Most adults who receive mental health services are treated in primary care such that, “primary care and general medical practices have long been considered the de facto or hidden mental health and addiction service system in the United States” (Speer & Schneider, 2003, p.86). Many older adults prefer to receive mental health services in primary care (Areán & Gum, 2013), yet evidence has shown that primary care providers often fail to screen for or treat mental health problems of their older patients (Bruce & Sirey, 2018; Unützer et al., 2003). Further, standard primary care provides suboptimal treatment and referral for those with known problems, possibly due to myriad barriers including stigma, ageism, medical comorbidity, misattribution of symptoms to physical illness, limited time, and reimbursement incentives to address psychosocial issues, and lack of access to qualified providers (Renn et al., 2022; Milan et al., 2020; Ulley et al., 2019; Jimenez et al., 2012; Carpenter et al., 2022; Choi & Gonzalez, 2005; Speer & Schneider, 2003; Wong et al., 2020). The confluence of patient, provider, and systemic barriers to services likely disproportionately impacts minority older adults, who may be least likely to venture out of a primary care setting to seek mental health treatment (Areán, et al., 2005; Rybarczyk et al., 2013), and those with limited English-proficiency report poorer physical and emotional health (Ponce et al., 2006).
Increased recognition of the critical role of primary care in mental health service delivery has led to the development and testing of models for collaborative treatment, in which mental health providers are integrated into the primary care setting (Goodrich et al., 2013). Models of integrated care share a core structure in which multiple disciplines actively collaborate in activities of evaluating, planning, and delivering coordinated mental health care to the patient and family (APA, 2008, 2015). Models differ with regard to how the mental health component is integrated:
- Behavioral health consultant model: the behavioral health provider merely consults with the physician about the patient
- Co-location model: the behavioral health provider works in physical proximity to the primary care physician
- Collaborative care model: services are both co-located and the behavioral health clinician regularly monitors symptoms, coordinates treatment decision making, and facilitates adherence to the intervention for patients with a specified diagnosis (Blount, 2018; Blount 2003).
Elements of such models typically include “provider education, patient activation, systematic treatment monitoring, mobilization of community resources and ready access to mental health services within the target system of care” (Areán, et al., 2005, p. 382). Models that focus on integrated care with older adults differ from those used with younger adults primarily in the assessment instruments employed (i.e. cognitive screening, diminished capacity assessment, suicide risk assessment, measures developed to assess geriatric depression and anxiety, etc.) and the scope of geropsychologically informed interventions (e.g. evaluation of caregiver burden) (Mast et al., 2022; Kube et al., 2021; Raue et al., 2014).
Several randomized multi-site studies (e.g. PROSPECT, PRISM-E, RESPECT-D, IMPACT), that aimed to improve detection and treatment of depressed older adults in primary care, have conclusively demonstrated that collaborative care models care are more effective than treatment-as-usual in improving treatment engagement, improving the course of depression, and reducing symptoms, suicidal ideation, and overall functional impairment (Areán & Gum, 2013; Alexopoulos et al., 2009; Holvast et al., 2017; Unutzer et al., 2002; Bartels et al., 2004; Moye et al., 2019). In practice, behavioral health clinicians provide both initial psychological assessment as well as follow-up psychological intervention to facilitate symptom improvement and continuity of care (Gunn & Blount, 2009). “Stepped care” ranges from low to moderate levels of treatment intensity, such as initial assessment and single follow-up appointments, to highly specialized psychological intervention (Blount, 2018). Psychotherapeutic treatments adapted for older adults in primary care (e.g. IPT-PC; PST-PC) have demonstrated effectiveness when delivered as part of an interdisciplinary collaborative care model (Areán et al., 2005; Areán et al., 2008; Skultety & Zeiss, 2006; Cuijpers et al., 2019) as have models adapted for ethnically diverse older adults (Alegría et al., 2019; Emery-Tiburcio et al., 2017).
