Excerpt

In 2008, the Agency for Healthcare Research and Quality (AHRQ), commissioned the University of Minnesota Evidence-based Practice Center (EPC) to conduct a systematic review of the literature evaluating the integration of mental health and substance abuse treatment with primary care. The review addressed six key questions (KQ); Table A lists a summary of findings, limitations, and future recommendations.

The report found substantial evidence for improved outcomes through integrated care, although most of the evidence was for treatment of depression in primary care settings. Studies reported positive results for symptom severity, treatment response, and achievement of remission when compared with usual care. The level of integration did not seem to be related to treatment outcomes. Most of the studies addressed the integration of mental health professionals into primary care; few examined the integration of primary care into mental health. The majority of the studies involved older patients. Some studies that found improved outcomes with integrated care have been largely composed of minority populations. The main barriers to a broader use of integrated care include programmatic costs, insurance coverage, and relationships with multiple payers. The U.S. Department of Veterans Affairs (VA) was shown to offer a good model of a sustained program. Key elements of successful models included active support at all levels of the organization and through specific funding.

The authors of the 2008 AHRQ review (Evidence Report/Technology Assessment No. 173) identified multiple research gaps and limitations (summarized in Table ES-1), including conditions other than depression or care integration in younger populations. Other gaps included research in rural areas, examination of the use of information technology (IT), and development of financial models. One of the largest gaps was on integrating medical care into mental health care for patients with serious and persistent mental illness.

In February 2010, AHRQ commissioned the RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) to work with stakeholders to develop a prioritized list of future research needs in this area that would inform researchers, funders, practitioners, advocacy groups, patients, and family members. A structured approach, including the AHRQ population, intervention, comparator, outcome, timeframe, setting (PICOTS) framework, to future research needs prioritization is new: this project, therefore, also served as a pilot for development and testing of methods to conduct such an evaluation. In the future, it is anticipated that all AHRQ-sponsored comparative effectiveness research systematic reviews will contain a documentation of future research needs.

Contents

• Preface
• External Inputs
• Executive Summary
  • Background
  • Methods
  • Results
  • Conclusions
• Background
• Methods
  • Identifying Research Gaps from the 2008 AHRQ Review
  • Identifying Recently Published and Ongoing Studies
  • Prioritizing Research
  • Engaging Stakeholders, Researchers, and Funders
  • Role of Stakeholders
  • Handling Conflicts of Interest
  • Determining Appropriate and Feasible Study Design
• Results
  • Prioritization of Research
  • Dissemination Gap
  • Power Analysis
  • Modified Analytic Framework
• Discussion
• Conclusions
• References
• Abbreviations
• Appendixes
  • Appendix A Rationale for Final Prioritized List of Potential Research Studies (Detailing Rationale, PICOTS, and Study Design Considerations)
  • Appendix B Methods for Paying for Care Management (figure 13 from Bachman et al., 2006)
  • Appendix C Search Strategy for Ongoing Trials and Publications Since Release of the Original 2008 Report
  • Appendix D Ongoing Trials and Recent Publications
  • Appendix E Prioritization Tools
  • Appendix F AHRQ’s EHC Program Selection Criteria for New Research
  • Appendix G Levels of Integration Matrix (Developed from the Integration Matrix Outlined in figure 3 of the 2008 AHRQ Review)
  • Appendix H Interim Results from the First and Second Rounds of Prioritization with Stakeholders
  • Appendix I Analytic Framework (figure 1 from the 2008 AHRQ review)

Acknowledgments: The RTI International–University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI–UNC EPC) would like to thank our stakeholder panel who gave generously of their time. Their expertise and enthusiasm helped drive this project. We would also like to thank our friends, Mary Butler and Bob Kane, from the Minnesota EPC, authors of the 2008 AHRQ report. Thanks also to Mattias Johnson and Roger Akers, from the University of North Carolina at Chapel Hill Cecil G. Sheps Center for Health Services Research, for their work in developing our online surveys; Megan Van Noord and Christiane Voisin, also from the Sheps Center, for library support; and our Task Order Officer, Sonia Tyutyulkova, for support and guidance. We also express our gratitude to RTI staff Loraine Monroe, our EPC Publications Specialist, and Jennifer Drolet, Editor.

AHRQ Contacts: Carolyn M Clancy, MD, Director, Agency for Healthcare Research and Quality; Stephanie Chang, MD, MPH, Director, Evidence-based Practice Center Program, Agency for Healthcare Research and Quality; Jean Slutsky, PA, MSPH, Director, Center for Outcomes and Evidence, Agency for Healthcare Research and Quality; Sonia Tyutyulkova, MD, PhD, Task Order Officer, Evidence-based Practice Center Program, Agency for Healthcare Research and Quality

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Contract No. 290-2007-10056-I. Prepared by: RTI UNC Evidence-based Practice Center, Research Triangle Park, NC

Suggested citation:

Carey TS, Crotty KA, Morrissey JP, Jonas DE, Viswanathan M, Thaker S, Ellis AR, Woodell C, Wines C. Future Research Needs for the Integration of Mental Health/Substance Abuse and Primary Care. Future Research Needs Paper No. 3. (Prepared by the RTI International University of North Carolina at Chapel Hill Evidence-based Practice Center under Contract No. 290-2007-10056-I.) AHRQ Publication No. 10-EHC069-EF. Rockville, MD: Agency for Healthcare Research and Quality. September 2010. Available at: www.effectivehealthcare.ahrq.gov/reports/final.cfm.

This report is based on research conducted by the RTI-UNC Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10056-I). The findings and conclusions in this document are those of the author(s), who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

The information in this report is intended to help health care researchers and funders of research make well-informed decisions in designing and funding research and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of scientific judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical research and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances.

This report may be used, in whole or in part, as the basis for research design or funding opportunity announcements. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

This information does not represent and should not be construed to represent a determination or policy of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report.

1

540 Gaither Road, Rockville, MD 20850; www​.ahrq.gov