Clinical Summary: Baseline Characteristics Associated With Referrals From a Primary Care Mental Health Collaborative Care Model to Specialty Mental Health Services

Most patients with depression or anxiety seen in primary care can stay in collaborative care, but some will need escalation to specialty psychiatry. Knowing which baseline features are linked to referral helps clinicians triage patients more efficiently and identify targets for earlier intervention inside a stepped-care model.

Design A retrospective cohort analysis was conducted on all individuals who were referred for enrollment in the Tampa Veterans’ Affairs (VA) ADM CoCM program from June 4, 2018, through December 4, 2019.

N 757 veterans included in analyses

Population veterans with depression and/or anxiety disorders receiving treatment exclusively in primary care clinics as opposed to specialty mental health clinics

Duration from June 4, 2018, through December 4, 2019

Key Findings

Of the 757 veterans in the ADM program, 131 (17.31%) were ultimately referred on to a higher level of service for specialty psychiatric care.
Among the 131 referred veterans, 121 (92.37%) continued to have at least moderate range symptoms of depression and/or anxiety at the time of referral, indicating that referral was driven primarily by inadequate symptomatic improvement.
In the multivariable logistic regression model, higher baseline PHQ-9 scores were associated with referral to specialty psychiatric services (OR=1.067, 95% CI, 1.016–1.121).
Sleep issues at the time of program enrollment were independently associated with referral to specialty psychiatric services (OR=1.752, 95% CI, 1.150–2.671).
Current or past history of alcohol use disorder (OR =1.702, 95% CI, 1.024–2.829) and current or past history of cannabis use disorder (OR=2.070, 95% CI, 1.116–3.840) were both associated with higher rates of referral to specialty psychiatric services.

Clinical Bottom Line

Most veterans in this primary care pharmacologic collaborative care program remained appropriately managed without specialty referral, but higher baseline depressive burden, sleep problems, alcohol use disorder, and cannabis use disorder marked patients more likely to need escalation. These baseline features should inform triage and early treatment planning in stepped care.

Practice Implications

Patients entering collaborative care with higher baseline PHQ-9 scores, sleep issues, alcohol use disorder, or cannabis use disorder warrant closer monitoring because each was independently associated with referral in the multivariable model.
If resources allow, consider earlier targeted intervention for modifiable risk factors identified at intake, particularly insomnia and substance use, because the authors highlight these as potential areas for proactive treatment.
Referral from collaborative care should be framed as appropriate stepped-care escalation rather than treatment failure, especially since 121 (92.37%) of referred patients still had at least moderate depression and/or anxiety symptoms at the time of referral.
Expect most referrals to go to general outpatient psychiatry rather than narrow subspecialty clinics, as 64 (48.85%) of the 131 referred veterans were sent to the general outpatient mental health clinic.