|Integration of mental health/substance abuse and primary care
|Butler M, Kane RL, McAlpine D, Kathol RG, Fu SS, Hagedorn H, Wilt TJ
This generally well-conducted review concluded that integrated care generally achieved positive outcomes, but there was insufficient evidence from high quality studies to determine whether integrated care was needed, or at what level, for quality care. The authors’ conclusion seems appropriate, but the applicability of the findings to countries other than the USA is unclear.
To assess the effects of integrated care programmes on outcomes in different populations.
MEDLINE, CINAHL, The Cochrane Library, and PsycINFO were searched between 1950 and December 2007 for published English language articles. Search terms were reported. Reference lists of relevant systematic reviews were manually searched. A search of the "grey" literature was conducted, including a search on Google and relevant organisation websites. Experts in the field were contacted.
Randomised controlled trials (RCTs) and quasi-experimental studies that assessed the effects of integration of mental health services into primary care settings and primary services into speciality outpatient settings to improve mental health outcomes were eligible for inclusion. Eligible studies had to have at least 100 patients and be conducted in the USA. Studies were excluded if they: were of integrated care for non-alcohol related substance use; included patients with Alzheimer’s disease or dementia; focused on development disorders in children, or on improving the transition from inpatient to outpatient care; were studies where improving mental health outcomes was a minor part of the intervention.
Included studies used collaborative care models, with most studies assessing the integration of mental health into primary care using the Wagner Chronic Care Model. All models were categorised as having either a high, intermediate or low level of integration of providers and integration of proactive care. Care management was delivered via telephone, interactive video, face-to-face, and by email, with assessment periods ranging from six weeks to 28 months. The providers involved varied across studies. The comparator in most of the studies was usual care, although one study compared integrated care with enhanced referral care. All participants were outpatients; most studies addressed depression uncomplicated by other mental health comorbidities. Other studies included patients with anxiety disorders, depression and alcohol-related disorders, somatising disorders, Attention Deficit and Hyperactivity Disorder, and patients with serious mental health or substance disorders.
Outcomes of interest included mental illness outcomes (symptom severity, response rates, and remission rates) and medical outcomes.
Two reviewers independently screened studies for inclusion, with disagreements resolved by arbitration and consensus.
Assessment of study quality
Two reviewers assessed the quality of the studies according to the Downs and Black 20-item checklist. Studies were rated as good, fair, and poor, with poor quality studies excluded from the review. Discrepancies were resolved by arbitration to at least one other reviewer and consensus between the reviewers.
At least two reviewers independently extracted means and standard deviations to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous outcomes, and mean differences (MD) and 95% confidence intervals for continuous outcomes. Data were checked by at least two reviewers, with disagreements resolved through consensus.
Methods of synthesis
Due to significant heterogeneity, data were presented as a narrative synthesis, as unpooled forest plots and in tables. Data were grouped by: outcome; level of integration of providers; level of integrated proactive process of care; and as a matrix integration model.
Sensitivity analyses were undertaken to assess the robustness of the findings by removing fair quality studies.
A simple additive approach was used in the process of care; a sensitivity analysis was performed to weight the contribution of each element of the care process on improvements in outcomes.
Results of the review
Integrating Mental Health into Primary Care (33 studies; number of patients not reported): Findings on symptom severity, response rates, and remission rates were generally positive and similar across all levels of provider integration and process of care in patients with depression or anxiety. Removal of fair quality studies and weighting the contribution of each element of the care process did not appear to alter the findings. Findings on symptom severity, response rates, and remission rates were similar across the matrix level of integration in patients with depression. It was not possible to assess studies of patients with anxiety. Medical outcomes (two studies) were reported in the review.
Integrating Primary Care into Speciality Mental Health (three studies; number of patients not reported): The studies showed improvements in primary care linkages, number of annual visits, or improved quality of medical care. Patient outcomes improved for mental and physical well-being, mortality rates, or alcohol abstinence rates.
Two studies integrating primary care into speciality mental health showed the programmes to be cost-neutral as increases in outpatient expenditures were offset by declines in inpatient and emergency room use. There was also a significant reduction in costs for a subsample of patients with substance-related mental and medical comorbidities compared to controls (one study).
Integrated care generally achieved positive outcomes, but there was insufficient evidence from high quality studies to determine whether integrated care was needed, or at what level, for quality care.
The review question was clear and was supported by appropriate criteria for study design, population and intervention, and broad criteria for outcomes. A comprehensive search of the literature was undertaken, which included attempts to locate unpublished data. However, as the search was restricted to the English language, language bias may possibly have been introduced. Each stage of the review process was conducted in duplicate, minimising the potential for reviewer error and bias.
The quality of the included studies was assessed; this was investigated as part of the analysis. The decision not to pool the results was appropriate given the variability among studies. Although study details were provided for some studies, it was difficult to identify the characteristics of those included as part of each review question.
This review was generally well conducted and the authors’ conclusion seems appropriate, but it should be borne in mind that all the included studies were conducted in the USA and the generalisability of the findings to other countries is unclear.
Implications of the review for practice and research
Practice: The authors stated that the findings from the included studies may not be generalisable to typical settings, for example, those in which there are no external sources of funding, patients have other mental health comorbidities. They also stated that it remains unclear how much integration is necessary to improve mental health care.
Research: The authors suggested a number of recommendations for future research, including the use of head-to-head trials to assess the effectiveness of integrated care programmes on all relevant patient populations, for example: patients with eating disorders; identification of the most effective elements of integrated care and the populations that benefit most from this type of care; and exploration of the effects of programmes in patients with comorbidities. The authors also stated that further research is needed to assess the effect of patient volume and case mix on financial feasibility.
Agency for Healthcare Research and Quality (AHRQ), contract number 290-02-0009.
Butler M, Kane RL, McAlpine D, Kathol RG, Fu SS, Hagedorn H, Wilt TJ. Integration of mental health/substance abuse and primary care. Rockville, MD, USA: Agency for Healthcare Research and Quality. Evidence Report/Technology Assessment; 173. 2008
Other publications of related interest
Butler M, Kane RL, McAlpine D, Kathol R, Fu SS, Hagedorn H, Wilt T. Does integrated care improve treatment for depression? A systematic review. Journal of Ambulatory Care Management 2011; 34(2): 113-25
Subject indexing assigned by CRD
Humans; Mental Disorders; Mental Health Services; Models, Organizational; Primary Health Care; Referral and Consultation; Substance Abuse Treatment Centers; Substance-Related Disorders
Database entry date
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.