Integration between Primary Care and Mental Health Services in Italy: Determinants of Referral and Stepped Care

This study, carried out in the context of a collaborative care program for common mental disorders, is aimed at identifying the predictors of Primary Care Physician (PCP) referral to Community Mental Health Center (CMHC) and patterns of care. Patients with depression or anxiety disorders who had a first contact with CMHCs between January 1, 2007–December 31, 2009 were extracted from Bologna Local Health Authority database. A classification and regression tree procedure was used to determine which combination of demographic and diagnostic variables best distinguished patients referred by PCPs and to identify predictors of patterns of care (consultation, shared care, and treatment at the CMHC) for patients referred by PCPs. Of the 8570 patients, 57.4% were referred by PCPs. Those less likely to be referred by PCPs were living in the urban area, suffered from depressive disorder, and were young. As to the pattern of care, patients living in the urban area were more likely to receive shared care compared with those living in the nonurban area, while the reverse was true for consultation. Predictors of CMHC treatment were depression and young age. Prospective studies are needed to assess length, quantity, and quality of collaborative treatment for common mental disorder delivered at any step of care. 1. Introduction Mental disorders are very common in primary care setting: the WHO Collaborative Study on Psychological Problems in General Health Care (PPGHC) reported a global prevalence of 24.0% [1]. In this study, that excludes schizophrenia spectrum disorders, the most frequent disorders were Depression (10.4%) and Generalized Anxiety Disorder (7.9%). The crucial role of primary care in the recognition and the management of mental disorders is receiving growing attention, and collaboration projects between Primary Care and Mental Health sectors are underway in many countries following models developed in the United Kingdom and in the USA [2–5]. In Italy, primary care is placed at the heart of the health care system. Primary care physicians (PCPs) are independent contracted professionals who operate under the control of Local Health Authorities (LHAs). On average, LHAs are responsible for the overall health of, and for the services offered to, a target population of 350,000 inhabitants. PCP are the first contact for the most common health problems and act as gatekeepers for drug prescription and for access to specialty and hospital care. Specifically, PCP are involved in delivering various primary care services like health promotion and preventive care