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.
Department of Psychiatry, Dartmouth Medical School, Lebanon, NH, USA. stephen.j.bartels@dartmouth.edu
Stephen J
SJ
Bartels
Eugenie H
EH
Coakley
Cynthia
C
Zubritsky
James H
JH
Ware
Keith M
KM
Miles
Patricia A
PA
Areán
Hongtu
H
Chen
David W
DW
Oslin
Maria D
MD
Llorente
Giuseppe
G
Costantino
Louise
L
Quijano
Jack S
JS
McIntyre
Karen W
KW
Linkins
Thomas E
TE
Oxman
James
J
Maxwell
Sue E
SE
Levkoff
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