Questions for Donald Cherry, M.S., Health Statistician, and Lead Author of “Mental Health-related Physician Office Visits by Adults Aged 18 and Over: United States, 2012-2014”
Q: Was there a result in your study that you hadn’t expected and that really surprised you?
DC: Most of the results confirmed what we’ve seen in current research, so there really was not a finding in this study that surprised me. But confirming existing knowledge is an important finding! Specifically, the results examining urban-rural visit differences are exactly in the expected direction; that is, in large metropolitan areas, psychiatrists are more concentrated (as suggested by prior research), and we would expect to see a higher percentage of visits to them for mental health-related issues. Rural areas have less psychiatrists and more primary care physicians (PCPs) (as suggested by prior research), and seeing 54% of mental health-related visits occurring at primary care physician offices suggests that in these rural areas, availability of provider type for outpatient mental health treatment might be limited.
Also, the results show no difference in a couple of areas. One area where you can see this is in the percent of health-related visits to psychiatrists vs. PCPs when Medicare is the expected source of payment. We see this too, in the rate of visits when the patient age is 65 years and older – which is interesting for its possible implications. These results together may indicate that older adults, who are also assumed more likely to use Medicare, are as inclined to visit a primary care physician as they are a psychiatrist for mental health-related issues.
Q: What would you say is the take-home message of this report?
DC: I think the real take-home message of this report is that continued monitoring of the utilization of mental health services is important in identifying the present and future needs of the U.S. adult population. As one might expect, the composite of mental health-related visits occur in psychiatrists’ offices; however, this does not seem to be a phenomenon that is always consistent. Differences in mental health-related visits by physician specialty did vary by age, payment type, and within patient sex. The most interesting difference is in large metropolitan areas where a higher percentage of mental health-related office visits are to psychiatrists compared to primary care physicians (PCPs). In rural areas, an opposite trend is observed. This is consistent with past research and further suggests that a greater supply of, and access to, primary care physicians vs. psychiatrists occurs in rural areas.
Q: What made you decide to conduct this study on mental health-related doctor’s office visits?
DC: My background is in psychology, and I’m very interested in mental health issues, so mental-health related doctor’s office visits is a natural topic for me to explore. Having access to the National Ambulatory Medical Care Survey (NAMCS) data has given me the opportunity to examine different research topics. In the past, I have also been privileged to collaborate with prominent researchers in the field who have used NAMCS data. I have specifically been interested in where people are going to get treatment for mental health issues. Data accessibility in NAMCS is especially useful becauses it collects visit details on both primary care physicians and psychiatrists in the same survey sample design.
Q: What differences or similarities did you see between or among various demographic groups in this analysis?
DC: We did note some differences among different age groups, between sexes, and between rural and urban areas of the United States. When examining age, the mental health-related office visit rate to psychiatrists is higher compared with the rate to primary care physicians among all adults, and among adults in age groups 18–34, 35–49, and 50–64. But there was no significant difference among adults aged 65 and over. Not seeing a difference in rates for the oldest patients is interesting, and some researchers indicate that psychiatrists have a proportionately smaller role in office-based mental health care among older adults — than younger — perhaps due to age-related attitudinal differences toward psychiatric services.
Looking at sex, mental health-related office visit rates to psychiatrists are higher compared with primary care physicians for both men and women, but the visit rate is higher for women compared to men (1,380 vs. 1,111 visits per 10,000 adults). Within-sex differences were expected given the overall premise of where adults as a group are getting their care. Within-sex differences follow 2016 data presented by The National Institutes of Mental Health that show the prevalence of any mental health illness is higher in women (21.7%) vs. men (14.5%).
Large metropolitan areas experienced a higher percentage of mental health-related office visits to psychiatrists compared to PCPs. In rural areas, an opposite trend was observed. This is consistent with past research and further suggests that a greater supply of, and access to, primary care physicians vs. psychiatrists occurs in rural areas. In medium to small metropolitan areas there was no difference in the percent of visits to either physician specialty, suggesting a possible absence of a supply-demand issue.
Q: What sort of trend data do you have on this topic that will help us see how mental health-related doctor’s office visits have evolved over time?
DC: Although we did not examine mental health-related office visits across years for this analysis, we certainly have the ability to examine the same characteristics in future research. An interesting finding in our current report is that mental health-related office visit rates to psychiatrists are higher compared with primary care physician visit rates in all age groups — except for adults aged 65 and over, and as a percentage of visits among all primary expected payment types except Medicare. These results together may indicate that older adults, who are assumed more likely to use Medicare, are as inclined to visit a primary care physician as they are a psychiatrist for mental health-related issues.
Q: What information do you have on the differences between or among the different types of physicians that are visited for mental health, e.g. what do patients get at a psychiatrist’s office visit that they may not receive at a primary care physician’s – and vice versa?
DC: There is information available about the type of care patients receive for mental health from different types of physicians. We do have the ability to determine some components of care which patients receive at mental health-related visits; for example, did the patient receive psychotherapy, health education/counseling, psychotropic medications, etc. However, this topic has been examined before as researchers outside The National Center for Health Statistics (NCHS) have studied care received at psychiatrist vs. PCP offices, so this data brief did not explore these factors extensively. Perhaps in a future NCHS study! The uniqueness of this research in how we define a mental health-related office visit should be recognized – and will be very useful in future studies. By using the patient’s reason for a visit, and not a physician’s diagnosis, we attempt to control that at least the initial reason for the visit was for a mental health issue.