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J Gen Intern Med. 2003 Jun;18(6):442-9.

Referral gridlock: primary care physicians and mental health services.

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  • 1Center for Studying Health System Change, Washington, DC, 20024-2512, USA.



Patients' barriers to mental health services are well documented and include social stigma, lack of adequate insurance coverage, and underdiagnosis by primary care physicians. Little is known, however, about challenges primary care physicians face arranging mental health referrals and hospitalizations.


To examine how practice setting and environment influence primary care physicians' ability to refer patients for medically necessary mental health services.


Cross-sectional analysis using nationally representative survey data from the 1998 to 1999 Community Tracking Study physician survey. The overall survey response rate was 61%.


A 1998 to 1999 telephone survey of 6586 primary care physicians.


Primary care physicians' report of whether they could obtain medically necessary referrals to high-quality mental health specialists or psychiatric admissions.


Overall, 54% of primary care physicians reported problems obtaining psychiatric hospital admissions, and 54% reported problems arranging outpatient mental health referrals. Primary care physicians practicing in staff and group model HMOs were much less apt to report difficulties than physicians in solo and small-group practices (P <.001). Reports of inadequate time with patients (P <.001) and smaller numbers of psychiatrists in a market area (P <.01) also were associated with problems obtaining mental health referrals. Pediatricians were more apt to report problems than general internists (P <.001).


Primary care physicians face greater hurdles obtaining mental health services than other medical services. Primary care is an important entry point for mental health services, yet inadequate referral systems between medical and mental health services may be hampering access.

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