Developing interventions to improve engagement in mental health treatment brings researchers to the most basic questions: Who participates in mental health care? How can we promote participation in care? Does good participation lead to better outcomes? Research on engagement seeks to address these fundamental questions with interventions designed to improve both participation and the clinical impact of care. This month Interian and colleagues review interventions to improve engagement of persons from underserved racial-ethnic minority groups. The importance of their work and the need for research to improve engagement cannot be overstated. Engagement may not be sufficient, but it is necessary—without engagement we cannot achieve successful clinical outcomes.

In working with older adults with depression, our research group has witnessed the steps that individuals take from accepting a referral, getting to a provider, agreeing to a treatment plan, participating in the treatment, and adhering to the recommended regimen. We work in non–mental health settings in the community, and thus 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, such as primary care, aging services, and home care. In our work, we have come to view engagement as a collaborative process.

Our interventions focus on interactions that help individuals articulate their attitudes toward depression and its care, define their distress in their own terms, identify potential barriers, 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 (such as stigma and loss of independence). Frequently, we must address the undercurrents of ageism and hopelessness—“I am just old”—as reasons for not seeking help. In the Open Door study, a community-based trial funded by the National Institute of Mental Health, engagement is promoted through a collaborative effort between the counselor and the older adult. During intervention meetings, they review the client’s symptoms, views and attitudes, personal goals, options, and useful information about mental health, and they problem solve to create an engagement plan. To conduct successful engagement research, investigators need to build strong partnerships with other providers, such as aging services, community partners, and health care 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.