Qualitative study finds primary care and psychiatry differ in managing complex mental illness

A qualitative study of 82 clinicians found that primary care providers and psychiatrists generally agreed that depression and anxiety were relatively easy to manage, but differed in their approaches to more complex mental health conditions. The findings also showed that access to psychiatric support shaped management and referral decisions among primary care providers.

The study used online, semi-structured interviews with 41 primary care providers and 41 psychiatrists recruited from Cambridge Health Alliance and the University of Washington system. Cambridge Health Alliance primarily serves urban and suburban communities, while the University of Washington network includes urban, suburban and rural populations. Interviews lasted approximately 30 to 40 minutes and were conducted through Microsoft Teams.

Interviews were not recorded to protect participants’ privacy. Two researchers attended each session: one served as interviewer and the other took notes. The researchers analyzed the notes deductively using a rapid framework approach, organizing material into predefined domains that included easy-to-treat and difficult-to-treat patients, referral processes, behavioral health service availability, and changes in treatment after failure. One team member coded the interviews, reported themes to the broader team and counted key terms, with some counts checked through software-assisted coding. Because participants were not given response options, the researchers cautioned that some agreements may have been undercounted when participants did not spontaneously mention a theme.

All primary care providers in the sample said they felt equipped to recognize the possibility of a mental health diagnosis, but their decisions about whether and how to diagnose and treat patients varied. When describing patients with actual or suspected mental disorders, 24 of 41 primary care providers referred to both symptoms and diagnoses. They often focused on patients’ experiences of distress, developed treatment plans in consultation with patients and considered social circumstances as influences on symptoms and treatment.

Psychiatrists described patients somewhat differently. Twenty-six of 41 psychiatrists said they viewed patients through their diagnoses and used symptoms to determine the type and amount of medication prescribed. Both groups also considered social support and access to resources relevant to patients’ ability to follow treatment plans. A little less than half of the primary care providers—18 of 41—said they relied on the Diagnostic and Statistical Manual of Mental Disorders, or DSM, to make diagnoses, compared with 32 of 41 psychiatrists. Psychiatrists acknowledged the limitations of the DSM but generally regarded it as important for diagnostic decisions.

Both groups described generalized anxiety and depression as relatively easy to treat and diagnose. Twenty-four of 41 primary care providers said they routinely saw these disorders and felt comfortable prescribing and managing treatment. The same number described using selective serotonin reuptake inhibitors as a primary treatment and tracking symptoms with patient-administered tools such as the Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9. Psychiatrists who did not routinely manage unipolar mood disorders that responded well to these drugs instead characterized easy-to-treat patients by their insight, social support and the absence of complex physical or mental health histories.

Social conditions were central to both groups’ accounts. Forty of 82 participants identified other social determinants of health, and 20 of 82 identified social support as important factors in determining whether patients were easy to treat. Participants described secure housing, transportation, family and friend support and access to resources as relevant to treatment engagement. Unstable housing, unreliable transportation, limited health literacy and difficulty obtaining or paying for prescriptions could make patients harder to diagnose and treat even when the underlying disorder was not considered inherently complex. Trauma, multiple physical or mental health conditions and substance use disorder were also described as complicating care; 22 of 82 participants mentioned trauma in relation to challenging cases.

Access to psychiatric services was associated with the range of conditions that primary care providers felt able to manage. Thirty-one of 41 primary care providers had some access to psychiatry, often through integrated behavioral health groups, while 18 of 41 had access to psychiatric e-consultation that could assist with medication decisions. Nineteen of 41 primary care providers reported seeing patients with schizophrenia or schizoaffective disorder, and 18 of 41 said they would refer such patients to psychiatry for continued mental health care. Sixteen said they would refer patients with bipolar disorder; participants also described referring patients with personality disorders to psychiatry or other behavioral health services. Seven primary care providers described managing the mental health care of patients with schizophrenia or schizoaffective disorder, often because of local shortages or insurance barriers.

The findings suggest that psychiatric consultation and collaboration may be especially relevant when primary care clinicians encounter complex cases, but the study did not test whether a particular support model improves diagnostic accuracy, prescribing safety or patient outcomes. The sample was not representative of all clinicians in the United States, included relatively few rural providers and relied on self-report. Interview notes could not establish whether clinicians ultimately diagnosed or treated patients accurately. Researchers also noted that patients described as easy to treat might never reach psychiatric care, while complex cases managed in primary care might already have received specialist assessment. Further research would be needed to connect clinicians’ reported perceptions with actual diagnostic and treatment practices.

Subject of Research: Primary care and psychiatry differences in conceptualizing and managing mental disorders

Article Title: Defining Mental Disorder: Differences in Primary Care Providers’ and Psychiatrists’ Conceptions of Illness

Article References: Miner, S. A., Breslau, J., Engel, C., Yi, S., & Matthews, L. J. (2026). Defining Mental Disorder: Differences in Primary Care Providers’ and Psychiatrists’ Conceptions of Illness. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10906-5

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10906-5

Keywords: mental health, primary care, psychiatry, qualitative research, clinical interviews, healthcare access, referral practices, social determinants, Defining, Mental, Disorder, Differences