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Copyright 1999 by The Cerontological Society of America The Cerontologist Vol. 39, No. 4, 417-425 This study examined differences by specialty of primary care physicians in managing suicidal and depressed geriatric patients. A probability sample of 300 Illinois physicians drawn from the American Medical Association Physician Masterfile was surveyed. Significant differences were found between specialties in estimates of the prevalence of psychiatric disorders; use of assessment procedures, treatment approaches, and referrals; perceptions of obstacles to providing mental health care; and confidence in diagnosing and treating depression and suicidality. Meeting the mental health needs of the rapidly growing older population will require a greater emphasis on geriatric mental health and consistency across primary care specialties. Key Words: Elderly suicide, Mental health, Physician specialty Managing Depressed and Suicidal Geriatric Patients: Differences Among Primary Care Physicians Mark S. Kaplan, DrPH,1 Margaret E. Adarriek, PhD,2 and Alvin Calderon, MA3 even more responsibility for diagnosing, treating, and managing all areas of health care, including care for ambulatory patients with mental disorders (Lanier & Clancy, 1996; Lebowitz, 1996; Wells, Sturm, Sherbourne, & Meredith, 1996). However, the quality of care provided by primary care physicians to such geriatric patients and the effects of such care are of growing concern, especially in light of the restrictions imposed by managed care plans (Unutzer et al., 1997). A variety of constraints inhibit primary care physicians from assessing and treating mental health symptoms. Productivity standards in managed care, with tighter scheduling of shorter appointments (the average patient-physician contact is 6 to 7 minutes; Cohen & Cairl, 1996), appear to discourage them from exploring emotional problems with their elderly patients (Waitzkin, Britt, & Williams, 1994). In addition, cost containment mechanisms restrain physicians from addressing the mental disorders of physically ill geriatric patients (Lebowitz, 1996). Moreover, many physicians do not recognize or screen for the prevailing patterns of mental disorders among ambulatory geriatric patients (Henderson, 1990; Lazarus, 1995; Lichtenberg, Gibbons, Nanna, & Blumenthal, 1993; Rapp & Davis, 1989; Waxman & Carner, 1984). According to Spitzer and his colleagues (1994), generalists are not sufficiently knowledgeable about diagnostic criteria and are not certain about the best questions to ask to evaluate whether those criteria are met. Therefore, they not only underrecognize mental disorders (Spitzer et al., 1994), but also underrefer patients for psychiatric consultations (Cassata & KirkmanLiff, 1981; Rogers, Wells, Meredith, Sturm, & Burnam, 1993), inappropriately prescribe psychotropic medications (Eisenberg, 1992; Kamerow, Pincus, & MacDonald, 1986; Katon, Von Korff, Lin, Bush, & Ormel, 1992; As many as 45% of the elderly patients who are seen by primary care physicians experience some level of depression (Rapp & Davis, 1989; Wells, Hays, Burnam, Greenfield, & Ware, 1989). The high rate of suicide among elderly persons (Mclntosh, Santos, Hubbard, & Overholser, 1994) and their greater likelihood of seeking mental health care from primary care physicians than from mental health specialists (Cohen & Cairl, 1996) underscore the importance of investigating how physicians manage depressed or suicidal elderly patients. Although numerous studies have examined how primary care physicians assess and treat psychiatric disorders (e.g., Badger et al., 1994; CooperPatrick, Crum, & Ford, 1994), few have focused on clinical practices with depressed geriatric patients (Callahan et al., 1994; German et al., 1987; Rapp & Davis, 1989). Primary care physicians have been increasingly involved in providing psychological interventions (Olfson etal., 1995; Orleans, George, Houpt, & Brodie, 1985; Spitzer et al., 1994). Furthermore, with the continuous expansion of managed care plans and hence the greater importance of primary care, they may assume This research was supported by grants from the Retirement Research Foundation (94-148) and the University of Illinois at Urbana-Champaign Campus Research Board. An earlier version of this article was presented at the 43rd annual meeting of the American Society on Aging, March 1997, Nashville, TN. The authors thank the Illinois State Medical Society, Dean C. C. C. O'Morchoe, Dr. Nestor Ramirez, Jon Rhoades, Wendy Almelen, Dr. Bentson McFarland, Dr. Larry Goldman, and Olga Celing for their assistance