Chapter  173:  Integration of Mental Health/Substance Abuse and Primary Care

Introduction

There is a need to improve care at the interface of general medicine and mental health.¹ Provision of care at this interface is the aim of integrated care. Integrated care occurs when mental health specialty and general medical care providers work together to address both the physical and mental health needs of their patients.

This comprehensive systematic review addresses the evidence for integration of mental health services into primary care settings and primary services into specialty outpatient settings. The research questions were:

• 1)

  What models of integration have been used?

  • a)

    What theoretical models support these programs?

  • b)

    What is the evidence that integrated care leads to better outcomes?

• 2)

  To what extent does the impact of integrated care programs on outcomes vary for different populations (e.g., specific mental illness conditions, chronically ill, racial/ethnic groups, elderly/youth)?

• 3)

  What are the identified barriers to successful integration?

  • a)

    How were barriers overcome?

  • b)

    What are the barriers to sustainability?

• 4)

  To what extent did successful integration programs make use of health information technology (IT)?

• 5)

  What financial and/or reimbursement structure was employed in successful integration programs? Is there evidence to suggest that any specific financial/reimbursement strategy is superior to another?

• 6)

  What are the key elements of programs that have been successfully implemented and sustained in large health systems? To what extent do they follow, or how do they differ from, models that have been studied in published research studies?

The scope of the review included alcohol addiction but not other forms of substance abuse. Inpatient settings are also excluded. The review focuses on four areas: (1) specifying what integration is (and is not); (2) detailing the process through which integrated care may affect clinical outcomes; (3) expanding beyond the scope of prior reviews to include multiple illnesses and patient populations; and (4) specifying the conditions under which various models of integrated care are likely (or unlikely) to work in ‘real-world’ settings. This review also conducted case studies in order to better understand the implementation of integrated care models.

Methods

Randomized controlled trials and high quality quasi-experimental studies conducted in the United States from 1950 to 2007 were reviewed for all questions. Dementia, Alzheimer's, and developmental disorder studies were deemed qualitatively different and were excluded. Descriptive studies were used for the last five questions, including companion articles to included studies; other relevant documents from the grey literature, including websites, conference proceedings, white papers, and governmental reports, were also used to address questions 2, 3, and 5.

The review used both quantitative and qualitative analyses. For quantitative analysis for question 1 we created a taxonomy of integration levels to examine whether integration was associated with improved outcomes. Trials were assigned to one of four levels of provider integration, based on the degree of shared decisionmaking between primary care and mental health providers and whether or not mental health providers were co-located with primary care providers. Simple additive scores were created for integrated process of care based on the presence or absence of ten elements:

• Screening

• Patient education/self-management

• Medication

• Psychotherapy

• Coordinated care

• Clinical monitoring

• Medication adherence

• Standardized followup

• Formal stepped care

• Supervision

The trials were scored and divided into terciles. We also further categorized the trials into an integration matrix based on their provider and process integration levels. We used Forest plots to examine the association of level of integration with patient outcomes for trials of depression care. There were not enough trials of other patient populations for quantitative analysis.

Results for Integrating Mental Health into Primary Care

We identified 33 trials that examined the impact of integrating mental health specialists into primary care. Twenty-six studies addressed depression care and four addressed anxiety disorders. The remaining studies were single studies for somatizing disorders, Attention Deficit and Hyperactivity Disorder (ADHD), and one study addressed both depression and alcohol-related disorders.

Results for Integrating Primary Care into Specialty Mental Health

Only three trials were identified, all of which were covered in a recent systematic review.¹⁵ The trials used collaborative care models with intermediate to high levels of involvement by primary care providers and regular contact between medical and mental health staff that may, or may not be, co-located.

The trials were consistent in reporting improvements in medical care, quality of care, and patient outcomes. Two programs were found to be cost-neutral as increases in outpatient expenditures were offset by declines in inpatient and emergency room use.^{16, 17} There was also a significant decline in annual costs for a subsample of patients with substance-related mental and medical comorbidities compared to the control group.¹⁸ The trials did not report results for serious mental or substance abuse illnesses by age, gender, or ethnicity.

All three trials took place in large, integrated health systems with considerable advantages in co-locating services and shared operational systems. Integration of primary health care into free-standing community substance use disorders treatment clinics with no immediate access to medical health care facilities would likely face additional barriers and challenges not encountered in the trials. Given the minimal cost savings for the subsample of patients with both medical and mental health comorbidities, a sufficiently large caseload to support medical practice may be the most critical concern for providers who are not part of a large system that assesses costs from a health plan perspective.

Case Studies

Thirteen case studies conducted to supplement the traditional systematic literature review help the reader translate the research covered in the comprehensive literature review into actual clinical and administrative practices. A tipping point is being reached as more programs are implemented. Networks of health care organizations developing and implementing various integrated care models are arising as communities of organizations learn together and share information and lessons learned as integrated care gathers momentum.

Discussion

In general, integrated care achieved positive outcomes. However, it is not possible to distinguish the effects of increased attention in general to mental health problems from the effects of specific strategies. The lack of correlation between measures of integration or specific elements of care processes and the various outcomes reinforces the underlying question about the specific effect of integrated care. All but two studies compared integrated care to usual care. The two studies that directly compared two levels of integration, integrated care and enhance referral or consultation-liaison, found no clear differences in outcomes by study end.

It makes sense that introducing a systematic approach and extra attention to treating mental illness in the context of primary health care should yield a beneficial result. There are possible concerns that raising the average level of practice might come at the expense of losing individually expert care. Some might be concerned that the value of introducing a structured approach might prevent some patients from receiving more individualized care.^{19, 20}

Efforts to implement integrated care will have to contend with the financial barriers posed by fee-for-service payment. Many of the costs involved are not regularly covered by a payment system based on specific in-person encounters. Integration can be fostered by improved health IT but the case for using this approach has not been well documented to date.

Future Research

A major unresolved issue remains to define just what elements of integration are vital in producing the desired goals. Head-to-head trials testing more explicit variation of integration components and elements of care process might help to resolve this issue.

There is considerable work to be done to understand who benefits from integrated care. The effects of comorbidities, both mental and physical, should be included in multivariate models. Eligibility criteria should be broadened to include patients with multiple mental health conditions. More attention should be given to powering studies and collecting data necessary for subgroup analysis for minority groups. Research aimed at efficiently matching clinical and organizational processes and resources to different levels of care for varying levels of severity, and patients stratified by risk and complexity, would build on the efforts the IMPACT trials and Intermountain Healthcare's examples.

Demonstration projects would advance our understanding of the financial structures that best support sustainable integrated programs. The VA's consortium on quality improvement processes is working towards describing best practices adapted to local requirements that facilitate efficient and effective change processes; more work along these lines in a wider range of settings is needed.

More exploration of the business case for integrated care will be needed if plans are ever going to finance such an approach. Programs will be needed to assure that each practice that works with multiple plans is adequately covered to make changing their approach financially feasible. More needs to be done to assess the effect of patient volume and case mix on financial feasibility.

Policy Implications

The big question is whether to view the cup as half full. There is a reasonably strong body of evidence to encourage integrated care, at least for depression. Encouragement can run the gamut from removing obstacles, to creating incentives, to mandating such care. The encouragement will likely differ between fee-for-service care and managed care, although both must address the issues of paying providers. However, without evidence for a clearly superior integrated model, there is a legitimate reason to worry about premature orthodoxy.

Overview

The Report of the President's New Freedom Commission on Mental Health¹ identified the need for better coordination between primary care and mental health care and called for dissemination of evidence-based models to improve care at the interface of general medicine and mental health. Provision of care at this interface is the aim of integrated care.

Primary care's defining features of continuity, comprehensiveness, and coordination match the needs of persons with chronic illnesses,²¹ and people with chronic mental illnesses, such as depression and anxiety disorders, often engage with health care by first presenting to the primary care provider.²² Integrating mental health into primary care settings brings the care to where the patient is. Further, mental health problems, including subsyndromal mental distress, exacerbate the disability associated with physical disorders and may complicate their management.²³ Thus, integrating mental health providers into primary care settings may improve the treatment of the “whole” patient with concomitant improvement in outcomes and reduced utilization. Mental illnesses have a wide range of severity and responsiveness to treatment, however, and primary care settings may not be the logical medical home for people with severe mental illnesses.

Conversely, specialty mental health centers are often the primary place of contact for people with severe mental illnesses. Yet, persons with severe and persistent mental illnesses often do not have their general medical needs adequately addressed.²⁴ Thus, some research has focused on integrating primary health care services into specialty substance use treatment settings to better prevent and address the physical comorbidities that often accompany severe mental illnesses and addictive disorders.¹⁵

At the simplest level, integrated mental and physical health care^* occurs when mental health specialty and general medical care providers work together to address both the physical and mental health needs of their patients. Integration can work in two directions: either (1) specialty mental health care introduced into primary care settings, or (2) primary health care introduced into specialty mental health settings.

The rationale for the first type of integration is predicated on five main findings from the research literature. First, persons with mental health problems often do not receive treatment.^{22, 25} Second, persons with mental health problems are as likely to be seen in the general medical care sector (23 percent) as in the specialty mental health care sector (22 percent).²² Third, patients are much more likely to see a primary care physician (PCP) each year than a mental health specialist;²⁶ therefore, PCPs may be in the best position to recognize and improve rates of appropriate treatment. Fourth, many people with mental health problems have comorbid physical health problems such as cardiovascular or pulmonary disease, diabetes, or arthritis.²⁷–²⁹ Mental health problems exacerbate the disability associated with physical disorders, and patients with such comorbidities consume high levels of medical care services and health care costs.³⁰–³² Treating mental health problems among patients with physical health problems, therefore, may potentially reduce overall health care costs. Finally, there is a strong body of evidence that effective care for common mental health problems, such as depression and anxiety, can be effectively delivered in the primary care setting,^{33, 34} although in usual practice the care often falls below quality standards.^{35, 36}

The second broad type of integration refers to integrating primary health care into specialty mental health care settings. Such efforts have responded to findings that persons with severe and persistent mental illnesses (SPMI), such as schizophrenia, often do not have their general medical needs adequately addressed. Those individuals are at higher risk for medical problems, such as hypertension, coronary heart disease, and diabetes, and have significantly shorter life expectancy than persons without mental illness.³⁷ Moreover, many of the most effective medications for persons with SPMI are associated with physical health problems, especially metabolic syndrome (e.g., obesity, elevated cholesterol, and blood pressure), that further increase the risk for cardiovascular disease and diabetes. These physical illnesses are also often under-treated for the SPMI population.³⁸ Persons with SPMI may also have inadequate access to primary care and preventive services.³⁹ The drastic difference in morbidity and mortality for persons with SPMI documented in the research—up to 25 years shorter life span compared to the general population—has generated a sense of urgency for governmental bodies and consumer advocacy groups to improve overall care.^{40, 41}

There is also a case for integrating primary health services into specialty substance use treatment settings.^{15, 24, 42} Physical comorbidities often accompany substance use,^{43, 44} and often primary care services may improve addiction outcomes.⁴⁵

Taken together, this literature suggests that the historical practice of separating mental and physical health care may be misguided. Integrated models of care offer the potential to improve access to treatment and improve quality.

Wagner's CCM is widely cited as a way to provide quality care to people with chronic illnesses.⁴⁶ This model includes system wide changes in practice organizations such as self-management support, delivery system design, decision support, and clinical information systems. Discrete disease management (DM) programs and support services have proliferated for treatment of specific chronic diseases to improve outcomes and reduce costs.²¹ CCM is complementary to the concept of patient-centered care. Both the CCM and DM focus on changing the organization of services from reacting to acute illnesses to proactively coordinating the provision of care.²¹ The CCM was conceived to be responsive to needs of patients with multiple comorbidities, and DM has been evolving to acknowledge a “whole person” model as well.⁴⁷ Integrated care for mental illnesses uses this same proactive perspective but differs in two important ways.

One major difference is the concept of collaboration. The term “collaboration” has been used in two ways in chronic illness literature. One use refers to collaboration between patients and health providers in developing care plans to achieve agreed-on treatment goals and ongoing education and support of the patient's self-management of the disease.⁴⁸ Patients and their families provide the bulk of care activities for chronic illnesses and are, in fact, the primary caregivers.⁴⁹

The second use of “collaboration” refers to collaboration between providers, ensuring that the treatment plan and provision of services is appropriate and coordinated across providers with different expertise and treatment domains. This second use is of particular importance in integrated care because the collaboration is taking place between providers from what has been two parallel health systems representing historically different perspectives and approaches to health and health care. Seaburn et al. argue that effective collaboration within the context of integrated care requires an ecological perspective that attends to collaboration with all participating and affected parties.⁵⁰

The second major difference from the CCM is how this second form of collaboration adds to the complexity of successfully providing sustainable integrated care. The Institute of Medicine's (IOM) Crossing the Quality Chasm report⁵¹ suggested the health care system as it currently exists may not be sufficient to support proactive, collaborative processes. Models of collaborative integrated care will not be sufficient without system wide integration. Integration takes place at many levels,^{51, 52} including organizational and financial, and is aided or hindered by the cultural integration of mental health, medical health domains, and world views. For example, the Four Quadrant Clinical Integration Model organizes patients across the medical and mental health spectrums based on their combined medical and psychiatric needs and outlines major system elements needed for that population or subset of the general population.

Terminology around this type of care has become confusing. The terms “integrated care” and “collaborative care” have sometimes been used in what appears to be interchangeable ways, but at other times they reflect subtle but important differences. Historically, the “Collaborative Care Model” was a term used in some of the earliest research on integrated care in the United States by Wayne Katon and his colleagues. Within the United States, the term “integrated care” has tended to be used, perhaps in part to distinguish other models from Katon's Collaborative Care Model, perhaps in part in recognition of bringing together into a unified health care whole what had previously been segregated into mental health and medical health care systems. On the other hand, international research efforts, specifically within the United Kingdom and Canada, have tended to use the term “collaborative care,” again, with the term's foundations in the Katon model. “Complex system interventions” and “multifaceted interventions” are also terms found in research that have been used to get at the comprehensiveness of the programs which may or may not emphasize the collaboration between providers of different health disciplines.

Defining Integration

Table 1

Definitions of clinically integrated health care

Table 1

Definitions of clinically integrated health care

Source	Definition of Integration
Institute of Medicine, 200655	Integrated treatment: “refers to interactions between clinicians to address the individual needs of the client/patient” and consists of “any mechanism by which treatment interventions for co-occurring disorders are combined within the context of a primary treatment relationship or service setting” (see page 213 of IOM report)
Shortell, 200059	Clinical integration: “extent to which patient care services are coordinated across people, functions, activities, and sites over time so as to maximize the value of the services delivered to the patient”
Strosahl, 1998 as reported in Robinson and Reiter, 200765	Integration: “integration occurs when the mental health provider is considered a regular part of the health care team.
Blount, 2003 (pages 122, 124)23	Integrated services “have medical and behavioral health components within one treatment plan for a specific patient or population of patients.” Integrated care: “describes care in which there is one treatment plan with behavioral and medical elements rather than two treatment plans. The treatment plan is delivered by a team that works together very closely or by pre-arranged protocol.”
Byrd et al, 2005 (page 2)66	Integrated care: “the process and product of medical and mental health professionals working collaboratively and coherently toward optimizing patient health through biopsychosocial modes of prevention and intervention.”
Veterans Administration, 200554	Integrated behavioral model: “is to support the primary care provider in identifying and treating patients with mental health diagnoses and/or need for behavioral interventions.”
Smith, 2007 67	Integrated care: “recognized by the acceptance of one individual clinician of responsibility for assessment, planning, linking, monitoring, advocacy, and outreach with respect to all factors that are pertinent to meeting an individual's health care needs and achieving cost-effectiveness outcomes”
Hogg Foundation, 200853	Integrated health care approach: “primary care and mental health providers partner to manage the treatment of mental health problems in the primary care or pediatric setting and to address barriers to implementation that they encounter.”
American Psychological Association, Presidential Task Force on Integrated Health Care for an Aging Population, 2008 (page 21)68	Integrated health care: “characterized by a high degree of collaboration among the various health professionals servicing patients in terms of assessment, treatment planning, treatment implementation, and outcome evaluation.”
	Definition of Collaborative Care
Bower, 200660	Collaborative Care: a multifaceted organisational intervention, which could include a number of components: (a) the introduction of a new role (case manager) into primary care, to assist in the management of patients with depression through structured and systematic delivery of interventions; (b) the introduction of mechanisms to foster closer liaison between primary care clinicians and mental health specialists (including case managers) around individual patient care; (c) the introduction of mechanisms to collect and share information on the progress of individual patients.
Katon, 200369	Collaborative care is a multimodal intervention that includes integration of a care manager into primary care who works with both patient and PCP and helps with developing a shared definition of the problem, providing patient education and support, developing a shared focus on specific problems, targeting goals and a specific action plan, offering support and problem-solving to optimize self-management, achieving closer monitoring of adherence and outcomes, and facilitating appointments to the PCP or specialist for patients with adverse outcomes or side-effects.
Gagne, 2005, Canadian collaborative Mental Health Initiative70	Collaborative care is not a fixed model or specific approach; rather, it is a concept that emphasizes the opportunities to strengthen the accessibility and delivery of mental health services through primary health care settings through interdisciplinary collaboration.

