use disorders. Archives of General Psychiatry, 59, 77–84.

Narrow, W. E., Regier, D. A., Rae, D. S., Manderscheid, R. W., & Locke, B. Z. (1993). Use of services by persons with mental and addictive disorders. Findings from the National Institute of Mental Health Epidemiologic Catchment Area Program. Archives of General Psychiatry, 50, 95–107.

National Committee for Quality Assurance. (Ed.). (1997). HEDIS 3.0: Narrative: What’s in it and why it matters. Washington, DC: Author.

Olfson, M., Marcus, S. C., Druss, B., Elinson, L., Tanielian, T., & Pincus, H. A. (2002a). National trends in the outpatient treatment of depression. JAMA, 287, 203–209.

Olfson, M., Marcus, S. C., Druss, B., & Pincus, H. A. (2002b). National trends in the use of outpatient psychotherapy. American Journal of Psychiatry, 159, 1914–1920.

Olfson, M., & Pincus, H. A. (1996). Outpatient mental health care in nonhospital settings: Distribution of patients across provider groups. American Journal of Psychiatry, 153, 1353–1356.

Olvera, R. L. (2002). Intermittent explosive disorder: Epidemiology, diagnosis and management. CNS Drugs, 16, 517–526.

Ost, L. G., Ferebee, I., & Furmark, T. (1997). One-session group therapy of spider phobia: Direct versus indirect treatments. Behaviour Research and Therapy, 35, 721–732.

Pincus, H. A., Hough, L., Houtsinger, J. K., Rollman, B. L., & Frank, R. G. (2003). Emerging models of depression care: Multi-level (‘6 P’) strategies. International Journal of Methods in Psychiatric Research, 12, 54–63.

Regier, D. A., Narrow, W. E., Rae, D. S., Manderscheid, R. W., Locke, B. Z., & Goodwin, F. K. (1993). The de facto US mental and addictive disorders service system. Epi-demiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 50, 85–94.

Relman, A. S. (1980). The new medical-industrial complex. New England Journal of Medicine, 303, 963-970.

Rhodes, A. E., & Fung, K. (2004). Self-reported use of mental health services versus administrative records: Care to recall? International Journal of Methods in Psychiatric Research, 13, 165–175.

Rhodes, A. E., Lin, E., & Mustard, C. A. (2002). Self-reported use of mental health services versus administrative records: Should we care? International Journal of Methods in Psychiatric Research, 11, 125–133.

Rosenthal, M. B., Berndt, E. R., Donohue, J. M., Frank, R. G., & Epstein, A. M. (2002). Promotion of prescription drugs to consumers. New England Journal of Medicine, 346, 498–505.

Rost, K., Fortney, J., Fischer, E., & Smith, J. (2002). Use, quality, and outcomes of care for mental health: The rural perspective. Medical Care Research Review, 59, 231–265, discussion 266–271.

Schatzberg, A. F., & Nemeroff, C. B. (2004). Textbook of psychopharmacology. Washington, DC: American Psychiatric Publishing.

Shapiro, S., Skinner, E. A., Kessler, L. G., Von Korff, M., German, P. S, Tischler G. L., et al. (1984). Utilization of health and mental health services. Three Epidemiologic Catchment Area sites. Archives of General Psychiatry, 41, 971–978.

Simon, G. E., Von Korff, M., Rutter, C. M., & Peterson, D. A. (2001). Treatment process and outcomes for managed care patients receiving new antidepressant prescriptions from psychiatrists and primary care physicians. Archives of General Psychiatry, 58, 395–401.

Simon, G. E., & Von Korff, M. (1995). Recognition, management, and outcomes of depression in primary care. Archives of Family Medicine, 4, 99–105.

Simon, G. E., Von Korff, M., Piccinelli, M., Fullerton, C., & Ormel, J. (1999). An international study of the relation between somatic symptoms and depression. New England Journal of Medicine, 341, 1329–1335.

Simon, G. E., Von Korff, M., Wagner, E. H., & Barlow, W. (1993). Patterns of antidepressant use in community practice. General Hospital Psychiatry, 15, 399–408.

