The article by Rabins et al,1
in this issue of THE JOURNAL, exemplifies what the 1999 Surgeon General's
report2
on mental health has called the public health approach to mental health
and mental illness. Characterized by concern for the health of a
population in its entirety, the public health model extends beyond the
traditional areas of diagnosis, treatment, and studies of the origins of
disease to include "epidemiological surveillance of the health of the
population at large, health promotion, disease prevention, and access to
and evaluation of services."2(p3)
In terms of clinical activities, this public health model extends beyond
simple models that provide treatment only for those who request care, to
include systematic approaches to identifying cases, facilitating access to
treatment, ensuring the delivery of quality care, and assessing the
outcomes of treatment with respect to psychiatric symptoms and other
outcomes of public health significance.
Among the elderly, the prevalence of mental illnesses is approximately
20%.2
The specific diagnoses include the early-onset disorders such as
schizophrenia and recurrent major affective disorders that continue to
affect people as they age, later-onset conditions that include the
depressions that often complicate medical illness, and the later-life
dementias. The relative rates of these disorders depend strongly on age
and the severity of coexisting medical illnesses. Although the mental
disorders of later life have a major impact on disability, care needs, and
care costs, they are less commonly recognized, diagnosed, and treated than
those of younger patients.2
There is compelling evidence that mental health care is efficacious in the
elderly,3
and evidence is accumulating both from randomized clinical trials4
and the outcomes of real-life care5
that treatment can improve day-to-day functioning. However, despite its
impact, mental health care accounts for only 5% of the Medicare budget.6
In this context, the study by Rabins et al should prompt a reevaluation of
current strategies for the delivery of mental health care and of the
interactions of mental health care with general medical and long-term care
in the elderly.
Following their observation that the residents of public housing
apartments in Baltimore, Md, had an increased prevalence of mental
disorders, Rabins et al randomly assigned residents from 6 apartment
buildings to receive either a Psychogeriatric Assessment and Treatment in
City Housing (PATCH) intervention or usual care. The intervention
consisted of several components: training building staff, including
managers, social workers, grounds keepers, and janitors to identify
persons at risk for psychiatric disorders; identifying potential cases by
these workers and referring them to a psychiatric nurse; and conducting
psychiatric evaluation and treatment of individuals in their own homes. To
evaluate the program, investigators conducted surveys to determine the
prevalence of mental disorders in the population and to evaluate their
severity before implementation of the program and at its conclusion. The
findings were that the intervention led to decreases in psychiatric
symptoms but not in "undesirable" moves from the apartments to nursing
homes or to personal care homes.
Assessing changes in psychiatric symptoms is a necessary step in
evaluating a mental health intervention, and the decrease in psychiatric
symptoms attributable to the PATCH program constitutes a validation of its
effectiveness. However, estimating the public health impact of an
intervention requires evaluations of other outcomes. In this context, it
is important to note the lack of an apparent effect of the PATCH
intervention on undesirable moves. The implicit hypothesis was that a
significant component of the residents' moves from the apartment buildings
into long-term care settings was precipitated by decreased capability for
self-care, or increased dangerous or disruptive behavior related to
untreated psychiatric disorders and that these could be prevented by the
delivery of effective treatment. However, other factors may be critical in
leading to moves or in mediating the effects of interventions. For
example, among patients with Alzheimer disease, family caregiving may be
necessary to maintain individuals in the community, and interventions that
focus on supporting caregivers have been shown to delay nursing home
placement.7,
8
Furthermore, determination of the undesirability of particular moves
should be made with caution. Some patients with Alzheimer disease or other
irreversible causes of disability may be overwhelmed by the demands of
independent living but reluctant to accept the need for more environmental
support. In such cases, helping patients recognize their impairments and
accept the need for long-term care should be viewed as a positive outcome
of mental health care. The lack of an effect of the PATCH intervention on
moves to nursing homes and related institutions could reflect the balance
between cases in which appropriate moves were facilitated, and others in
which avoidable ones were prevented. In retrospect, it appears that
counting moves into long-term care may have been too crude and nonspecific
a measure for evaluating the impact of improved psychiatric care on
outcomes beyond the reduction of symptoms.
The need for a comprehensive intervention such as PATCH is supported by
an impressive accumulation of studies conducted in primary care settings
that have demonstrated that educating physicians or patients, screening
and facilitating detection of mental disorders, and providing
recommendations about their treatment are not sufficient to improve
outcomes either on an individual or population basis.9-12
Enhancing follow-up with attention to treatment adherence, early
recognition of adverse effects of medication, and modification of
treatment as needed, on the basis of the patient's response, is crucial to
improving outcomes. This principle was confirmed by Rabins et al whose
intervention was effective, even in a sample in which substantial numbers
of patients were receiving psychiatric treatment at study entry. Further
research may be necessary to determine optimal approaches for case
identification, treatment planning, patient education, implementation of
treatment, monitoring of outcomes, and modifications of the treatment plan
when necessary, but the need for interventions to include each of these
elements of care has been established.
The PATCH model is an example of a community-based program that should
be replicable in areas characterized by a high density of vulnerable older
adults. Other public health models for mental health care have focused on
primary medical care settings, and a number of initiatives are currently
evaluating strategies for the treatment of mental disorders in older
primary care patients. The National Institute of Mental Health–supported
Prevention of Suicide in the Primary Care Elderly Collaborative Trial
(PROSPECT) study13
and the Hartford Foundation–supported Improving Mood: Promoting Access to
Collaborative Treatment for Late Life Depression (IMPACT) study14
are both evaluating the effectiveness of models in which treatment for
depression is delivered within primary care practices by nurse health
specialists. The Substance Abuse and Mental Health Services Administration
and the Department of Veterans Affairs' projects on Mental Health Services
in Primary Care15
are evaluating the relative effectiveness of integrated mental health
services delivered in the medical care setting vs referral to mental
health professionals for older primary care patients with depression,
anxiety disorders, and alcohol abuse. The PROSPECT study was designed to
evaluate the extent to which an intervention targeting depression in older
primary care patients could reduce risk factors for suicide, including
suicidal ideation, hopelessness, and depression. All of these studies are
testing for the effect of their interventions on an array of outcomes
including functioning, general health outcomes, health-related quality of
life, and health care use. Thus, within the next few years, data will be
available to complement studies of the PATCH program to guide the design
of population-based systems of care.
The success of the PATCH intervention raises questions about the
financing of mental health care for the elderly that should be considered
in evolving debates about the future of Medicare and Medicaid.
Specifically, Rabins et al propose extending Medicare home care benefits
to make interventions such as the PATCH program more widely available.
More generally, the public health model suggests the importance of
modifying current public policy to support bringing care for mental
disorders out of the mental health care system and encouraging its
integrations with housing, long-term care, and medical care systems. The
accumulating evidence for the effectiveness of mental health interventions
demonstrates the value of policies that support the public health model.
The Surgeon General's report2
expressed concerns about the arbitrary restrictions for mental health
insurance coverage and the enormous disparity in coverage for mental
disorders in contrast to other illnesses. This is certainly true for
Medicare, which covers 50% of mental health care costs rather than the 80%
it pays for other conditions, and for which parity in mental health
coverage could have a major impact on the public health. Furthermore, in
demonstrating the value of interactions between mental health care and
both general medical and residential care for the elderly, the public
health model demonstrates the fallacies behind financial models that
ignore important interactions with other components of care while
attempting to carve out distinct budgets for mental health services.
Editorials represent the opinions of the authors and THE JOURNAL and
not those of the American Medical Association.