Figure 1. Characteristics of Integration Linked to (more...)

   Figure 1. Characteristics of Integration Linked to Process of Care

Figure 1

To capture the full breadth of models that may be considered integrated, we conceptually define integration as the systematic linkage of mental health and primary care providers. This conceptualization most closely reflects the IOM definition of integrated treatment and is inclusive of the five levels of collaboration elaborated by Doherty et al.⁵⁶ Mental health providers are broadly defined to include not only professionals such as psychologists and psychiatrists, but also providers such as nurses and care managers whose roles focus on the mental health needs of patients, if such providers are supervised by specialty mental health professionals. The nature of the linkages between providers may also vary widely.

The presence of integration needs to be separated from its effects. One of those effects may be implementing a more structured, evidence-based approach to mental health care. Models of integration may not simply rely on linking providers but are multifaceted and target other elements of the care process. Identification of patients with mental health problems in primary care has long been recognized as inadequate,^{57, 58} and many models of integration include systematic screening as one element to improve care. With a substantial body of evidence indicating that improving case identification alone is not sufficient for improving clinical outcomes,²³ other elements of the care process are targeted by integration efforts. These include educating patients about the nature of the disorder and self-management, introduction of evidence-based guidelines for care (including stepped care), the availability of new therapies in primary care settings (e.g., psychotherapy), and systematic followup of patients to assess clinical status and/or medication adherence. It is not enough, however, just to have the enhancements to primary care settings. There must be time to implement them and to follow through on evidence-based interventions for patients found to have mental health and substance use disorder problems. This involves restructuring personnel and workflows.

Clinical integration is supported by integration at the system or organizational level.^{55, 59} Linkages in the administrative functions, clinical records, claims processing, financing, disease management programs, and the like that take place at the organizational or systems level may facilitate clinical integration.

Key Questions

Through consultation with Agency for Healthcare Quality (AHRQ) and the Technical Expert Panel (TEP) (identified in Appendix A), six key questions were defined. They are restated here as:

• 1)

  What models of integration have been used?

  • a)

    What theoretical models support these programs?

  • b)

    What is the evidence that integrated care leads to better outcomes?

• 2)

  To what extent does the impact of integrated care programs on outcomes vary for different populations (e.g., specific mental illness conditions, chronically ill, racial/ethnic groups, elderly/youth)?

• 3)

  What are the identified barriers to successful integration?

  • a)

    How were barriers overcome?

  • b)

    What are the barriers to sustainability?

• 4)

  To what extent did successful integration programs make use of health IT?

• 5)

  What financial and/or reimbursement structure was employed in successful integration programs? Is there evidence to suggest that any specific financial/reimbursement strategy is superior to another?

• 6)

  What are the key elements of programs that have been successfully implemented and sustained in large health systems? To what extent do they follow, or how do they differ from, models that have been studied in published research studies?

Scope of the Review

While integration may occur in numerous sectors, this review is focused on models that integrate primary care with specialty mental health care in outpatient settings. Studies of integrated care within inpatient settings are beyond the scope of the review. As well, we do not review studies of integrated care that have been conducted in regions outside the United States. However, we utilize reviews of existing models of integrated care (i.e., Bower et al., 2006)⁶⁰ that include primary research done within and outside the United States. Finally, studies that focus on integrating primary care services with drug abuse services are beyond the scope of the review.

Table 2

Summary of prior reviews involving some form of integrated (more...)

Table 2

Summary of prior reviews involving some form of integrated care for persons with mental illness

Source First Author	Criteria for Inclusion	Population of Interest	Question	Number of Trials/Period
A. Systematic Reviews of Studies that Integrate Mental Health Services Into Primary Care
Badamgarav, 200371 Systematic review	“Interventions that include systematic approach to care...(set of systematically developed statements to assist practitioner's and patient's decision about appropriate health care for specific clinical circumstance”	13,220 adult patients with depression	Do disease management programs improve depression outcomes in primary care? Includes some studies of single components of disease management programs, not all were integrated care.	19 trials, from 1987 to June 2001. Includes non-U.S. trials. Not all trials were integrated care.
Bower, 200660 Meta analysis and meta regression	Multifaceted organization intervention that could include: a) new role to assist in management of depression b) mechanisms to foster closer liaison between clinical and mental health specialists c) mechanisms to share information about progress of patients	Adult patients with depression	What are the active ingredients in collaborative care?	34 trials, through October 2005. Includes non-U.S. trials
Craven, 200672 Systematic review	Collaborative care: involving providers from different specialties [at least one must be a primary care provider]...can involve better communication, closer personal contacts, sharing of clinical care, joint educational programs and/or joint program and system planning)	Depression and high utilizers	What are better practices within collaborative care?	38 trials and followup reports, 1985 through June 2005. Includes non-U.S. trials
Gensichen, 200673 Meta-analysis	Case-management including at least the systematic monitoring of symptoms	4,320 adult patients with depression	Does case management improve major depression in primary care? Not all trials were integrated care.	13 trials, through May 2003 Includes non-U.S. trials
Gilbody, 200374 Systematic review	“Guidelines and organizational and educational interventions” “studies that examined the effectiveness of an organizational or educational intervention targeted at primary health care professionals (medical or nonmedical) and patients or novel models of providing health care were selected”	Adult patients with depression	Do educational and organizational interventions improve depression management in primary care?	36 trials, through March 2003. Includes non-U.S. trials. Not all trials were integrated care.
Gilbody, 200664 Meta-analysis	Multifaceted intervention, needed to involve at least 2 of 3 of specialists: a case manger, a primary care provider, or a mental health specialist	12,355 adult patients with depression	What are short- and long-term effects of collaborative care compared to standard care?	37 trials, through February 6, 2006. Includes non-U.S. trials
Gilbody, 200675 Systematic review	Organization interventions defined as (any of following) a) clinical education b) dissemination and implementation of guidelines c) reconfiguration of roles within primary care d) case management or active followup e) consultation-liaison or other methods of improving the working relationship between primary care and specialist/secondary services	4,757 adult patients with depression	Is enhanced primary care cost effective?	11 evaluations, through October 2005. Includes non-U.S. trials. Not all trials were integrated care.
Gunn, 200676 Systematic review	System level interventions defined as including all of the following: a) multi-professional involved in patient care - at least a general provider and one other health professional b) structured management plan - access to evidence based information c) Scheduled patient followups d) Enhanced inter-professional communication	Adult patients with depression	Do complex system level interventions improve recovery from depression in primary care?	11 trials, through June 2004 Includes non-U.S. trial.
Skultety, 200677 Systematic review	Psychosocial treatments: “include systems of care, direct interventions or psychotherapy, telephone care, and psychoeducational efforts aimed at patients”	6,545 patients 55 and older with depression	What is evidence base for depression treatments for older adults in primary care settings?	8 trials, 1994 through April 2004; 4 integrated models, 4 Geriatric Evaluation Management (GEM) models
Smith, 200767 Systematic review	Shared care models: “joint participation of primary care physicians and specialty care physicians in the planned delivery of care for patients with a chronic condition, informed by an enhanced information exchange over and above routine discharge and referral”	Patients with chronic illness, including depression and serious mental illness	Does shared care work for chronic disease management?	20 trials, through April 2006: 6 trials of depression care, 3 studies of serious mental illness, some in-patient. Includes non-U.S. trials
Williams, 200778 Systematic review	Multifaceted intervention in primary care: at least one patient centered component of chronic care model (e.g., patient self-management or active followup)	10,910 adult primary care patients with depression	Do multifaceted interventions improve depression outcomes, what are key elements, who is likely to benefit?	84 articles representing 28 trials, 1966 through February 2006. Includes non-U.S. trials
Vergouwen, 200379 Systematic review	Interventions that directly targeted the patient to improve adherence to antidepressants	Adult patients with depression	Are programs to enhance antidepressant adherence effective?	19 trials, through 2001. Includes non-primary care settings. Not all trials were integrated care.
B. Systematic Reviews of Studies that Integrate Primary Care into Specialty Mental Health Settings
Druss, 200615 Systematic review	Studies focused on improving medical care for persons with mental and addictive disorders	1,477 adults with mental and addictive disorders	Can interventions improve general medical care for persons with specialty mental health needs?	7 articles representing 6 trials, through June 2005, Includes inpatient settings

Search Strategy

Our study search plan included electronic and manual searching. We searched a wide variety of electronic sources, including MEDLINE^®, CINAHL, Cochrane databases, and PsychINFO. The electronic searches were performed on December 6, 2007, and included English language articles from 1950 to the present. We also manually searched reference lists from systematic reviews.

The main search strategy included an extensive list of terms intended to identify all research publications associated with three domains: collaborative or integrated care, primary care, and mental illness. We used medical subject heading (MeSH) terms as well as key words relevant to the three domains as the search basis for all key questions. (The search strategies are provided in Appendix B). The results were separated into two libraries. One library contained articles identified by search strings as controlled trials and observational studies, including qualitative research, and formed the basis for Key Questions 1 and 4. The other library contained all articles not included in the first library and served as additional sources for Key Questions 2, 3, and 5.

We also included a search of the ‘grey’ literature that does not appear in the peer-reviewed publications. We accessed the websites of specific organizations known to be involved in integrated health care initiatives. We also conducted Internet searches on Google™ using the key words “primary care mental health integrated” to identify any relevant integrated care programs. The TEP also identified further sources that were not in the published literature.

For the case studies, after consulting with the TEP, we polled national experts about sites that might illustrate the range of experiences. We were especially interested in identifying practices that either appeared to have the requisite components but did not sustain an integrated program or those that lacked some presumably crucial element but succeeded nonetheless.

Eligibility

Two investigators independently reviewed article abstracts for eligibility. Full articles were examined if (1) there were no abstracts, (2) the abstracts were inconclusive, or 3) there was disagreement between the investigators on article eligibility. Differences of opinion regarding eligibility were resolved through consensus adjudication. All controlled trials and quasi-experimental design studies were included for Key Questions 1 through 5.

The initial review of controlled trials and quasi-experimental design studies included two main criteria for eligibility:

• 1)

  Setting: Outpatient (primary care or specialty mental health care).

• 2)

  Providers: Primary Care and Mental Health Specialty.

The first criterion included studies that integrated mental health care into primary care and those that integrated primary care into specialty mental health outpatient settings. We excluded studies that focused on improving the transition from inpatient to outpatient care.

The second criteria required the involvement of both primary care and mental health specialty providers. We used liberal definitions for each. PCPs included family physicians, general internists, primary care clinics, and urban and rural health centers. Specialty providers included psychiatrists, psychologists, social workers, and psychiatric nurses. We included studies that involved a care manager who had the specific role of addressing or coordinating the primary or mental health needs of patients. Any evidence that there was systematic communication between the primary care provider and the mental health provider was sufficient for inclusion based on our definition of integrated care. Thus, studies that only introduced a new mental health service within a primary care outpatient setting but did not include systematic communication between the PCP and mental health providers were not included.

Additional exclusion criteria included:

• Studies conducted outside the United States.

• Studies where improving mental health outcomes were a minor part of the intervention. For example, we excluded studies of interventions aimed to address the broad mental, physical, and psychosocial needs of new mothers that measured some mental health outcomes. Similarly, we excluded studies that included mental health outcomes as a minor part of an overall geriatric intervention, e.g., the geriatric evaluation and management (GEM) studies.

• Studies of integrated care for non-alcohol related substance use (at the request of AHRQ).

• Studies focused on integrating care for persons with Alzheimer's or dementia.

• Studies focused on development disorders of children.

• Quasi-experimental studies with fewer than 100 subjects per study arm.

Articles from the other literature library that provided insight into program elements and the environmental context of a trial identified for Key Questions 1 and 4 were retained for narrative discussion.

Data Extraction

At least two researchers independently abstracted each included article using a standard abstraction form (Appendix C). We generated a series of detailed evidence tables containing all the relevant information extracted from eligible studies. Results of the evidence tables were used to prepare the text of the report and selected summary tables. At least two researchers checked the quality of each evidence table. Differences were resolved through consensus.

Quality Assessment

Studies were assigned a rating of Good, Fair, and Poor based on a 20 item checklist for designed for both randomized controlled trials (RCTs) and quasi-experimental designs.⁸⁰ Two reviewers assessed the quality of all included studies. Differences of opinion were resolved by consensus adjudication of at least three reviewers. Completion of the checklist was based solely on what was reported in the articles. Poor quality studies were not retained. Analyses were subjected to sensitivity analysis by assessing whether dropping Fair quality studies would change the results.

Applicability

Applicability of the results of this review is affected by the representativeness of the populations recruited to the studies. Refer to Appendix D for patient inclusion and exclusion criteria for included trials. Articles reporting secondary data analysis of RCTs for subgroup analysis were included for Key Question 4.

Many of the studies examined here were conducted under special circumstances of funding and implementation. As with many demonstration projects, the amount of external influence and support makes it hard to generalize from their experience to more typical practice environments. An especially relevant issue in this context is the source of ongoing financial support. Many of the activities tested are not easily reimbursable under conventional payment approaches. We have examined this issue in the discussion and in the case studies.

Rating the Body of Evidence

In looking across the body of evidence available, we have judged both the quality and consistency of the material and tested the effects of restricting our conclusions to only those studies of high quality. We have based our approach on the summarization methods advocated by the GRADE Working Group.⁸¹

Although the extent of heterogeneity among the studies precluded formal meta-analysis and pooling, we sought to explore the patterns across study groupings.

Summary Scores

We created two summary scores to use in our analysis.

Case Studies

Potential case study participants were collected from internet searches, canvassing printed literature, and nominations from TEP members, staff at Federal Government agencies, and experts in the field. An elite interview process was used to allow the case study to follow the unique narrative offered by the case study participant. The participant was given the opportunity to vet the case study write up before inclusion in the publication.

Search Results

Figure 2. QUORUM Statement Data

   Figure 2. QUORUM Statement Data

Figure 2

The results for the key questions are divided into several sections. First we address studies that integrated mental health services into primary care. In the second part we examine efforts to bring primary care into mental health settings. The third section will present findings from the case studies.

Integrating Mental Health into Primary Care

Key Question 1: What Models have been Used? What is the Evidence that Integrated Care Leads to Better Outcomes?

Table 3

Level of integration of providers

Table 3

Level of integration of providers

Project Name or Author, Year	Decision Making	Location
High Level Integrated Providers
Price, 200091	Consensus	On-site
Katon, 1992107	Consensus	On-site
Katon, 1995102	Consensus	On-site
Katon, 1999103	Consensus	On-site
Hedrick, 200387	Consensus	On-site
Swindle, 200385	Consensus	On-site
Intermediate I Level Integrated Providers
IMPACT2,94,121,130,173	Coordinated	On-site
Grypma, 2006 93	Coordinated	On-site
Pathways69,113	Coordinated	On-site
Katon, 199688	Coordinated	On-site
Katon, 200198	Coordinated	On-site
Roy-Byrne, 2001109	Coordinated	On-site
Intermediate II Level Integrated Providers
Clarke, 200583	Coordinated	Unclear
Simon, 2004842 arm	Coordinated	Separate
Escobar, 2007174	Coordinated	Unclear
Epstein, 2007112	Coordinated	Separate
Boudreau, 2002104,175	Coordinated	Separate
Simon, 200484 1 arm	Coordinated	Separate
Finley, 2003108	Coordinated	Separate
Hilty, 2007105	Coordinated	Separate
CCAP9,90	PCP directed	On-site
PROSPECT95,125,135	PCP directed	On-site
PIC Therapy86,122,123,136,176	PCP directed	On-site
Asarnow, 2005114	PCP directed	On-site
Low Level Integrated Providers
Tutty, 200089	PCP directed	Separate
Rollman, 2005101,177	PCP directed	Separate
Hunkeler, 2000110	PCP directed	Separate
Fortney, 200692,131	PCP directed	Telemed
Adler, 2004106,178	PCP directed	Separate
QuEST5,111,124	PCP directed	Separate
Datto, 200397	PCP directed	Separate
RESPECT-D96,120	PCP directed	Separate
Katzelnick, 2000100	PCP directed	Separate
Simon, 200099	PCP directed	Separate
PIC Med86,122,123,136,176	PCP directed	Separate

If care manager is high level, provided, and on location, coded as on-site. If care manager is low level and all other therapy is provided by referral, coded as separate.

Levels of integration of providers. Table 3 identifies how each of the studies assessed was classified into one of four levels of integration based on the two integration parameters.

