People with serious mental illnesses (SMIs) like schizophrenia have 2–3 times greater mortality than the overall population due to high rates of poorly controlled medical conditions including cardiovascular disease.1 Evidence shows sub-optimal care of medical conditions among many people with SMI.2 Primary care physicians have an important role to play in improving receipt of guideline-concordant physical healthcare for people with SMI.3 But little is known about PCPs’ views on caring for patients with SMI.
METHODS
We surveyed a nationally representative sample of 1000 US physicians identifying as family, internal, or general medicine practitioners using a tailored Dillman method.4 A simple random sample of physicians selected from the American Medical Association (AMA) Masterfile were mailed a questionnaire, $2 incentive, and postage-paid return envelope in February 2019. Non-respondents received identical packets in March, April, June, July, and August 2019. Eligible physicians were those in the original N = 1000 sample definitively identified as practicing primary care at the address on file for the entire field period. The instrument (Appendix in the Electronic Supplementary Material [ESM]) was developed by the study team. The four survey domains are italicized in Table 2 (see Table 2 and Appendix (ESM) for item wording/responses).
Table 2.
US Primary Care Physicians’ Views Regarding Care for Patients with Serious Mental Illness (N = 336)
| % (95% CI) | |
|---|---|
| Premature mortality and health behavior change in SMI (% agree)1 | |
| People with SMI are more likely to die prematurely from medical conditions than psychiatric causes. | 76.0% (71.0–80.3) |
| People with SMI can make health behavior change. | 74.3% (69.3–78.7) |
| People with SMI want to make health behavior change. | 52.1% (46.6–57.4) |
| Ability to care for patients with SMI (% able)2 | |
| How would you rate your ability to: | |
| Treat chronic physical health conditions (e.g., diabetes mellitus) experienced by people with SMI? | 93.8% (90.6–95.9) |
| Communicate with people with SMI? | 90.7% (87.1–93.4) |
| Provide smoking cessation treatment to people with SMI? | 79.8% (75.1–83.8) |
| Treat mental health symptoms experienced by people with SMI? | 78.2% (73.4–82.4) |
| Provide weight management counseling to people with SMI? | 77.3% (72.4–81.5) |
| Treat substance use issues experienced by people with SMI? | 40.9% (35.7–46.3) |
| Responsibility for treating patients with SMI3 | |
| Who should have primary responsibility for treating physical health conditions among people with SMI? | |
| Primary care physicians | 22.6% (18.4–27.5) |
| Specialty mental health providers | 6.6% (4.3–9.8) |
| Joint responsibility | 70.8% (65.6–75.5) |
| Who should have primary responsibility for addressing tobacco smoking among people with SMI? | |
| Primary care physicians | 22.9% (18.6–27.7) |
| Specialty mental health providers | 5.7% (3.7–8.8) |
| Joint responsibility | 71.4% (66.3–76.1) |
| Who should have primary responsibility for addressing healthy diet and exercise among people with SMI? | |
| Primary care physicians | 26.7% (22.1–31.7) |
| Specialty mental health providers | 1.2% (0.5–3.3) |
| Joint responsibility | 72.1% (70.0–76.7) |
| Resources to support care for patients with SMI4 | |
| Are there resources that would help you to provide primary care more effectively to people with SMI? | |
| A health educator trained in working with people with SMI to provide behavioral counseling related to chronic medical conditions (e.g., diabetes education, smoking cessation) | 68.6% (63.4–73.4) |
| A nurse to provide care coordination for patients with SMI (e.g., making appointments, lab follow-up) | 63.2% (57.8–68.2) |
| A higher-than-typical reimbursement rate for providing primary care to people with SMI | 47.9% (42.5–53.3) |
| Training on how to effectively communicate with patients with SMI | 44.5% (39.2–49.9) |
| A lay caregiver to accompany patients with SMI to primary care appointments | 43.9% (38.6–49.3) |
| A nurse to accompany patients with SMI to primary care appointments | 30.8% (26.1–36.0) |
| None of these resources would help me provide primary care to patients with SMI | 8.2% (5.6–11.7) |
1Premature mortality and health behavior change in SMI items: Response options included strongly agree, somewhat agree, agree/disagree, somewhat disagree, and strongly disagree. “Strongly agree” and “Somewhat agree” were combined to indicate % agree
2Ability to care for patients with SMI items: Response options included entirely unable, mostly unable, somewhat able, and very able. “Somewhat able” and “Very able” were combined to indicate % able
3Responsibility for treating patients with SMI items: Respondents were asked to choose one option: “primary care physicians,” “specialty mental health providers,” or “joint responsibility”
4Resources to support care for patients with SMI items: Respondents were asked to select all that apply from the resources listed
The response rate was 54% (361 returned surveys from 668 eligible physicians). Eligible physicians represented 50 states and responding physicians represented 49 states (WY absent). Twenty-five surveys with > 50% missing data were excluded from analyses. Response did not differ by specialty, age, sex, degree (MD/DO), or practice type. Chi-squared tests showed that more non-responders (37.2%) than responders (22.1%) were from the south; analyses incorporated weights adjusting for this difference. Data were analyzed descriptively. We used chi-squared tests to compare responses among physicians with versus without onsite mental health and care coordination services. This study was deemed exempt from review by the JHSPH Institutional Review Board.
