One-year outcomes of a randomized clinical trial treating depression in low-income minority women

Ethnic Identity and Mechanisms of Mental Health Service Engagement Among Young Adults with Serious Mental Illnesses

PURPOSE

Young adults from minoritized racial and ethnic groups have lower rates of engagement in treatment for serious mental illnesses (SMI). Previous research suggests a relationship between ethnic identity development and engagement in mental health services, but it remains unclear how a sense of belonging and attachment to one's racial and ethnic group influences participation in treatment among young adults with SMI.

METHODS

Bivariate analyses and structural equation modeling (SEM) were used to examine whether ethnic identity was associated with treatment engagement (attendance and investment in treatment) and how ethnic identity might influence engagement through theoretical proximal mediators. Eighty-three young adults with SMI (95% from minoritized racial and ethnic groups) were recruited from four outpatient psychiatric rehabilitation programs and assessed at least 3 months after initiating services.

RESULTS

Stronger ethnic identity was associated with greater investment in treatment but not with treatment attendance. The SEM analysis indicated that stronger ethnic identity may improve investment in treatment by enhancing hope (0.53, p < .05) and beliefs that mental health providers are credible (0.32, p < .05), and by increasing self-efficacy (-0.09, p < .05). Proximal mediators of engagement were associated with investment in treatment (hope and credibility, p < .05, and self-efficacy p = 0.055).

CONCLUSIONS

Findings provide preliminary evidence of an empirical and theoretical relationship between ethnic identity development and engagement in treatment among young adults with SMI. Assessment and strengthening of a young person's ethnic identity may be a promising approach for improving their engagement in services and reducing inequities in their care.

Emotional Distress in a Marginalized Population as a Function of Household-Level Social Determinants of Health

Low-income, underrepresented communities of color are disproportionally affected by emotional distress. Little is known about malleable, household-level determinants of emotional distress, addressable by feasible, stigma-neutral interventions. The present study addressed this knowledge gap by analyzing secondary data from a cross-sectional community needs assessment survey in a marginalized urban community (N = 677). Relying on dominance analyses, authors found that, on average, the largest household-level contributions to respondents' emotional distress included exposures to fellow household members' alcohol use and anger-driven behaviors. Both determinants are arguably feasible to address via household-level interventions and community-level preventive efforts. Household members' physical and serious mental illness and drug use were moderately associated with respondents' emotional distress; household cohesion and communications, residential overcrowding, and child behavior played a minimal role. Article concludes with a discussion of public health implications of the results.

Impact of a brief intervention to improve engagement in a recovery program for young adults with serious mental illness

OBJECTIVE

Serious mental illnesses (SMI) commonly emerge during young adulthood. Effective treatments for this population exist; however, engagement in treatment is a persistent challenge. This study examines the impact of Just Do You (JDY), an innovative intake-focused intervention designed to improve engagement in treatment and enhance personal recovery.

METHODS

The study used a parallel group randomized trial to examine if and how JDY improved recovery among 121 young adults with SMI from low-resourced communities referred to personalized recovery-oriented services (PROS). Measures of engagement (buy-in and attendance) and personal recovery in this pilot study were assessed at baseline and 3-month follow-up.

RESULTS

Participants in JDY reported more positive engagement outcomes; that is, relative to the control group they reported higher past two week attendance (b = 0.72, p < 0.05, Cohen's d = 0.56) and higher levels of buy-in to treatment (b = 2.42, p < 0.05, Cohen's d = 0.50). JDY also impacted young adults' personal recovery (b = 0.99, p < 0.05, Cohen's d = 1.15) and did so largely by increasing their level of buy-in to the treatment program.

CONCLUSION

This study suggests that an engagement intervention for young adults that orients, prepares, and empowers them to be active and involved in the larger treatment program makes a difference by improving engagement and enhancing recovery. Data also support conceptualizing and examining engagement beyond treatment attendance; in this study what mattered most for recovery was the level of buy-in to treatment among young adults.

A Preliminary Investigation of Psychoneurological Symptoms in Low-Income Mothers

BACKGROUND

Exposure to chronic stressors may contribute to the development of psychoneurological symptoms (i.e., fatigue, cognitive dysfunction, sleep disturbance, depressed mood, and pain) that can compromise maternal function.

OBJECTIVES

In two studies of low-income mothers, we investigated the presence of psychoneurological symptoms and explored associations between mothers' stressors and psychoneurological symptoms as well as between symptoms and function. We also considered the possible mediating role of the symptoms between stressors and function.

METHODS

We conducted secondary analyses of psychoneurological symptoms in two studies of low-income mothers of infants and toddlers in the United States. Study 1 sampled Latina women with limited English proficiency, whereas Study 2 was conducted with English-speaking women from diverse backgrounds. In both studies, symptoms were measured using items from the Center for Epidemiological Studies Depression Scale and the Medical Outcomes Study Short-Form Health Survey. Maternal function was measured through self-report and researcher observation. In Study 2, stressors were measured using the Everyday Stressors Index. Multiple linear regressions were used to investigate associations while controlling for relevant covariates.

