Physician competence in diagnosing and treating adolescent mental conditions obviously matters, but it is especially important because virtually all agree that with adequate care adolescents can be successfully treated for mental health conditions. Some physicians reported feeling more strongly about this than others: 71% strongly agreed that with adequate care adolescents can be successfully treated, whereas an additional 25% agreed somewhat. Very few physicians (3%) reported feeling that mental disorders cannot be successfully treated with adequate care.

The most systematic way to learn about potential mental health problems is to screen patients for these conditions. According to physicians surveyed, not quite one in two adolescents will encounter such a test during an office visit. Roughly half of providers (48%) said that their office “routinely screens adolescent patients for mental health disorders.” However, slightly more physicians said their office does not routinely conduct a screening test (51%). Physicians who are more likely to screen are also more likely to be open and engaged and to be knowledgeable about mental health issues. Physicians who say they always ask about mental health issues, who strongly feel it is their responsibility to talk to adolescents about mental health issues, and who describe their knowledge as excellent are more likely to say they routinely screen their patients for mental disorders.

Physicians who reported screening patients tended to use either a screening instrument developed by the physician (36%) or a standard patient questionnaire that is administered to the adolescent (34%) (Table 30.5). Considerably fewer physicians reported using a standard questionnaire that is administered to the parent (4%) or do the screening themselves or have an associate do the screening (17%).

Physicians who routinely screen patients for mental disorders were more likely to do so during the office visit itself (81%) rather than while the patient is in the waiting room (13%) or at some other time (6%).

A majority of physicians who do not routinely screen patients reported being aware (64%) that there are screening instruments for common mental conditions that can be completed by adolescents while they wait to see the physician. At the same time, more than a third (36%) said they are not aware of these screening instruments.

To find out more about physicians' actual treatment practices, we asked how they would proceed given a set of symptoms often associated with different mental health conditions—depression, anxiety disorders, bipolar disorders, eating disorders, alcohol abuse, and schizophrenia. (To reduce respondent burden, we only asked each physician about three of the disorders.) In particular, we asked if they would talk to the adolescent's parents about the symptoms, refer the patient to a mental health professional, or treat the patient themselves. We also asked physicians to estimate how many patients with each set of symptoms they actually referred in the last year and to what type of professional.

Physicians were remarkably consistent in their chosen course of treatment across different mental health conditions. Most physicians reported that they would talk to the adolescent's parents and would refer the adolescent to another professional. In a smaller percentage of cases, physicians claimed they would treat the patient themselves.

As seen in Table 30.6, physicians said they would be very likely to talk to parents of adolescents who presented symptoms of depression (91%) or schizophrenia (90%). A large majority also said they would be very likely to consult parents if an adolescent had symptoms of bipolar disorder (83%), eating disorder (81%), or an anxiety disorder (78%) or if an adolescent was showing signs of alcohol abuse (75%).

Very few among the physicians interviewed said they would not be likely to talk to the parent of an adolescent who had symptoms of one of these conditions.

In addition to talking to a parent, a majority of physicians said they would be very likely to refer an adolescent to a mental health professional for further testing or treatment (Table 30.7). Fewer than 1 in 10 physicians said they would not be likely to make a referral if a patient was showing symptoms associated with a mental disorder.

An adolescent presenting with symptoms of schizophrenia was most likely to be referred to a mental health professional (94%). A large majority of physicians also said they would be very likely to make a referral for symptoms associated with depression (79%), anxiety disorders (76%), alcohol abuse (76%), or bipolar disorders (71%). Somewhat fewer but still a solid majority said they would be very likely to refer an adolescent with symptoms of an eating disorder (61%) to a mental health professional.

Referring a patient to a mental health professional for further diagnostic tests does not mean that the physician will refrain from treating the patient in-house. Many physicians who said

they are very likely to refer adolescents with symptoms of a specific disorder to another professional also said they would be likely to treat the patient themselves.

When asked about treating an adolescent with a mental health condition, roughly half said they are likely to treat these patients themselves, but relatively few said they are very likely to do so (Table 30.8).

Physicians were particularly cautious about treating patients with symptoms of schizophrenia. Only 9% said they would be very likely to treat the patient themselves. By contrast, a solid majority (72%) said they would not be too likely (34%) or not likely at all (38%) to treat an adolescent with these symptoms.

Physicians express greater willingness to treat adolescents with symptoms associated with other conditions. Even so, only a quarter or fewer said they would be very likely to treat any of these conditions themselves. Slim majorities, however, said they would be very or somewhat likely to treat adolescents with symptoms of depression (57%), eating disorders (56%), bipolar disorders (52%), or anxiety disorders (51%). Somewhat fewer said they would be somewhat or very likely to treat symptoms of alcohol abuse (46%).

