Two-minute mental health care for elderly patients: inside primary care visits.

OBJECTIVES To assess how care is delivered for mental disorders using videotapes of office visits involving elderly patients. DESIGN Mixed-method observational analysis of the nature of the topics discussed, content of discussion, and the time spent on mental health. SETTINGS Three types of settings: an academic medical center, a managed care group, and fee-for-service solo practitioners. PARTICIPANTS Thirty-five primary care physicians and 366 of their elderly patients. MEASUREMENTS Videotapes of 385 visits covering 2,472 diverse topics were analyzed. Coding of the videotapes identified topics, determined talk time, and coded the dynamics of talk. RESULTS Mental health topics occurred in 22% of visits, although patient survey indicated that 50% of the patients were depressed. A typical mental health discussion lasted approximately 2 minutes. Qualitative analysis suggested wide variations in physician effort in providing mental health care. Referrals to mental health specialists were rare even for severely depressed and suicidal patients. CONCLUSION Little time is spent on mental health care for elderly patients despite heavy disease burdens. Standards of care based on a count of visits "during which a mental health problem is discussed" may need to be supplemented with guidelines about what should happen during the visit. System-level interventions are needed.