Integrated care models draw on existing and newly developed assessment methods to detect and monitor psychological problems in primary care patients. Standardized psychological measures that are brief and multifaceted are prioritized within the primary care setting. Many settings follow a stepped-model of screening, in which a positive screen on a very brief measure is followed by a screening tool with a higher level of diagnostic accuracy. A variety of screening tools have been validated for use with older adults seen in primary care for problems ranging from depression, anxiety (Areán & Ayalon, 2005; Pifer & Segal, 2020; Wild et al., 2014), and substance use (Ejaz et al., 2020) to cognitive impairment (Segal et al., 2020).
As part of its “Foundations of Integrated Care” website, the Veteran’s Administration has developed a training program which includes instruction on screening for mental disorders including depression, anxiety, and alcohol misuse in primary care settings.
Instructional modules and measures that are in the public domain and available online:
Psychologists may have direct roles on integrated healthcare teams providing services to older adults in primary care, including evaluation, psychotherapeutic treatment, and mobilizing of community resources, as well as indirect roles, including supervising care, promoting interdisciplinary collaboration, and research and program evaluation (APA, 2008). Practice in primary care requires competencies that draw on and extend psychologists’ foundational knowledge and skills, and has led to the delineation of specific Competencies for Psychology Practice in Primary Care (APA, 2015). Geropsychology training (Zweig et al., 2005) and practice in primary care (Emery-Tiburcio et al, 2017; Zeiss & Karlin, 2008) are rapidly expanding. The full implementation of the collaborative care model, in which psychologists and interdisciplinary team members all play vital roles, holds great promise for improving the detection and treatment of mental health problems in primary care, and thereby improving the quality of life of older adults (Areán & Gum, 2013; Moye, et al., 2019; Zeiss & Karlin, 2008).
Written by Cathryn Goldman, MA and Richard A. Zweig, PhD, Yeshiva University
Alegría, M., Frontera, W., Cruz-Gonzalez, M., Markle, S. L., Trinh-Shevrin, C., Wang, Y., Herrera, L., Ishikawa, R. Z., Velazquez, E., Fuentes, L., Guo, Y., Pan, J., Cheung, M., Wong, J., Genatios, U., Jimenez, A., Ramos, Z., Perez, G., Wong, J. Y., . . . Shrout, P. E. (2019). Effectiveness of a disability preventive intervention for minority and immigrant elders: The positive minds-strong bodies randomized clinical trial. The American Journal of Geriatric Psychiatry, 27(12), 1299–1313 doi: 10.1016/j.jagp.2019.08.008
American Psychological Association Presidential Task Force on Integrated Health Care for an Aging Population. (2008). Blueprint for change: Achieving integrated health care for an aging population. Washington DC: American Psychological Association. http://www.apa.org/pi/aging/programs/integrated/integrated-healthcare-report.pdf
American Psychological Association. (2015). Competencies for Psychology Practice in Primary Care. http://www.apa.org/ed/resources/competencies-practice.pdf.
Areán, P. A., & Gum, A. M. (2013). Psychologists at the table in health care reform: The case of geropsychology and integrated care. Professional Psychology: Research & Practice, 44(3), 142-149. doi: 10.1037/a0031083
Blount, A. (2003). Integrated Primary Care: Organizing the Evidence. Families, Systems, & Health, 21(2), 121–133. https://doi.org/10.1037/1091-75184.108.40.206
Blount, A. (2018) It takes a team. In S. Gold and L. Green (Eds.), Behavioral Health Integration in Primary Care: Your Patients Are Waiting. Springer, New York. pp 131-155.