Table 4

Level of integrated proactive process of care

Table 4

Level of integrated proactive process of care

Care Process Elements
Outcome Author	Screening	Patient Education/Self-Management	Medication	Psychotherapy	Coordinate Care	Clinical Monitoring	Medication Adherence	Standardized Followup	Formal Stepped Care	Supervision
High Integrated Process of Care
Fortney, 200692	Yes	2	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes
Grypma, 200693	No	2	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
IMPACT2,94,121,130,173	Yes	2	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Clarke, 200583	No	2	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes
PROSPECT95,125,135	Yes	2	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NR
Pathways69,113	Yes	2	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
PIC-Med86,122,123,136,176	Yes	1	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes
Hedrick, 200387	Yes	2	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Katon, 199688	No	2	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NA
Katon, 200198	No	2	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes
CCAP9,90	Yes	2	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Rollman, 2005101,177	Yes	2	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes
Price, 200091	Yes	2	Yes	Yes	Yes	Yes	Yes	No	Yes	NA
Asarnow, 2005114	Yes	2	Yes	Yes	Yes	Yes	Yes	Yes	Yes	NR
Intermediate Integrated Process of Care
RESPECT-D96,120	No	1	Yes	No	Yes	Yes	Yes	Yes	No	Yes
Simon, 200484 arm 1	No	1	Yes	No	Yes	Yes	Yes	Yes	No	Yes
Simon, 200484 arm 2	No	1	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes
Adler, 2004106	Yes	1	Yes	No	Yes	Yes	Yes	Yes	No	Yes
Swindle, 2003,85	Yes	0	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes
Datto, 200397	No	2	Yes	No	Yes	Yes	Yes	Yes	No	Yes
Boudreau, 2002104,175	No	0	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes
Tutty, 200089	No	2	Yes	Yes	No	Yes	Yes	No	No	NA
QuEST5,111,124	Yes	1	Yes	No	No	Yes	Yes	Yes	Yes	Yes
Hilty, 2007105	No	1	Yes	No	Yes	Yes	Yes	Yes	NR	NR
Katzelnick, 2000100	No	1	Yes	No	Yes	Yes	Yes	Yes	Yes	No
Roy-Byrne, 2001109	Yes	1	Yes	No	No	No	Yes	Yes	Yes	NA
Low Integrated Process of Care
Finley, 2003108	No	1	Yes	No	No	Yes	Yes	Yes	No	Yes
PIC therapy86,122,123,136,176	Yes	1	No	Yes	No	Yes	No	No	Unclear	Yes
Katon, 1995102	No	2	Yes	No	No	No	Yes	Yes	No	NA
Katon, 1999103	No	1	Yes	No	No	No	Yes	Yes	No	NA
Hunkeler, 2000110	No	0	Yes	No	No	No	Yes	Yes	No	Yes
Simon, 200099	No	0	Yes	No	Yes	No	Yes	Yes	No	Yes
Katon, 1992107	No	0	Yes	No	No	No	No	No	No	NA
Epstein, 2007112	No	0	Yes	No	No	Yes	Yes	No	No	NA

Screen - since many took place under research conditions, coded as “yes” if the tools used were ones already, or easily, implemented in PC settings

Levels of integrated care process and proactive followup. Table 4 identifies how each of the studies assessed was classified into the integration terciles based on the composite process score.

Figure 3. Matrix Integration

   Figure 3. Matrix Integration

Matrix integration. The matrix in Figure 3 reveals an imbalance in cell population. Only two studies are high in both parameters. A few cells have only one or no studies.

One study could not be incorporated into this review's operational definitions of integration. PRISM-E used a research design in which clinic eligibility for enrollment was based on meeting definitional criteria for integrated or enhanced referral care.⁸² The clinics followed a standardized study protocol across sites, however, clinics were allowed some variation in care processes to meet location conditions. The reports do not provide detailed information or results at clinic levels necessary for inclusion in levels of integration analysis. Because of PRISM-E's unique study design, it will be discussed separately later in the section.

Each of the integration scores, separately and combined, was used to assess the relationship with potential outcomes of integrated care. Those outcomes include severity of mental illness symptoms, treatment response rates, and remission rates. Results for the Partners in Care project were reported in matrix cell 9 if the results for the therapy and medication treatment arms were not reported separately.

Data analysis. Only depression disorder studies were included in data analysis, due to the limited number of articles representing other mental health disorders. Data abstracted from articles comparing interventions to usual care were entered into an Excel table and analyzed using Stata 9.0. Odds ratios (OR) and confidence intervals (CI) were calculated for categorical data using reported counts, or ORs when provided. Mean differences and CIs were calculated for continuous data using group means and standard deviations. Data was not pooled due to significant heterogeneity. Unfortunately, a number of trials reported results as time trends, which could not be included in the analysis. Other articles did not supply sufficient information for calculations. While trials with nonsignificant findings can always be included in analysis by inputting nonsignificant but mathematically correct numbers, we included only trials that reported useable data. There were also a number of articles reporting significant findings that did not report the data in a form usable in the analysis. The evidence tables do report the outcomes for all studies. The results are displayed in groups of six month intervals. If a single trial reported more than one result within a six-month period, the result closest to the end of the period was reported.

Results for Key Question 1 are limited to the most commonly used clinical outcomes of interest, symptom severity, treatment response, and remission. Comprehensive reporting of outcomes, including functioning, quality of life, utilization, and costs, by mental health illness category, is provided in the results section for Key Question 4.

Models of integration. We identified 32 trials that examined the impact of integrating mental health specialists into primary care. The majority of these studies (N=25) addressed depression care, and four studies addressed anxiety disorders. The remaining studies were single studies for somatizing disorders, ADHD, and one study addressed both depression and alcohol-related disorders. The search did identify several studies of integrated care for addiction disorders; however, since the studies did not adequately report separate results for alcohol disorders alone, they were not included in the review. The included trials were reviewed for characteristics of provider integration, elements of the care process, and a description of the care manager role, if one was used, to provide an overview of the operational models of integrated care in use.

Table 5

Characteristics of integration programs for mental (more...)

Table 5

Characteristics of integration programs for mental health into primary care

Outcome Project Name or Author	Case Identification	Providers Involved	Communication Methods	MH Location	Shared Medical Records	Decisionmaking
Depression Disorders
Fortney, 200692,131	Recruitment screening by PHQ-9	PCP, care manager, pharmacist, consult telepsychiatrist, supervisory psychiatrist	Electronic medical record recommendations and progress notes, interactive video with PCP, weekly face-to-face meetings with care manager, pharmacist, and psychiatrist. Care manager as link.	Separate, linked by telemedicine technology	Yes	Team recommendations, PCP directed
Grypma, 200693	Referral	PCP, disease care manager, consulting psychiatrist	Care manager reviewed cases weekly with team psychiatrist and expert PCP. Unclear how communicated to PCP. Care manager as link.	Co-located	Yes	Care manager coordinates care with PCP
IMPACT2,94,121,130,173	50% by referral, 50% by screening by PRIME-MD items	PCP, care manager, supervisory psychiatrist, expert PCP	Web-based tracking system. Care manager reviewed cases weekly with team psychiatrist and expert PCP. Unclear how communicated to PCP. Care manager as link.	PST on-site, Stepped referral care unclear	Yes	Care manager coordinates care with PCP
Clarke, 2005 83	None	PCP, research trained therapist, who also provided case management	Occasional consult between PCP and therapist.	Unclear	Yes (HMO)	Therapist coordinated with PCP
PROSPECT95,125,135,160	Recruitment screening by CES-D	PCP, care manager, supervising psychiatrist	Care manager and psychiatrist review cases weekly. Formal and informal care manager and PCP contact. Care manager as link.	Separate, care manager on site	Unclear	PCP directed
Pathways69,113	Recruitment screening by PHQ-9	PCP, care manager, psychiatrist, psychologist	Care manager, psychiatrist, psychology team reviewed cases bi-weekly. Formal and informal care manager and PCP contact. Care manager as link.	Co-located. Stepped care referral separate	No, but shared monitoring system	Care manager coordinates care with PCP
RESPECT-D96,120	Referral	PCP, care manager, consulting psychiatrist	Care manager and psychiatrist reviewed cases weekly. PCP received written care management report forms. Consulting psychiatrist as liaison between referral care and PCP.	Separate, care manager on site.	Unclear	PCP directed
Simon, 200484	None (Recruitment by computerized pharmacy and visit registry records)	Treatment 1: PCP, care manager, supervising psychiatrist/psychologist	Care manager and psychiatrist reviewed cases weekly. PCP received structured report and computer generated recommendations. Care manager contacted PCP for treatment changes.	Separate, linked by telemedicine technology	Unclear	Care manager coordinates care with PCP. PCP directed
Treatment 2: PCP, care manager, therapist, supervising psychiatrist/psychologist	Care manager and psychiatrist reviewed cases weekly. Therapist not in contact with PCP. Care manager contacted PCP for treatment changes. PCP received structured report and computer generated recommendations.	Separate, linked by telemedicine technology	Unclear	Care manager coordinates care with PCP. PCP directed
Adler, 2004106,178	Recruitment screening by PC-SAD	PCP, clinical pharmacist, consulting psychiatrist available	Pharmacist provided formal computer report to PCP.	Separate, pharmacist on site	No	PCP directed
Finley, 2003108	Referral	PCP, clinical pharmacist, supervising psychiatrist	Pharmacist and psychiatrist reviewed cases weekly. Pharmacist consulted PCP regarding medication change. Progress reports to medical records.	Separate, pharmacist on-site	Unclear	Pharmacist and PCP within defined roles
Swindle, 200385	Recruitment screening by PRIME-MD	PCP, clinical nurse specialist, consulting psychiatrist	PCP and CNS develop and present treatment plan to patient. Warm hand-off if CBT referral.	Co-located	Unclear	PCP and CNS within defined roles
Partners in Care86,122,123,136,176	Recruitment screening by CIDI	QI meds: PCP, care manager, nurse supervisor, psychiatrist, expert PCP	Monthly expert team meetings and case review. Care manager provided written reports to PCP.	Separate, care manager on-site	Unclear	PCP directed
QI therapy: PCP, therapist, therapy supervisor, psychiatrist, expert PCP	Monthly expert team meetings and case review. Therapist provided written reports to PCP.	Co-located CBT, separate for warm hand-off referral	Unclear	PCP directed
Datto, 200397	Referral	PCP, care manager, supervising psychiatrist	Care manager faxed assessment letters and scores to PCP. PCP consulted with supervising psychiatrist as needed.	Separate, linked by telemedicine technology	No	PCP directed
Hedrick, 200387	Both screening and referral	PCP, social worker clinical psychologist, psychiatrist, psychology technician	Regular team meetings, electronic medical records with alert system. Team psychiatrist contacted PCP for treatment plan consensus.	Co-located	Yes	Consensus. Psychiatrist would write scrip if PCP did not.
Katon, 1995102	None	PCP, psychiatrist	Monthly case conferences and consultation between PCP and psychiatrist. Verbal consult followed by consult letter within one week.	Co-located	Not reported, HMO	Consensus
Katon, 1999103	None	PCP, psychiatrist	Monthly case conferences and consultation between PCP and psychiatrist. Verbal consult followed by consult letter within one week.	Co-located	Not reported, HMO	Consensus
Katon, 199688	None	PCP, psychologist, consulting psychiatrist	Case-by-case consultation between PCP and psychologist. Weekly meetings between psychiatrist and psychologist. Psychologist as link between psychiatrist and PCP.	Co-located	Not reported, HMO	Collaborative, manualized
Katon, 200198,115	None	PCP, depression specialist, study psychiatrist	PCP received intermittent verbal and written updates on patient progress from depression specialist. (Patient in maintenance phase)	Co-located	Not reported, HMO	Collaborative
Boudreau, 2002104,175	Referral	PCP clinical pharmacist, study psychiatrist	Bi-monthly conferences between psychiatrist and pharmacist. Medication changes communicated to PCP.	Separate, pharmacist on-site	Yes	PCP directed, pharmacist for med changes
Tutty, 200089	None	PCP, psychotherapist who also provided case management	Computer generated reports and treatment algorithms provided to PCP and therapist.	Separate	Not reported, HMO	PCP directed
Hunkeler, 2000110	Referral	PCP, telehealth nurse, supervising psychologist	Nurse reported patient progress to PCP, method not reported. No reported communication.	Not reported	Not reported	PCP directed
QuEST5,111,124	2-stage recruitment screening by staff	PCP, clinic nurse, consulting psychiatrist (never utilized)	No communication between behavioral health and PCP noted.	Separate	No	PCP directed
Simon, 200099 arm 1 Feedback only	Computerized pharmacy records	PCP	PCP received computer generated feedback with visits and medication history and algorithm based treatment recommendations.	Separate	Not reported, single HMO	PCP directed
Simon, 200099 arm 2 Feedback and care management	Computerized pharmacy records	PCP, care manager, supervising psychiatrist	PCP received computer generated feedback with visits and medication history and algorithm based treatment recommendations. Care manager as link.	Separate	Not reported, single HMO	PCP directed
Hilty, 2007105	Referral	PCP, telemedicine coordinator, consulting psychiatrist	PCP and psychiatrist held case reviews, psychiatrist trained PCP on guidelines, coordinator role not reported.	Separate, telemedicine	Not reported	PCP and psychiatrist collaborated on initial care plan
Katzelnick, 2000100	Recruitment screening with CES-D	PCP, care manager, consulting psychiatrist	PCP and study psychiatrist held periodic case reviews, telephone consultations, PCP received written updates of care monitoring, care manager contacted by phone if patient not doing well.	Not reported	Not reported, HMOs	PCP directed
Asarnow, 2005114	Recruitment screening by brief written CIDI questionnaire and CES-D	PCP, care manager, expert leader quality improvement team for consultation	PCP approved treatment plan created by care manager; methods of communication not reported	On-site	Not reported	PCP directed
Anxiety Disorders
Rollman, 2005101,177	Recruitment screening by PRIME-MD	PCP, care manager, supervisory psychiatrist	Electronic medical record for treatment and progress notes. Care manager and psychiatrist review cases weekly. Care manager as link.	Unclear	Yes	PCP free to reject recommendations
CCAP9,90	Both screening by DSM-IV and referral	PCP, research trained therapist who also provided care management, supervising psychiatrist	Therapist and psychiatrist review cases weekly. Written communication by therapist to PCP. Therapist as link.	Co-located	No	PCP directed
Roy-Byrne, 2001109	Recruitment screening by DSM-IV	PCP, psychiatrist	PCP received consultation letter after each psychiatric visit.	Unclear	Not reported	Psychiatrist led
Price, 200091	PCP screened and referred	PCP, clinical psychologist, consulting psychiatrist available	Psychologist met with PCP in formal department meetings and informal “curbside” meetings, joint meetings with patient	Co-located	Not reported, single HMO	Consensus
Other Disorders
Katon, 1992107	Recruitment screening	PCP, research psychiatrist	PCP and psychiatrist met with patient as team. Consult letters and meetings.	Co-located	Not reported, single HMO	Consensus
Epstein, 2007112	Referral	PCP, research psychiatrists	Consultation reports	Separate	No	PCP directed

Provider integration. As mentioned previously, the key to integration is the linkage between primary care and specialty mental health providers. Table 5 details how the studies operationalized integration of providers. The providers involved varied widely, although all models included a psychiatrist or clinical psychologist who minimally was available for consultation. Some models assigned mental health therapists, who could be a doctorate or master's level psychologist, a clinical nurse with behavioral health training and experience, or a social worker.⁸³–⁹¹ Many models incorporated a care manager whose duties included acting as a communication link between the primary care and specialty mental health providers.^{69, 86, 92}–¹⁰¹ (More detail on the care manager roles and functions, including communication with patients, is provided later in this section.)

Other forms of communication links between providers ranged from consultations on an as-needed basis^{83, 97} to regularly scheduled case reviews^{69, 84, 86}–^{88, 90, 92}–^{96, 100}–¹⁰⁵ and formal protocols for updating primary care providers on patient progress.^{69, 84, 86, 89, 90, 92, 95, 96, 98}–^{101, 106} These updates were provided in the form of computer generated reports, notes and flags in electronic medical records, standardized reports from care managers, or updating consultation letters following patient treatment by a mental health provider. Noted is the lack of information on whether communication linkages included specific training of medical and mental health providers' interpersonal collaborative skills.

Co-located services are intended to facilitate care coordination and communication between providers as well as increase access for patients. Published reports did not always clearly report the location of mental health services. Of those that did, the majority either co-located mental health providers or behavioral health trained care managers in the primary care site^{69, 85}–^{88, 90, 91, 93, 94, 98, 102, 103, 107} or used telemedicine technology to bring otherwise unavailable services to rural or small clinic settings.^{84, 92, 97, 105}

Shared medical records provide a common information base to involved providers, a systematic level of integration. Unfortunately, published reports that included specific information on shared medical records were scarce. Only seven trials clearly stated that providers shared medical records.^{83, 87, 92}–^{94, 101, 104} Single HMOs were the settings for another nine trials,^{88, 89, 91, 98}–^{100, 102, 103, 107} which might imply improved access to medical records by providers, but this remains speculation without further documentation.

