Improving treatment access and primary care referrals for depression in a national community-based outreach programme for the elderly.

Background: Mental illness is highly prevalent and disabling, but is under-treated. Outreach services attempt to overcome system and personal barriers to care, but there are few reports of their effects in improving access and use of mental health services. In the Community-based Early Psychiatric Interventional Strategy (CEPIS) programme in Singapore, community nurses routinely screened seniors for depressive symptoms, and provided psychoeducation and referral for primary care treatment. We evaluated the impact of the outreach programme and the extent to which determinants of treatment-seeking were altered by removing socioeconomic, physical and cognitive barriers to care.

Methods: Participants were screened using the geriatric depression scale (GDS) and independently assessed using structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnosis. Treatment-seeking at 1 month post-outreach was compared retrospectively to pre-outreach spontaneous treatment-seeking in the previous 1 year.

Results: Among 4633 participants, 370 (8%) with depressive symptoms included 214 (57.8%) with diagnosed mental disorder(s). Pre-outreach treatment-seeking was 10.3%. The programme resulted in 73.8% being successfully referred to GP treatment. Pre-outreach treatment-seeking was significantly associated with a diagnosed mental disorder (OR = 2.22), fair or poor self-reported mental health (OR = 3.26), > or = 10 depressive symptoms (OR = 3.18), perceived need for professional help (OR = 3.58), > or = 3 medical comorbidities (OR = 2.67), younger age <70 (OR = 2.55), female gender (OR = 3.58) and at least primary education (OR = 3.06). All but a few of these predisposing and enabling variables were not associated with post-outreach treatment-seeking.

Conclusion: By eliminating socioeconomic, physical and cognitive barriers, equitable care provided in an outreach programme vastly increased referrals for primary care treatment for depression.