with this project. Address corresponaence to Mark S. Kaplan, DrPH, School of Community Health, Portland State University, P.O. Box 751, Portland, OR 97207-0751. E-mail: [email protected] 2 Office of Gerontology, School of Social Work, Indiana University, Indianapolis, IN. 3 Medical Scholars Program, University of Illinois at Urbana-Champaign, Urbana, IL. Vol. 39, No. 4, 1999 417 Lazarus, 1995), and often attribute psychiatric symptoms either to changes expected with age or to concomitant physical disorders (Solomon, 1996). Depression, a common risk factor for suicide, is one of the mental health problems that primary care physicians often do not recognize (Bell, 1997; Greene & Adelman, 1996). Studies have indicated that primary care physicians do not diagnose depression in at least 50% to 75% of their depressed elderly patients (Stults, 1984; Wells et al., 1996). Furthermore, in a randomized clinical trial, Callahan, Hendrie, Nienaber, and Tierney (1996) found that nearly 5% of clinically depressed older patients seen in a primary care setting were potentially suicidal. Numerous studies have found that most elderly persons who committed suicide—as many as 75%—had seen their physicians shortly before their deaths (Conwell, Olsen, Caine, & Flannery, 1991; Cooper-Patrick et al., 1994; Courage, Godbey, Ingram, Schramm, & Hale, 1993; Frierson, 1991; Lin, Von Korff, & Wagner, 1989; Tobias, Pary, & Lippmann, 1992). Despite these findings, little is known about the interactions between suicidal elderly persons and their primary care providers, such as the extent to which these physicians inquire about methods of suicide available to the patients. Less is known about whether these interactions vary by specialty of the primary care physician. One recent study has suggested that family physicians had a more positive attitude or orientation toward geriatric patients with depression compared to general internists (Glasser & Gravdal, 1997). Because family practice, internal medicine, and geriatric internal medicine specialists are the primary care providers that elderly persons see most frequently (Selma, Schwartz, Koch, & Nelson, 1993), they are in a good position to detect and manage geriatric depression and suicidality. In this article, we report on a study of these three specialties' use of assessment procedures, treatment approaches, referrals, perceptions of obstacles to providing mental health care, ana confidence in diagnosing and treating depression and suicidality. We also discuss innovative approaches to mental health treatment in primary care practice as well as the implications of the findings for medical education and training. Instrument The instrument, consisting of 20 single- and multiple-response items, was developed on the basis of consultation with leading scholars, recommendations from the literature, and extensive pilot testing. It included questions on the physicians' primary and secondary specialties, practice patterns and training, years in practice, and demographic information (e.g., age, gender, and ethnicity) as well as on their practice settings (outpatient, inpatient, nursing home, communitybased clinics, or other) and the location of their practices (rural, urban, or suburban). In addition, several questions were designed to measure the physicians' confidence in their ability to perform specific diagnostic and treatment tasks related to their geriatric patients' mental health. Procedures In May 1996, packets that included a cover letter (signed by the investigators and the dean of the University of Illinois College of Medicine), a letter of endorsement from the Illinois State Medical Society (ISMS), a postage-paid return envelope, and the instrument were sent to these 300 physicians. Every effort was made to reach the nonrespondents, including follow-up mailings and contacts by telephone and fax. Several sources were consulted (including the ISMS, the Directory of Medical Specialists [1996], and telephone directories) to verify the nonrespondents' addresses. Twenty-seven physicians' names were removed from the mailing list because they were ineligible for the study (i.e., were not practicing in Illinois, were not MDs or DOs, were retired, had no geriatric patients, or were deceased). An additional nine surveys were undeliverable. Of the remaining 264 valid addresses, 167 usable surveys were returned, for a 63% response rate. This rate compares favorably with other surveys of physicians (Frank, Rothenberg, Brown, & Maibach, 1997; Mort, Edwards, Emmons, Covery, & Blumenthal, 1996). Furthermore, the respondents did not differ from the study population on such