Decisionmaking processes operationalize the nature of the relationship between the medical and mental health providers. Wulsin et al. describe seven relationship levels ranging from completely autonomous to a fully integrated team that provides comprehensive care.⁵² The trials fell into three patterns of decisionmaking used by providers. The majority of trials were evenly split between coordinated decisionmaking practices^{69, 83, 84, 88, 93, 94, 98, 105, 108, 109} and the primary care provider principally responsible for care, with the assistance of care management and specialty mental health providers as support^{86, 92, 95, 96, 106, 89, 90, 97, 99}–^{101, 104, 110}–¹¹² Only five trials reported consensus decisionmaking between medical and mental health providers.^{87, 91, 102, 103, 107}

Systematic screening. As shown in Table 5, half of the studies integrating specialty mental care into primary care included a method of systematic screening for mental health problem.^{69, 82, 85}–^{87, 90}–^{92, 94, 95, 101, 106, 107, 109, 111} The remaining studies either relied only on referrals from the PCP^{93, 96, 97, 104, 105, 108, 110, 112} or were targeted toward all patients starting treatment for a mental health problem, such as antidepressant medication treatment.^{83, 84, 88, 89, 98, 99, 102, 103} A variety of tools were used by those studies that employed screeners; no single screener predominated.

Table 6

Elements of care process

Table 6

Elements of care process

Outcome Project Name or Author	Screening	Patient Education of Condition	Patient Self-management Skills	Psychotherapy	Mental Health Specialist Involvement	Clinical and Adherence Monitoring	Standardized Followup	Formal Stepped Care
Depression Disorders
Fortney, 200692,131	Yes	Patient and care manager	Care manager	By referral	Tele-psychiatrist, available for PCP consult	Care manager, clinical, medication adherence	Yes, scripted, 12 months	Yes
Grypma, 200693	Not reported	Care manager, optional group education by HMO patient education department	Care manager	6 to 8 PST sessions by care manager	Psychiatrist, available for consult	Care manager, PHQ9 clinical	Yes, based on patient's self-determined need	Yes
IMPACT2,94,121,130,173	2 item from PRIME-MD	Care manager	Care manager	6 to 8 PST sessions by care manager	Psychiatrist, available for consult	Care manager, PHQ9 clinical	Yes, 12 months	Yes
Clarke, 200583	No	Therapist	Therapist	Up to 9 60-minute CBT sessions	Mental health therapist, provide CBT, consult with PCP	Mental health provider, clinical, medication adherence	Yes, 9 months	Yes
PROSPECT95,125,135	CESD	Care manager	Care manager	IPT	Nurse, social worker, or clinical psychologist, provide IPT and care management	Care manager, clinical and adherence	Yes, unclear	Yes
Pathways69,113	Mailed screen, PHQ	Care manager	Care manager	6 to 8 PST sessions by care manager	Psychiatrist, psychologist, available for consult	Care manager, PHQ9 clinical	Yes, 12 months	Yes
RESPECT-D96,120	No	No	Care manager	By referral	Psychiatrist, available for consult, liaison between referral care and PCP	Care manager, PHQ9 clinical, medication adherence	Yes, 12 month continuation phase, then maintenance	No
Simon, 200484	No	No	Patient workbook (adapted from CBT in Treatment 2)	Treatment 1: By referral	Psychiatrist, psychologist available for consult	Limited, care manager, clinical, medication adherence	Yes, 20 weeks	No
No	No	Therapist	Treatment 2: 8 30–40 minute CBT sessions	Mental health clinician, provide CBT and care management	Care manager, clinical and adherence	Yes, 20 weeks	No
Adler, 2004106,178	PC-SAD	Pharmacist	No	No	Psychiatrist, available for consult	Pharmacist, MADRS clinical, medication adherence	Yes, 18 months	No
Finley, 2003108	No	Pharmacist care manager	No	No	Psychiatrist, available for consult	Pharmacist care manager, clinical and medication adherence	Yes, 6 months	No
Swindle, 200385	2 item PRIME-MD	No	No	Warm hand off referral	Mental health clinical nurse specialist as care manager; psychiatrist, available for consult	Limited, care manager, clinical medication	Yes, 2 months	Yes
Partners in Care86,122,123,136,176	CIDI	Care manager	No	QI Med: By referral	Psychiatrist, available for consult	Care manager, clinical, medication adherence	Yes, randomized to 6 or 12 months	Yes
No	QI Therapy: 12 to 16 sessions CBT or 2 session brief CBT	Therapist, provide CBT; psychiatrist, available for consult	Therapy adherence. Unclear if clinical monitoring	No	Unclear
Datto, 200397	No	Patient and care manager	Limited, care manager	By referral	Psychiatrist, available for consult	Care manager, CESD clinical, medication adherence	Yes, 16 weeks	No
Hedrick, 200387	4 methods	Patient	Patient	6 session CBT	Social worker or clinical psychologist, provide CBT; psychiatrist, available for consult	Care manager, CESD clinical, medication adherence	Yes, 9 months	Yes
Katon, 1995102	No	Patient, psychiatrist	No	By referral	Psychiatrist, provide direct patient care, consulted with PCP	Psychiatrist, medication adherence	Yes, up to 9 months	No
Katon, 1999103	No	Patient, psychiatrist	No	By referral	Psychiatrist, provide direct patient care, consulted with PCP	Psychiatrist, medication adherence	Yes, up to 6 months	No
Katon, 199688	No	Patient, psychologist	Psychologist	Manualized brief CBT and adherence counseling, completed in 4 to 6 sessions	Psychologist, provide 4 to 6 sessions, clinical monitoring. Psychiatrist review medications.	Psychologist and psychiatrist, clinical and medication adherence	Yes, up to 6 months	No
Katon, 200198,115	No	Patient	Patient and care manager collaboration, devised during 2 face-to-face meetings	By referral	Psychiatrist, available for consult	Care manager, BDI clinical, results mailed to patients, patient care plan and medication	Yes, up to 3 months	No
Boudreau, 2002104,175	No	No	No	By referral	Psychiatrist, available for consult	Pharmacist, PRIME-MD clinical, medication adherence	Yes, 12 months	Yes
Tutty, 200089	No	Patient	Therapist	6 weekly 30 minute CBT	Psychotherapist, provided CBT	Therapist, medication adherence	No	No
Hunkeler, 2000110	No	No	No	10 6-minute calls by telehealth nurse for emotional support and behavioral interventions for medication adherence	Supervising clinical psychologist	Telehealth nurse, medication adherence	Yes, 16 weeks	No
QuEST5,111,124	2 stage screener	Patient	No	By referral	Psychiatrist, available for consult	Primary care clinic nurse, clinical and adherence	Yes, 8 weeks	Yes
Simon, 200099 Feedback and care management	No	No	No	By referral	Psychiatrist, available for consult	Medication adherence	Yes, 16 weeks	No
Hilty, 2007105	No	Yes	No	Telepsychiatry visits (50 minutes at first, 20 minutes thereafter) offered at 2, 6, 10, 14, and 18 weeks	Telepsychiatrist, direct patient care and also consultation and training	Clinical, medication, and therapy adherence	Yes, 18 weeks	Not reported
Katzelnick, 2000100	SCID	Patient	No	By referral	Psychiatrist, available for consult	Clinical and medication adherence	Yes, 42 weeks	No
Asarnow, 2005114	CES-D, brief CIDI questionnaire	Care manager	Care manager	Up to 14 50-minute sessions of manualized CBT	Psychotherapist care manager, provide CBT and care management	Care manager, clinical, medication adherence	Yes, 6 months	Yes, based on Texas Algorithm Study
Anxiety Disorders
Rollman, 2005101,177	Items from PRIME-MD	Care manager	Patient, workbook with care manager followup	Assisted referral	Psychiatrist, available for consult	Care manager, clinical and adherence	Yes, 12 months	Yes
CCAP9,90	2 item screen	Patient and care manager	Patient and care manager	6 CBT sessions in 3 months	Behavioral health specialist, provide CBT and care management	Care manager, clinical and adherence	Yes, 9 months	Yes
Roy-Byrne, 2001109	2 item screen	Patient	No	By referral	Psychiatrist, provide direct patient care, consulted with PCP	Psychiatrist, medication adherence	Yes, 12 months	No
Price, 200091	Shedler Quick Psycho Diagnostics Panel	Psychologist	Psychologist	CBT, not manualized. Goal of 4–6 sessions.	Psychologist, provide direct patient care, consulting psychiatrist	Psychologist, treatment adherence	No	Yes
Other Disorders
Katon, 1992107	No	No	No	By referral	Psychiatrist, provided direct patient care, available for consult	No	No	No
Epstein, 2007112	No	No	No	No	Psychiatrist, interpret behavioral scoring and provide titration recommendations	Researchers	Yes, 12 months	No

Integrated process of care. Integrated care provides a structure within which the process of care is enacted. Table 6 details how studies operationalized common elements of an integrated process of care. These elements included patient collaboration features, provision of limited psychotherapy, and systematic followup.

Patient collaboration features aim to improve a patient's engagement in the care process and support self-care. Reporting of program elements of patient education regarding the diagnosed mental illness and training in self-management skills was frequently limited. Even so, the large majority of studies reported providing patient education.^{69, 83, 86}–^{95, 97, 98, 100}–^{103, 105, 106, 108, 109, 111} Ten studies provided printed or video materials to patients for self-study,^{84, 87 88, 89, 98, 100, 102, 103, 109, 111} while 13 studies involved a care manager or mental health therapist in the education process.^{83, 86, 90}–^{95, 97, 101, 106, 108, 113} Training patients in self-management skills was less common.^{83, 84, 87}–^{98, 101, 113} Of those studies, only one study intervention arm relied solely on the patient to complete a self-help workbook on self-management skills without supervision by a care manager or therapist.⁸⁴ Studies of integrated care programs for anxiety disorders were more likely to use patient education and skill development, perhaps reflecting anxiety programs adapting what was learned from depression programs.

The Agency for Healthcare Research and Policy (AHRQ) guidelines for depression care included recommendations for evidence-based forms of psychotherapy. However, psychotherapy is a relatively new service for the primary care setting. About one-third of the studies used therapists or care managers to provide psychotherapy;^{69, 83, 84, 86}–^{88, 90, 91, 93}–^{95, 105} referral to specialty mental health services was more commonly used.⁸⁴–^{86, 92, 96}–^{104, 107, 109, 111} Cognitive behavioral therapy (CBT) was the most frequent form,^{83, 84, 86}–⁹¹ with problem solving therapy (PST) specifically used in three studies,^{93, 94 69} and one study reporting using interpersonal therapy (IPT).⁹⁵ One study relied only on the potentially therapeutic relationship, with a telehealth nurse providing emotional support but not counseling.¹¹⁰

Systematic followup was a strong component of the integrated care models, with 23 studies clearly reporting monitoring clinical outcomes of patients^{69, 83}–^{88, 90, 92}–^{98, 100, 101, 104}–^{106, 108, 111, 114} and 29 studies monitoring patient adherence.⁸³–^{106, 108}–^{111, 114} The studies that did not utilize systematic patient monitoring were early investigations of integrated care.¹⁰⁷ Monitoring and followup of patients were generally performed by care managers or therapists. Twenty-eight studies used formal followup protocols,^{69, 83}–^{88, 90, 92}–^{106, 108}–¹¹² with eight studies following patients during the acute phase of treatment^{84, 85, 97}–^{99, 105, 110, 111} and 20 studies with longer term followup into a continuation or maintenance phase.^{69, 83, 86}–^{88, 90, 92}–^{96, 100}–^{104, 106, 108, 109, 112} Formal stepped care processes for patients not responding to treatment were used in 14 studies.^{69, 83, 85}–^{87, 90}–^{95, 101, 104, 111}

One study worthy of mention is a depression relapse prevention program that provided feedback of clinical outcomes to the patients themselves. This feedback to patients was unique among the integrated care programs. Ludman et al. described using bar charts as visual feedback aids for patients who were constructing written self-management plans.¹¹⁵

Table 7

Description of care management

Table 7

Description of care management

Outcome Project Name or Author	Title Certificate Training	New Staff	Role/Responsibilities*	Mode	Contact Frequency	Supervision
Depression Disorders
Fortney, 200692,131	Depression nurse care manager, RN, training or behavioral health experience not reported	Yes	Coordinate care, provide medical care	Telephone, interactive video website	Bi-weekly in acute phase, otherwise monthly for-up to 12 months through watchful waiting or continuance phase	Yes, psychiatrist
Grypma, 200693	Depression care manager (IMPACT post-study. Medical assistant hired to help DCM with patient tracking)	Yes	Coordinate care; provide medical care; provide behavioral health care, including relapse prevention plan.	Face-to-face, telephone	Based on patient's self-determined need	Psychiatrist consultation as needed
IMPACT2,13094,121,173	Depression care specialist, nurse or psychologist, training in behavioral care for study.	Yes	Coordinate care; provide medical care; provide behavioral health care, including relapse prevention plan.	Face-to-face, telephone	Bi-weekly in acute phase, otherwise monthly for up to 12 months	Yes, psychiatrist
Clarke, 200583	No title, duties performed by master's level mental health specialist	Yes	Provide medical care; provide behavioral health care	Face-to-face, telephone	Up to 9 sessions during 3 month acute phase, 6 contacts over 9 month continuation phase	Yes, study psychiatrist
PROSPECT95,125,135	Depression care managers, nurse, social worker, clinical psychologist	Yes	Coordinate care, provide medical care, provide behavioral health care	Face-to-face, telephone	Unclear	Not reported
Pathways69,113	Depression care specialist, RN, trained for study	Yes	Coordinate care, provide medical care, provide behavioral health care	Face-to-face, telephone, mail	Bi-weekly for acute phase, monthly thereafter for up to 12 months	Yes, psychiatrist
RESPECT-D96,120	Care manager, no special training, during trial; most were primary care or mental health nursing	No	Coordinate care, provide medical care	Telephone	Minimum of monthly for acute phase, bi-monthly for continuation phase, every 6–12 months for maintenance.	Yes, psychiatrist
Simon, 200484	Care manager, mental health clinicians with at least 1 year of depression assessment experience	Yes	Coordinate care Treatment 1: Provide medical care Treatment 2: Provide medical care, provide behavioral health care	Telephone, mail	3 telephone contacts within 12 weeks, 1 mail contact at 20 weeks.	Yes, psychiatrist
Adler, 2004106,178	No title, duties performed by pharmacist	No	Coordinate care, provide medical care	Face-to-face, telephone	At least 9 contacts over 18 months.	Yes, psychiatrist
Finley, 2003108	Care manager, clinical pharmacist	Yes	Provide medical care	Face-to-face, telephone	4 contacts during medication trial, 3 followups over remainder of 6 months	Yes, psychiatrist
Swindle, 200385	Clinical nurse specialist, mental health service experience	No (transfer of staff)	Coordinate care, provide medical care	Face-to-face, telephone	Contact at 2 weeks, 1 month, and 2 months following initial visit.	Yes, psychiatrist
Partners in Care86,122,123,136,176	QI - Med: Depression nurse specialist, local practice nurse trained for study	Yes	Provide medical care	Face-to-face	Weeks 2, 4, and monthly thereafter, randomized to 6 or 12 month followup	Yes, psychiatrist
QI - Therapy: Depression nurse specialist in limited capacity	No	Patient assessment and education	Face-to-face	No	Yes, psychiatrist
Datto, 200397	Disease management nurse, extra training and experience in mental health	Yes	Coordinate care, provide medical care	Telephone	Interval monitoring for 16 week acute phase	Yes, psychiatrist
Hedrick, 200387	No title, social work staff	Yes	Coordinate care, provide medical care	Telephone	Regular schedule for 9 months	Yes, psychiatrist
Katon, 1995102	No care manager	NA	Psychiatrist reviewed records for adherence	Face-to-face	2 to 4 visits in acute phase	NA
Katon, 1999103	No care manager	NA	Psychiatrist reviewed records for adherence	Face-to-face, telephone	2 to 4 visits in acute phase, 1 to 2 telephone followup contacts between visits	NA
Katon, 199688	No care manager	NA	Psychologist collected medication and clinical monitoring	Face-to-face, telephone	4 to 6 visits in first 6 weeks, 4 telephone contacts at 8, 12, 18, and 30 weeks	NA
Katon, 200198,115	Depression specialist, psychologist, nurse practitioner, and social worker with advanced degrees	Yes	Coordinate care, provide medical care, provide behavioral care	Face-to-face, telephone, mail	2 face-to-face, 3 telephone contacts mixed with 4 mailed personalized feedback letters over 12 months	Yes, psychiatrist
Boudreau, 2002104,175	No title, duties performed by pharmacist	Yes	Provide medical care	Face-to-face, telephone	Weekly for 4 weeks, biweekly for 2 months, then bimonthly until 12 months	Yes, psychiatrist
Tutty, 200089	No care manager	NA	Therapist may prompt PCP based on computer report of clinical monitoring and medication adherence	Telephone	6 telephone sessions over 6 weeks	NA
Hunkeler, 2000110	No care manager	No	Primary care nurses offered emotional and instrumental support, medication adherence	Telephone	12 to 14 calls during 16 weeks of acute phase	Yes, clinical psychologist
QuEST5,111,124	No care manager	No	Clinical monitoring and medication adherence by clinic nurse	Face-to-face, telephone	6 contacts over 6 weeks, with option to extend for 2 weeks	Yes, PCP
Simon, 200099 arm 2 Feedback and care management	Care manager, no behavioral health experience	Yes	Coordination of care	Telephone	A minimum of 3 10–15 minute telephone contacts, weeks 1, 8 and 16	Yes, psychiatrist (case load approximately 100 patients)
Hilty, 2007105	Telemedicine coordinator, training not reported	Yes	Coordination of care, provide medical care	Telephone	Not reported	Not reported
Katzelnick, 2000100	Coordinator, clinical mental health experience	Yes	Coordination of care, provide medical care	Telephone	2 to 5 contacts over 42 weeks (PCP visits at weeks 1, 3, 6, and 10, then every 10 weeks)	No
Asarnow, 2005114	Care manager, master's or doctorate in mental health or nursing	Yes	Coordinate care, provide medical care, provide behavioral health care	Face-to-face, telephone	Variable by site as determined by quality improvement team	Not reported
Anxiety Disorders
Rollman, 2005101,177	Care manager, no special behavioral training beyond training for study	Yes	Coordinate care; provide medical care	Telephone	Every 1–3 months in continuation phase for up to 12 months	Yes, team of psychiatrist, psychologist, internist, family practitioner
CCAP9,90	Behavioral health specialist, master or new doctoral levels with no or minimal CBT, trained for study	Yes	Coordinate care, provide medical care, provide behavioral health care	Face-to-face, telephone	6 session during 3 month acute phase, 6 contacts over 9 month continuation phase	Yes, psychiatrist
Roy-Byrne, 2001109	No care manager	NA	Psychiatrist provided medication and followup care	Face-to-face, telephone	2 visits and 2 telephone contacts in acute stage, through 8 weeks, 5 contacts in 10 month continuation phase	NA
Price, 200091	No care manager	NA	Coordination of care clinical, medication, and treatment monitoring performed by psychologist	Face-to-face	Goal of 4 to 6 sessions	NA
Other Disorders
Katon, 1992107	No care manager	NA	None	NA	Not reported	NA
Epstein, 2007112	No care manager	NA	Monitor medication maintenance carried out by consultation service and reported to PCP	NA	NA	NA