Carpenter, B. D., Gatz, M., & Smyer, M. A. (2022). Mental health and aging in the 2020s. American Psychologist, 77(4), 538–550. https://doi.org/10.1037/amp0000873
Gunn, W. B., Jr, & Blount, A. (2009). Primary care mental health: a new frontier for psychology. Journal of clinical psychology, 65(3), 235–252. https://doi.org/10.1002/jclp.20499
Jimenez, D.E., Bartels, S.J., Cardenas, V., Dhaliwal, S.S., Alegria, M. (2012). Cultural beliefs and mental health treatment preferences of ethnically diverse older adult consumers in primary care. American Journal of Geriatric Psychiatry, 20(6) ,533-42. doi: 10.1097/JGP.0b013e318227f876
Ponce, N. A., Hays, R. D., & Cunningham, W. E. (2006). Linguistic disparities in health care access and health status among older adults. Journal of General Internal Medicine, 21(7), 786–791. https://doi.org/10.1111/j.1525-1497.2006.00491.x
Wong, S., Zhang, D., Sit, R., Yip, B., Chung, R. Y., Wong, C., Chan, D., Sun, W., Kwok, K. O., & Mercer, S. W. (2020). Impact of COVID-19 on loneliness, mental health, and health service utilisation: a prospective cohort study of older adults with multimorbidity in primary care. The British journal of general practice : Journal of the Royal College of General Practitioners, 70(700), e817–e824. https://doi.org/10.3399/bjgp20X713021
Zweig, R. A., Siegel, L., Hahn, S., Kuslansky, G., Byrne, K., Fyffe, D., Passman, V., Stewart, D., & Hinrichsen, G. A. (2005). Doctoral clinical geropsychology training in a primary care setting. Gerontology & Geriatrics Education, 25(4), 109–129. https://doi.org/10.1300/J021v25n04_07
Bruce, M. L., & Sirey, J. A. (2018). Integrated Care for Depression in Older Primary Care Patients. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 63(7), 439–446. https://doi.org/10.1177/0706743718760292
Ejaz, F. K., Rose, M., Reynolds, C., Bingle, C., Billa, D., & Kirsch, R. (2020). A novel intervention to identify and report suspected abuse in older, primary care patients. Journal of the American Geriatrics Society, 68(8), 1748–1754. Doi: 10.1111/jgs.16433
Mast, B. T., Fiske, A., & Lichtenberg, P. A. (2022). Assessment: A foundational geropsychology knowledge competency. Clinical Psychology: Science and Practice, 29(1), 43–58. doi: 10.1037/cps0000055
Penders, K., Peeters, I., Metsemakers, J., & van Alphen, S. (2020). Personality Disorders in Older Adults: a Review of Epidemiology, Assessment, and Treatment. Current Psychiatry Reports, 22(3), 14. https://doi.org/10.1007/s11920-020-1133-x
Pifer, M. A., & Segal, D. L. (2020). Geriatric Anxiety Scale: Development and Preliminary Validation of a Long-Term Care Anxiety Assessment Measure. Clinical Gerontologist, 43(3), 295–307. https://doi.org/10.1080/07317115.2020.1725793
Raue, P. J., Ghesquiere, A. R., & Bruce, M. L. (2014). Suicide risk in primary care: identification and management in older adults. Current Psychiatry Reports, 16(9), 1-8. https://doi.org/10.1007/s11920-014-0466-8
Romirowsky, A., Zweig, R., Glick Baker, L., & Sirey, J. A. (2018). The relationship between maladaptive personality and social role impairment in depressed older adults in primary care. Clinical Gerontologist: The Journal of Aging and Mental Health. Doi: 10.1080/07317115.2018.1536687
Segal, D. L., Granier, K. L., Pifer, M. A., & Stone, L. E. (2020). Mental health in older adults: An introduction for integrated care professionals. Clinics in Integrated Care, 2, 100015. https://doi.org/10.1016/j.intcar.2020.100015
Wild, B., Eckl, A., Herzog, W., Niehoff, D., Lechner, S., Maatouk, I., Schellberg, D., Brenner, H., Müller, H., & Löwe, B. (2014). Assessing generalized anxiety disorder in elderly people using the GAD-7 and GAD-2 scales: results of a validation study. American Journal of Geriatric Psychiatry, 22(10), 1029–1038. https://doi.org/10.1016/j.jagp.2013.01.076
Alexopoulos, G. S., Reynolds, C. F., 3rd, Bruce, M. L., Katz, I. R., Raue, P. J., Mulsant, B. H., Oslin, D. W., Ten Have, T., & PROSPECT Group (2009). Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT study. The American journal of psychiatry, 166(8), 882–890. https://doi.org/10.1176/appi.ajp.2009.08121779
Areán, P. A., Ayalon, L., Hunkeler, E., Lin, E. H., Tang, L., Harpole, L.,. . . Unützer, J. (2005). Improving depression care for older, minority patients in primary care. Medical Care, 43, 381–390. doi:10.1097/01.mlr.0000156852.09920.b1
Arean, P., Hegel, M., Vannoy, S., Fan, M., & Unuzter, J. (2008). Effectiveness of problem-solving therapy for older, primary care patients with depression: Results from the IMPACT project. The Gerontologist, 48, 311-323. doi:10.1093/geront/48.3.311
Bartels, S. J., Coakley, E. H., Zubritsky, C., Ware, J. H., Miles, K. M., Area´n, P. A., et al. (2004). Improving access to geriatric mental health services: A randomized trial comparing treatment engagement with integrated versus enhanced referral care for depression, anxiety, and at-risk alcohol use. American Journal of Psychiatry, 161, 1455–1462.
