Table 3.

Consequences for primary care physicians of institutional and administrative barriers to mental health referrals.

Frustration	Burnout	Bitterness, Equity and Professional Relationships
“I cannot believe how much other medicine I do that I really don’t want to do. It’s not that I don’t want to do this--but there are aspects that I really don’t want to do. (1012) “I can request all I want but a utilization management committee reviews everything and that’s who has the final say….If a referral gets denied then I toss it back in the hands of the utilization people and say “Sorry but this is not my field so you tell me where you want them to go.”(1008)	“I think we are drowning with just the other patients that we have and they expect primary care to take this on too (1016). “It’s frustrating to be primary care and not have the resources to send your patients to when you need them. (1079).” “We need to have more providers here so that the work is distributed…I mean the risk of burnout is always an issue, and we have a frequent turnover of physicians here.” (1013	“If you’re here and having chest pain, if I think that you need a cardiologist I have the capacity to do that. If you’re here and you’re crying in the office, very anxious, very depressed and I say that you need a psychiatrist, I should have the capacity to do that too. There should be no approval…you know medicine is medicine (1007).” “It doesn’t foster doctor/doctor communication. I’d like to learn, get some feedback from the psychiatrists like I do in the other specialties—what I could do better with this patient in working with him. Especially since we’re out in a rural area it would be nice to be the eye and ears to that doc to some extent to save the patient going down. I’d learn more if I was contacted.” (1095) Now it’s like everybody’s a carve-out. Somebody else now has to decide…So what ends up happening is they [the patients] come to me for psychiatric care, and very quickly I get a thing from the biller. You know their insurance won’t let me see them for depression, they won’t give me any money.” (1012)