Original Research

Mental Illness, Functional Impairment, and Patient Preferences for Collaborative Care in an Uninsured, Primary Care Population

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OBJECTIVE: Our goal was to compare the prevalence of mental illness and its impact on functional status in an indigent uninsured primary care population with a general primary care sample. We also hoped to assess patient preferences about mental health and medical service integration.

STUDY DESIGN: We compared a survey of consecutive primary care adults in April and May 1999 with a 1997-98 survey of 3000 general population primary care patients. Both studies used the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire and the 20-question Medical Outcomes Study Short Form.

POPULATION: The patients were from a private nonprofit primary care clinic in Grand Junction, Colorado, that served only low-income uninsured people. We approached a total of 589 consecutive patients and enrolled 500 of them.

MAIN OUTCOME MEASURE: The main outcomes were the prevalence of psychiatric illnesses and the relationship with functional impairment. We compared our findings with a more generalizable primary care population.

RESULTS: This low-income uninsured population had a higher prevalence of 1 or more psychiatric disorders (51% vs 28%): mood disorders (33% vs 16%), anxiety disorders (36% vs 11%), probable alcohol abuse (17% vs 7%), and eating disorders (10% vs 7%). Having psychiatric disorders was associated with lower functional status and more disability days compared with not having mental illness. Patients indicated a preference for mental health providers and medical providers to communicate about their care.

CONCLUSIONS: This low-income uninsured primary care population has an extremely high prevalence of mental disorders with impaired function. It may be important in low-income primary care settings to include collaborative care designs to effectively treat common mental disorders, improve functional status, and enhance patient self-care.

Poverty is bad for a person’s health,1 diminishing physical, cognitive, and psychological2 well-being.3 Attempts to understand why persons with low socioeconomic status have poor health point to psychosocial and behavioral variables,4 such as smoking, bad dietary habits, exposure to trauma and violence, sedentary lifestyles, hopelessness, hostility, and depression.5 Mental illnesses6 (particularly depression7) cause more disability8 and diminished functional status than most physical illnesses.9 It is no surprise, therefore, that people with untreated mental illness use a disproportionate amount of health care resources.10 Thus, the more than 11 million11 people living in poverty who are uninsured are a particularly vulnerable sector of our society.12

In primary care settings the prevalence of mental illness13,14 and its relationship to functional status9 and health care use10 is well studied. However, we know little about these issues in indigent primary care populations. Miranda and colleagues15 studied 205 women at an urban, public sector, gynecology clinic and found that 48% had at least 1 psychiatric disorder. Olfson and coworkers16 studied an urban, older, low-income, mostly Hispanic, general medical population and found a high prevalence of depression, anxiety, substance use, and suicidal ideation associated with decreased function. A recent study by Woolf and colleagues17 found the functional status of inner city, indigent, primary care patients to be lower than the general population and lower than a national sample of patients with common chronic illnesses. We found no studies examining the prevalence of mental disorders and their relationship with functional status and health care use in low-income uninsured patients in primary care settings.

Family physicians18 and the Surgeon General19 have advocated for the integration of mental health into medical settings to improve care and reduce the stigmatization of mental illness. Models of collaboration20,21 between mental health and medical providers have been shown to be effective22-25 and cost-effective.26,27 Attending to patient preferences about therapeutic modality enhances the effectiveness of mental disorder treatments.28 However, we found no studies examining indigent patient preferences regarding the separation versus integration of medical and mental health services.

We predicted that an underprivileged, uninsured sample of primary care patients would have higher levels of mental illness and more impaired function than has been reported in general primary care samples. We also suspected that heath care utilization would be higher for indigent patients with more psychiatric symptoms compared with indigent primary care patients without psychiatric distress. Because policy,19 provider,18 and research23,25 recommendations endorse collaborative care designs, we wanted to initiate exploration of patient preferences for these service structures, since attending to patient wishes might enhance the effectiveness of future interventions.



We conducted our study at the Marillac Clinic in Grand Junction, Colorado. Marillac is a privately funded, nonprofit, primary care clinic serving Mesa County, Colorado (3313 square miles), with a population of 113,000 in 1999. Marillac serves only people without any form of health insurance (no Medicare or Medicaid) and with household incomes less than 150% of federal poverty guidelines. In 1998,14.5% of the Mesa County population lived below the poverty level, 16.6% lacked health insurance, 4.5% were unemployed, 90% were white, and 8% were Hispanic.29 The Human Subjects Review committee of St. Mary’s Hospital, Grand Junction, Colorado, approved our study.


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