Whether in a primary care or a mental health specialty office, elderly
people with depression experienced some degree of symptom reduction when they
received mental health treatment such as antidepressants, talk therapy, or
However, older people with more severe forms of depression experienced a
greater degree of symptom relief in a specialist's office than in the primary
care setting, according to a trial examining the effectiveness of two mental
health service delivery models.
Findings from the Primary Care Research in Substance Abuse and Mental
Health for the Elderly (PRISM-E) study appeared in the July Psychiatric
The PRISM-E study was designed to determine if enhancement to and
standardization of two models of health care improved access to mental health
services and outcomes for people with at-risk drinking (see article above),
depression, and anxiety.
As part of the study, 1,531 patients over age 65 at 10 primary care sites
were assessed at baseline with the Mini-International Neuropsychiatric
Interview and randomized to receive treatment for depression at a primary care
clinic or mental health clinic.
Three and six months after baseline, researchers measured depressive
symptoms with the Center for Epidemiological Studies Depression Scale
In the integrated care model, mental health and substance abuse services
(including assessment, care planning, counseling, case management,
psychotherapy, and pharmacological treatment) were offered at the primary care
sites, and patients began receiving treatment within two to four weeks after
the initial primary care visit.
Patients assigned to the integrated-care model received services from
psychiatrists or licensed mental health professionals, including social
workers, psychologists, psychiatric nurses, and master's-level counselors.
Under the enhanced specialty referral model, patients were referred to a
mental health clinic in the community within two to four weeks of the primary
care visit. Patients who were referred to specialty care had access to urgent
or emergency consults and transportation.
In addition, when patients missed their first referral appointment, someone
from the specialist's office called to try to engage the patient in care as
part of the study protocol.
Researchers conducted the study between March 2000 and March 2002.
According to Dean Krahn, M.D., the study's primary investigator, there was
no specific treatment protocol for mental health clinicians to practice under
either model of care.
Krahn is chief of mental health at the William S. Middleton Memorial
veterans Hospital in Madison, Wis., and a professor of psychiatry at the
University of Wisconsin.
The majority of the patients had major depression (962 participants),
followed by minor depression (325), dysthymia (109), and depression not
otherwise specified (135).
The findings are based on an "intent to treat" analysis, which
means that the study includes all data from patients in the groups to which
they were assigned even if they never received the treatment.
After the six-month assessment, Krahn found that depression severity
declined in both models as measured by CES-D scores, with a trend toward
greater reduction of CES-D scores in the referral group (7.8 points) than the
integrated care group (6.6 points).
For participants with major depression, the referral model was associated
with a significantly greater decline in depression severity compared with the
integrated care model.
For example, mean scores on the CES-D for those with major depression
receiving integrated care dropped by 7.5 points between baseline and the
six-month assessment, while scores for those in the referral group dropped by
Under both models, pharmacotherapy and individual psychotherapy were the
most common modes of depression treatment.
Further analyses showed that "the combination of talk therapy plus
pharmacotherapy worked better in the enhanced specialty referral model than in
the integrated care model for patients with major depression," according
to the report.
Krahn told Psychiatric News that "there are important but
somewhat subtle reasons to have both models functioning in a health care
He commented that each model may work better for particular patients under
"For older people with less-severe depression, integrated care may be
effective" at alleviating depressive symptoms, "while for those
with more-severe depression, there is still a place for referral to specialty
Krahn noted that not all patients received depression treatment under each
model. The study authors said that overall, 70 percent of those assigned to
the integrated care model actually saw a mental health professional in that
setting, and only 49 percent of participants in the enhanced specialty
referral group ever attended a mental health or substance abuse
Interpreting the findings may also be hampered by the fact that there was
no control group in the study.
Krahn noted that "this line of research highlights the fact that we
as professionals need to examine how we get people to care, as much [we need
to] try and figure out what care is most effective," he said.
"If they don't receive the treatment, it won't work," he
The Substance Abuse and Mental Health Services Administration and its three
centers, the Center for Mental Health Services, Center for Substance Abuse
Treatment, and Center for Substance Abuse Prevention, funded the study.
"PRISM-E: Comparison of Integrated Care and Enhanced Specialty
Referral Models in Depression Outcomes" is posted at<http://psychservices.psychiatryonline.org/cgi/content/full/57/7/946>.▪