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

Despite poor health outcomes and increased health care costs associated with psychiatric disorders in older adults, mental health services are underutilized, and access to assessment and treatment by specialty mental health providers is poor. Fewer than 3% of older adults report seeing a mental health professional for treatment, a rate lower than that of any other adult age group (5). Instead, older adults tend to seek mental health treatment in primary care, a system stressed by the demands of complex medical disorders and severe time constraints. One approach to overcoming barriers to mental health consultation and treatment services involves improving the system of referral to specialty mental health clinics. Enhancements include selecting mental health clinics with services tailored to older persons, providing transportation and third-party payment coverage, and minimizing time from referral to visit with the specialty mental health provider. An alternative approach consists of improving access through co-location of services and collaboration between mental health and primary care providers (9). Integrated, collaborative care management has been shown to improve outcomes for older adults with depression relative to usual care by the primary care provider.

However, no study has compared an integrated mental health/substance abuse services model to that of enhanced referral to specialty mental health/substance abuse clinics in improving access for older adults. Furthermore, no study has evaluated treatment engagement in these competing models for a broader array of common disorders, including depression, anxiety disorders, and at-risk alcohol use. This article reports the initial results of the Primary Care Research in Substance Abuse and Mental Health for the Elderly study, a randomized clinical trial comparing an enhanced referral model with integrated mental health/substance abuse services in primary care. Specific questions addressed include the following:

  1. Which service delivery model results in greater engagement in mental health/substance abuse services by older primary care patients with depression, anxiety disorders, or at-risk alcohol use?
  2. Are specific demographic characteristics, diagnoses, or severity of symptoms associated with greater engagement in either model?

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. 

 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.

Publication Date: 
Journal Name: 
American Journal of Psychiatry