Developing interventions to improve mental health engagement brings researchers to the most basic questions: Who participates in mental health care? How can we promote participation in care? And if there is good participation, does it lead to better treatment outcomes? Research on engagement seeks to address some of these fundamental questions, with interventions designed to improve both participation and the clinical impact of care. This month Interian and colleagues review the interventions to improve mental health engagement among underserved racial-ethnic minorities. The importance of their work and the need for research to improve engagement in mental health care cannot be overstated. Engagement may not be sufficient-- but it is necessary; and without engagement we cannot achieve successful clinical outcomes.
In working with older adults with depression, our group has witnessed the steps individuals take from accepting a referral, getting to a provider, agreeing to a treatment plan, participating in the treatment and adhering to the regimen that is recommended (described in Raue & Sirey in Psychiatric Clinics of North America, 2010). Working within community (non-mental health) settings, we have no choice but to embrace the challenge of engagement with all of its complexity. Many older adults with new mental health needs do not ‘seek’ treatment but are ‘identified’ by providers in other settings, (e.g., primary care, aging services, and homecare). Working with these individuals, we have come to view engagement as a collaborative process.
Our interventions focus on interactions that help individuals identify their attitudes towards depression and its care, define their distress in their own terms, locate potential barriers to treatment, assess options for care and determine preferences for its delivery. Logistics of transportation and costs are frequent initial barriers, as are the anticipated social costs of care (e.g., stigma, losing independence). Frequently, we face the undercurrent of ageism and hopelessness (‘I am just old’) as reasons for not seeking help. In the Open Door study (R01 MH 079265), engagement is promoted through a collaborative effort between the counselor and the older adult. During the intervention meetings they review the older adults’ symptoms, views and attitudes, personal goals, options, useful information about mental health, and they problem-solve to create an engagement plan. Beyond the individual interactions, successful engagement research often goes beyond mental health providers and settings, and is embedded into strong collaborative partnerships with other providers, e.g., aging services, community partners, healthcare agencies. We recognize that engagement might or might not lead to good pharmacotherapy or psychotherapy and, ultimately, to significant clinical improvements. But, in our experience engagement is best framed as both a process and an outcome. This process may also serve as the beginning of good collaborative mental health treatment.