RESULTS
Respondents’ demographic characteristics were similar to PCPs nationally (Table 1). Over 40% of practices did not perform population health tracking or care coordination; one-third had onsite mental healthcare. Fifty-two percent of PCPs thought that people with SMI want to change their health behaviors (Table 2). More than three-quarters reported ability to treat physical and mental health symptoms in SMI, but only 40.9% reported ability to treat substance use. Over 70% endorsed joint responsibility with specialty mental health providers for caring for people with SMI. Physicians at clinics with onsite mental health services reported greater ability to provide smoking cessation, mental health, and weight management services (p < 0.05; Appendix Table 1 in the ESM). Physicians at clinics with care coordination services were more likely to report need for a health educator and nurse to support care coordination and enhanced reimbursement (p < 0.05; Appendix Table 2 in the ESM).
Table 1.
Characteristics of Primary Care Physician Survey Respondents, 2019 (N = 336)
| Survey respondents | National primary care physician population1 | |
|---|---|---|
| Specialty | ||
| Family practice | 52.4% | 51.5% |
| Internal medicine | 43.2% | 44.9% |
| General practice | 4.5% | 3.6% |
| Age | ||
| <35 | 7.6% | 5.7% |
| 35–44 | 19.1% | 22.6% |
| 45–54 | 29.4% | 30.7% |
| 55–64 | 28.5% | 27.3% |
| 65+ | 15.5% | 13.7% |
| Sex | ||
| Male | 58.8% | 60.9% |
| Female | 41.2% | 39.1% |
| Region | ||
| South | 29.8% | 35.6% |
| West | 26.1% | 24.6% |
| Midwest | 22.1% | 20.9% |
| Northeast | 22.1% | 19.0% |
| Practice type2 | ||
| Group practice | 50.9% | Data not available |
| Solo or two-physician practice | 17.5% | Data not available |
| Government-based practice | 11.4% | Data not available |
| Non-governmental hospital | 4.6% | Data not available |
| Other3 | 15.6% | Data not available |
| Percent of patient panel with bipolar disorder or schizophrenia | ||
| 0–10% | 79.1% | Data not available |
| 10–20% | 17.6% | Data not available |
| 30–40% | 2.7% | Data not available |
| 40+% | 0.6% | Data not available |
| Services provided at physician’s practice | ||
| Weight management or dietary counseling | 81.2% | Data not available |
| Diabetes education | 79.1% | Data not available |
| Tobacco smoking cessation treatment | 77.3% | Data not available |
| Population health tracking of chronic disease metrics (e.g., HBA1c, flu shots) in the practice’s patient panel | 58.0% | Data not available |
| Care coordination for high-need patients | 57.4% | Data not available |
| Onsite mental health treatment services | 31.8% | Data not available |
| Onsite substance use treatment services | 19.0% | Data not available |
| An online patient portal where patients can log-in to see appointments, lab results, etc. | 8.2% | Data not available |
| My practice does not provide any of these services for any patients | 5.3% | Data not available |
1Petterson S, McNellis R, Klink K, Meyers D, Bazemore A. The State of Primary Care in the United States: A Chartbook of Facts and Statistics. January 2018
2National data on practice type among primary care physicians defined as family, internal, and general medicine physicians is not available
3Includes the following: other—patient care; locum tenens; no classification
DISCUSSION
The majority of US PCP respondents endorsed joint responsibility for caring for patients with SMI alongside specialty mental health providers, but the population health management and care coordination functions needed for integrated care5 were absent from more than 40% of practices. Only 52% of respondents believed that people with SMI wanted to make health behavior change, an attitude at odds with evidence showing people with SMI’s desire and ability to lose weight and quit smoking.6 Only 41% of PCPs reported that they were able to treat substance use, suggesting a need to bolster capacity to treat this common co-occurring issue in SMI. PCPs with onsite mental health services reported greater ability to deliver services (mental health, smoking cessation, and weight management) involving counseling. PCPs with onsite care coordination reported a higher need for additional coordination supports, perhaps suggesting that practices with care coordination serve high-need patient populations and/or recognition of the value of care coordination.
About one-third (N = 332) of physicians in the original sample had an incorrect practice status, specialty, or address and were deemed ineligible. While our sample was fairly small, with eligible physicians representing all 50 states but only 660 of 47,701 zip codes, respondents’ characteristics were similar to those of PCPs nationally. Our survey did not assess whether PCPs’ views on needed resources differed for SMI versus other chronic conditions.
A national sample of US PCPs viewed specialty mental healthcare providers and PCPs as jointly responsible for the health of people with SMI; financing and delivery models that effectively support such shared responsibility are needed.
Electronic Supplementary Material
(DOCX 22 kb).
Funding Information
Dr. McGinty received support from NIMH grant K01MH106631.
Compliance with Ethical Standards
This study was deemed exempt from review by the JHSPH Institutional Review Board.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
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Associated Data
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Supplementary Materials
(DOCX 22 kb).