characteristics as gender, age, and ethnicity. Analysis Method To determine whether there were intergroup differences, we compared the three specialties on the various physician and practice characteristics using analysis of variance for continuous variables and chisquare for categorical variables. To correct for the possibility of Type I error due to multiple comparisons, a more stringent significance level (p < .01) was used than the conventional p < .05. We then performed logistic regression and analysis of covariance using physicians' specialties and any potential confounders (demographic and practice characteristics that had a univariate association with physicians' specialties) as independent variables. Except for the continuous-level confidence items, all other dependent variables (assessment procedures, treatment approaches, referrals, and obstacles to mental health care) were categorical. Sample We obtained a probability sample of primary care physicians in Illinois from the American Medical Association (AMA) Physician Masterfile, a continuously updated and primary source of data on all physicians in the United States (Grumbach, Becker, Osborn, & Bindman, 1995). From the population of 4,980 family practice and internal medicine physicians listed in Illinois (excluding students and retirees), we drew a sample of 300 physicians: a stratified random sample of 247 family practice and internal medicine physicians chosen according to their proportion in the state and the entire population of 53 internal medicine geriatric physicians. 418 The Gerontologist The probability levels of the odds ratios (OR) were ascertained using Wald's test (Morrow-Howell & Proctor, 1992). spondents (85%) practiced in urban or suburban communities. Three quarters estimated that at least 25% of their patients were aged 65 or older, indicating that the respondents had substantial experience with elderly patients. Of the seven characteristics shown in Table 1, three (practice setting, practice location, and percentage of patients 65+) had categories that varied significantly among the three specialties and were therefore used as control variables in subsequent analyses. Results Physician Characteristics Of the 167 respondents, 77% were male, and 74% were Caucasian, 17% were Asian American, 4% were African American, and 3% each were Latino and "other" (see Table 1). The respondents ranged in age from 30 to 80, with a mean age of 46 years {SD = 10.6); 40% were aged 3 5 ^ 4 . With regard to specialties, 43% were in general internal medicine (GIM), 27% were in general family practice (GFP), and 30% had a primary or secondary specialty in geriatrics (GER). Of the GERs, 92% of those with a primary specialty and 86% with a secondary specialty reported being certified. The respondents had been in practice from 1 to 53 years, with a mean of 14 years (SD - 9.8); the largest group (43%) had been in practice 10 or fewer years. The majority reported seeing patients in outpatient (87%) or inpatient (78%) settings, and 55% saw them in nursing homes. In addition, most of the re- identification of Mental Health Problems In response to the question on which of five mental health problems (anxiety disorders, organic brain syndrome, affective disorders, phobias, substance abuse) was the most common among their elderly patients, 37% of physicians mentioned affective disorders (including depression), 27% mentioned organic brain syndromes, and 26% mentioned anxiety disorders; none mentioned phobias or substance abuse (see Table 2). Of the five types of disorders, only one—anxiety disorders—showed a significant difference (p < .01) among the specialties. When asked to estimate the Table 1 . Comparisons of Demographic and Practice Characteristics Total (n = 167) GERa (n = 50) GFP (n = 45) GIM (n = 72) Sex (%) Male Female 77 23 78 22 71 29 81 19 Ethnicity (%) Caucasian Asian American African American Latino Other 74 17 4 3 3 81 15 2 0 2 81 14 0 5 0 65 19 8 3 5 Age (M) 46.3 (SD = 10.6) 47.3 (SD = 9.4) 43.8 (SD = 11.1) 47.1 (SD = 10.9) Years in practice (M) 14.3 (SD = 9.8) 16.1 (SD = 8.9) 12.1 (SD = 10.9) 14.4 (SD = 9.6) Practice setting (%)b Outpatient Inpatient Nursing home Community-based clinic Other 87 78 55 12 15 82 80 72* 12 22 91 76 58 13 16 89 79 41* 11 9 Practice location (%) Suburban Urban Rural 46 39 15 54 39 6 32 28 39* 49 45 6 Patients aged 6 5 + (%) 1-25% 26-50% 51-75% 76-100% 25 30 24 21 4 20 22 54* 50* 33 13 2 25 33 32 10 Note: GER (geriatrics), GFP (general family practice), GIM (general internal medicine). *Significantly different from other specialties (p < .01). includes GFP and GIM physicians with