*

Role/Responsibilities: Coordinate care is noted when the care manager coordinates care for the patient, including follow up if patients miss appointments. Provide medical care is noted when the care managers monitor medication adherence, side effects, etc. Provide behavioral health care is noted when the care manager providing brief psychotherapeutic treatments, etc.

Care management. Care management is a function, not a role. Care management is defined as “a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes.”¹¹⁶ Many integrated models used designated care managers for the care management function and applied a limited, disease-focused approach. Table 7 describes the training and experience of care managers and how the care management function was performed.

For 19 studies, the care manager was a new position in the practice.^{69, 83, 84, 86, 87, 90, 92}–^{95, 97}–^{101, 104, 105, 108, 114} Training and prior experience for these care managers ranged from bachelor level employees with some clinic staff experience or nurses with no prior mental health experience to master's or doctoral level mental health providers. Of note were two studies that used clinical pharmacists to deliver care management.^{106, 108} Virtually all care managers were supervised by psychiatrists.

Delivery of care management was most commonly accomplished by face-to-face meetings with patients^{69, 83, 85, 86, 88, 90, 91, 93}–^{95, 98, 102}–^{104, 106, 108, 109, 111} and/or telephone contact.^{69, 83}–^{88, 90, 92}–^{101, 103}–^{106, 108}–¹¹¹ There was a wide range of frequency of contacts. Protocols for contacts may call for a minimum of two to three contacts in the acute phase for care managers who do not provide some form of psychotherapy, to six or more sessions for care managers who do. Monthly contact with patients was typical for the continuation phase of protocols.

There was a marked difference in the use of care management for the disorders represented by the studies. Somatizing and other disorders were far less likely to use care management in the integration models.

Of those illnesses that routinely used care managers in integrated care, there were no major discernible differences in models applied to different mental health illnesses, except for one noteworthy study. The Katon et al., 2001 study⁹⁸ focused on relapse prevention for depression patients, many of whom had already participated in a collaborative care model. As reported by Ludman et al.,¹¹⁵ the care managers, known as depression specialists, provided support and counseling to patients and guided them through a process to develop self-care prevention plans. Patients received graphical representations of their depression severity scores over time. By linking the severity score feedback with the prevention plan created by the patient, the patient might learn to recognize triggers and presyndromal signs of possible impending relapses.

Theoretical support for models. Wagner's CCM⁴⁶ is the conceptual model most often identified as informing the intervention; nine of the studies explicitly mentioned the model of integration was based on at least some elements of the CCM^{86, 87, 92, 94, 96, 98, 99, 101, 111} and some of the reviews in the area frame the study of integration within the CCM.^{71, 78} For the most part, however, the interventions fall well short of fully implementing all the key elements of the CCM. Wagner⁴⁶ suggested that practice re-design, patient education, an enhanced expert system (providing education and decision support to clinicians) and a developed information system that could track outcomes and provide feedback to providers are essential to providing high quality chronic care. All should also be implemented in an environment characterized by the use of evidence-based care. These recommendations are quite broad, and to some degree one can argue that each integration intervention addresses at least part of the CCM. But, the models of integration often fail to explicate how (and why) they operationalize the CCM in specific ways for the treatment of mental illness within the primary care settings or how the specific elements of the interventions are linked to the process of care.

While the conceptual models underlying studies of integration are not well developed, all of the studies at least implicitly argue that integration is needed to address specific problems in the process of care that lead to poor clinical and quality of life outcomes. Figure 1 in Chapter 1 shows the elements of the care process that are generally targeted by integration efforts because they are assumed to be associated with improved clinical and quality of life outcomes.

First, identification of patients with mental health problems in primary care has long been recognized as inadequate. For example, studies show that primary care fails to recognize between one-third and one-half of depression cases.^{57, 117} A substantial body of evidence, however, indicates that improving case identification alone is not sufficient for improving outcomes for patients;⁵⁷ systematic therapeutic action is required. Thus integration efforts do not simply target case-identification.

Second, integration proponents recognize that provider practices often lead to inadequate care. The separation of mental and physical health into different medical specialties encourages providers to focus on only the conditions that fit within their specialty. Primary care physicians are often uncomfortable addressing mental health issues. Moreover, when primary care physicians do provide treatment for mental health problems, it often falls below standards for quality care.^{35, 36} Greater structure through guidelines may help to address this problem.

Effect of levels of integration on outcomes: Provider integration. Forest plots of symptom severity, response rates, and remission rates were created for the three forms of integration described above: provider integration, integrated process of care, and matrix integration. These plots examine essentially the same pool of studies, which are regrouped to reflect their meeting various taxonomic approaches to integration. Because of high levels of heterogeneity, it was not possible to pool studies to estimate mean effects. Improvements in symptom severity are plotted to the left of the nonsignificance line as reductions in scores are better. Improvements in treatment response and remission rates are plotted to the right of the nonsignificance line. If increased levels of provider integration improve outcomes, one would expect to see a drift from greater to lesser improvements as the level of integration declines.

Figure 4. Symptom severity outcomes by level of provider (more...)

   Figure 4. Symptom severity outcomes by level of provider integration

Figure 5. Treatment response by level of provider integration (more...)

   Figure 5. Treatment response by level of provider integration

Figure 6. Remission rate by level of provider integration (more...)

   Figure 6. Remission rate by level of provider integration

Table 8

Clinical outcomes by level of provider integration

Table 8

Clinical outcomes by level of provider integration

Outcome Project or Author	Measurement	Patient Category	Assessment Period	Direction of Effect	Result/Effect Size	Comment
MENTAL ILLNESS SYMPTOMS (SEVERITY)
High Level (Depression)
Katon, 1999 and 20023,103	SCL-20	All patients	3 months	Intervention	P=.003
		6 months	Intervention	P=.04	Treatment × time
		All patients	28 months	Intervention	P=.05	Treatment × time
		Moderate severity	28 months	Intervention	P=.004	Treatment × time
High severity	28 months		NS
Lin, 19994 (followup of Katon, 1995 and Katon, 1996)	SCL-20		19 months		NS
Inventory for depressive symptomatology		19 months		NS
Hedrick, 200387	SCL-20		3 months	Intervention	-0.17, 95% CI 0.31; -0.03, p<.05	Equalized amount of treatment between collaborative and consult-liaison models; attention control
9 months		NS
Swindle, 200385	Beck depression inventory	All patients	3 months		NS	No difference in outcomes for major depression or dysthymia. Several CNS were not voluntary, did not follow protocol, etc.
		12 months		NS
		Major depression	3 months		NS
12 months		NS
High Level (Anxiety)
Price, 200091	Shedler Quick Psycho Diagnostics Panel (Anxiety)		6 months	Intervention	P=.046
High Level (Other Disorders)
Katon, 1992107	SCL somatization		6 months		NS
	12 months		NS
	SCL depression		6 months		NS
	12 months		NS
	SCL anxiety		6 months		NS
12 months		NS
Intermediate I Level (Depression)
IMPACT2,179	SCL-20		3 months	Intervention	-0.28, 95% CI 0.34; -0.21, p<.001
			6 months	Intervention	-0.28, 95% CI 0.35; -0.19, p<.001
			12 months	Intervention	NNT=4
			18 months	Intervention	NNT=6
24 months	Intervention	NNT=9
Grypma, 200693	PHQ-9 score	All depression patients	6 months		NS	IMPACT intervention group compared to post-study integrated care group. Same results for less resources
Patients over 60 years	6 months		NS
PROSPECT125	Hamilton Depression Rating Scale	All patients	4 months		-3.5, 95% CI -4.7; -2.4, p<.001
			8 months		-2.1, 95% CI -3.4; -0.9, p<.001
		12 months		-1.8, 95% CI -3.1; -0.5, p=.006
		Major depression	4 months		-4.6, 95% CI -6.2; -3.1, p<.001
			8 months		-2.5, 95% CI -4.1; -0.9, p.003
		12 months		-2.1, 95% CI -3.7; -0.4, p=.02
		Clinically significant minor depression	4 months		NS
			8 months		NS
12 months		NS
Katon, 200198	SCL-20		12 months		NS
Intermediate I Level (Anxiety)
Roy-Byrne, 2001109	PDSS Panic disorder severity scale		3 months		NS	Intervention × time p=.05, driven by reduction in anticipatory anxiety
			6 months	Intervention	P=.003
			9 months		NS
	12 months		NS
	Anxiety sensitivity scale		3 months	Intervention	P=.002	Intervention × time p=.018
			6 months	Intervention	P<.001
			9 months		NS
	12 months	Intervention	P=.035
	Panic related agoraphobic avoidance		12 months		NS
	Fear Questionnaire agoraphobic subscale		12 months		NS
	CES-D		3 months	Intervention	P=.002	Intervention × time p=.03
			6 months	Intervention	P=.005
			9 months	Intervention	P=.036
12 months	Intervention	P=.02
Intermediate II Level (Depression)
Clarke, 200583	CES-D		12 months		NS	Study may have been under-powered to compare 2 active treatments. About 75% remission in both groups within 3 months.
	Hamilton Depression Rating Scale		12 months		NS
Youth Self Report		12 months		NS
Simon, 200484	SCL-20	Telephone psycho-therapy plus care management	6 months	Intervention	P<.001	Difference between groups is equal to ½ of the SD of scores in general population
Telephone care management	6 months	Intervention	NS
Boudreau, 2002175	SCL-20		12 months		NS
Finley, 2003108	Brief inventory for depressive symptoms		6 months		NS
Partners in Care122,123	Percent with probable depression based on CIDI screen	All interventions	6 months	Any intervention	P=.001
		12 months	Any intervention	P=.005
		QI-Therapy	6 months	Intervention	P<.05
			12 months	Intervention	P<.05
			18 months		NS
	24 months		NS
	Overall poor outcome: patient scored depressed if score in depressed range of all 3 CIDI screen, full 12-month CIDI, and CES-D, vs. 2 or fewer measures.	QI-Therapy	6 months	Intervention	P<.05