RESULTS

In both studies, mothers endorsed a wide range of psychoneurological symptoms. In Study 1, psychoneurological symptoms had significant negative associations with role function, social function, and developmental stimulation. In Study 2, psychoneurological symptoms had significant negative associations with role function, social function, and physical function. Using Aroian test for mediation, we found that psychoneurological symptoms mediated all significant relationships between stressors and maternal functions in Study 2.

DISCUSSION

In two samples of low-income mothers, psychoneurological symptoms were prevalent and associated with chronic stressors and with maternal function and may mediate the association between those two factors. These findings extend prior research on depressive symptoms in mothers by investigating pain as an additional key symptom. The studies advance symptom science by highlighting psychoneurological symptoms in a heterogeneous sample without known health conditions.

Achieving Mental Health Equity: Collaborative Care

The literature supports the effectiveness of systems-based integrated care models, particularly collaborative care, to improve access, quality of care, and health outcomes for behavioral health conditions. There is growing evidence for the promise of collaborative care to reduce behavioral health disparities for racial and ethnic, low-income, and other at-risk populations. Using rapid literature review, this article highlights what is known about how collaborative care may promote health equity for behavioral health conditions, by reducing disparities in access, quality, and outcomes of care. Further, it explores innovative intervention and engagement strategies to promote behavioral health equity for at-risk groups.

Engagement intervention versus treatment as usual for young adults with serious mental illness: a randomized pilot trial

BACKGROUND

Young adults have elevated rates of mental health disorders, yet they often do not receive consistent care. The challenge of continuing to engage young adults has been pervasive worldwide. Few engagement interventions have been designed for young adults with serious mental illness. Just Do You is a theoretically guided engagement intervention. It uses innovative modalities (i.e., technology, expressive arts activities, narrative expression, mentoring) to engage participants in conversations about services and how they work, while simultaneously orienting them to treatment.

METHODS/DESIGN

This pilot and feasibility study utilizes a hybrid research design, examining feasibility, acceptability, and preliminary impact, alongside implementation. The study combines qualitative methods, a small pilot randomized trial, and a small cost-benefit analysis. Respondents are clinic staff and young adults who have made initial contact with the Personalized Recovery Oriented Services (PROS) program. Quantitative survey data are collected at baseline, 2 weeks (post-intervention), 1 month, and 3 months. The assessments focus on measuring feasibility, acceptability, engagement, and mental health outcomes. Medical record extraction will be used to triangulate self-report data. We will conduct single degree of freedom contrasts to examine whether Just Do You leads to improved outcomes relative to Treatment-As-Usual using robust regression for each outcome measure. We will examine whether changes in the proposed mediating variables occur across groups using a similar contrast strategy. In addition, we will use structural equation modeling to examine the contribution of mediators to ultimate outcomes. Finally, we will use constant comparison coding techniques for qualitative analyses.

DISCUSSION

The aim of this study is to examine the feasibility of a young adult engagement meta-intervention through an intensive preliminary pilot trial, learning through collaboration with stakeholders. Just Do You has the potential to fill a gap in the service system for young adults with serious mental illnesses, improving the seemingly intractable problem of disengagement. The program uses culturally responsive strategies, is recovery-oriented, and builds upon the best evidence to date. Our efforts align with local and national health care reform efforts embedding people with lived experience.

TRIAL REGISTRATION

This trial was registered with ClinicalTrials.gov (Identifier: NCT03423212) on April 18, 2018, as Protocol Record R34 MH111861-01, New York University, as the Just Do You Program for Young Adults with Serious Mental Illness.

Two Methods for Calculating Symptom Cluster Scores

BACKGROUND

Symptom clusters are conventionally distilled into a single score using composite scoring, which is based on the mathematical assumption that all symptoms are equivalently related to outcomes of interest; this may lead to a loss of important variation in the data.

OBJECTIVES

This article compares two ways of calculating a single score for a symptom cluster: a conventional, hypothesis-driven composite score versus a data-driven, reduced rank regression score that weights the symptoms based on their individual relationships with key outcomes.

METHODS

We conducted a secondary analysis of psychoneurological symptoms from a sample of 356 low-income mothers. Four of the psychoneurological symptoms (fatigue, cognitive dysfunction, sleep disturbance, and depressed mood) were measured with the Center for Epidemiological Studies Depression Scale; the fifth (pain) was measured using an item from the Medical Outcomes Study 12-item Short Form Health Survey (SF-12). Mothers' function was measured using the 12-item Short Form Health Survey. The composite score was calculated by summing standardized scores for each individual psychoneurological symptom. In contrast, reduced rank regression weighted the individual symptoms using their respective associations with mothers' function; the weighted individual symptom scores were summed into the reduced rank regression symptom score.

RESULTS

The composite score and reduced rank regression score were highly correlated at .93. The cluster of psychoneurological symptoms accounted for 53.7% of the variation in the mothers' function. Depressed mood and pain accounted for almost all the explained variation in mothers' function at 37.2% and 15.0%, respectively.

DISCUSSION

The composite score approach was simpler to calculate, and the high correlation with the reduced rank regression score indicates that the composite score reflected most of the variation explained by the reduced rank regression approach in this data set. However, the reduced rank regression analysis provided additional information by identifying pain and depressed mood as having the strongest association with a mother's function, which has implications for understanding which symptoms to target in future interventions. Future studies should also explore composite versus reduced rank regression approaches given that reduced rank regression may yield different insights in other data sets.

