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Integration of Mental Health Services Into Primary Care Overcomes Ethnic Disparities in Access to Mental Health Services Between Black and White Elderly

From the School of Social Work, Bar Ilan University, Ramat Gan, Israel (LA); the Langley Porter Psychiatric Institute (PAA) and Institute for Health and Aging (CLE), University of California, San Francisco; The Lewin Group, Falls Church, VA (KL); and Lifelong Medical Care, Berkeley, CA (ML).

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

Key Words: Mental health services • ethnic minorities • access to care • disparity