Improving access to geriatric mental health services: a randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use.
OBJECTIVE
The authors sought to determine whether integrated mental health services or enhanced referral to specialty mental health clinics results in greater engagement in mental health/substance abuse services by older primary care patients.


METHODS
This multisite randomized trial included 10 sites consisting of primary care and specialty mental health/substance abuse clinics. Primary care patients 65 years old or older (N=24,930) were screened. The final study group consisted of 2,022 patients (mean age=73.5 years; 26% female; 48% ethnic minority) with depression (N=1,390), anxiety (N=70), at-risk alcohol use (N=414), or dual diagnosis (N=148) who were randomly assigned to integrated care (mental health and substance abuse providers co-located in primary care; N=999) or enhanced referral to specialty mental health/substance abuse clinics (i.e., facilitated scheduling, transportation, payment; N=1,023).


RESULTS
Seventy-one percent of patients engaged in treatment in the integrated model compared with 49% in the enhanced referral model. Integrated care was associated with more mental health and substance abuse visits per patient (mean=3.04) relative to enhanced referral (mean=1.91). Overall, greater engagement was predicted by integrated care and higher mental distress. For depression, greater engagement was predicted by integrated care and more severe depression. For at-risk alcohol users, greater engagement was predicted by integrated care and more severe problem drinking. For all conditions, greater engagement was associated with closer proximity of mental health/substance abuse services to primary care.


CONCLUSIONS
Older primary care patients are more likely to accept collaborative mental health treatment within primary care than in mental health/substance abuse clinics. These results suggest that integrated service arrangements improve access to mental health and substance abuse services for older adults who underuse these services.
Bartels
Stephen J
SJ
Department of Psychiatry, Dartmouth Medical School, Lebanon, NH, USA. stephen.j.bartels@dartmouth.edu
Coakley
Eugenie H
EH
Zubritsky
Cynthia
C
Ware
James H
JH
Miles
Keith M
KM
Areán
Patricia A
PA
Chen
Hongtu
H
Oslin
David W
DW
Llorente
Maria D
MD
Costantino
Giuseppe
G
Quijano
Louise
L
McIntyre
Jack S
JS
Linkins
Karen W
KW
Oxman
Thomas E
TE
Maxwell
James
J
Levkoff
Sue E
SE
D000367:Age Factors; D000368:Aged; D000428:Alcohol Drinking / Q000453:epidemiology / Q000628:therapy*; D001008:Anxiety Disorders / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D003155:Community Mental Health Centers; D019033:Delivery of Health Care, Integrated / Q000379:methods* / Q000592:standards; D003866:Depressive Disorder / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D003865:Major Depressive Disorder / Q000453:epidemiology / Q000628:therapy; D005260:Female; D006297:Health Services Accessibility / Q000592:standards* / Q000706:statistics & numerical data; D006300:Health Services Misuse / Q000706:statistics & numerical data; D006299:Health Services for the Aged / Q000706:statistics & numerical data / Q000600:supply & distribution*; D006801:Humans; D008297:Male; D011320:Primary Health Care / Q000379:methods* / Q000592:standards; D012017:Referral and Consultation; D012720:Severity of Illness Index; D016320:Substance Abuse Treatment Centers; D016896:Treatment Outcome