Resilience Against Depression Disparities (RADD): a protocol for a randomised comparative effectiveness trial for depression among predominantly low-income, racial/ethnic, sexual and gender minorities

INTRODUCTION

Depression is the leading cause of adult disability and common among sexual and gender minority (SGM) adults. The current study builds on findings showing the effectiveness of depression quality improvement (QI) and delivery of cognitive behavioural therapy (CBT) skills provided by community health workers in reducing depression. Depression QI approaches across healthcare and social/community services in safety-net settings have shown improvements in mental wellness, mental health quality of life and depression over 12 months. Further, a randomised study showed improved depression among low-income racial/ethnic minorities enrolled in a CBT-informed resiliency class (Building Resilience and Increasing Community Hope (B-RICH)). The current protocol describes a comparativeness effectiveness study to evaluate whether predominantly low-income, SGM racial/ethnic minority adults randomised to a CBT-informed resiliency class have improvements in depressive symptoms over and above community-engaged QI resources and training only.

METHODS AND ANALYSIS

The study approached three clusters of four to five programs serving predominantly SGM and racial/ethnic minority communities in the USA: two clusters in Los Angeles, California, and one in New Orleans, Louisiana. Clusters are comprised of one primary care, one mental health and two to three community agencies (eg, faith-based, social services/support, advocacy). All programs received depression QI training. The current study employed a community-partnered participatory research model to adapt the CBT-informed resiliency class, B-RICH+, to SGM communities. Study participants were screened and recruited in person from participating programs, and will complete baseline, 6- and 12-month survey follow-ups. Participants were depressed adults (8-item Patient Health Questionnaire ≥10; ≥18 years of age) who provided contact information. Enrolled participants were individually randomised to B-RICH+ or depression QI alone. Primary outcomes are depressive symptoms; secondary outcomes are mental health quality of life, mental wellness and physical health quality of life. Data collection for this study is ongoing.

ETHICS AND DISSEMINATION

The current study was approved by the UCLA Institutional Review Board. Study findings will be disseminated through scientific publications and community conferences.

TRIAL REGISTRATION NUMBER

https://clinicaltrials.gov/ct2/show/NCT02986126.

Association of Maternal Depressive Symptoms and Offspring Physical Health in Low-Income Families

Objectives The present study sought to examine the association between maternal depressive symptoms and characteristics of offspring physical health, including health status, health behaviors, and healthcare utilization, among low-income families. Maternal engagement was explored as a mediator of observed effects. Methods Cross-sectional survey data from a community sample of 4589 low-income women and their preschool-age children participating in the WIC program in Los Angeles County were analyzed using logistic, Poisson, and zero-inflated negative binomial regression. Mediation was tested via conditional process analyses. Results After controlling for the effects of demographic characteristics including maternal health insurance coverage, employment status, education, and preferred language, children of depressed women (N = 1025) were significantly more likely than children of non-depressed women (N = 3564) to receive a "poor" or "fair" maternal rating of general health (OR 2.34), eat fewer vegetables (IRR: 0.94) more sweets (IRR: 1.20) and sugary drinks daily (IRR: 1.32), and consume fast food more often (OR 1.21). These children were also less likely to have health insurance (OR 1.59) and more likely to receive medical care from a public medical clinic or hospital emergency room (OR 1.30). Reduced maternal engagement partially mediated associations between maternal depressive symptoms and several child health outcomes including poor diet, health insurance coverage, and use of public medical services. Conclusions for Practice Maternal depressive symptoms are associated with poor health among preschool-age children in low-income families. Prevention, screening, and treatment efforts aimed at reducing the prevalence of maternal depression may positively affect young children's health.

Community Partners in Care: 6- and 12-month Outcomes of Community Engagement versus Technical Assistance to Implement Depression Collaborative Care among Depressed Older Adults

Objective

Community Partners in Care, a community-partnered, cluster-randomized trial with depressed clients from 95 Los Angeles health and community programs, examined the added value of a community coalition approach (Community Engagement and Planning [CEP]) versus individual program technical assistance (Resources for Services [RS]) to implement depression collaborative care in underserved communities. This exploratory subanalysis examines 6- and 12-month outcomes among CPIC participants aged >50 years.

Design

Community-partnered, cluster-randomized trial conducted between April 2010 and March 2012.

Setting

Hollywood-Metropolitan (HM) and South Los Angeles (SLA) Service Planning Areas (SPAs), Los Angeles, California.

Participants

394 participants aged >50 years with depressive symptoms (8-item Patient Health Questionnaire score ≥ 10).

Intervention

A community-partnered multi-sector coalition approach (Community Engagement and Planning [CEP]) vs individual program technical assistance (Resources for Services [RS]) to implement depression collaborative care.

Main Outcome Measures

Depressive symptoms (PHQ-8 score), mental health-related quality of life (MHRQL), community-prioritized outcomes including mental wellness, homelessness risk and physical activity, and services utilization.

Results

At 6 months, CEP was more effective than RS at improving MHRQL and mental wellness among participants aged >50 years; no differences were found in the effects of CEP vs RS on other outcomes. No significant outcome differences between CEP and RS were found at 12 months.

