Effect of a medical-legal partnership on mental health and utilization: A randomized controlled trial in primary care

Context: Family physicians lack resources to effectively intervene on health-harming legal needs (HHLNs), despite growing calls to address social determinants of health. One promising model is the medical-legal partnership (MLP), which embeds legal screening and referral in clinics, but more evidence is needed prior to broader implementation. Objective: To examine whether an MLP reduces stress, depression, and medical overutilization. Study design: Randomized controlled trial. Setting: Urban, primary care clinic in Houston. Population studied: Low-income individuals, aged 18 or older, who are English or Spanish speaking with positive screens for HHLNs. Intervention: Randomization to an MLP referral or 6-month waitlist. Outcome measures: The primary outcome was perceived stress at 6 months (Perceived Stress Scale (PSS); 0-40 range). Secondary outcomes were depression (Center for Epidemiologic Studies Depression Scale (CES-D); 0-60 range), anxiety (Generalized Anxiety Disorder scale (GAD-7); 0-21 range) and self-reported emergency department, urgent care, and hospital visits. Assessments occurred at 3, 6, and 9 months. Analysis: Generalized linear modeling was used to fit each outcome at 6-months as a function of MLP group, controlling for baseline. Bayesian statistical inference with weakly informative priors and a 75% posterior probability (PP) threshold was used to identify noteworthy differences. Results: One hundred sixty individuals were randomized to intervention (80) and control (80) groups. Analyses did not find meaningful group differences for emergency department visits, urgent care visits, or CES-D. Being in the intervention group was associated with lower PSS scores (18.8 vs. 19.9; PP = 75%) but higher hospitalizations (0.4 vs. 0.3; PP = 78%) and GAD-7 scores (10.3 vs. 6.7; PP=90%). Conclusion: Findings in this trial of an MLP referral were mixed. At 6 months, participants who received an MLP referral appeared to be less stressed but also reported higher anxiety and more hospitalizations.