Choi, N. G., & Gonzalez, J. M. (2005). Barriers and Contributors to Minority Older Adults’ Access to Mental Health Treatment: Perceptions of Geriatric Mental Health Clinicians. Journal of Gerontological Social Work, 44(3-4), 115–135. https://doi.org/10.1300/J083v44n03_08
Cuijpers, P., Quero, S., Dowrick, C., & Arroll, B. (2019). Psychological Treatment of Depression in Primary Care: Recent Developments. Current psychiatry reports, 21(12), 129. https://doi.org/10.1007/s11920-019-1117-x
Cully, J.A., Paukert, A., Falco, J., & Stanley, M.A. (2009). Cognitive-behavioral therapy: Innovations for cardiopulmonary patients with depression and anxiety. Cognitive and Behavioral Practice, 16 , 394-407.
Emery-Tiburcio, E. E., Mack, L., Lattie, E. G., Lusarreta, M., Marquine, M., Vail, M., & Golden, R. (2017). Managing Depression among Diverse Older Adults in Primary Care: The BRIGHTEN Program. Clinical gerontologist, 40(2), 88–96. https://doi.org/10.1080/07317115.2016.1224785
Emery, E.E., Lapidos, S., Eisenstein, A., Ivan, I., & Golden, R. (2012). The BRIGHTEN Program: Implementation and evaluation of a program to Bridge Resources of an Interdisciplinary Geriatric Health Team via Electronic Networking. The Gerontologist, 52 (6): 857-865. DOI: 10.1093/geront/gns034.
Gallo, J. J., Morales, K. H., Bogner, H. R., Raue, P. J., Zee, J., Bruce, M. L., & Reynolds, C. F. (2013). Long term effect of depression care management on mortality in older adults: Follow-up of cluster randomized clinical trial in primary care. BMJ, 346(jun05 2). https://doi.org/10.1136/bmj.f2570.
Goodrich, D. E., Kilbourne, A. M., Nord, K. M., & Bauer, M. S. (2013). Mental health collaborative care and its role in primary care settings. Current Psychiatry Reports, 15(8), 383. https://doi.org/10.1007/s11920-013-0383-2
Holvast, F., Massoudi, B., Oude Voshaar, R. C., & Verhaak, P. (2017). Non-pharmacological treatment for depressed older patients in primary care: A systematic review and meta-analysis. PloS One, 12(9), e0184666. https://doi.org/10.1371/journal.pone.0184666
Kroenke, K., & Unutzer, J. (2017). Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care. Journal of General Internal Medicine, 32(4), 404–410. https://doi.org/10.1007/s11606-016-3967-9.