a primary or secondary specialty in geriatrics. b Multiple response item. Vol. 39, No. 4, 1999 419 percentage of their elderly patients who had diagnoses of depression in the past 12 months, 19% indicated that 26-50% of their elderly patients were depressed. the mental health status of their elderly patients. Virtually all respondents (99%) reported interviewing the patients directly, 83% said that they also interviewed the patients' family members, and 66% indicated that they included a medical workup in their assessments. Only 28% noted that they used formal questionnaires or scales in their assessments or took into account information obtained by other members of the medical staff from patients (25%) and their families (21%). Differences among the three specialties in the use of assessment procedures were tested for statistical significance after adjusting for potential confounders (percentage of patients 654-, practice location, and nursing home practice). We found that the GERs were significantly more likely than the GFPs (OR = 3.71, p = .0001) to use questionnaires or scales and to have staff interview family members to assess their elderly patients' mental health status. The GIMs were less likely than the GFPs to use medical workups (OR = .58, p = .03) and questionnaires or scales (OR = .19, = .0000) and to have staff interview family memers (OR = .47, p = .02). Assessing Mental Health Problems Treating and Referring Patients With regard to their use of the six assessment techniques examined (see Table 3), the respondents reported using an average of three approaches to assess The most common approach to treating depression in elderly patients was to prescribe medications (92% of the respondents), followed by the use of brief sup- Table 2. Physicians' Estimation of the Most Prevalent Mental Health Problems (Percentage) Affective disorders Organic brain syndromes Anxiety disorders* Multiple conditions3 Other CER (n - 49) CFP (n = 44) GIM (n - 72) 37 39 14 6 4 27 23 43 7 0 42 21 24 13 1 Note: GER (geriatrics), CFP (general family practice), CIM (general internal medicine). Physicians were asked: "Among the patients 65 and over you see in your practice, what is the most common mental health problem?" * Difference between all pairs of specialties are significant at p < .01. a Some physicians provided multiple responses to a singleresponse item. Table 3. Physicians' Assessment, Intervention, and Referral Patterns With Depressed and Suicidal Patients Aged 65+, by Specialty (Percentage) Assessment of mental health status Interview patient Interview family members Medical workup Questionnaires or scales Staff interviews patient Staff interviews family members Intervention used with depressed patients Prescribed medication Brief supportive counseling Observed and managed without medication Long-term psychotherapy Hospitalization Electroconvulsive therapy Referrals for treating depression Prescribed medication Let referred clinician decide treatment Long-term psychotherapy Brief supportive counseling Hospitalization Electroconvulsive therapy Referrals for suicidal patients Psychiatrist Hospital emergency room Crisis assessment team GER (n = 50) CFP (n = 45) GIM (n = 72) 98 88 76 65 35 39 100 80 73 22 27 20 100 82 54 6 18 10 98 88 41 25 33 12 89 87 42 22 7 2 90 75 39 19 10 1 70 31 47 39 51 43 39 39 44 44 30 12 44 58 42 33 22 4 92 82 36 32 21 14 9 85 45 21 13 14 11 47 33 Mental health clinic 14 Psychologist Social worker 14 10 Note: GER (geriatrics), CFP (general family practice), GIM (general internal medicine). All items allowed multiple responses. 420 The Gerontologist portive counseling (82% of the respondents). It is important to note that these data do not mean that 92% and 82% of depressed elderly patients are treated with medications and brief supportive counseling. Hence, although 9 of 10 physicians reported using medications to treat depression, 4 of 10 reported observing and managing depression without medications. This apparent inconsistency in the data is most likely the result of physicians describing their approaches with different patients. In actual practice, most respondents used a combination of approaches to treat patients. For example, 64% prescribed medication along with brief supportive counseling, 2 1 % prescribed medication in conjunction with brief counseling and longterm psychotherapy, and 13% prescribed medications only. In comparing the three specialties, we found a similar pattern in their approaches to intervention. However, the GERs were significantly more likely than the GFPs (OR = 3.41, p = .004) to report using hospital ization. The respondents