INTERVENTIONS TO IMPROVE RECOGNITION AND MANAGEMENT OF MENTAL DISORDERS IN PRIMARY CARE: A CRITICAL REVIEW OF THE LITERATURE

Kurt Kroenke, M.D., Department of Medicine, Indiana University School of Medicine and Regenstrief Institute For Health Care, Indianapolis, IN; Anne Taylor-Vaisey, M.S., Office of Continuing Education, University of Toronto; Allen J. Dietrich, M.D., Dept. of Community and Family Medicine, Dartmouth Medical School; Thomas E. Oxman, M.D., Department of Psychiatry, Dartmouth Medical School

Purpose: Mental disorders are prevalent in primary care and numerous studies have been conducted to improve their recognition and management. This paper provides a critical review of the literature on interventions to improve the detection and management of mental disorders in primary care.

Methods: The MEDLINE database was searched for all relevant articles published in English between 1966 through May 1998. Forty-four controlled studies met inclusion criteria, including 25 randomized controlled trials and 19 quasi-experimental studies (pre-post design or nonrandomized controlled trials). All studies were independently reviewed by 2 investigators and data were abstracted using explicit criteria.

Results: The types of interventions used were predisposing in 30 studies, enabling in 23, and reinforcing in 17, with half of the studies incorporating two or more types of intervention. Improved diagnosis of mental disorders was reported in 17of 22 (77%) of the studies examining this outcome, and improved treatment in 14 of 19 (74% studies. Clinical improvement as measured by psychiatric symptoms or functional status was documented in 4 of 10 (40%) and 4 of 8 (50%) studies, respectively. Internists appeared somewhat more refractory to Interventions than other primary care specialties. Considerable study heterogeneity precluded demonstrating and clear association between efficacy of an intervention and study design, number or types of interventions, provider training status, primary care setting, or psychiatric disorder. Only three studies assessed durability of an intervention, and tow of these found that providers' practices reverted to usual care after an intervention had ceased.

Conclusion: While the superiority of any particular intervention remains to be determined, our findings suggest health care systems can intervene to improve the process of care for mental disorders, and potentially patient outcomes.

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