Milan, R., & Vasiliadis, H. M. (2020). The association between side effects and adherence to antidepressants among primary care community-dwelling older adults. Aging & mental health, 24(8), 1229–1236. https://doi.org/10.1080/13607863.2019.1594165
Moye, J., Harris, G., Kube, E., Hicken, B., Adjognon, O., Shay, K., & Sullivan, J. L. (2019). Mental health integration in geriatric patient aligned care teams in the Department of Veterans Affairs. American Journal of Geriatric Psychiatry, 27(2), 100–108. https://doi.org/10.1016/j.jagp.2018.09.001
Niknejad, B., Bolier, R., Henderson, C. R., Jr, Delgado, D., Kozlov, E., Löckenhoff, C. E., & Reid, M. C. (2018). Association Between Psychological Interventions and Chronic Pain Outcomes in Older Adults: A Systematic Review and Meta-analysis. JAMA internal medicine, 178(6), 830–839. https://doi.org/10.1001/jamainternmed.2018.0756
O’Shea Carney, K., Gum, A. M., & Zeiss, A. M. (2015). Geropsychology in interprofessional teams across different practice settings. In P. A. Lichtenberg, B. T. Mast, B. D. Carpenter, & J. Loebach Wetherell (Eds.), APA handbook of clinical geropsychology, Vol. 1. History and status of the field and perspectives on aging (pp. 73–99). American Psychological Association. https://doi.org/10.1037/14458-005
Oxman, TE, Deitrich, AJ & Schulberg HC (2003). The depression care manager and mental health specialist as collaborators within primary care. American Journal of Geriatric Psychiatry, 11, 507–516.
Renn, B. N., Johnson, M., Powers, D. M., Vredevoogd, M., & Unützer, J. (2022). Collaborative care for depression yields similar improvement among older and younger rural adults. Journal of the American Geriatrics Society, 70(1), 110–118. https://doi.org/10.1111/jgs.17457
Roy-Byrne, P. B., Katon, W., Cowley, D. S., & Russo, J. (2001). A randomized effectiveness trial of collaborative care for patients with panic disorder in primary care. Archives of General Psychiatry, 58, 869–876.
Rybarczyk, B., Garroway, A. M., Auerbach, S. M., Rodríguez, V. M., Lord, B., & Sadock, E. (2013). Primary care psychology: An opportunity for closing the gap in mental health services for older adults. Clinical Gerontologist: The Journal of Aging and Mental Health, 36(3), 195–215. https://doi.org/10.1080/07317115.2013.767870
Sirey, J., Bruce, M., & Kales, H. (2010). Improving antidepressant adherence and depression outcomes in primary care: The treatment initiation and participation program. American Journal of Geriatric Psychiatry 18(6), 554-562.
Skultety, K. M., & Zeiss, A. (2006). The treatment of depression in older adults in the primary care setting: An evidence-based review. Health Psychology, 25(6), 665-674. doi:10.1037/0278-6220.127.116.115
Speer, D. C., & Schneider, M. G. (2003). Mental health needs of older adults and primary care: Opportunity for interdisciplinary geriatric team practice. Clinical Psychology: Science and Practice, 21, 85–101.
Stanley, M. A., Diefenbach, G. J., Hopko, D.R. (2004). Cognitive behavioral treatment for older adults with generalized anxiety disorder: A therapist manual for primary care settings. Behavior Modification, 28, 73-117.
Stuart, M.R. & Lieberman , J.A. (2002). The fifteen minute hour: Practical therapeutic intervention in primary care. Philadelphia: Saunders.
Ulley, J., Harrop, D., Ali, A., Alton, S., & Fowler Davis, S. (2019). Deprescribing interventions and their impact on medication adherence in community-dwelling older adults with polypharmacy: a systematic review. BMC geriatrics, 19(1), 15. https://doi.org/10.1186/s12877-019-1031-4.
Unutzer, J., Katon, W., Callahan, C. M., Williams, J. W., Hunkeler, E., Harpole, L., et al. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. Journal of the American Medical Association, 288, 2836–2845.
Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Jr., Hunkeler, E., Harpole, L., Hoffing, M., Penna, R. D. D., Noel, P. H., Lin, E. H. B., Tang, L., & Oishi, S. (2003). Depression treatment in a sample of 1,801 depressed older adults in primary care. Journal of the American Geriatrics Society, 51(4), 505–514. DOI: 10.1046/j.1532-5415.2003.51159.x
Zeiss, A. M., & Karlin, B.E. (2008). Integrating mental health and primary care services in the Department of Veterans Affairs health care system. Journal of Clinical Psychology in Medical Settings, 15(1), 73-78. doi:10.1007/s10880-008-9100-4
Ziess, A., & Karlin, B. (2008). Integrating Mental Health and Primary Care Services in the Department of Veterans Affairs Health Care System. Journal of Clinical Psychology in Mental Health Settings, 15, 73-78.