This chapter presents research conducted as part of the Sunnylands Adolescent Mental Health Initiative (SAMHI) to determine primary care provider practices in identifying and referring adolescents for treatment of mental health problems. It is estimated that over 70% of youth visit a primary care physician in an average year (Wells, Kataoka, & Asarnow, 2001), and with the advent of managed care, primary care physicians also serve as the gateway to obtaining specialist care, including mental health services (Glied & Neufield, 2001). However, research suggests that less than half of adolescents in the United States with a significant mental disorder are seen by an appropriate mental health service provider (Costello et al., 1998; Horwitz, Leaf, Leventhal, Borsyth, & Speechley, 1992; Sturm, Ringel, & Andreyeva, 2003).

Several explanations have been proposed for the poor treatment rate of adolescents with mental health problems. Most primary care providers are not extensively trained to identify or treat mental health problems (Wells et al., 2001), and their ability to screen patients for mental disorders is limited by time constraints per office visit (Chang, Warner, & Weissman, 1988) and restrictive reimbursement policies (Wells et al., 2001). Indeed, studies of primary care providers indicate that they recognize symptoms of mental disorder in only about 50% of adolescents reporting those symptoms prior to their visit (Horwitz et al., 1992; Kelleher et al., 1997). Even when symptoms are recognized, less than half of youth are referred for care to mental health specialists (Gardner et al., 2000; Rushton, Bruckman, & Kelleher, 2002). Although pediatric primary care providers increasingly recognize mental health problems in their patients (Kelleher, McInerny, Gardner, Childs, & Wasserman, 2000), it is clear that improving identification and referral practices represents a significant opportunity to increase appropriate treatment of adolescent mental disorders.

Despite long-standing weaknesses in the primary care system, recent changes in the delivery of mental health services may be influencing the treatment of adolescent mental disorders. Many managed care plans now contain dedicated services, or “carve-outs,” for mental health care that may encourage referral to specialists (Conti, Frank, & McGuire, 2004; Forrest et al., 1999; Glied & Neufield, 2001). Experience with these arrangements in adult managed care suggests that they may eliminate costly (and ineffective) inpatient mental health services, but very little is known about the effects of managed care on youth (Glied & Neufield, 2001; Scholle & Kelleher, 1998). Another development is the increase in public financing of children's health. More children are now covered by Medicaid and the State Children's Health Insurance Program, both of which may provide more comprehensive coverage than available through other mechanisms (Glied & Cuellar, 2003).

In addition to changes in the financing of health care, many initiatives have focused on the need for better mental health screening of children and adolescents, most notably the Report of the Surgeon General on Child Mental Health (U.S. Department of Health and Human Services, 2000) and the President's New Freedom Commission on Mental Health (2003). Furthermore, the American Academy of Pediatrics as part of its Bright Futures program (Jellinek, Patel, & Froehle, 2002) and the National Association of Pediatric Nurse Practitioners as part of its Keep Your Children/Yourself Safe and Secure initiative (KySS) (Melnyk, Brown, Jones, Kreipe, & Novak, 2003) now encourage primary care practitioners to screen their patients for common mental disorders and to refer those who meet diagnostic criteria to appropriate providers.

In this ever-changing policy environment, it is important to determine how well primary care physicians, especially those serving patients in managed care, are able to identify and refer adolescent patients with serious mental disorders. In particular, we were interested to determine if primary care physicians who treat adolescents view the mental health of their patients as their responsibility and, if so, whether their diagnostic skills and office practices enable them to identify a variety of mental health problems and to seek referrals for those in need of treatment. We were also interested in providers' views of stigma and beliefs about the efficacy of treatment in their decisions about mental health care.

To determine the status of current practices in adolescent primary care, the Annenberg Public Policy Center, with funding from SAMHI, com

missioned Princeton Survey Research Associates to conduct a survey of over 700 primary care physicians who regularly treat adolescents ages 10 to 18 (pediatricians, family physicians, and general practitioners). The interviews were conducted by telephone between September 29, 2003, and January 23, 2004. The details of the methodology are provided in the Appendix to this chapter.