Conclusions

A multisector community coalition approach may offer additional benefits over individual program technical assistance to improve outcomes among depressed adults aged >50 years living in underserved communities.

Predictors and Patterns of Psychiatric Treatment Dropout During Pregnancy Among Low-Income Women

Objective This study compared psychiatric treatment discontinuation rates among pregnant women using psychotropic medications, outpatient psychotherapy, or both before conception. Methods Using data from Pennsylvania Medicaid Fee-For-Service and Managed Care Organization claims and Medicaid enrollment, 3030 women were identified who gave birth between 2007 and 2009, had ≥ 1 claim for psychiatric treatment during the 120 days prior to pregnancy, and were enrolled in Medicaid until they delivered. Kaplan-Meier and Cox regression analyses were used to estimate psychiatric treatment dropout rate during pregnancy and examine relationships between treatment dropout and age, race/ethnicity, and pre-pregnancy psychiatric diagnosis and treatment pattern. Results After the first trimester, the probability of discontinuing psychotropic medications was 83 versus 37.8% for cessation of psychotherapy among combined treatment users. Two or more psychotherapy sessions in the 4 months prior to pregnancy were associated with decreased psychotherapy dropout during pregnancy. Psychotherapy during pregnancy was associated with prenatal psychotropic medication adherence. Conclusions To retain women in treatment during pregnancy, when discontinuation from care is common, innovative models of care should consider type of pre-pregnancy mental healthcare and individual characteristics.

Effectiveness of school-based humanistic counselling for psychological distress in young people: Pilot randomized controlled trial with follow-up in an ethnically diverse sample

OBJECTIVES

The aim of this study was to pilot a test of the effectiveness of school-based humanistic counselling (SBHC) in an ethnically diverse group of young people (aged 11-18 years old), with follow-up assessments at 6 and 9 months.

DESIGN

Pilot randomized controlled trial, using linear-mixed effect modelling and intention-to-treat analysis to compare changes in levels of psychological distress for participants in SBHC against usual care (UC).

TRIAL REGISTRATION

ISRCTN44253140.

METHODS

In total, 64 young people were randomized to either SBHC or UC. Participants were aged between 11 and 18 (M = 14.2, SD = 1.8), with 78.1% of a non-white ethnicity. The primary outcome was psychological distress at 6 weeks (mid-therapy), 12 weeks (end of therapy), 6-month follow-up and 9-month follow-up. Secondary measures included emotional symptoms, self-esteem and attainment of personal goals.

RESULTS

Recruitment and retention rates for the study were acceptable. Participants in the SBHC condition, as compared with participants in the UC condition, showed greater reductions in psychological distress and emotional symptoms, and greater improvements in self-esteem, over time. However, at follow-up, only emotional symptoms showed significant differences across groups.

CONCLUSIONS

The study adds to the pool of evidence suggesting that SBHC can be tested and that it brings about short-term reductions in psychological and emotional distress in young people, across ethnicities. However, there is no evidence of longer-term effects.

PRACTITIONER POINTS

School-based humanistic counselling can be an effective means of reducing the psychological distress experienced by young people with emotional symptoms in the short term. The short-term effectiveness of school-based humanistic counselling is not limited to young people of a White ethnicity. There is no evidence that school-based humanistic counselling has effects beyond the end of therapy.

What Is Being Measured? A Comparison of Two Depressive Symptom Severity Instruments with a Depression Diagnosis in Low-Income High-Risk Mothers

BACKGROUND

Adequate assessment of depressive symptomatology is a necessary step toward decreasing income-related mental health treatment inequity. No studies have focused on comparing instruments used to detect depression in women from low-income backgrounds who are mothers of young children-a period of increased risk for depressive symptoms.

METHODS

To address this gap, two commonly used instruments (Center for Epidemiologic Studies Depression Scale [CES-D] and Hamilton Rating Scale for Depression [Hamilton]) were compared with a depression diagnosis (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-V]) in a sample (n = 251) of mothers from low-income backgrounds with children ranging from 1 to 54 months old. Diagnostic utility was examined in light of contextual factors associated with maternal depressive symptoms.

RESULTS

In this sample, CES-D had better screening sensitivity and specificity than Hamilton. Our results suggest that Hamilton may underdiagnose cases of major depressive episodes (MDE) as defined by DSM-V among black and low-income mothers compared with CES-D. In addition, we identify items in CES-D, which do not contribute to alignment with DSM-V and are appropriate targets for future improvements. Our analysis identifies interpersonal relationships and mother's age as the primary risk factors, which differentiate between CES-D and Hamilton determinations versus MDE diagnosis. In addition, we find regional differences in CES-D and Hamilton.

CONCLUSIONS

It is important to tailor the measure to the context, and a calibration sample should be considered for studies of sufficient size.

Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care

Mental disorders account for 25% of all health-related disability worldwide. More patients receive treatment for mental disorders in the primary care sector than in the mental health specialty setting. However, brief visits, inadequate reimbursement, deficits in primary care provider (PCP) training, and competing demands often limit the capacity of the PCP to produce optimal outcomes in patients with common mental disorders. More than 80 randomized trials have shown the benefits of collaborative care (CC) models for improving outcomes of patients with depression and anxiety. Six key components of CC include a population-based approach, measurement-based care, treatment to target strategy, care management, supervision by a mental health professional (MHP), and brief psychological therapies. Multiple trials have also shown that CC for depression is equally or more cost-effective than many of the current treatments for medical disorders. Factors that may facilitate the implementation of CC include a more favorable alignment of medical and mental health services in accountable care organizations and patient-centered medical homes; greater use of telecare as well as automated outcome monitoring; identification of patients who might benefit most from CC; and systematic training of both PCPs and MHPs in integrated team-based care.

A sanctuary of tranquillity in a ruptured world: Evaluating long-term counselling at a women’s community health centre

The longitudinal study described in this article evaluated long-term counselling provided at a women’s health centre in the UK for service users on low incomes. The article focuses on the qualitative aspect of the study in which 59 women were interviewed individually before and/or after their counselling. The interviews explored how women make sense of long-term counselling in the context of their gendered experiences and complex needs. The data were analysed using thematic analysis informed by a feminist orientation and attachment theory. Four main themes emerged: “violence and loss in the context of female oppression”, “a sanctuary for women”, “non-medicalised long-term counselling in a safe setting”, and “benefits of the long view”. Participants attributed various benefits to receiving long-term counselling in a women-only environment. These included gaining employment; reduced suicidal ideation, anxiety and depression; improved physical health, improved confidence and being able to make positive changes in their relationships. The women interviewed post-counselling valued long-term counselling in this context, in contrast to short-term therapy in a medicalised environment. Wider implications with regard to clinical practice and research are discussed.

Cost-effectiveness of In-Home Cognitive Behavioral Therapy for low-income depressed mothers participating in early childhood prevention programs

BACKGROUND

To determine the cost-effectiveness of In-Home Cognitive Behavioral Therapy (IH-CBT) for low-income mothers enrolled in a home visiting program.

METHODS

A cost-utility analysis was conducted using results from a clinical trial of IH-CBT and standard of care for depression derived from the literature. A probabilistic, patient-level Markov model was developed to determine Quality Adjusted Life Years (QALYs). Costs were determined using the Medical Expenditure Panel Survey. A three-year time horizon and payer perspective were used. Sensitivity analyses were employed to determine robustness of the model.

RESULTS

IH-CBT was cost-effective relative to standard of care. IH-CBT was expected to be cost-effective at a three-year time horizon 99.5%, 99.7%, and 99.9% of the time for willingness-to-pay thresholds of US$25,000, US$50,000, and US$100,000, respectively. Patterns were upheld at one-year and five-year time horizons. Over the three-year time horizon, mothers receiving IH-CBT were expected to have 345.6 fewer days of depression relative to those receiving standard home visiting and treatment in the community.

CONCLUSIONS

IH-CBT is a more cost-effective treatment for low-income, depressed mothers than current standards of practice. These findings add to the growing literature demonstrating the cost-effectiveness of CBT for depression, and expand it to cover new mothers. From a payer perspective, IH-CBT is a sound option for treatment of depressed, low-income mothers. Limitations include a restricted time horizon and estimating of standard of care costs.

The Impact of Community Engagement on Health, Social, and Utilization Outcomes in Depressed, Impoverished Populations: Secondary Findings from a Randomized Trial

BACKGROUND

Disparities in depression care exist among the poor. Community Partners in Care (CPIC) compared a community coalition model with technical assistance to improve depression services in under-resourced communities. We examine effects on health, social, and utilization outcomes among the poor and, non-poor depressed, and poor subgroups.

METHODS

This study analyzed clients living above (n = 268) and below (n = 750) the federal-poverty level and, among the poor, 3 nonoverlapping subgroups: justice-involved (n = 158), homeless and not justice-involved (n = 298), and other poor (n = 294). Matched programs (n = 93) from health and community sectors were randomly assigned to community engagement and planning (CEP) or resources for services (RS). Primary outcomes were poor mental health-related quality of life and 8-item Patient Health Questionnaire scores, whereas community-prioritized and utilization outcomes were secondary. Effects were scrutinized using false discovery rate-adjusted P values to account for multiple comparisons.

RESULTS

In the impoverished group, CEP and RS clients of participating study programs did not differ in primary outcomes, but CEP more than RS improved mental wellness among the depressed poor (unadjusted P = .004) while providing suggestive evidence for other secondary outcomes. Within the poor subgroups, evidence favoring CEP was only suggestive but was strongest among justice-involved clients.

CONCLUSIONS

A coalition approach to improving outcomes for low-income clients with depression, particularly those involved in the justice system, may offer additional benefits over standard technical assistance programs.

THE LONG-TERM EFFICACY OF ACUTE-PHASE PSYCHOTHERAPY FOR DEPRESSION: A META-ANALYSIS OF RANDOMIZED TRIALS

BACKGROUND

Understanding the effectiveness of treatment for depression in both the short term and long term is essential for clinical decision making. The present meta-analysis examined treatment effects on depression and quality of life in acute-phase psychotherapeutic interventions compared to no treatment control groups for adult depression at 6 months or longer postrandomization.