			12 months	Intervention	P<.05
18 months			Intervention, usual care and QI-Meds	P<.05
24 months	Intervention, QI-Meds	P<.05
Asarnow, 2005114	CES-D		6 months	Intervention	-2.9, 95% CI -5.3; -0.4, p=.02
Percent with CES-D in severe range ≥ 24		6 months	Intervention	OR 0.6, 95% CI 0.4, 0.9, p=.02
Intermediate II Level (Anxiety)
CCAP9	Anxiety sensitivity index score		3 months	Intervention	Effect size 0.44
			6 months	Intervention	Effect size 0.45
			9 months	Intervention	Effect size 0.44
	12 months	Intervention	Effect size 0.43
	CES-D		3 months	Intervention	Effect size 0.29
			6 months	Intervention	Effect size 0.29
			9 months	Intervention	Effect size 0.27
12 months	Intervention	Effect size 0.26
Intermediate II Level (Other Disorders)
Epstein, 2007112	Conners Parent Rating Scale		12 months		NS
Low Level (Depression)
Tutty, 200089	SCL-20		3 months	Intervention	P=.03
6 months	Intervention	P=.03
Hunkeler, 2000110 (reporting telehealth nurse only, not peer support)	Hamilton depression rating score		6 weeks		NS
	6 months	Intervention	P=.006
	Beck depression rating score		6 weeks		NS
6 months		NS
RESPECT-D120	SCL-20		3 months	Intervention	-0.16, 95% CI -0.32; -0.002, p=.048
6 months	Intervention	-0.20, 95% CI -0.39 -0.014, p=.036
Adler, 2004106	Modified Beck depression inventory		3 months		NS
6 months		NS
Partners in Care122,123	Percent with probable depression based on CIDI screen	QI-Meds	6 months	Intervention	P<.05	Time trends: Percent of usual care with probable depression dropped from 6 to 24 months while QI-Meds climbed. QI-Therapy remained relatively flat. QI-Meds significantly higher than QI-Therapy at 24 months.
			12 months	Intervention	P<.05
			18 months		NS
	24 months		NS
	Overall poor outcome: patient scored depressed if score in depressed range of all 3 CIDI screen, full 12-month CIDI, and CES-D, vs. 2 or fewer measures.	QI-Meds	6 months		NS
			12 months		NS
			18 months		NS
24 months		NS
QuEST124	Modified CES-D	Patients beginning new treatment episode	6 months	Intervention	Effect size = 0.43
		Patients recently treated	6 months		NS
Patients beginning new treatment episode, who find antidepressants acceptable	6 months	Intervention	Effect size = 0.83	This patient group also showed improvement in physical functioning, SF12 PCS, and satisfaction with care
Simon, 200099	SCL-20	Care management arm	6 months	Intervention	P=.008
Katzelnick, 2000100	Hamilton depression score		3 months	Intervention	P=.04	Significant group × time as well
			6 months	Intervention	P<.001
12 months	Intervention	P=.005
Low Level (Anxiety)
Rollman, 2005101	PDSS Panic Disorder Severity Scale	All patients	12 months	Intervention	0.33, 95% CI 0.04; 0.62, p=.02	Intervention × time
	Panic disorder	12 months	Intervention	0.57, 95% CI 0.18; 0.96, p=.003	Intervention × time
	SIGH-A Hamilton anxiety rating scale	All patients	12 months	Intervention	0.38, 95% CI 0.09; 0.67, p=.03	Intervention × time,
	General anxiety disorder	12 months		NS
Hamilton depression rating scale	All patients	12 months	Intervention	0.57, 95% CI 0.25; 0.46, p=.03	Intervention × time
TREATMENT RESPONSE
High Level (Depression)
Hedrick, 200387	Percent with 50% improvement in SCL-20		3 months		NS
9 months		NS
Intermediate I Level (Depression)
Grypma, 200693	Percent with 50% improvement in PHQ-9	All depression patients	6 months		NS	IMPACT intervention group compared to post-study integrated care group
Patients over 60 years	6 months		NS
IMPACT2,179	Percent with 50% improvement in SCL-20		3 months	Intervention	2.73, 95% CI 2.10; 3.54, p<.001
			6 months	Intervention	2.21, 95% CI 1.76; 2.76, p<.001
			12 months	Intervention	26.85, 95% CI 22.34; 31.35, p<.0001
			18 months	Intervention	16.99, 95% CI 12.34; 21.64, p<.0001
24 months	Intervention	10.87, 95% CI 6.16; 15.57, p<.0001
Pathways113	Percent with 50% improvement in SCL-90		6 months		NS
12 months		NS
Katon, 199688	Percent with 50% improvement in SCL-20	Major depression	4 months	Intervention	P=.002	Group × time trend
		7 months	Intervention	P=.04	Group × time trend
		Minor depression	4 months		NS
7 months		NS
Intermediate I Level (Anxiety)
Roy-Byrne, 2001109	40% reduction in PDSS		3 months		NS
			6 months	Intervention	P=.001
			9 months		NS
12 months	Intervention	P=.048
Intermediate II Level (Depression)
Simon, 200484	Percent with 50% improvement in SCL-20	Telephone care management	6 months	Intervention	NS	Usual care as comparison
Telephone psychotherapy plus care management	6 months	Intervention	NNT=6.4	Usual care as comparison
Finley, 2003108	Percent with 50% improvement in brief inventory for depressive symptoms		6 months		NS
Low Level (Depression)
Tutty, 200089	Percent with 50% improvement in SCL-20		3 months		NS
6 months		NS
Hunkeler, 2000110 (reporting telehealth nurse only, not peer support)	Percent with 50% improvement in Hamilton depression rating score		6 weeks	Intervention	P=.01
6 months	Intervention	P=.003
Fortney, 200692	Percent with 50% improvement in SCL-20		6 months	Intervention	NNT=11
12 months	Intervention	NS
PROSPECT125,127	Percent with 50% improvement in HRSD	All patients	4 months		OR 2.7, 95% CI 1.5; 4.9, p=.001	At 8 months, patients taking medication only showed more improvement than patients with IPT only, P=.02
			8 months		OR 2.1, 95% CI 1.1; 3.8, p=.02
		12 months		OR 2.0, 95% CI 1.1; 3.8 P=.02
		Major depression	4 months		OR 3.9, 95% CI 1.8; 8.5, p<.001
			8 months		OR 3.0, 95% CI 1.4; 6.4 P=.006
		12 months		NS
		Clinically significant minor depression	4 months		NS
			8 months		NS
12 months		NS
RESPECT-D120	Percent with 50% improvement in SCL-20		3 months	Intervention	OR 2.2, 95% CI 1.4; 3.4, p=.001
6 months	Intervention	OR 1.7, 95% CI 1.1; 2.7, p=.021
Datto, 200397	Percent with 50% improvement in CES-D		16 weeks		NS
	Percent with 50% improvement in Beck depression rating score		6 weeks		NS
6 months		P=.05
Simon, 200099	Percent with 50% improvement in SCL-20	Care management arm	6 months	Intervention	OR 2.22, 95% CI 1.31; 3.75
Katzelnick, 2000100	Percent with 50% improvement in Hamilton depression score		12 months	Intervention	P<.001	53.2% compared to 32.8%
Low Level (Anxiety)
Rollman, 2005101	40% reduction in SIGH-A	All patients	12 months	Intervention	30.8, 95% CI 17.0; 44.7, p<.001
	General anxiety disorder	12 months		NS
	40% reduction in PDSS	All patients	12 months	Intervention	20.7, 95% CI 9.7; 31.5, p<.001
	Panic disorder	12 months	Intervention	32.2, 95% CI 15.5; 48.9, p<.001
40% reduction in Hamilton depression rating	All patients	12 months	Intervention	28.5, CI 15 to 42.6, p<.001
REMISSION
High Level (Depression)
Katon, 1999103	Percent with SCID ≤ 1		3 months	Intervention	P=.01
6 months	Intervention	P=.05
Hedrick, 200387	Percent with SCL-20 ≥1.75		3 months		NS	Collaborative care patients with baseline scores above 1.75 were significantly less likely to be above 1.75 at 3 months.
High Level (Anxiety)
Roy-Byrne, 2001109	Anxiety sensitivity score <20		3 months	Intervention	P=.004
			6 months	Intervention	P=.004
			9 months		NS
12 months	Intervention	P=.005
Intermediate I Level (Depression)
IMPACT2,121	Percent with SCL-20 <0.5		3 months	Intervention	3.63, 95% CI 2.46; 5.38, p<.001
			6 months	Intervention	2.16, 95% CI 1.69; 2.76, p<.001
			12 months	Intervention	17.48, 95% CI 13.78; 21.18, p<.0001
			18 months	Intervention	9.31, 95% CI 5.77; 12.85, p<.0001
	24 months	Intervention	5.65, 95% CI 2.12; 9.17, p=.0018
Percent with SCID ≤1		6 months	Intervention	OR 0.50, 95% CI 0.40; 0.62, P<.001
Intermediate I Level (Anxiety)
Price, 200091	Shedler quick diagnostics panel <10 (anxiety)		6 months	Intervention	P=.025	55.6% intervention vs. 22.8% control achieved remission
Intermediate II Level (Depression)
Boudreau, 2002175	Percent with major depression as measured with SCID		12 months		NS
Finley, 2003108	Percent with brief inventory for depressive symptoms <9		6 months		NS
Intermediate II Level (Anxiety)
CCAP9	Anxiety sensitivity score <20		3 months	Intervention	Effect size 0.40
			6 months	Intervention	Effect size 0.48
			9 months	Intervention	Effect size 0.47
	12 months	Intervention	Effect size 0.51
	High end-state functioning		3 months	Intervention	Effect size 0.23
			6 months	Intervention	Effect size 0.29
			9 months	Intervention	Effect size 0.32
12 months	Intervention	Effect size 0.34
Low Level (Depression)
Tutty, 2000)89	Percent with SCID ≤1		3 months		NS
6 months		NS
Partners in Care122	Percent with modified CES-D < 20		6 months	All interventions	P=.005
	12 months	All interventions	P=.04
Percent without clinical diagnosis, based on full 12-month CIDI		2 years	QI-Therapy, vs. QI-Meds	P=.04
Fortney, 200692	Percent with SCL-20 <0.5		6 months	Intervention	NS
12 months	Intervention	NNT=11
PROSPECT125,127	Percent with HRSD <10	All patients	4 months		OR 3.7, 95% CI 1.7; 7.7, p=<.001	Treatment × time p<.01 for medication only, vs. IPT only
			8 months		NS
		12 months		NS
		Major depression	4 months		OR 6.7, 95% CI 2.5; 17.9, p<.001
			8 months		NS
		12 months		NS
		Clinically significant minor depression	4 months		NS
			8 months		NS
	12 months		NS
	Percent with HRSD <7	All patients	4 months		OR 2.0, CI 1.0 to 3.8, p=.04
			8 months		OR 2.1, CI 1.1 to 4.2, p=.02
		12 months		NS
		Major depression	4 months		OR 3.6, 95% CI 1.4; 9.4, p=.007
			8 months		OR 3.2, 95% CI 1.3; 7.9, p=.01
		12 months		NS
		Clinically significant minor depression	4 months		NS
			8 months		NS
12 months		NS
RESPECT-D120	Percent with SCL-20 <0.5		3 months	Intervention	OR 2.1, 95% CI 1.2; 3.7, p=.018
6 months	Intervention	OR 1.9, 95% CI 1.2; 3.3, p=.014
Datto, 200397	Percent below CES-D=16 (low level symptoms)		16 weeks	Intervention	OR 6.58, 95% CI 1.57; 27.03, p=.01
	Percent below CES-D=11		16 weeks		NS
9 months		NS
QuEST5	Percent below CES-D=16		24 months	Intervention	P<.02	Treatment × time
Katzelnick, 2000100	Percent below Hamilton depression score<7		12 months	Intervention	P<.001	27.7% compared to 12.8%
MEDICAL
Intermediate Level I (Depression)
IMPACT128,129	Arthritis pain intensity		3 months	Intervention	-0.58, 95% CI -0.9; -0.25, p<.001
			6 months		NS
	12 months	Intervention	-0.53, 95% CI-0.92; -0.14, p=.009
	Arthritis interferes with daily activities		3 months	Intervention	-0.67, 95% CI -1.06; -0.27, p=.001
			6 months	Intervention	-0.56, 95% CI-0.96; -0.16, p=.006
	12 months	Intervention	-0.59, CI -1 to -0.19, p=.004
	Arthritis pain interferes with daily activities		3 months	Intervention	-0.24, 95% CI -0.39; -0.09, p=.002
			6 months	Intervention	-0.22, 95% CI-0.36; -0.09, p=.005
	12 months	Intervention	-0.26, 95% CI -0.41; -0.10, p=.002
	Graded chronic pain scale for arthritis pain severity		12 months	Intervention	Beta 0.15 (SE 0.06), p=.026	Interaction: intervention × pain severity
	12 months		NS	Interaction: intervention × pain activity interference
	Graded chronic pain scale for arthritis pain activity interference		12 months	Intervention	Beta 0.14 (SE 0.07), p=.04	Interaction: intervention × pain severity
12 months		Beta 0.13 (SE 35), p=.015	Interaction: intervention × pain activity interference
Pathways113	HbA1c level		6 months		NS
12 months		NS

