This document summarizes research on strategies for integrating mental health care into primary care practices. It finds that screening patients for mental health issues alone is not effective and does not change outcomes. The most effective strategy found is collaborative care, which involves primary care providers, case managers with mental health backgrounds, and supervision from mental health professionals. However, more research is still needed to identify best practices and overcome financial barriers to fully integrating services.

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Mental Health Disparities in Primary Care Practices
Lindsey Hunt, BSN, RN ~ Jesika Moore, BSN, RN
Jennifer Peifer, BSN, RN ~ Jennifer Raines, BSN, RN ~ Ann Sparks, BSN, RN
Faculty Mentor: Elizabeth Carlson, PhD, MPH, GNP-BC, PHCNS-BC
In 2001, the Surgeon General
issued a report on the cultural,
racial, and ethical issues that
contribute to mental health
disparities in the U.S. In that
report, the recommendations
identified the necessity of
integrating mental health
careintoprimary health care; this
process would callfor research and
demonstration programs that would
strengthen the capacity of primary
care providers in the delivery of
integrated services. The purpose of
this research project is to find the
best strategies and evidence for
shifting the cultural norms of
primary care practice.
Researching mental health issues
in primary care has
demonstratedthereis still not
cohesive integration of services.
Nursing cannot tackle the PICO
question without collaborative
efforts and it will be difficult to
change cultural norms for patient
screening and treatment by nurse-
driven commitment alone.
Multidisciplinary perspective for a
collaborative approach is required
in order to yield a cohesive
integration of mental health into
primary care. Individualized case-
by-case nursing treatment plans
that include multidisciplinary
resources are required. Ultimately,
further nursing research integrating
other disciplines is still needed to
clearly identify best practices.
(P) In primary care practices,
(I) What strategies are effective at shifting cultural norms of service delivery,
(C) Versus the current compartmentalization of mental health and primary care,
(O) So that mental health care is cohesively integrated with primary care services?
In primary care practices, what strategies are effective
at shifting cultural norms of service delivery,
versus the current compartmentalization of mental health and primary care,
so that mental health care is cohesively integrated with primary care services?
Consistent findings from two
systematic reviews of primary
literature, three quasi-experimental
studies and one observational study
identify that screening for mental
health problems is an inadequate
response for cohesive integration of
mental health with primary care
practice. Varied screening
techniques were utilized in the
studies and screening did not
change the rate of antidepressants
prescribed, referrals to mental
health providers or patient
outcomes. Therefore, the answer of
what strategies are most effective in
shifting cultural norms and causing
integration between providers
remains unknown.
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Two librarians specializing in
nursing research were consulted
and a search was conducted of
CINAHL, PubMed, Cochrane,
Medline, PsychInfo and TRIP
databases; using the MeSh
terminology as database
appropriate. We limited our search
to English written articles published
between the years 1999-2009 and
used the keywords: Health Care
Delivery, Mental Health, Integrated,
Primary Care, strategies, Medical
Home Model. Exclusion criteria
were of articles focusing on
dementia and Alzheimer’s disease.
Of thearticles meeting the known
criteria for the PICO question, five
were selected successfully.
Background
Methods and Search
Strategy
Nursing Implications
& Recommendations
ConclusionObjectives/PICO Statement
Article1 Article2 Article 3 Article4 Article 5
Article Citation Gilbody, S., Sheldon, T., & House, A. (2008).
Screening and case-findinginstruments for
depression: a meta-
analysis.CanadianMedicalAssociation Journal,
178(8), 997-1003.
Bower, P., Gilbody, S., Richards, D., Fletcher, J., &
Sutton, A. (2006).Collaborative care for depression
in primary care: Making sense ofa
complexintervention: systematic review and meta-
regression. British Journal of Psychiatry, 189, 484-
493.
Sousa, K. H., & Zunkel, G. M. (2003). Optimizing
mental health in an academic nurse-managed clinic.
Journal of the American Academyof Nurse
Practitioners, 15(7), 313-318.
Horwitz, S. M., Hoagwood, K. E., Garner, A., Macknin,
M., Phelps, T., Wexberg, S., Foley, C., Lock, J. C.,
Hazen, J. E., Sturner, R.,Howard, B., & Kelleher, K. J.
(2008). No technological innovation is a panacea: A
case series in qualityimprovement for primary care
mental health services. Clinical Pediatrics, 47(7),
685-692.
Rost, K., Nutting, P., Smith, J., Werner, J., & Duan, N.
(2001). Improving depression outcomes in community
primary care practice: A randomized trial of the QuEST
intervention. Journal of GeneralInternal Medicine, 16,
143-149.
Type of Article Systematic Meta-Analysis Systematic review Experimental Case Study Experimental Randomized Trial
Level of Evidence Level I Level I Level IV Level III Level III
Background In many health care systems, the use of
screening questionnaires in primary care
without additional enhancement of care has
become the most commonly used quality-
improvement strategy for care of depression.
Nonetheless, the potential of these screening
instruments to improve the ability of
nonspecialists to recognize and manage
depression is substantial but cannot be
assumed under mandates of evidence-based
practice implementation.
Current management of depression is
suboptimal.Collaborative care interventions are
effective, but little is known about which aspects of
these complex interventions are essential.
When a patient presents at a primary care practice,
evaluation and treatment of mental health disorders
is not being tracked.
It is unclear weather increased awareness and
adequate recognition would improve health outcomes
if more closely tracked.
The available data for primary pediatric practices
does not demonstrate a consistent ability to
recognize, treat and follow through on patient mental
health care.