METHODS

A systematic literature search resulted in 44 randomized controlled trials with 6,096 participants. Acute-phase psychotherapy was compared to control groups at 6-month or longer postrandomization. Odds ratios of a positive outcome were calculated.

RESULTS

Psychotherapy outperformed control groups at 6 months or longer postrandomization (OR = 1.92, 95% CI: 1.60-2.31, P < .001). Heterogeneity was moderate (I²: 65, 95% CI: 53-74, P < .001). However, effects significantly decreased with longer follow-up periods. Additionally, a small positive effect of psychotherapy was observed for quality of life, while similar effects were obtained in separate analyses of each type of psychotherapy, with the exception of nondirective supportive therapy. Studies that provided booster sessions had better treatment results compared with studies that did not provide any further sessions. Finally, we found that trials on psychotherapy aimed at major depressive disorder (MDD) had better outcomes than those that were aimed at elevated depressive symptoms.

CONCLUSIONS

There is substantial evidence that acute-phase psychotherapy results in a better treatment effects on depression and quality of life in the long term for adult patients with depression.

Managing Depression Among Homeless Mothers: Pilot Testing an Adapted Collaborative Care Intervention

OBJECTIVE

Although depression is common among homeless mothers, little progress has been made in testing treatment strategies for this group. We describe pilot test results of an adapted collaborative care model for homeless mothers with depression.

METHOD

We conducted a pilot intervention study of mothers screening positive for depression in 2 randomly selected shelter-based primary care clinics in New York over 18 months in 2010-2012. Study participants completed a psychosocial, health, and mental health assessment at baseline, 3 months, and 6 months.

RESULTS

One-third of women screened positive for depression (123 of 328 women). Sixty-seven women (63.2% of the eligible sample) enrolled in the intervention. At 6 months, compared to usual-care women, intervention group women were more likely to be receiving depression treatment (40.0% vs 5.9%, P = .01) and antidepressant medication (73.3% vs 5.9%, P = .001, respectively) and had more primary care physician and care manager visits at both 3 months (74.3% vs 53.3%, P = .009 and 91.4% vs 26.7%, P < .001, respectively) and 6 months (46.7% vs 23.5%, P = .003 and 70% vs 17.7%, P = .001, respectively). More women in the intervention group compared to usual-care women reported ≥ 50% improvement in depression symptoms at 6 months (30% vs 5.9%, P = .07).

CONCLUSIONS

This pilot study found that implementing an adapted collaborative care intervention was feasible in a shelter-based primary care clinic and had promising results that require further testing.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02723058.

Evidence-Based Applications of Combination Psychotherapy and Pharmacotherapy for Depression

Combination treatment with psychotherapy and antidepressant medication can be provided from the initiation of treatment, sequentially after nonremission with a single-modality treatment or sequentially after remission to buttress the patient's recovery to prevent recurrence. Combination treatment from the initiation of care is best reserved for patients with high depression severity. Sequential addition of treatments, particularly psychotherapy after nonremission to antidepressant medication, is the best supported method of combination, improving remission rates and reducing relapse and recurrence in the long term. However, uncertainty persists around the optimal form of psychotherapy to combine with antidepressant medication for maximizing long-term gains. Better outcomes from combination treatment have been strongest in clinical trials that limited pharmacotherapy to a single antidepressant; benefits of combination treatment have been substantially smaller in trials that allowed flexible use of multiple antidepressant classes. Patients with recurrent major depressive disorder who benefit from combination treatment have better long-term outcomes if an active treatment component is maintained during recovery.

Study design to evaluate cognitive behavioral therapy among a diverse sample of adults with a first-time DUI offense

BACKGROUND

Driving under the influence (DUI) of alcohol is a major public health concern, and many individuals continue to drink and drive even after being convicted of a DUI offense. Latinos, in particular, are disproportionately likely to be arrested for a DUI, have higher rates of recidivism, and are more likely to die in alcohol-related accidents than non-Latino Whites. Latinos also experience significant disparities in accessing alcohol-related treatment.

METHODS/DESIGN

This study protocol paper describes a randomized trial of cognitive behavioral therapy (CBT) compared to usual care in DUI programs for individuals with a first-time offense and at-risk drinking. We will utilize a two-group randomized design where individuals enrolled in a DUI program with a first-time conviction will be randomized to CBT (n = 150) or usual care (n = 150). Participants will be assessed at baseline, immediately post-treatment, and 6-months post-treatment. Recidivism data will be collected using administrative data within 2 years post-treatment.

DISCUSSION

This project has the potential to benefit a large population of vulnerable individuals who are at risk of DUI recidivism. It also develops a new model of care by providing treatment in DUI programs to reduce disparities associated with poor treatment access. Trial registration NCT02588703.

Mental Health and Substance Use Among Patients in a North Carolina HIV Clinic

BACKGROUND

The HIV/AIDS epidemic is a significant public health concern in North Carolina, and previous research has pointed to elevated mental health distress and substance use among HIV-infected populations, which may impact patients' adherence to medications. The aims of this study were to describe the prevalence of mental health and substance use issues among patients of a North Carolina HIV clinic, to examine differences by demographic characteristics, and to examine factors associated with suboptimal adherence to HIV medications.