were much more likely to refer depressed elderly patients for long-term psychotherapy, hospitalization, and electroconvulsive therapy (41%, 33%, and 20%, respectively) than to initiate these treatments themselves (22%, 16%, and 5%, respectively). Prescribing medications was the most common treatment for which referrals were made—reported by 51% of the respondents. The GERs were significantly more likely than the GFPs (OR = 2.02, p = .02), and the GlMs were significantly less likely than the GFPs (OR = .58, p = .04), to refer for hospitalization. Likewise, the GERs were significantly more likely than the GFPs (OR = 3.28, p = .003), and the GlMs were significantly less likely than the GFPs (OR = .25, p = .002), to refer for electroconvulsive therapy. Although the differences between specialties were statistically significant, it may be useful to point out that only 1 of 45 GFPs and 1 of 72 GlMs actually recommendea this procedure. The GlMs were nearly twice as likely as the GERs (OR = 1.80, p = .01) and the GFPs (OR = 1.80, p = .01) to let the clinicians referred to decide the course of treatment. Physicians in the three specialties used similar referral practices with suicidal elderly patients. The majority (86%) would refer these patients to psychiatrists, followed by a hospital emergency room (43%), a crisis assessment team (27%), a mental health clinic (15%), psychologists (14%), and social workers (10%). There were no significant differences by specialty in the types of referral resources used for suicidal geriatric patients. With regard to assessing access to suicide methods (Table 4), we found significant differences by specialty, with the GERs more likely than the GFPs to ask patients (OR = 2.26, p = .01) about their access to firearms. The GlMs were half as likely as the GERs to ask patients (OR = .49, p = .004) or their family members (OR = .49, p = .005) about access to firearms. Overall, 58% of the physicians reported asking patients or their families about firearm access. Interestingly, the respondents were more likely to ask their depressed and suicidal patients about the misuse of medications {77%) than about the use of firearms as a suicide method (56%). Vol.39, No. 4, 1999 421 Table 4. Physicians' Methods of Assessing Suicidality (Percentage) Asked patient about firearms access Asked family of patient about firearms access Assessed patient for intentional misuse of medication GER (n - 50) GFP (n = 45) GIM (n = 72) 75 61 39 67 50 30 88 76 71 Note: GER (geriatrics), GFP (general family practice), GIM (general internal medicine). Barriers to Providing Mental Health Care The respondents' perceptions of barriers to providing mental health care were similar across the three specialties (see Table 5). The two most common obstacles reported by all three specialties were patients' "unwillingness to seek help" (76%) and "not complying with treatment" (63%), followed by the lack of time (47%). The GlMs were significantly more likely than the GERs (OR = 2.04, p = .002) to note the lack of time. Other obstacles reported were restrictions on mental health coverage (29%), lack of referral resources (20%), not the physician's area of expertise (20%), insufficient training in geriatric mental health (18%), lack of financial reimbursement (15%), and concern about stigmatizing the patient (8%). Overall, the respondents more frequently identified health system and patient issues, rather than physicians' knowledge or attitudes (e.g., concern about stigmatizing patients), as barriers to providing mental health care. The respondents were asked to rate their level of confidence, on a scale ranging from 1 (not at all) to 5 Table 5. Obstacles to Providing Mental Health Care to Patients Aged 6 5 + , Cited by Physicians (Percentage) Patients unwilling to seek help Patients not complying with treatment Lack of time Restrictions on mental health coverage Lack of referral resources Not my area of expertise Insufficient training in geriatric mental health Lack of financial reimbursement for MD Concern about stigmatizing patient GER (n = 50) GFP (n - 45) GIM (n = 72) 80 80 72 69 31 66 43 57 60 37 16 8 32 32 18 22 15 28 8 25 19 14 23 10 8 11 7 Note: GER (geriatrics), GFP (general family practice), GIM (general internal medicine); multiple response item. (very confident), in four areas of their practice with elderly patients: diagnosing depression, treating depression, assessing suicidality, and treating suicidality (see Figure 1). As a group, they were most confident about diagnosing depression {M = 4.0, SD = 1.1), followed by treating depression {M = 3.8, SD = 1.0), assessing suicidality {M = 3.6, SD = .8), and treating suicidality (M = 2.4, SD = .8). In examining differences by specialty after adjusting for potential confounders, we found that GERs were significantly more confident than the other specialties in treating depression (F = 2.93, df = 2, p < .001). They were also more confident in diagnosing depression and assessing and treating suicidality, but these differences were not statistically significant. The GIMs rated themselves as less confident than the other specialties in assessing suicidality (F = 3.78, df = 2, p = .026) and in treating suicidality (F = 3.62, df= 2, p = .030). Discussion A few points must be acknowledged in interpreting the results. First, although the respondents were representative of the population of Illinois physicians on key demographic variables, we have little information on the nonrespondents, who may have been less inclined to identify or treat the mental health problems of their geriatric patients or less well trained and less confident to do so than the respondents. Second, the respondents may have sought to describe their activi- ties and level of competence in the most favorable light. Third, the information on the sample obtained from the AMA Physician Masterfile (Grumbach et al., 1995) may not have been precise, given that 15% of the pilot sample and 12% of the final sample did not meet the study criteria or could not be located. Fourth, although the data collected were often categorical, rather than continuous (to promote ease of administration), the level of measurement of some variables (e.g., "% of patients 65 + ") precluded more precise statistical analyses. Despite the expectation that the physicians would differ by specialty in their care of elderly persons with mental health problems, overall we found more similarities than differences. For example, the GFPs, GIMs, and GERs were similar in the extent to which they prescribed medications for depression and used brief supportive counseling, as well as in their referral patterns for suicidal patients and perceptions of obstacles to providing mental health care. Other results followed the expected pattern: the GERs were significantly different in their management of geriatric depression and suicidality. Significant differences were found among the specialties in their estimates of the prevalence of psychiatric disorders and their use of assessment procedures, treatment approaches, and referrals. For example, among the three groups, the GERs were more confident in diagnosing and treating depression and suicidality; the GFPs generally ranked second on most assessment, treatment, and referral measures, and the GIMs ranked third. In addition, the results regarding Physicians' confidence in . . . Very Confident • GER(n = 50) DGFP(n = 45) • GIM(n = 72) 2 - Not at all 1 diagnosing depression treating depression assessing suicidality treating suicidality Figure 1. Physicians' confidence in assessing and treating depression and suicidality, by specialty. Note: GER (geriatrics), GFP (general family practice), GIM (general internal medicine). *Significantly different from other groups (p < .05) after adjusting for % of patients aged 65 + , practice location, and nursing home practice. 422 The Gerontologist the most common mental disorders are consistent with other studies of elderly persons in primary care settings (Pearson, Conwell, & Lyness, 1997). Despite the recommended protocol of conducting complete medical workups (Depression Guideline Panel, 1993; Tobias et al., 1992) and using assessment instruments (Lichtenberg et al., 1993; Mclntosh et al., 1994) with elderly patients who may be depressed or suicidal, we found wide variations in the use of these approaches by specialty. For example, only 6% of the GIMs versus 65% of the GERs reported using questionnaires or scales to assess mental health status. The most common approach both for treating depression (92% of the respondents) and for making referrals for depression (51% of the respondents) was the prescription of medications. This finding raises questions about the heavy reliance on psychotropic medications (Semla et al., 1993; Willcox, Himmelstein, & Woolhandler, 1994) and the underuse of psychosocial interventions as approaches to treating geriatric depression. Although studies have demonstrated the efficacy of individual and group treatment of geriatric depression (Callahan, Hendrie, & Tierney, 1996; Mossey, Knott, Higgins, & Talerico, 1996; Rosen et al., 1997; Scogin & McElreath, 1994), little is known about the reasons why psychosocial interventions are not more widely used in primary care settings. Although