Solomon, P., & Gordon, B. (1988). Outpatient compliance of psychiatric emergency room patients by presenting problems. Psychiatric Quarterly, 59, 271–83.

Spitzer, R. L., Kroenke, K., & Williams, J. B. (1999). Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient health questionnaire. JAMA, 282, 1737–1744.

Starfield, B., Lemke, K. W., Bernhardt, T., Foldes, S. S., Forrest, C. B., & Weiner, J. P. (2003). Comorbidity: Implications for the importance of primary care in ‘case’ management. Annals of Family Medicine, 1, 8–14.

Sturm, R., & Klap, R. (1999). Use of psychiatrists, psychologists, and master’s-level therapists in managed behavioral health care carve-out plans. Psychiatric Services, 50, 504–508.

Substance Abuse and Mental Health Services Administration. (1996). Consumer-oriented Mental Health Report Card. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration.

SUDAAN. (2002). Professional software for survey data analysis, Version 8.0.1. Research Triangle Park, NC: Research Triangle Institute.

Trude, S., & Stoddard, J. J. (2003). Referral gridlock: Primary care physicians and mental health services. Journal of General Internal Medicine, 18, 442–449.

Turner, C. F., Ku, L., Rogers, S. M., Lindberg, L. D., Pleck, J. H., & Sonenstein, F. L. (1998). Adolescent sexual behavior, drug use, and violence: Increased reporting with computer survey technology. Science, 280, 867–873.

U.S. Department of Health and Human Services. (1999). Mental health: A report of the Surgeon General. 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.

U.S. Census Bureau. (2000). County and city databook, 2000. Washington, DC: U.S. Government Printing Office.

Wang, P. S., Berglund, P., & Kessler, R. C. (2000). Recent care of common mental disorders in the United States: Prevalence and conformance with evidence-based recommendations. Journal of General Internal Medicine, 15, 284–292.

Wang, P. S., Demler, O., & Kessler, R. C. (2002). Adequacy of treatment for serious mental illness in the United States. American Journal of Public Health, 92, 92–98.

Wang, P. S., Simon, G., & Kessler, R. C. (2003). The economic burden of depression and the cost-effectiveness of treatment. International Journal of Methods in Psychiatric Research, 12, 22–33.

Weissman, E., Pettigrew, K., Sotsky, S., & Regier, D. A. (2000). The cost of access to mental health services in managed care. Psychiatric Services, 51, 664–666.

Wells, K. B., Hays, R. D., Burnam, M. A., Rogers, W., Greenfield, S., & Ware, J. E., Jr. (1989). Detection of depressive disorder for patients receiving prepaid or fee-for-service care. Results from the Medical Outcomes Study. JAMA, 262, 3298–3302.

Wells, K. B., Manning, W. G., Duan, N., Newhouse, J. P., & Ware, J. E., Jr. (1986). Sociodemographic factors and the use of outpatient mental health services. Medical Care, 24, 75–85.

Wells, K. B., Schoenbaum, M., Unutzer, J., Lagomasino, I. T., & Rubenstein, L. V. (1999). Quality of care for primary care patients with depression in managed care. Archives of Family Medicine, 8, 529–536.

Wells, K. B., Sherbourne, C., Schoenbaum, M., Duan, N., Meredith, L., Unutzer, J., et al. (2000). Impact of disseminating quality improvement programs for depression in managed primary care: A randomized controlled trial. JAMA, 283, 212–220.

Williams, J. W., Jr. (1998). Competing demands: Does care for depression fit in primary care? Journal of General Internal Medicine, 13, 137–139.

Williams, J. W., Jr., Rost, K., Dietrich, A. J., Ciotti, M. C., Zyzanski, S. J., & Cornell, J. (1999). Primary care physicians’ approach to depressive disorders. Effects of physician specialty and practice structure. Archives of Family Medicine, 8, 58–67.

World Health Organization. (1991). International classification of diseases (ICD-10). Geneva, Switzerland: World Health Organization.

Young, A. S., Klap, R., Sherbourne, C. D., & Wells, K.B. (2001). The quality of care for depressive and anxiety disorders in the United States. Archives of General Psychiatry, 58, 55–61.