METHODS

This study was a secondary analysis of clinical data routinely collected through a health behavior questionnaire at a large HIV clinic in North Carolina. We analyzed data collected from February 2011 to August 2012.

RESULTS

The sample included 1,398 patients. Overall, 12.2% of patients endorsed current symptomology indicative of moderate or severe levels of depression, and 38.6% reported receiving a psychiatric diagnosis at some point in their life. Additionally, 19.1% had indications of current problematic drinking, and 8.2% reported problematic drug use. Nearly one-quarter (22.1%) reported suboptimal adherence to HIV medications. Factors associated with poor adherence included racial/ethnic minority, age less than 35 years, and indications of moderate or severe depression.

LIMITATIONS

The questionnaire was not completed systematically in the clinic, which may limit generalizability, and self-reported measures may have introduced social desirability bias.

CONCLUSION

Patients were willing to disclose mental health distress, substance use, and suboptimal medication adherence to providers, which highlights the importance of routinely assessing these behaviors during clinic visits. Our findings suggest that treating depression may be an effective strategy to improve adherence to HIV medications.

COLLABORATIVE CARE FOR PERINATAL DEPRESSION IN SOCIOECONOMICALLY DISADVANTAGED WOMEN: A RANDOMIZED TRIAL

BACKGROUND

Both antenatal and postpartum depression have adverse, lasting effects on maternal and child well-being. Socioeconomically disadvantaged women are at increased risk for perinatal depression and have experienced difficulty accessing evidence-based depression care. The authors evaluated whether "MOMCare,"a culturally relevant, collaborative care intervention, providing a choice of brief interpersonal psychotherapy and/or antidepressants, is associated with improved quality of care and depressive outcomes compared to intensive public health Maternity Support Services (MSS-Plus).

METHODS

A randomized multisite controlled trial with blinded outcome assessment was conducted in the Seattle-King County Public Health System. From January 2010 to July 2012, pregnant women were recruited who met criteria for probable major depression and/or dysthymia, English-speaking, had telephone access, and ≥18 years old. The primary outcome was depression severity at 3-, 6-, 12-, 18-month postbaseline assessments; secondary outcomes included functional improvement, PTSD severity, depression response and remission, and quality of depression care.

RESULTS

All participants were on Medicaid and 27 years old on average; 58% were non-White; 71% were unmarried; and 65% had probable PTSD. From before birth to 18 months postbaseline, MOMCare (n = 83) compared to MSS-Plus participants (n = 85) attained significantly lower levels of depression severity (Wald's χ(2) = 6.09, df = 1, P = .01) and PTSD severity (Wald's χ(2) = 4.61, df = 1, P = .04), higher rates of depression remission (Wald's χ(2) = 3.67, df = 1, P = .05), and had a greater likelihood of receiving ≥4 mental health visits (Wald's χ(2) = 58.23, df = 1, P < .0001) and of adhering to antidepressants in the prior month (Wald's χ(2) = 10.00, df = 1, P < .01).

CONCLUSION

Compared to MSS-Plus, MOMCare showed significant improvement in quality of care, depression severity, and remission rates from before birth to 18 months postbaseline for socioeconomically disadvantaged women. Findings suggest that evidence-based perinatal depression care can be integrated into the services of a county public health system in the United States.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.govNCT01045655.

Cognitive behavioral therapy: a meta-analysis of race and substance use outcomes

Cognitive behavioral therapy (CBT) is an effective intervention for reducing substance use. However, because CBT trials have included predominantly White samples caution must be used when generalizing these effects to Blacks and Hispanics. This meta-analysis compared the impact of CBT in reducing substance use between studies with a predominantly non-Hispanic White sample (hereafter NHW studies) and studies with a predominantly Black and/or Hispanic sample (hereafter BH studies). From 322 manuscripts identified in the literature, 16 met criteria for inclusion. Effect sizes between CBT and comparison group at posttest had similar effects on substance abuse across NHW and BH studies. However, when comparing pre-posttest effect sizes from groups receiving CBT between NHW and BH studies, CBT's impact was significantly stronger in NHW studies. T-test comparisons indicated reduced retention/engagement in BH studies, albeit failing to reach statistical significance. Results highlight the need for further research testing CBT's impact on substance use among Blacks and Hispanics.

A culturally adapted depression intervention for African American adults experiencing depression: Oh Happy Day

The purpose of this article is to describe development of a culturally adapted depression intervention (Oh Happy Day Class, OHDC) designed for African American adults experiencing major depressive disorder (MDD). This project included 2 pilot studies testing the feasibility and acceptability of the OHDC and examining short-term effects of the OHDC in reducing symptoms of MDD. The OHDC is a 2.5-hr weekly, culturally specific, cognitive behavioral, group counseling intervention for 12 weeks. Cultural adaptations of the OHDC are based on the ecological validity and culturally sensitive framework, along with an Afrocentric paradigm. Fifty African American participants with MDD were enrolled (15 in Pilot I and 35 in Pilot II). All participants in Pilots I and II received the 12-week intervention and completed assessments at baseline, mid-intervention, end-intervention, and 3 months postintervention. General linear mixed modeling for assessment of pre-post longitudinal data analysis was conducted. Results for Pilot I showed 73% of participants completed the full OHDC, a statistically significant decline in depression symptoms from pre- to postintervention, and a 0.38 effect size. Participants were very satisfied with the OHDC. In Pilot II, 66% of participants completed the full OHDC, and there was a significant pre-post intervention decrease in depression symptoms. For men, the OHDC showed a 1.01 effect size and for women, a 0.41 effect size. Both men and women were very satisfied with the OHDC based on the satisfaction measure. These promising findings are discussed with a focus on future plans for examining efficacy of the OHDC in a large-scale, randomized, control trial.