the two most common obstacles to mental health treatment reported by the majority of physicians were "patient unwilling to seek help" and "patient not complying with treatment," the factors that account for the physicians' perceptions are not clear. It is likely that several factors play a role. For example, physicians may initiate discussions about depression, but patients are resistant, or physicians may hold their patients responsible for not communicating their symptoms. Another factor could be that if physicians are rushed, they may not create a climate in which patients feel Tree to discuss their symptoms. Also, patients may think it is natural for them, as elderly people, to feel depressed. It is also possible that patients and some physicians are not familiar with the signs of latelife depression or know it is treatable. The fact that the one barrier that the GIMs were the most likely to report was the lack of time may partly explain why the GIMs were less likely to use time-consuming assessment procedures, such as medical workups and questionnaires or scales. In addition, the finding that the GIMs had the least confidence of the three groups in diagnosing and treating depression is supported by other studies (e.g., Banazak, 1996). However, it is uncertain how the findings on physician confidence relate to clinical outcomes. The data also raise questions about the adequacy of lethality assessment of depressed and suicidal elderly patients by primary care physicians. For example, despite the fact that firearms are the most common suicide method among both elderly men and women (Adamek & Kaplan, 1996a, 1996b; Kaplan, Adamek, & Johnson, 1994), a sizeable proportion (44%) of respondents reported that they did not ask their depressed and suicidal elderly patients about their access to firearms. It is unclear why physicians were Vol. 39, No. 4, 1999 423 more likely to inquire about the misuse of medications than about firearms as suicide methods. Could it be a reflection of physicians' reluctance to probe about guns or a lack of information about the use of firearms among suicidal older adults? There have been longstanding questions about how well the mental health needs of geriatric patients are met (Butler, Lewis, & Sunderland, 1991). According to Mechanic (1989, p. 55), this uncertainty is due, in part, to the "lack of knowledge among physicians in recognizing mental health problems and making appropriate referrals, or attitudes among physicians that inhibit appropriate care and referral." In light of the increasing enrollment of elderly people in managed care plans, there may be an even greater cause for concern. Primary care physicians have become an important point of entry for both the general health care and behavioral health care systems and are likely to play an even greater part as their gatekeeping functions expand, particularly for elderly patients (Lebowitz, 1996). Primary care providers are increasingly expected to provide mental health care themselves (Lanier & Clancy, 1996). In this regard, our finding that some primary care physicians lack confidence in managing geriatric mental health care prompts two important questions: Are primary care physicians in managed health care plans prepared to assume an expanding role that includes mental health care? And, are elderly patients in increasing jeopardy of not having their mental health needs met? Recommendations Despite calls for increased referrals to a broad range of mental health specialists with expertise in psychosocial issues (e.g., Badger, Ackerson, Buttell, & Rand, 1997; Waitzkin et al., 1994), 9 out of 10 physicians in this study referred their suicidal elderly patients to psychiatrists, and relatively few referred them to psychologists or social workers. Collaboration among members of an interdisciplinary team must be made an integral part of medical education. Issues that need to be covered include the roles of ancillary professionals, such as social workers, psychologists, and nurse practitioners, and how to gain access to them. There is evidence that the use of diverse personnel could enhance the role of primary care physicians who treat elderly persons (Netting & Williams, 1996). Furthermore, the investment in fostering collaborative approaches may lead to more cost-effective interventions (Katon et al., 1997). The use of other mental health professionals may also address the concern that psychiatrists often refuse to see Medicare patients due to low reimbursement (B. McFarland, personal communication, April 23, 1998). Innovative approaches are needed to improve geriatric mental health