University of Pennsylvania, School of Medicine and Philadelphia, VAMC
Primary Care Research in Substance Abuse and Mental Health for the Elderly
Integrated/Referral Service Delivery Models
Frequency of Psychiatric Disorder in Primary Care Patients
11% - 36%
Non-Specific Presentations
- Fatigue 20-40% depressive disorder
- Insomnia 33-66% psychiatric disorder
1 in 3 patients present in the ER with acute chest pain have panic disorder, or depression
Yingling, K.W. J., Gen.Internal Med. 1993; 8:231-35
Primary Care is a defacto mental health system responsible for its care of more patients with mental disorders than the specialty mental health sector.
Regier, DA. Arch Gen Psychiatry 1993; 50:85-94
Top 10% of Primary Care Outpatient are "Heavy Utilizers"
During past year:
- Average 15 medical visits and 15 phone calls
- Most requested at least one med/surg subspecialty referral
- 43% Doctor - Patient relationship difficulties
Psychiatric Disorders in Top 10% of "Heavy Utilizers"
| Prevalence | Current % | Lifetime % |
| Major Depression | 23.5 | 68.1 |
| Dysthymia | 16.8 | 31.9 |
| Anxiety, generalized | 21.8 | 40.3 |
| Somatomization Disorder | 20.2 | 20.2 |
| Panic Disorder | 11.8 | 21.8 |
| Alcohol Abuse | 5.0 | 24.3 |
Katon, et al, Gen Hospital Psych 1990
Primary Care Physician Assessment
- 119 High Utilizers Primary Care
- 45% warranted antidepression medication
- 11% received adequate dosage and appropriate length of treatment.
Katon, W. Med Care 1987; 25:1078-88
Primary Care Outpatients
Two-thirds of Major Depression Unrecognized
Spitzer, R. JAMA 1994; 272:1749-56
Reasons Why Behavioral Health Disorders Underrecognized and Undertreated
- Attitudes about mental illness
- Education and training issues
- Structure of health care delivery system
Dimensions of Integration
- Co-location
- Integrated treatment planning
- Shared responsibility
- Integrated financial system
Advantages of Integration
- Increase recognition of illness
- Decrease stigma
- Increase access
- Decrease no-show
- Improves communication
- Increases integrated planning
- Increases continuity of care
- Increased opportunity for professional development
Disadvantages of Integration
- Emphasize short-term treatment
- Special services not available (eg. group therapy)
- Requires highly trained staff
- Logistics - travel time
The PRISMe Project
A research study to examine the effectiveness of two types of mental health and at-risk drinking services for older adults in primary care practices.
Types of Services Studied
- Integrated/Collaborative Care -Mental health providers and substance abuse providers are physically present within the primary care setting and work jointly with primary care providers to treat patients for any MH/SA needs that they may have.
- Referral Specialty Care -MH/SA services exist in a separate physical location than that of the primary care setting and require the PCP to refer the patient out to the separate clinic.
Coordinating & Federal Teams Study Sites
Dates of Implementation
- 1998 - 1999 Study Design
- 1999 -- 2002 Study Implementation
- 2002 - 2003 Follow-up
Research Organization
- Coordinating Center- Harvard University &JSI Research &Training Institute, Inc.
- 11 Research Sites
- Consumer Representatives
- Federal Research Team - SAMHSA, HRSA and VA Representatives
Inclusion Criteria
- 65 years or older;
- An appointment in a participating primary care clinic;
- Assess positive, at the baseline assessment, for one or more target conditions; and
- Give informed consent to participate.
Target Conditions
- Depression
- Major Depression
- Dysthymic Disorder
- Minor Depression
- Depressive Disorder NOS
- Anxiety
- Generalized Anxiety Disorder (GAD)
- Panic Disorder
- Anxiety Disorder NOS
- Alcohol
- At Risk Drinking
- At Risk Drinking w/ Medications
Timing of Assessments
- Baseline Assessment
- 3-Month Assessment
- 6-Month Assessment
NUMBER OF SCREENS AND BASELINES COMPLETED
- TOTAL SCREENS COMPLETED: 3,999
- POSITIVE SCREENS: 1156
- POSITIVE + REFERRALS: 1233 SCREENS
- MET TARGET CONDITION: 404
Types of Clinics: PRISMe
Male Female Ratio: PRISMe
Race/Ethnicity: PRISMe
Martial Status: PRISMe
Target Conditions: PRISMe
UNIVERSITY OF PA &PHILADELPHIA VA SITES
- 3,999 Screens Completed
- 1156 - Positive Screens + Referrals = 1233 eligible for baseline assessment
- 404 Met Target Conditions
University of PA Site
- 2004 Screens Completed
- 506 Positive Screens + 36 Referrals = 542 Eligible for Baseline Assessment
- 177 Met Target Conditions
Philadelphia VA Site
- 1995 Screens Completed
- 650 Positive Screens + 41 Referrals = 691 Eligible for Baseline Assessment
- 227 Met Target Conditions