Figures 4–6 are forest plots for symptom severity, response rates, and remission rates, respectively, for unpooled depression trials sorted by provider integration levels. The large majority of trials (N=22) had lower levels of provider integration. Also noted is that trials in the higher integration levels tend to be older. There is no discernable effect of provider integration level on outcomes based on this data. Of the plotted data, only the IMPACT trial shows consistent improvement in symptom severity. Significant improvements in treatment response and remission rates are consistent across the integration levels. Looking at the full set of trials listed in Table 8, which groups all trial outcomes by integration level and mental health illness category, it does not appear that the exclusions biased the results. The limited numbers of anxiety trials exhibit a similar pattern. The results would not differ if the two low quality trials were not included in the analysis.^{85, 105} The pattern of results is also not affected by comparison group.

Figure 7. Symptom severity outcomes by level of integrated (more...)

   Figure 7. Symptom severity outcomes by level of integrated process of care

Figure 8. Treatment response by level of integrated (more...)

   Figure 8. Treatment response by level of integrated process of care

Figure 9. Remission rate by level of integrated process (more...)

   Figure 9. Remission rate by level of integrated process of care

Table 9

Clinical outcomes by level of integrated proactive (more...)

Table 9

Clinical outcomes by level of integrated proactive process of care

Outcome Project or Author	Measurement	Patient Category	Assessment Period	Direction of Effect	Effect Size	Comment
MENTAL ILLNESS SYMPTOMS (SEVERITY)
High Level (Depression)
Price, 200091	Shedler Quick Psycho Diagnostics Panel (Anxiety)		6 months	Intervention	P=.046
Hedrick, 200387	SCL-20		3 months	Intervention	-0.17, 95% CI -0.31; -0.03, p<.05	Equalized amount of treatment between collaborative and consult-liaison models; attention control
9 months		NS
IMPACT2,179	SCL-20		3 months	Intervention	-0.28, 95% CI -0.34; -0.21, p<.001
			6 months	Intervention	-0.28, 95% CI -0.35; -0.19, p<.001
			12 months	Intervention	NNT=4
			18 months	Intervention	NNT=6
24 months	Intervention	NNT=9
Grypma, 200693	PHQ-9 score	All depression patients	6 months		NS	IMPACT intervention group compared to post-study integrated care group
Patients over 60 years	6 months		NS
Pathways113	SCL-20		6 months	Intervention	OR 3.5, 95% CI 2.16; 5.68
12 months	Intervention	OR 3.5, 95% CI 2.14; 5.72
Clarke, 200583	CES-D		12 months		NS	Study may have been under-powered to compare 2 active treatments. About 75% remission in both groups within 3 months.
	Hamilton Depression Rating Scale		12 months		NS
Youth Self Report		12 months		NS
Katon, 200198	SCL-20		12 months		NS
Asarnow, 2005114	CES-D		6 months	Intervention	-2.9, 95% CI -5.3; -0.4, p=.02
Percent with CES-D in severe range ≥24	6 months	Intervention	OR 0.6, 95% CI 0.4, 0.9, p=.02
High Level (Anxiety)
Price, 200091	Shedler Quick Psycho Diagnostics Panel (Anxiety)		6 months	Intervention	P=.046
CCAP9	Anxiety sensitivity index score		3 months	Intervention	Effect size 0.44
			6 months	Intervention	Effect size 0.45
			9 months	Intervention	Effect size 0.44
	12 months	Intervention	Effect size 0.43
	CES-D		3 months	Intervention	Effect size 0.29
			6 months	Intervention	Effect size 0.29
			9 months	Intervention	Effect size 0.27
12 months	Intervention	Effect size 0.26
Rollman, 2005101	PDSS Panic disorder severity scale	All patients	12 months	Intervention	0.33, 95% CI; 04 to 0.62, p=.02	Intervention × time
	Panic disorder	12 months	Intervention	0.57, 95% CI 0.18; 0.96, p=.003	Intervention × time
	*SIGH-A Hamilton anxiety rating scale	All patients	12 months	Intervention	0.38, 95% CI 0.09; 0.67, p=.03	Intervention × time
	General anxiety disorder	12 months		NS
Hamilton depression rating scale	All patients	12 months	Intervention	0.57, 95% CI 0.25; 0.46, p=.03	Intervention × time
Intermediate Level (Depression)
Swindle, 200385	Beck depression inventory	All patients	3 months		NS	No difference in outcomes for major depression or dysthymia. Several CNS were not voluntary, did not follow protocol, etc.
		12 months		NS
		Major depression	3 months		NS
12 months		NS
Simon, 200484	SCL-20	Telephone psychotherapy plus care management	6 months	Intervention	P<.001	Difference between groups is equal to ½ of the SD of scores in general population
		Telephone care management	6 months	Intervention	NS
9 months post-treatment		NS
Boudreau, 2002175	SCL-20		12 months		NS
PROSPECT125	Hamilton Depression Rating Scale	All patients	4 months		-3.5, 95% CI -4.7; -2.4, p<.001
			8 months		-2.1, 95% CI -3.4; -0.9, p<.001
		12 months		-1.8, 95% CI -3.1; -0.5, p=.006
		Major depression	4 months		-4.6, 95% CI -6.2; -3.1, p<.001
			8 months		-2.5, 95% CI -4.1; -0.9, p.003
		12 months		-2.1, 95% CI -3.7; -0.4, p=.02
		Clinically significant minor depression	4 months		NS
			8 months		NS
12 months		NS
Tutty, 200089	SCL-20		3 months	Intervention	P=.03
6 months	Intervention	P=.03
RESPECT-D120	SCL-20		3 months	Intervention	-0.16, 95% CI -0.32; -0.002, p=.048
6 months	Intervention	-0.20, CI -0.39 to -0.014, p=.036
Adler, 2004106	Modified Beck depression inventory		3 months		NS
6 months		NS
Partners in Care122,123	Percent with probable depression based on CIDI screen	QI-Meds	6 months	Intervention	P<.05	Time trends: Percent of usual care with probable depression dropped from 6 to 24 months while QI-Meds climbed. QI therapy remained relatively flat. QI meds significantly higher than QI therapy at 24 months.
			12 months	Intervention	P<.05
			18 months		NS
	24 months		NS
	Overall poor outcome: patient scored depressed if score in depressed range of all 3 CIDI screen, full 12-month CIDI, and CES-D, vs. 2 or fewer measures.	QI-Meds	6 months		NS
			12 months		NS
			18 months		NS
24 months		NS
QuEST124	Modified CES-D	Patients beginning new treatment episode	6 months	Intervention	Effect size = 0.43
		Patients recently treated	6 months		NS
Patients beginning new treatment episode, who find antidepressants acceptable	6 months	Intervention	Effect size = 0.83	This patient group also showed improvement in physical functioning, SF12 PCS, and satisfaction with care
Simon, 200099	SCL-20	Care management arm	6 months	Intervention	P=.008
Katzelnick, 2000100	Hamilton depression score		3 months	Intervention	P=.04	Significant group × time as well
			6 months	Intervention	P<.001
12 months	Intervention	P=.005
Intermediate Level (Anxiety)
Roy-Byrne, 2001109	PDSS Panic disorder severity scale		3 months		NS	Intervention × time p=.05, driven by reduction in anticipatory anxiety
			6 months	Intervention	P=.003
			9 months		NS
	12 months		NS
	Anxiety sensitivity scale		3 months	Intervention	P=.002	Intervention × time p=.018
			6 months	Intervention	P<.001
			9 months		NS
	12 months	Intervention	P=.035
	Panic related agoraphobic avoidance		12 months		NS
	Fear Questionnaire agoraphobic subscale		12 months		NS
	CES-D		3 months	Intervention	P=.002	Intervention × time p=.03
			6 months	Intervention	P=.005
			9 months	Intervention	P=.036
12 months	Intervention	P=.02
Low Level (Depression)
Finley, 2003108	Brief inventory for depressive symptoms		6 months		NS
Katon, 19993,103	SCL-20	All patients	3 months	Intervention	P=.003
		6 months	Intervention	P=.04	Treatment × time
		All patients	28 months	Intervention	P=.05	Treatment × time
		Moderate severity	28 months	Intervention	P=.004	Treatment × time
High severity	28 months		NS
Lin, 19994 (followup of Katon, 1995 and Katon, 1996)	SCL-20		19 months		NS
Inventory for depressive symptomatology		19 months		NS
Partners in Care122,123	Percent with probable depression based on CIDI screen	All interventions	6 months	Any intervention	P=.001
		12 months	Any intervention	P=.005
		QI-Therapy	6 months	Intervention	P<.05
			12 months	Intervention	P<.05
			18 months		NS
	24 months		NS
	Overall poor outcome: patient scored depressed if score in depressed range of all 3 CIDI screen, full 12-month CIDI, and CES-D, vs. 2 or fewer measures.	QI-Therapy	6 months	Intervention	P<.05
			12 months	Intervention	P<.05
			18 months	Intervention, usual care and QI-Meds	P<.05
24 months	Intervention, QI-Meds	P<.05
Hunkeler, 2000110(reporting telehealth nurse only, not peer support)	Hamilton depression rating score		6 weeks		NS
	6 months	Intervention	P=.006
	Beck depression rating score		6 weeks		NS
6 months		NS
Low Level (Other Disorders)
Katon, 1992107	SCL somatization		6 months		NS
	12 months		NS
	SCL depression		6 months		NS
	12 months		NS
	SCL anxiety		6 months		NS
12 months		NS
TREATMENT RESPONSE
High Level(Depression)
Hedrick, 200387	Percent with 50% improvement in SCL-20		3 months		NS
9 months		NS
IMPACT2,179	Percent with 50% improvement in SCL-20		3 months	Intervention	2.73, 95% CI 2.10; 3.54, p<.001
			6 months	Intervention	2.21, 95% CI 1.76; 2.76, p<.001
			12 months	Intervention	26.85, 95% CI 22.34; 31.35, p<.0001
			18 months	Intervention	16.99, 95% CI 12.34; 21.64, p<.0001
24 months	Intervention	10.87, 95% CI 6.16; 15.57, p<.0001
Fortney, 200692	Percent with 50% improvement in SCL-20		6 months	Intervention	NNT=11
12 months	Intervention	NS
Pathways113	Percent with 50% improvement in SCL-90		6 months		NS
12 months		NS
Grypma, 200693	Percent with 50% improvement in PHQ-9	All depression patients	6 months		NS	IMPACT intervention group compared to post-study integrated care group.
Patients over 60 years	6 months		NS
PROSPECT125,127	Percent with 50% improvement in HRSD	All patients	4 months		OR 2.7, 95% CI 1.5; 4.9, p=.001	At 8 months, patients taking medication only showed more improvement than patients with IPT only, P=.02
			8 months		OR 2.1, 95% CI 1.1; 3.8, p=.02
		12 months		OR 2.0, 95% CI 1.1; 3.8P=.02
		Major depression	4 months		OR 3.9, 95% CI 1.8; 8.5, p<.001
			8 months		OR 3.0, 95% CI 1.4; 6.4P=.006
		12 months		NS
		Clinically significant minor depression	4 months		NS
			8 months		NS
12 months		NS
Katon, 199688	Percent with 50% improvement in SCL-20	Major depression	4 months	Intervention	P=.002	Group × time trend
		7 months	Intervention	P=.04	Group × time trend
		Minor depression	4 months		NS
7 months		NS
High Level (Anxiety)
Rollman, 2005101	40% reduction in SIGH-A	All patients	12 months	Intervention	30.8, 95% CI 17.0; 44.7, p<.001
	General anxiety disorder	12 months		NS
	40% reduction in PDSS	All patients	12 months	Intervention	20.7, 95% CI 9.7; 31.5, p<.001
	Panic disorder	12 months	Intervention	32.2, 95% CI 15.5; 48.9, p<.001
40% reduction in Hamilton depression rating	All patients	12 months	Intervention	28.5, 95% CI 15; 42.6, p<.001
Intermediate Level (Depression)
Simon, 200484	Percent with 50% improvement in SCL-20	Telephone care management	6 months	Intervention	NS	Usual care as comparison
Telephone psychotherapy plus care management	6 months	Intervention	NNT=6.4	Usual care as comparison
Tutty, 200089	Percent with 50% improvement in SCL-20		3 months		NS
6 months		NS
RESPECT-D120	Percent with 50% improvement in SCL-20		3 months	Intervention	OR 2.2, 95% CI 1.4; 3.4, p=.001
6 months	Intervention	OR 1.7, 95% CI 1.1; 2.7, p=.021
Finley, 2003108	Percent with 50% improvement in brief inventory for depressive symptoms		6 months		NS
Datto, 200397	Percent with 50% improvement in CES-D		16 weeks		NS
	Percent with 50% improvement in Beck depression rating score		6 weeks		NS
	6 months		P=.05
Simon, 200099	Percent with 50% improvement in SCL-20	Care management arm	6 months	Intervention	OR 2.22, 95% CI 1.31; 3.75
Katzelnick, 2000100	Percent with 50% improvement in Hamilton depression score		12 months	Intervention	P<.001	53.2% compared to 32.8%
Intermediate Level (Anxiety)
Roy-Byrne, 2001109	40% reduction in PDSS		3 months		NS
			6 months	Intervention	P=.001
			9 months		NS
12 months	Intervention	P=.048
Low Level (Depression)
Hunkeler, 2000110 (reporting telehealth nurse only, not peer support)	Percent with 50% improvement in Hamilton depression rating score		6 weeks	Intervention	P=.01
6 months	Intervention	P=.003
REMISSION
High Level (Depression)
Katon, 1999103	Percent with SCID ≤1		3 months	Intervention	P=.01
6 months	Intervention	P=.05
Hedrick, 200387	Percent with SCL-20 ≥1.75		3 months		NS	Collaborative care patients with baseline scores above 1.75 were significantly less likely to be above 1.75 at 3 months.
Fortney, 200692	Percent with SCL-20 <0.5		6 months		NS
12 months	Intervention	NNT=11
IMPACT2,121	Percent with SCL-20 <0.5		3 months	Intervention	3.63, 95% CI 2.46; 5.38, p<.001
			6 months	Intervention	2.16, 95% CI 1.69; 2.76, p<.001
			12 months	Intervention	17.48, 95% CI 13.78; 21.18, p<.0001
			18 months	Intervention	9.31, 95% CI 5.77; 12.85, p<.0001
	24 months	Intervention	5.65, 95% CI 2.12; 9.17, p=.0018
Percent with SCID ≤1		6 months	Intervention	OR 0.50, 95% CI 0.40; 0.62, P<.001
PROSPECT125,127	Percent with HRSD <10	All patients	4 months	Intervention	OR 3.7, 95% CI 1.7; 7.7, p=<.001	Treatment × time p<.01 for medication only, vs. IPT only
			8 months		NS
		12 months		NS
		Major depression	4 months	Intervention	OR 6.7, 95% CI 2.5; 17.9, p<.001
			8 months		NS
		12 months		NS
		Clinically significant minor depression	4 months		NS
			8 months		NS
	12 months		NS
	Percent with HRSD <7	All patients	4 months	Intervention	OR 2.0, 95% CI 1.0; 3.8, p=.04
			8 months	Intervention	OR 2.1, 95% CI 1.1; 4.2, p=.02
		12 months		NS
		Major depression	4 months	Intervention	OR 3.6, 95% CI 1.4; 9.4, p=.007
			8 months	Intervention	OR 3.2, 95% CI 1.3; 7.9, p=.01
		12 months		NS
		Clinically significant minor depression	4 months		NS
			8 months		NS
12 months		NS
High Level (Anxiety)
CCAP9	Anxiety sensitivity score <20		3 months	Intervention	Effect size 0.40
			6 months	Intervention	Effect size 0.48
			9 months	Intervention	Effect size 0.47
	12 months	Intervention	Effect size 0.51
	High end-state functioning		3 months	Intervention	Effect size 0.23
			6 months	Intervention	Effect size 0.29
			9 months	Intervention	Effect size 0.32
12 months	Intervention	Effect size 0.34
Price, 200091	Shedler quick diagnostics panel <10 (anxiety)		6 months	Intervention	P=.025	55.6% intervention vs. 22.8% control achieved remission
Intermediate Level (Depression)
Boudreau, 2002175	Percent with major depression as measured with SCID		12 months		NS
Tutty, 200089	Percent with SCID ≤1		3 months		NS
6 months		NS
Partners in Care122,123	Percent with modified CES-D <20		6 months	All interventions	P=.005
	12 months	All interventions	P=.04
Percent without clinical diagnosis, based on full 12-month CIDI		2 years	QI-therapy vs. QI-meds	P=.04
RESPECT-D120	Percent with SCL-20 <0.5		3 months	Intervention	OR 2.1, 95% CI 1.2; 3.7, p=.018
6 months	Intervention	OR 1.9, 95% CI 1.2; 3.3, p=.014
Datto, 200397	Percent below CES-D=16 (low level symptoms)		16 weeks	Intervention	OR 6.58, CI 1.57 to 27.03, p=.01
	Percent below CES-D=11		16 weeks		NS
9 months		NS
QuEST5	Percent below CES-D=16		24 months	Intervention	P<.02	Treatment × time
Katzelnick, 2000100	Percent below Hamilton depression score<7		12 months	Intervention	P<.001	27.7% compared to 12.8%
Intermediate Level (Anxiety)
Roy-Byrne, 2001109	Anxiety sensitivity score <20		3 months	Intervention	P=.004
			6 months	Intervention	P=.004
			9 months		NS
12 months	Intervention	P=.005
Low Level (Depression)
Finley, 2003108	Percent with brief inventory for depressive symptoms <9		6 months		NS
MEDICAL
High Level (Depression)
IMPACT128,129	Arthritis pain intensity		3 months	Intervention	-0.58, 95% CI -0.9; -0.25, p<.001
			6 months		NS
	12 months	Intervention	-0.53, 95% CI-0.92; -0.14, p=.009
	Arthritis interferes with daily activities		3 months	Intervention	-0.67, 95% CI -1.06; -0.27, p=.001
			6 months	Intervention	-0.56, 95% CI -0.96; -0.16, p=.006
	12 months	Intervention	-0.59, 95% CI -1; -0.19, p=.004
	Arthritis pain interferes with daily activities		3 months	Intervention	-0.24, 95% CI -0.39; -0.09, p=.002
			6 months	Intervention	-0.22, 95% CI -0.36; -0.09, p=.005
	12 months	Intervention	-0.26, 95% CI -0.41; -0.10, p=.002
	Graded chronic pain scale for arthritis pain severity		12 months	Intervention	Beta 0.15 (SE 0.06), p=.026	Interaction: intervention × pain severity
	12 months		NS	Interaction: intervention × pain activity interference
	Graded chronic pain scale for arthritis pain activity interference		12 months	Intervention	Beta 0.14 (SE 0.07), p=.04	Interaction: intervention × pain severity
12 months	Intervention	Beta 0.13 (SE 35), p=.015	Interaction: intervention × pain activity interference
Pathways113	HbA1c level		6 months		NS
12 months		NS

Effect of levels of integration on outcomes: Process of care. Figures 7–9 are forest plots for symptom severity, response rates, and remission rates, respectively, for unpooled depression trials sorted by levels of process of care. The results are very similar to the plots for the levels of provider integration. There is no discernable effect of provider integration level on outcomes based on this data. IMPACT remains the standout positive trial for plotted symptom severity, while results are consistently positive across all levels of integration for treatment response and remission rates. Looking at the full set of trials listed in Table 9, which groups all trial outcomes by level of process of care and mental health illness category, it does not appear that excluding trials that did not report results in a usable format biased the results. The limited numbers of anxiety trials again exhibit a similar pattern. The results would not differ if the two low-quality trials (Swindle, Hilty) were not included in the analysis.^{85, 105} The pattern of results is also not affected by comparison group.

Research on the relative contribution of each element of the care process to improved outcomes is limited, which is why a simple additive approach was used in this analysis. We also performed a sensitivity analysis of the approach by combining expert estimations of relative weights of the components. All expert responses were treated with equal weight in the combined score. The resulting weighted scores did not materially affect the rankings of the trials. Given the low variability in use of supervision across the studies, using Bower et al's. meta-analysis of “active ingredients” in collaborative care (which included international studies with large patient samples) would have reduced the list of elements to merely the presence of screening, an approach deemed insufficient for this analysis.⁶⁰

Figure 10. Symptom severity by matrix level of integration (more...)

   Figure 10. Symptom severity by matrix level of integration

Figure 11. Treatment response by matrix level of integration (more...)

   Figure 11. Treatment response by matrix level of integration

Figure 12. Remission by matrix level of integration (more...)

   Figure 12. Remission by matrix level of integration

Effect of levels of integration on outcomes: Matrix integration. Figures 10–12 are forest plots for symptom severity, response rates, and remission rates, respectively, for unpooled depression trials sorted by matrix levels of integration. There were a small number of trials in each matrix cell integration level and several cells did not have representative studies. Given that, the matrix integration provides a view of integration that may provide a more refined gradient. Again, with the available plotted data, there is no discernable effect of matrix integration level on outcomes based on this data, and the results would not differ if the two low quality trials were not included in the analysis.^{85, 105} The pattern of results is also not affected by comparison group. The anxiety trials are so limited that a matrix analysis is not tenable.

PRISM-E trial. The PRISM-E study⁸² was a multisite randomized comparative trial funded by an interagency collaboration including the Substance Abuse and Mental Health Services Administration (SAMHSA), the Veteran's Administration (VA), the Health Resources and Services Administration (HRSA), and the Center for Medicare and Medicaid Services (CMS). The trial examined two models of care for three common mental health concerns for the elderly; depression, anxiety, and at-risk drinking. To be eligible to participate in the integrated treatment model arm, clinics had to exhibit a number of features, including co-location of available mental health services provided by licensed mental health providers with formal communication linkages. To be eligible to participate in the enhanced referral model arm, clinics had to exhibit strong communication and monitoring linkages with, and ensure transportation to, available specialty mental health clinics. Both study arms are considered integrated care by this review's operational definitions, since they both involve linkages between primary care and mental health specialty providers. However, as mentioned above, the participating clinics did not have mandated standardized depression treatment algorithms or interventions other than the brief alcohol intervention.