care in primary care settings. One idea is to develop an office-based system to screen for affective symptoms that could reduce the burden on physicians (S. Counsell, personal communication, November 7, 1997). In such a system, a social worker or nurse practitioner may act as a consultant to the primary care physician and routinely screen for and treat mental health problems among the physician's geriatric patients. Another alternative may be a computerized telephone screening system for mental health symptoms. Baer and colleagues (1995) developed a low-cost, confidential method of screening for depression using computerized digital voice recordings and touchtone responses, and Gonzalez, Costello, La Tourette, Joyce, and Valenzuela (1997) found support for an automated voice-interactive program for screening for depression in English and Spanish. An innovative way of coordinating the efforts of a primary care physician and community providers (e.g., adult day care, mental health centers, and other outreach services) serving at-risk elderly persons would be for the physician to have a social worker or other professional on the staff who is familiar with community resources. As a way to improve physicians' care and communication with emotionally distressed elderly patients, we recommend that medical training in geriatric mental health be expanded to include a greater emphasis on psychosocial interventions in conjunction with psychotropic medications. As Leggatt (1996, p. 250) noted, physicians who are "trained in techniques of psychological assessment, problem-solving and development of strategies to help better cope with future difficulties, had better outcomes with their patients." Therefore, general medical education and continuing education courses for primary care physicians should include training in interviewing and counseling and information on educational and self-help programs to improve physicians' ability to identify and treat mental illness in elderly patients. Furthermore, primary care physicians could more frequently use available assessment instruments for detecting depression with their geriatric patients (e.g., the short Geriatric Depression Scale, the Beck Depression Inventory, or the Hopelessness Scale; Valente, 1997). In addition, increased public education about geriatric depression may enhance patient-physician cooperation. We also recommend that primary care physicians of all specialties conduct firearm-availability histories with their depressed and suicidal elderly patients (Adamek & Kaplan, 1996a). Although few residency programs offer training in firearm safety counseling (Price, Bedell, Everett, & Oden, 1997), there is evidence that patients are amenable to physicians counseling them about firearms (Price, Clause, & Everett, 1995). Reference guides that are specifically designed to assist physicians in detecting, diagnosing, and treating geriatric depression and suicidality need to be developed and widely disseminated ana should include information on firearms. Conclusions The education and training of physicians must change to meet the mental health needs of the rapidly growing older population. More geriatricians and physicians who are trained in geriatric mental health will be needed, particularly if future cohorts of elderly persons are more likely to seek such care. Furthermore, there must be adequate and more consistent geriatric mental health training in all primary care spe424 cialties. Research directed at improving primary care physicians' ability to detect, diagnose, and treat mental illness is urgently needed, especially in light of the anticipated increase in primary care practice devoted to elderly people (Stults, 1984). Research is also needed to assess the extent to which the health care system affects physicians' ability to provide high-quality mental health care to geriatric patients. For example, little is known about the organizational and individual factors associated with physicians' use of referral resources (Lanier & Clancy, 1996). Future studies might investigate whether some of the variability in treatment approaches is due to patient factors such as severity of illness. It is also important to know when and why elderly patients do or do not raise mental health issues in their primary care visits. Primary care physicians can play a critical role in suicide prevention (Murphy, 1986). One of the targets of trie Healthy People 2000 initiative is to reduce the suicide rate among older White men by 8% to 39.2 per 100,000 (National Center for Health Statistics [NCHS], 1994). 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