Physicians who say they are very likely to treat a particular condition themselves are more likely to say they are very capable of identifying that disorder than those who say they are not likely to treat the condition themselves. This is true for all mental conditions except for schizophrenia, a condition which very few physicians, regardless of their confidence in their diagnostic skills, say they are very likely to treat themselves.

It is encouraging that physicians who feel less than total confidence in their diagnostic skills with regard to a particular disorder are less likely to treat that disorder themselves. At the same time, however, many physicians who said they are very likely to treat a condition themselves also said that they are only somewhat or not too

confident in their ability to diagnose that condition. Of those physicians who said they are very likely to treat a condition, large proportions said they are less than very capable to identify alcohol abuse (47%), eating disorders (39%), and depression (37%). A majority of physicians (56%) who said they are very likely to treat bipolar disorders themselves said they are only somewhat confident in their diagnostic ability when it comes to identifying adolescents with this disorder.

Providers who say they are likely to refer their adolescent patients are most likely to refer to a psychiatrist. More than half of physicians who reported being at least somewhat likely to refer, said they would refer an adolescent with symptoms of schizophrenia (63%), bipolar disorders (57%), or anxiety disorders (55%) to a psychiatrist.

Referrals to psychologists were second most likely, with nearly as many saying they would refer an adolescent showing signs of depression, eating disorders, or alcohol abuse to a psychol ogist as a psychiatrist. Substantially fewer said they would refer adolescents to a mental health worker or social worker. Alcohol abuse is an exception, with a sizable minority of physicians (28%) saying they would send adolescents showing signs of alcohol abuse to a mental health worker, such as a substance abuse counselor.

Providers talk to parents and make referrals to mental health professionals despite the fact that many of them worry about stigmatizing their adolescent patients with the diagnosis of a mental disorder. About one in two physicians (54%) said they very often (16%) or somewhat often (38%) worry that diagnosing an adolescent with a mental disorder will stigmatize the patient. Only 15% of physicians said they rarely worry about stigmatizing their patients.

A sizable minority of providers who said they often worried about the stigma of a mental health problem acknowledged that this makes them reluctant to actually diagnose an adolescent with a mental health disorder. Forty-three percent said that this concern causes them to be

reluctant to a great (7%) or moderate extent (36%). Only about a quarter (24%) said that this concern plays no role in their diagnostic decision.

Based on responses to the two stigma questions, we created a single stigma score that reflected the degree to which physicians were concerned about diagnosing an adolescent with a mental disorder. Those who thought about stigma infrequently were given the two lowest scores (“not too often” and “not often at all”). Those who thought about stigma more often were given the highest score if they expressed either great or moderate reluctance to diagnose a patient with a mental disorder and an intermediate score if they only expressed a small or nonexistent reluctance to diagnose.

A regression analysis of this score indicated that providers with greater diagnostic knowledge about the disorders were less likely to be concerned about stigma than those with less knowledge. In addition, those with a patient population that contained high proportions of privately insured adolescents were less likely to be concerned about stigma. Belief in treatment efficacy was not related to concerns about stigma.

Most providers say they would refer adolescent patients with symptoms of a mental disorder to another health professional. But only 32% said that there are adequate mental health treatment resources in their community, whereas 67% reported that the treatment resources are inadequate. Indeed, 44% reported that they felt very strongly about this.

Views about treatment resources are apparently shaped in part by the type of patient being treated and the location the doctor practices in. Providers who treat predominantly low-income patients were more likely to say that treatment resources are inadequate (71%) than those who treat mostly middle-or high-income patients (57%). We also found that physicians who practice in rural communities (80%) were much more likely than those who practice in an urban (64%) or suburban setting (65%) to say that the treatment resources in their community are inadequate. Views about the adequacy of treatment resources were unrelated to beliefs about the potential efficacy of treatment.

Despite inadequate resources, many primary care physicians often work closely with mental health care specialists. It is generally accepted that patients experience better outcomes when the referring physician works closely with the mental health specialist treating the patient. A solid majority of providers (68%) reported that they collaborate to a great (27%) or moderate (41%) extent with the mental health professionals to whom they refer their adolescent patients. An additional 27% reported collaborating to a small extent. Only a handful of doctors (5%) said they do not work with the mental health care professionals at all. Physicians who practiced in rural areas were much more likely to say they collaborate to a great extent (41%) than those who practice in suburban (26%) or urban areas (24%).

Physicians who claimed to collaborate with mental health specialists tended to view the experience in positive terms: 85% said they have a good relationship with these mental health professionals, and 42% said the relationship is very good.