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Integration of Mental Health Services Into Primary Care Overcomes Ethnic Disparities in Access to Mental Health Services Between Black and White Elderly

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Objective

The authors evaluated whether the integration of mental health into primary care overcomes ethnic disparities in access to and participation in mental health (MH) and substance abuse (SA) treatment.

Methods

The authors conducted site-specific analysis of a multisite clinical trial to compare participation of black and white elderly in an integrated model of care (all MH/SA services are provided at primary care clinics) versus an enhanced referral model of care (all MH/SA services are provided at specialized MH clinics). In all, 183 elderly (56% black) diagnosed with depression (82%), anxiety (32%), and/or problem drinking (22%) were randomized.

Results

Blacks in the integrated arm were significantly more likely to have at least one MH/SA visit (77.5%) relative to blacks in the enhanced referral arm (22%; adjusted odds ratio [OR]: 14.13; confidence interval [CI]: 4.76–41.95, Wald χ2: 22.75, df = 1, p <0.0001). There was no statistically significant difference between whites in the integrated treatment arm (66.6%) and whites in the enhanced referral arm (46.9%, adjusted OR: 2.98; CI: 0.98–9.06, Wald χ2: 3.72, df = 1, p = 0.05). In the enhanced referral arm, blacks had a significantly smaller number of overall MH/SA visits (mean [SD]: 2.08 [5.28]) relative to whites (mean [SD]: 5.31 [7.76], adjusted incident rate ratio [IRR]: 2.87; CI: 1.06–7.73, Wald χ2: 4.37, df = 1, p = 0.03). In the integrated arm, there was no statistically significant difference between blacks (mean [SD]: 3.22 [3.71]) and whites (mean [SD]: 2.75 [4.29], adjusted IRR: 0.58; CI: 0.25–1.33, Wald χ2: 1.64, df = 1, p = 0.20). For both groups, time between baseline evaluation to first MH/SA visit was significantly shorter in the integrated treatment arm (for blacks: mean days [SD]: 31.06 [28.66]; for whites: mean days [SD]: 22.18 [33.88]) than in the enhanced referral arm (mean [SD]: 62.45 [43.53], adjusted hazard ratio [HR]: 7.82; CI: 3.65–16.75, Wald χ2: 28.02, df = 1, p <0.0001; mean [SD]: 63.46 [32.41], adjusted HR: 2.48; CI: 1.20–5.13, Wald χ2: 6.02, df = 1, p = 0.01, respectively).

Conclusion

An integrated model of care is particularly effective in improving access to and participation in MH/SA treatment among black primary care patients.

Section snippets

Design

The Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study is a randomized clinical trial designed to compare integrated versus enhanced referral models of MH/SA treatment for older adults with depression, anxiety, and/or problem drinking. For a detailed description of study design, see Levkoff et al.19

In the present study, we report data from 1 of 10 U.S study sites, comparing engagement and participation rates in black and white elderly in the two

RESULTS

Demographic and clinical characteristics of the sample are described in Table 1. Eighty-two participants (60% black) were assigned to the enhanced referral arm and 73 (54% black) were assigned to the integrated treatment arm. There were no statistically significant differences between the enhanced referral and the integrated models of care within each ethnic group. However, statistically significant differences between the white and the black samples were evident, with the white sample being

HAVING AT LEAST ONE MH/SA VISIT

After adjusting for all covariates, the interaction between ethnicity and model of care was significant (odds ratio [OR]: 0.21, confidence interval [CI]: 0.046– 0.96, Wald χ2: 4.02, df = 1, p = 0.04). Results indicated that black elderly in the integrated arm were significantly more likely to have at least one MH/SA visit (77.5%) than blacks in the enhanced referral arm (22%). There was no statistically significant difference between white elderly in the integrated model of care (66.6%) and

OVERALL NUMBER OF MH/SA VISITS

In predicting overall number of visits, controlling for all covariates, we found a significant interaction between ethnicity and treatment assignment (incident rate ratio [IRR]: 0.20; CI: 0.06–61, Wald χ2: 8.00, df = 1, p = 0.005). We then compared the two ethnic groups within each treatment arm because the two models of care advocate different lengths of treatment. In the enhanced referral arm, Blacks had a significantly smaller number of overall MH/SA visits (mean [SD]: 2.08 [5.28]) relative

TIME TO FIRST MH/SA VISIT

Controlling for all covariates and stratifying by level of education, we used Cox regression analysis to assess time between baseline evaluation to first MH/SA visit. The interaction between ethnicity and treatment assignment was statistically significant (hazard ratio [HR]: 0.31; CI: 0.11–0.89, Wald χ2: 4.66, df = 1, p = 0.03). However, time from baseline evaluation to engagement in first MH/SA visit was significantly shorter in the integrated arm for both blacks (mean days [SD]: 31.06

DISCUSSION

This study is unique because it evaluates ethnic minority engagement and participation in integrated MH/SA services against a strong alternative, an enhanced referral model of care that actively encourages participation in MH/SA services. Results are encouraging and suggest that the integration of MH/SA treatment into primary care clinics results in better access to and greater use of MH/SA services among black elderly, even in comparison to a strong alternative such as the enhanced referral

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  • Cited by (0)

    This work was supported by the Substance Abuse and Mental Health Services Administration, Veterans Affairs, and the Health Resources and Services Administration.

    Presented in part at the annual meeting of the American Association of Geriatric Psychiatry, 2006.

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