JOURNAL, exemplifies what the 1999 Surgeon General’s report 2 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 earlyonset 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 trials 4 and the outcomes of real-life care 5 that treatment can improve dayto-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
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May 1, 2005
T Y Lum + 2
Open Access
