Integration of mental health services into primary care overcomes ethnic disparities in access to mental health services between black and white elderly.

ABSTRACT

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 chi(2) 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 chi(2) 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 chi(2) 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 chi(2) 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 chi(2) 28.02, df = 1, p <0.0001; mean [SD] 63.46 [32.41], adjusted HR 2.48; CI 1.20-5.13, Wald chi(2) 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.