Table 10

Clinical outcomes by mental illness

Table 10

Clinical outcomes by mental illness

Outcome Project or Author	Measurement	Patient Category	Assessment Period	Direction of Effect	Results	Comment
DEPRESSION
Depression symptoms (severity)
PRISM-E118	CES-D score	Major depression	3 months	Enhanced referral	NS	Secondary analysis showed combination of talk therapy plus medication worked better in enhanced referral than integrated care model for patients with major depression.
		6 months	Enhanced referral	Mean 2.8, 95% CI 1.0; 4.5, p=.003
		Other depression	3 months		NS
		6 months		NS
		All depression	3 months		NS
6 months		NS
Grypma, 200693	PHQ-9 score	All depression patients	6 months		NS	IMPACT intervention group compared to post-study integrated care group.
Patients over 60 years	6 months		NS
IMPACT2,121	SCL-20		3 months	Intervention	-0.28, 95% CI -0.34; -0.21, p<.001
			6 months	Intervention	-0.28, 95% CI -0.35; -0.19, p<.001
			12 months	Intervention	NNT=4
			18 months	Intervention	NNT=6
24 months	Intervention	NNT=9
Clarke, 2005180	CES-D		12 months		NS	Study may have been under-powered to compare 2 active treatments. About 75% remission in both groups within 3 months.
	Hamilton Depression Rating Scale		12 months		NS
Youth Self Report		12 months		NS
Pathways113	SCL-20		6 months	Intervention	OR 3.5, 95% CI 2.16; 5.68
12 months	Intervention	OR 3.5, 95% CI 2.14; 5.72
PROSPECT125	Hamilton Depression Rating Scale	All patients	4 months		-3.5, 95% CI -4.7; -2.4, p<.001
			8 months		-2.1, 95% CI -3.4; -0.9, p<.001
		12 months		-1.8, 95% CI -3.1; -0.5, p=.006
		Major depression	4 months		-4.6, 95% CI -6.2; -3.1, p<.001
			8 months		-2.5, CI -4.1 to -0.9, p.003
		12 months		-2.1, 95% CI -3.7; -0.4, p=.02
		Clinically significant minor depression	4 months		NS
			8 months		NS
12 months		NS
RESPECT-D120	SCL-20		3 months	Intervention	-0.16, 95% CI -0.32; -0.002, p=.048
6 months	Intervention	-0.20, 95% CI -0.39; -0.014, p=.036
Simon, 200484	SCL-20	Telephone psychotherapy plus care management	6 months	Intervention	P<.001	Difference between groups is equal to ½ of the SD of scores in general population
Telephone care management	6 months	Intervention	NS
Adler, 2004106	Modified Beck depression inventory		3 months		NS
6 months		NS
Finley, 2003108	Brief inventory for depressive symptoms		6 months		NS
Swindle, 200385	Beck depression inventory	All patients	3 months		NS	No difference in outcomes for major depression or dysthymia.
		12 months		NS
		Major depression	3 months		NS
12 months		NS
Partners in Care6,122,123	Percent with probable depression based on CIDI screen	All interventions	6 months	Any intervention	P=.001
			12 months	Any intervention	P=.005
		5 years	Any intervention	6.6, 95% CI 0.4; 12.8, p=.04
		QI-Meds	6 months	Intervention	P<.05	Time trends: Percent of usual care with probable depression dropped from 6 to 24 months while QI-Meds climbed. QI-therapy remained relatively flat. QI-meds significantly higher than QI-therapy at 24 months.
			12 months	Intervention	P<.05
			18 months		NS
			24 months		NS
		5 years		NS
		QI-Therapy	6 months	Intervention	P<.05
			12 months	Intervention	P<.05
			18 months		NS
			24 months		NS
	5 years	Intervention	P=.05
	Overall poor outcome: patient scored depressed if score in depressed range of all 3 CIDI screen, full 12-month CIDI, and CES-D, vs. 2 or fewer measures.	QI-Meds	6 months		NS
			12 months		NS
			18 months		NS
		24 months		NS
		QI-Therapy	6 months	Intervention	P<.05
			12 months	Intervention	P<.05
			18 months	Intervention, usual care and QI-meds	P<.05
24 months	Intervention, QI-meds	P<.05
Hedrick 200387	SCL-20		3 months	Intervention	-0.17, 95% CI -0.31; -0.03, p<.05	Equalized amount of treatment between collaborative and consult-liaison models; attention control
9 months		NS
Katon, 19993,103	SCL-20	All patients	3 months	Intervention	P=.003
		6 months	Intervention	P=.04	Treatment × time
		All patients	28 months	Intervention	P=.05	Treatment × time
		Moderate severity	28 months	Intervention	P=.004	Treatment × time
High severity	28 months		NS
Lin, 19994 (followup of Katon, 1995 and Katon, 1996)	SCL-20		19 months		NS
Inventory for depressive symptomatology		19 months		NS
Katon, 200198	SCL-20		12 months		NS
Boudreau, 2002175	SCL-20		12 months		NS
Tutty, 200089	SCL-20		3 months	Intervention	P=.03
6 months	Intervention	P=.03
Hunkeler, 2000110 (reporting telehealth nurse only, not peer support)	Hamilton depression rating score		6 weeks		NS
	6 months	Intervention	P=.006
	Beck depression rating score		6 weeks		NS
6 months		NS
QuEST124	Modified CES-D	Patients beginning new treatment episode	6 months	Intervention	Effect size = 0.43
		Patients recently treated	6 months		NS
Patients beginning new treatment episode, who find antidepressants acceptable	6 months	Intervention	Effect size = 0.83	This patient group also showed improvement in physical functioning, SF12 PCS, and satisfaction with care
Simon, 200099	SCL-20	Care management arm	6 months	Intervention	P=.008
Katzelnick, 2000100	Hamilton depression score		3 months	Intervention	P=.04	Significant group × time as well
			6 months	Intervention	P<.001
12 months	Intervention	P=.005
Asarnow, 2005114	CES-D		6 months	Intervention	-2.9, 95% CI -5.3; -0.4, p=.02
Percent with CES-D in severe range ≥ 24		6 months	Intervention	OR 0.6, 95% CI 0.4, 0.9, p=.02
Treatment response
Fortney, 2006131	Percent with 50% improvement in SCL-20		6 months	Intervention	NNT=11
12 months	Intervention	NS
Grypma, 200693	Percent with 50% improvement in PHQ-9	All depression patients	6 months		NS	IMPACT intervention group compared to post-study integrated care group.
Patients over 60 years	6 months		NS
IMPACT2,179	Percent with 50% improvement in SCL-20		3 months	Intervention	2.73, 95% CI 2.10; 3.54, p<.001
			6 months	Intervention	2.21, 95% CI 1.76; 2.76, p<.001
			12 months	Intervention	26.85, 95% CI 22.34; 31.35, p<.0001
			18 months	Intervention	16.99, 95% CI 12.34; 21.64, p<.0001
24 months	Intervention	10.87, 95% CI 6.16; 15.57, p<.0001
Pathways12	Percent with 50% improvement in SCL-90		6 months		NS
12 months		NS
PROSPECT125,127	Percent with 50% improvement in HRSD	All patients	4 months		OR 2.7, 95% CI 1.5; 4.9, p=.001	At 8 months, patients taking medication only showed more improvement than patients with IPT only, P=.02
			8 months		OR 2.1, 95% CI 1.1; 3.8, p=.02
		12 months		OR 2.0, 95% CI 1.1; 3.8 P=.02
		Major depression	4 months		OR 3.9, 95% CI 1.8; 8.5, p<.001
			8 months		OR 3.0, 95% CI 1.4; 6.4 P=.006
		12 months		NS
		Clinically significant minor depression	4 months		NS
			8 months		NS
12 months		NS
RESPECT-D120	Percent with 50% improvement in SCL-20		3 months	Intervention	OR 2.2, 95% CI 1.4; 3.4, p=.001
6 months	Intervention	OR 1.7, 95% CI 1.1; 2.7, p=.021
Simon, 200484	Percent with 50% improvement in SCL-20	Telephone psychotherapy plus care management	6 months	Intervention	NNT=6.4	Usual care as comparison.
Telephone care management	6 months	Intervention	NS	Usual care as comparison
Finley, 2003108	Percent with 50% improvement in brief inventory for depressive symptoms		6 months		NS
Datto, 200397	Percent with 50% improvement in CES-D		16 weeks		NS
Hedrick, 200387	Percent with 50% improvement in SCL-20		3 months		NS
9 months		NS
Tutty, 200089	Percent with 50% improvement in SCL-20		3 months		NS
6 months		NS
Katon, 1995102	Percent with 50% improvement in SCL-20	Minor depression			NS
	Major depression	7 months	Intervention	P<.005	Post hoc analysis showed improvement accrued to patients who required a medication adjustment
	Percent with 50% improvement in Inventory of depressive symptomatology (clinician rated)	Minor depression			NS
Major depression	7 months	Intervention	P<.02	Post hoc analysis showed improvement accrued to patients who required a medication adjustment.
Katon, 199688	Percent with 50% improvement in SCL-20	Major depression	4 months	Intervention	P=.002	Group × time trend
		7 months	Intervention	P=.04	Group × time trend
		Minor depression	4 months		NS
7 months		NS
Hunkeler, 2000110 (reporting telehealth nurse only, not peer support)	Percent with 50% improvement in Hamilton depression rating score		6 weeks	Intervention	P=.01
	6 months	Intervention	P=.003
	Percent with 50% improvement in Beck depression rating score		6 weeks		NS
6 months		P=.05
Simon, 200099	Percent with 50% improvement in SCL-20	Care management arm	6 months	Intervention	OR 2.22, 95% CI 1.31; 3.75
Katzelnick, 2000100	Percent with 50% improvement in Hamilton depression score		12 months	Intervention	P<.001	53.2% compared to 32.8%
Remission
Fortney, 2006131	Percent with SCL-20 <0.5		6 months	Intervention	NS
12 months	Intervention	NNT=11
IMPACT2,121	Percent with SCL-20 <0.5		3 months	Intervention	3.63, 95% CI 2.46; 5.38, p<.001
			6 months	Intervention	2.16, 95% CI 1.69; 2.76, p<.001
			12 months	Intervention	17.48, 95% CI 13.78; 21.18, p<.0001
			18 months	Intervention	9.31, 95% CI 5.77; 12.85, p<.0001
	24 months	Intervention	5.65, 95% CI 2.12; 9.17, p=.0018
Percent with SCID ≤1		6 months	Intervention	OR 0.50, 95% CI 0.40; 0.62, P<.001
PROSPECT125,127	Percent with HRSD <10	All patients	4 months		OR 3.7, 95% CI 1.7; 7.7, p=<.001	Treatment × time p<.01 for medication only, vs. IPT only
			8 months		NS
		12 months		NS
		Major depression	4 months		OR 6.7, 95% CI 2.5; 17.9, p<.001
			8 months		NS
		12 months		NS
		Clinically significant minor depression	4 months		NS
			8 months		NS
	12 months		NS
	Percent with HRSD <7	All patients	4 months		OR 2.0, 95% CI 1.0; 3.8, p=.04
			8 months		OR 2.1, 95% CI 1.1; 4.2, p=.02
		12 months		NS
		Major depression	4 months		OR 3.6, 95% CI 1.4; 9.4, p=.007
			8 months		OR 3.2, 95% CI 1.3; 7.9, p=.01
		12 months		NS
		Clinically significant minor depression	4 months		NS
			8 months		NS
12 months		NS
RESPECT-D120	Percent with SCL-20 <0.5		3 months	Intervention	OR 2.1, 95% CI 1.2; 3.7, p=.018
6 months	Intervention	OR 1.9, 95% CI 1.2; 3.3, p=.014
Finley, 2003108	Percent with brief inventory for depressive symptoms <9		6 months		NS
Partners in Care122,123	Percent with modified CES-D <20		6 months	All interventions	P=.005
	12 months	All interventions	P=.04
Percent without clinical diagnosis, based on full 12-month CIDI		2 years	QI-therapy, vs. QI-meds	P=.04
Datto, 200397	Percent below CES-D=16 (low level symptoms)		16 weeks	Intervention	OR 6.58, 95% CI 1.57; 27.03, p=.01
Percent below CES-D=11		16 weeks		NS
Hedrick, 200387	Percent with SCL-20 ≥1.75		3 months		NS	Collaborative care patients with baseline scores above 1.75 were significantly less likely to be above 1.75 at 3 months.
9 months		NS
Boudreau, 2002175	Percent with major depression as measured with SCID		12 months		NS
Tutty, 200089	Percent with SCID ≤1		3 months		NS
6 months		NS
Katon, 1999103 (4 sites, N=228)	Percent with SCID ≤1		3 months	Intervention	P=.01
6 months	Intervention	P=.05
QuEST)5	Percent below CES-D=16		24 months	Intervention	P<.02	Treatment × time
Katzelnick, 2000100	Percent below Hamilton depression score<7		12 months	Intervention	P<.001	27.7% compared to 12.8%
Medical
IMPACT128,129	Arthritis pain intensity		3 months	Intervention	-0.58, 95% CI -0.9; -0.25, p<.001
			6 months		NS
	12 months	Intervention	-0.53, 95% CI-0.92; -0.14, p=.009
	Arthritis interferes with daily activities		3 months	Intervention	-0.67, 95% CI -1.06; -0.27, p=.001
			6 months	Intervention	-0.56, 95% CI-0.96; -0.16, p=.006
	12 months	Intervention	-0.59, 95% CI -1; -0.19, p=.004
	Arthritis pain interferes with daily activities		3 months	Intervention	-0.24, 95% CI -0.39; -0.09, p=.002
			6 months	Intervention	-0.22, 95% CI-0.36; -0.09, p=.005
	12 months	Intervention	-0.26, 95% CI -0.41; -0.10, p=.002
	Graded chronic pain scale for arthritis pain severity		12 months	Intervention	Beta 0.15 (SE 0.06), p=.026	Interaction: intervention × pain severity
	12 months		NS	Interaction: intervention × pain activity interference
	Graded chronic pain scale for arthritis pain activity interference		12 months	Intervention	Beta 0.14 (SE 0.07), p=.04	Interaction: intervention × pain severity
12 months		Beta 0.13 (SE 35), p=.015	Interaction: intervention × pain activity interference
Pathways113	HbA1c level		6 months		NS
12 months		NS
ANXIETY DISORDERS
Panic symptoms
Roy-Byrne, 2001109	PDSS Panic disorder severity scale		3 months		NS	Intervention × time p=.05, driven by reduction in anticipatory anxiety
			6 months	Intervention	P=.003
			9 months		NS
12 months		NS
Rollman, 2005101	PDSS Panic Disorder Severity Scale	All patients	12 months	Intervention	0.33, 95% CI 0.04; 0.62, p=.02	Intervention × time
Panic disorder	12 months	Intervention	0.57, 95% CI 0.18; 0.96, p=.003	Intervention × time
Anxiety symptoms
Roy-Byrne, 2001109	Anxiety sensitivity scale		3 months	Intervention	P=.002	Intervention × time p=.018
			6 months	Intervention	P<.001
			9 months		NS
12 months	Intervention	P=.035
	Panic related agoraphobic avoidance		12 months		NS
CCAP9	Anxiety sensitivity index score		3 months	Intervention	Effect size 0.44
			6 months	Intervention	Effect size 0.45
			9 months	Intervention	Effect size 0.44
12 months	Intervention	Effect size 0.43
Rollman, 2005101	* SIGH-A Hamilton anxiety rating scale	All patients	12 months	Intervention	0.38, 95% CI 0.09; 0.67, p=.03	Intervention × time,
General anxiety disorder	12 months		NS
Fear symptoms
Roy-Byrne, 2001109	Fear questionnaire agoraphobic subscale		12 months		NS
Depression symptoms
Roy-Byrne, 2001109	Mean CES-D		3 months	Intervention	P=.002	Intervention × time p=.03
			6 months	Intervention	P=.005
			9 months	Intervention	P=.036
12 months	Intervention	P=.02
CCAP9	Mean CES-D		3 months	Intervention	Effect size 0.29
			6 months	Intervention	Effect size 0.29
			9 months	Intervention	Effect size 0.27
12 months	Intervention	Effect size 0.26
Rollman, 2005101	Hamilton depression rating scale	All patients	12 months	Intervention	0.57, 95% CI 0.25; 0.46, p=.03	Intervention × time
Price, 200091	Mean Shedler Quick Psycho Diagnostics Panel		6 months	Intervention	P=.046
Treatment response
Roy-Byrne, 2001109	40% reduction in PDSS		3 months		NS
			6 months	Intervention	P=.001
			9 months		NS
12 months	Intervention	P=.048
Rollman, 2005101	40% reduction in SIGH-A	All patients	12 months	Intervention	30.8, 95% CI 17.0; 44.7, p<.001
	General anxiety disorder	12 months		NS
	40% reduction in PDSS	All patients	12 months	Intervention	20.7, 95% CI 9.7; 31.5, p<.001
	Panic disorder	12 months	Intervention	32.2, 95% CI 15.5; 48.9, p<.001
40% reduction in Hamilton depression rating	All patients	12 months	Intervention	28.5, 95% CI 15; 42.6, p<.001
Remission
Roy-Byrne, 2001109	Anxiety sensitivity score <20		3 months	Intervention	P=.004
			6 months	Intervention	P=.004
			9 months		NS
12 months	Intervention	P=.005
CCAP9	Anxiety sensitivity score <20		3 months	Intervention	Effect size 0.40
			6 months	Intervention	Effect size 0.48
			9 months	Intervention	Effect size 0.47
	12 months	Intervention	Effect size 0.51
	High end-state functioning		3 months	Intervention	Effect size 0.23
			6 months	Intervention	Effect size 0.29
			9 months	Intervention	Effect size 0.32
12 months	Intervention	Effect size 0.34
Price, 200091	Shedler quick diagnostics panel <10		6 months	Intervention	P=.025	55.6% intervention vs. 22.8% control achieved remission
OTHER DISORDERS
Somatization symptoms
Katon, 1992107	Mean SCL somatization		6 months		NS
12 months		NS
Depression symptoms
Katon, 1992107	Mean SCL depression		6 months		NS
12 months		NS
Anxiety symptoms
Katon, 1992107	Mean SCL anxiety		6 months		NS
12 months		NS
ADHD symptoms
Epstein, 2007112	Conners Parent Rating Scale		12 months		NS
Drinking severity
PRISM-E126	Mean change in number of drinks per week		6 months		NS	In total, 21% reduced drinking; 18% in integrated care, 23% in referral care
Mean change in number of binge episodes		6 months		NS

Results from this direct comparison of integration and enhanced referral in real world settings (Table 10) suggest that enhanced referral had improved outcomes for major depression, while outcomes for other forms of depression or all patients showed no difference between treatment arms.¹¹⁸ Secondary analysis suggested that the combination of talk therapy plus medication worked better for major depression patients in the enhanced referral model. A critical advantage provided by specialty mental health settings is the full range of psychotherapeutic options, which is generally unavailable in a busy primary care clinic.¹¹⁸ There were no reported results based on anxiety alone or anxiety and alcohol as comorbidities with depression.

The PRISM-E authors noted that the frequency of treatment response across all patient populations was closer to treatment-as-usual outcomes in other trials such as IMPACT and PROSPECT.¹¹⁸ Since treatment-as-usual in practice generally involves referral care, it appears that the PRISM-E trial results are consistent with the null finding that increased levels of integration do not demonstrate improved outcomes. The results of this effectiveness study using naturalistic settings highlights the importance of the need to understand what makes a good clinical process: adequate implementation, proper adaptive fit of an intervention to the clinical environment, and an intervention that positively impacts outcomes are all necessary for effectiveness to be achieved.