This review is published as a Cochrane Review in the Cochrane Database of Systematic Reviews 2012, Issue 10. Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the Review.

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Collaborative care for depression and anxiety problems

Context: In the United States, more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Despite the frequency of referrals and the importance of the specialty-referral process, the process itself has been a long-standing source of frustration among both primary care physicians (PCPs) and specialists. These frustrations, along with a desire to lower costs, have led to numerous strategies to improve the specialty-referral process, such as using gatekeepers and referral guidelines.

Methods: This article reviews the literature on the specialty-referral process in order to better understand what is known about current problems with the referral process and what solutions have been proposed. The article first provides a conceptual framework and then reviews prior literature on the referral decision, care coordination including information transfer, and access to specialty care.

Findings: PCPs vary in their threshold for referring a patient, which results in both the underuse and the overuse of specialists. Many referrals do not include a transfer of information, either to or from the specialist; and when they do, it often contains insufficient data for medical decision making. Care across the primary-specialty interface is poorly integrated; PCPs often do not know whether a patient actually went to the specialist, or what the specialist recommended. PCPs and specialists also frequently disagree on the specialist's role during the referral episode (e.g., single consultation or continuing co-management).

Conclusions: There are breakdowns and inefficiencies in all components of the specialty-referral process. Despite many promising mechanisms to improve the referral process, rigorous evaluations of these improvements are needed.

/pdf/dropping-the-baton-specialty-referrals-in-the-united-states-l8weodr3ly.pdf

Dropping the baton: specialty referrals in the United States.

As many as 70 per cent of primary care visits in the United States are related to behavioral health needs. And many common medical problems seen in primary care involve poor health habits that may have initiated or exacerbated the symptoms, yet medical providers often lack the training or time to help patients manage these behaviors. The authors of this book draw on years of experience to provide practical information for behavioral care practitioners who wish to work effectively in this fast-paced setting.Interwoven through each chapter are practical tips for success and traps to avoid. The book includes a rich array of reproducible assessment questions, patient handouts, and sample scripts. All of these help the clinician condense the traditional 50-minute session into the 30-minute consultations typical of managed care. Each chapter addresses a single clinical topic or content area following the 5A's model of assessment and intervention: Assess, Advise, Agree, Assist and Arrange. Detailed guidance is provided for these common health problems: generalized anxiety disorder, panic disorder, posttraumatic stress disorder, depression, tobacco use, weight issues, sleep problems, diabetes, asthma, irritable bowel syndrome, cardiovascular disorders, pain disorders, sexual problems, and health anxiety. Special chapters cover cultural competency, special concerns for older adults, women's health, and 'health anxiety'.This comprehensive book belongs on the bookshelf of a range of clinicians including psychologists and social workers, as well as family physicians, physician assistants, nurses, and health care educators.

/pdf/integrated-behavioral-health-in-primary-care-step-by-step-4l3651jpb0.pdf

Integrated Behavioral Health in Primary Care: Step-by-Step Guidance for Assessment and Intervention

Background
Few studies have tested the effects of a depression intervention on the risk for death associated with depression.

/pdf/the-effect-of-a-primary-care-practice-based-depression-4hxxlxn6td.pdf

The Effect of a Primary Care Practice–Based Depression Intervention on Mortality in Older Adults: A Randomized Trial

Background Beliefs concerning the causes of mental illness may help to explain why there are significant disparities in the rates of formal mental health service use among racial/ethnic minority elderly as compared with their white counterparts. This study applies the cultural influences on mental health framework to identify the relationship between race/ethnicity and differences in 1) beliefs on the cause of mental illness, 2) preferences for type of treatment, and 3) provider characteristics. Method Analyses were conducted using baseline data collected from participants who completed the cultural attitudes toward healthcare and mental illness questionnaire, developed for the Primary Care Research in Substance Abuse and Mental Health for the Elderly study, a multisite randomized trial for older adults (65+) with depression, anxiety, or at-risk alcohol consumption. The final sample consisted of 1,257 non-Latino whites, 536 African Americans, 112 Asian Americans, and 303 Latinos. Results African Americans, Asian Americans, and Latinos had differing beliefs regarding the causes of mental illness when compared with non-Latino whites. Race/ethnicity was also associated with determining who makes healthcare decisions, treatment preferences, and preferred characteristics of healthcare providers. Conclusions This study highlights the association between race/ethnicity and health beliefs, treatment preferences, healthcare decisions, and consumers' preferred characteristics of healthcare providers. Accommodating the values and preferences of individuals can be helpful in engaging racial/ethnic minority patients in mental health services.

/pdf/cultural-beliefs-and-mental-health-treatment-preferences-of-3zu3u5m1qb.pdf

Cultural Beliefs and Mental Health Treatment Preferences of Ethnically Diverse Older Adult Consumers in Primary Care

BACKGROUND Recent studies have shown that integrated behavioral health services for older adults in primary care improves health outcomes. No study, however, has asked the opinions of clinicians whose patients actually experienced integrated rather than enhanced referral care for depression and other conditions.

METHOD The Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISM-E) study was a randomized trial comparing integrated behavioral health care with enhanced referral care in primary care settings across the United States. Primary care clinicians at each participating site were asked whether integrated or enhanced referral care was preferred across a variety of components of care. Managers also completed questionnaires related to the process of care at each site.

RESULTS Almost all primary care clinicians (n = 127) stated that integrated care led to better communication between primary care clinicians and mental health specialists (93%), less stigma for patients (93%), and better coordination of mental and physical care (92%). Fewer thought that integrated care led to better management of depression (64%), anxiety (76%), or alcohol problems (66%). At sites in which the clinicians were rated as participating in mental health care, integrated care was highly rated as improving communication between specialists in mental health and primary care.

CONCLUSIONS Among primary care clinicians who cared for patients that received integrated care or enhanced referral care, integrated care was preferred for many aspects of mental health care.

https://www.annfammed.org/content/annalsfm/2/4/305.full.pdf

Primary care clinicians evaluate integrated and referral models of behavioral health care for older adults: results from a multisite effectiveness trial (PRISM-e).

Heidi J. Syropoulos

Papers

Primary care clinicians evaluate integrated and referral models of behavioral health care for older adults: results from a multisite effectiveness trial (PRISM-e).