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SAMHSA News - January/February 2007, Volume 15, Number 1


Treatment for Older Adults: What Works Best? (Part 1)

For retired psychiatric social worker Trudy Persky, M.A., L.S.W., A.C.S.W., older people’s attitudes toward mental health issues boil down to one word: fear.

“My generation has great fears about mental illness,” said Ms. Persky, a Philadelphian in her eighties. “They think that if they go to a mental health center it means they’re crazy, which of course isn’t so.”

As a result of this fear and other problems, many older adults don’t get the mental health or substance abuse treatment they need.

To find out how best to help, SAMHSA and several Federal partners launched the 6-year Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study in 1998.

The goal? To determine whether older consumers do better when they receive mental health and substance abuse treatment that’s integrated into primary care settings or when they’re referred to specialists. (See SAMHSA News, Summer 2000.)

“PRISM-E was the first large-scale, real-world study of the effectiveness of integrating mental health and substance abuse treatment for older people into primary care,” said A. Kathryn Power, M.Ed., Director of SAMHSA’s Center for Mental Health Services (CMHS). CMHS led the effort, which also included SAMHSA’s Center for Substance Abuse Prevention and Center for Substance Abuse Treatment.

The Department of Veterans Affairs (VA), the Health Resources and Services Administration, and the Centers for Medicare & Medicaid Services provided additional support.

Now the study’s results are in. PRISM-E researchers have already published papers announcing major findings, and many more are in the works.

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Major Findings

At 10 experimental sites across the country, PRISM-E researchers screened thousands of older patients for depression, anxiety, and at-risk drinking. Settings ranged from community health clinics to managed care organizations to VA facilities.

The researchers then randomly assigned those who needed treatment to receive care from mental health providers in primary care settings or from providers in specialty settings located elsewhere. The final study sample consisted of 2,022 patients age 65 or older.

The referrals to specialty care weren’t ordinary referrals, emphasized Project Officer Betsy McDonel Herr, Ph.D., a social science analyst at CMHS. “We know from the literature that people referred to specialty care tend not to follow up even when they clearly need the care,” she explained. “To avoid that problem, we added some key enhancements.”

These included scheduling appointments much sooner than usual, following up with patients who missed appointments, and providing assistance with transportation.

The researchers are still analyzing data, but they have already published several major findings:

  • Engagement. In a 2004 paper published in the American Journal of Psychiatry, the researchers found that study participants were more open to receiving mental health and substance abuse treatment within primary care (the integrated model) than in specialty clinics (the referral model).

    A total of 71 percent of patients in the group receiving integrated care engaged in treatment, compared to just 49 percent of the group receiving referrals. “People vote with their feet,” said lead author Stephen J. Bartels, M.D., M.S., a professor of psychiatry and community and family medicine at Dartmouth Medical School in Hanover, NH. “The engagement step is substantially facilitated by integrated, collaborative care, even when we did everything we could to make the referral model the Cadillac of referrals.”

  • Depression. When it comes to depression, according to a 2006 paper published in Psychiatric Services, both the integration and referral groups saw significant improvements in their rates of remission and symptom reduction.

    But while overall rates were similar for both groups, there was one exception: For the subgroup with major depression, referral to specialty care did a better job of lessening the severity of symptoms. “The answer to the integration/referral question isn’t ‘either/or.’ It’s ‘both/and,’ ” explained lead author Dean D. Krahn, M.D., Chief of the Mental Health Service Line at William S. Middleton Veterans Hospital in Madison, WI, and a professor of psychiatry at the University of Wisconsin School of Medicine.

  • At-risk alcohol use. PRISM-E let practitioners provide whatever mental health treatment they thought most appropriate, but the study did standardize the treatment provided to at-risk drinkers at integrated sites.

    The researchers trained practitioners at primary care sites to use a proven intervention consisting of three brief, alcohol-related counseling sessions. In a 2006 paper published in Psychiatric Services, the researchers reported that both the integrated and referral groups reduced the number of drinks they had each week as well as incidences of binge drinking.

“The most important finding is that you can get people to change their behavior,” said lead author David W. Oslin, M.D., an associate professor of psychiatry at the University of Pennsylvania’s School of Medicine and Acting Director of the Mental Illness Research, Education, and Clinical Center at the Philadelphia Veterans Affairs Medical Center. And it doesn’t really matter which model of care consumers use. “The idea that every patient has to go to an addiction program to get better just isn’t the case,” he said.

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