There remains a gray area between preparation of
physicians, identification of mental health issues, and
application of the tools that are most appropriate for
improving the problem.
Patients with major depression are likely to receive
substandard care and management leading to poor
outcomes.
Would an intervention program in a primary care
setting improve outcomes for patients beginning a new
treatment episode for major depression?
Purpose The purpose of this review was to determine
the specific clinical effectiveness of screening
and case-finding instruments without
additional enhancement of care in improving
the recognition, management and outcome
of depression.
The purpose of this article is to examine the
relationship between the content of collaborative
care interventions and outcomes to assist in the
design of collaborative care needed for the care of
depression.
The purpose of the article is to evaluate the initial
results of tracking and health outcomes, specifically
in mental health, for clients at an academic nursing
clinic and to describe an approach to mental health
treatment in this setting.
The purpose of this article was to evaluate the
findings of three different methods of identification of
pediatric mental health issues, in hopes to improve
healthcare outcomes as reported by clinicians.
The purpose of this article was to provide suggestions
for primary care clinics who did not employ onsite
mental health specialists.
Methodology Research Design:
Cochrane Systematic Review
Setting:
Not applicable
Population:
N=11,389 research studies
Sample:
N=16 randomized controlled studies
Variables:
•In-patient and out-patient settings
•Unselected versus high-risk patients
•U.S. studies versus other
Tools:
•Data extraction
•Two Independent Data Reviewers
•Mediation for bias
Outcomes:
•Rates of detection
•Rates of intervention/referral
•Outcomes
• < 6 months
• 6-12 months
• > 6 months
Research Design:
Systematic review
Setting:
Not applicable
Population:
N=12,398 research studies
Sample:
N=62 collaborative care studies
Variables:
•Collaborative care
•Primary care provider
•Mental health specialist
•Case management
Tools:
•Data extraction
•Two Independent Data Reviewers
•Discussion for bias
Outcomes:
•Antidepressant usage
•Reduction in depressive symptoms
Research Design:
Descriptive-survey
Setting:
Nurse-managed clinic
Population:
Audited charts at a Primary Care Clinic
Sample:
N=151 patient charts
Variables:
•Monitoring of health perceptions and quality of life
Tools:
•Mental Component Scale (MCS- comprised of:
Vitality Scale; SF-36 Social Functioning Scale; Role-
Emotional Scale; Mental Health Scale)
Outcomes:
•Rates of detection
•Adequacy of treatment
•Availability of detection facility
Research Design:
Quasi-experimental
Setting:
Ohio
Population:
Physicians and clients of pediatric clinics
Sample:
N=3 pediatric practices
N= 11 pediatricians
N= 376 parents
Variables:
•MD knowledge
•Parent participation
Tools:
•Pretest/Posttest
•Child Health And Development Interactive System
(CHADIS)
•Edinburgh Postnatal Depression Scale
Outcomes:
•Change in practice
•Physician perceptions
•Parent perceptions
Research Design:
Randomized effectiveness trial
Setting:
Community primary care practices
Population:
Primary care patients with major depression
Sample:
N=12 primary care clinics
N=479 patients
Variables:
•Antidepressants
•Prescription therapy
•Psychotherapy
•Satisfaction of care
Tools:
•Modified 23 Item Center for Epidemiologic Studies-
Depression Scale (mCES-D)
•SF-36
•Patient recall
•Satisfaction
Outcomes:
•Depressive symptoms
Statistics •Random effects pooling •Random effects meta-regression •Multi-variant analysis
•Linear T-score transformation
•Descriptive statistics •SAS 8.0
•Multivariate analysis
•T tests w/p values
Key Findings •Use of screening, questionnaires, or case-
finding instruments had a modest increase in
recognition/management of depression by
clinicians.
•Once identified with depression through a
screening tool, there was no documented
increase of antidepressant initiation.
•Positive effect of collaborative care on decreased
depressive symptoms
•Case managers with specific mental health
backgrounds and regular supervision has a
positive effect decreased symptoms
•Mental health scores for these clinic patients were
lower than the national norms, likely reflecting
unmet needs.
•This confirmed the problem but did not address the
solution.
•Comprehensive electronic systems appear to have
the potential to overcome several obstacles to
primary mental health care.
•A reasoned, organized approach to screening and
clear clinical guidelines for management of problems
need to be developed.
•Redefining staff roles significantly improved outcomes
in patients with newly identified depressive symptoms.
•Redefined roles were beneficial but impractical due to
financial constraints, more research on sustaining
these roles would improve longevity of patient
outcomes.
Clinical
Meaningfulness
The findings of this study suggest that, in
patients presenting to their primary care
practice, the utilization of a screening
tool/questionnaire/case-finding instrument
was not beneficial in the cohesive integration
and management of those with depression.
The findings of this study suggest that, in shifting
cultural norms in primary care practice
collaborative care (which includes primarycare,
case manager with a mental health background,
and regular supervision by a mental health care
professional) shows efficacy in terms of decreases
in depressive symptoms.
The findings of this study suggest that, in patients
presenting to their primary care practice, the
utilization of a screening tool was not beneficial in
cohesively integrating mental health care.
The findings of this study suggest that strategies to
effectively shift the cultural norms of current primary
care will require a great deal of education and
technical support to integrate mental health and
primary care service-delivery-systems.
The findings of this study suggest that redefining staff
roles to effectively shift cultural norms of current
primary care will require further evaluation of financial
re-distribution for maintenance of these roles and
improved health outcomes for mental health patients.
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Level I
40%
Level III
40%
Level IV
20%
Levels of Article Evidence
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