12-month outcomes of community engagement versus technical assistance to implement depression collaborative care: a partnered, cluster, randomized, comparative effectiveness trial

BACKGROUND

Depression collaborative care implementation using community engagement and planning (CEP) across programs improves 6-month client outcomes in minority communities, compared with technical assistance to individual programs (resources for services [RS]). However, 12-month outcomes are unknown.

OBJECTIVE

To compare effects of CEP and RS on mental health-related quality of life (MHRQL) and use of services among depressed clients at 12 months.

DESIGN

Matched health and community programs (n = 93) in 2 communities randomly assigned to receive CEP or RS. (ClinicalTrials.gov: NCT01699789).

MEASUREMENTS

Self-reported MHRQL and services use at baseline, 6 months, and 12 months.

SETTING

Los Angeles, California.

PATIENTS

1018 adults with depressive symptoms (8-item Patient Health Questionnaire score ≥10), 88% of whom were an ethnic minority.

INTERVENTION

CEP and RS to implement depression collaborative care.

MEASUREMENTS

The primary outcome was poor MHRQL (12-item mental health composite score ≤40) at baseline, 6 months, and 12 months; the secondary outcome was use of services at 12 months.

RESULTS

At 6 months, the finding that CEP outperformed RS to reduce poor MHRQL was significant but sensitive to underlying statistical assumptions. At 12 months, some analyses suggested that CEP was advantageous to MHRQL, whereas others did not confirm a significant difference favoring CEP. The finding that CEP reduced behavioral health hospitalizations at 6 months was less evident at 12 months and was sensitive to underlying statistical assumptions. Other services use did not significantly differ between interventions at 12 months.

LIMITATION

Data are self-reported, and findings are sensitive to modeling assumptions.

CONCLUSION

In contrast to 6-month results, no consistent effects of CEP on reducing the likelihood of poor MHRQL and behavioral health hospitalizations were found at 12 months. Still, given the needs of underresourced communities, the favorable profile of CEP, and the lack of evidence-based alternatives, CEP remains a viable strategy for policymakers and communities to consider.

PRIMARY FUNDING SOURCE

National Institute of Mental Health, Robert Wood Johnson Foundation, California Community Foundation, National Library of Medicine, and National Institutes of Health/National Center for Advancing Translational Science for the UCLA Clinical and Translational Science Institute.

Combined medication and CBT for generalized anxiety disorder with African American participants: reliability and validity of assessments and preliminary outcomes

Using data from a study of combined cognitive behavioral therapy (CBT) and venlafaxine XR in the treatment of generalized anxiety disorder (GAD), the current article examines the reliability and convergent validity of scales, and preliminary outcomes, for African American compared with European American patients. Internal consistency and short-term stability coefficients for African Americans (n=42) were adequate and similar or higher compared with those found for European Americans (n=164) for standard scales used in GAD treatment research. Correlations among outcome measures among African Americans were in general not significantly different for African Americans compared with European Americans. A subset of patients with DSM-IV-diagnosed GAD (n=24 African Americans; n=52 European Americans) were randomly selected to be offered the option of adding 12 sessions of CBT to venlafaxine XR treatment. Of those offered CBT, 33.3% (n=8) of the African Americans and 32.6% (n=17) of the European Americans accepted and attended at least one CBT treatment session. The outcomes for African Americans receiving combined treatment were not significantly different from European Americans receiving combined treatment on primary or secondary efficacy measures.

Effectiveness of cognitive behavior therapy for severe mood disorders in an acute psychiatric naturalistic setting: a benchmarking study

The current study examined the effectiveness of brief cognitive behavior therapy (CBT) for severe mood disorders in an acute naturalistic setting. The sample included 951 individuals with either major depressive disorder (n = 857) or bipolar disorder with depressed mood (n = 94). Participants completed a battery of self-report measures assessing depression, overall well-being, and a range of secondary outcomes both before and after treatment. We found significant reductions in depressive symptoms, worry, self-harm, emotional lability, and substance abuse, as well as significant improvements in well-being and interpersonal relationships, post-treatment. Comparable to outpatient studies, 30% of the sample evidenced recovery from depression. Comparison of findings to benchmark studies indicated that, although the current sample started treatment with severe depressive symptoms and were in treatment for average of only 10 days, the overall magnitude of symptom improvement was similar to that of randomized controlled trials. Limitations of the study include a lack of control group, a limitation of most naturalistic studies. These findings indicate that interventions developed in controlled research settings on the efficacy of CBT can be transported to naturalistic, "real world" settings, and that brief CBT delivered in a partial hospital program is effective for many patients with severe depressive symptoms.

Community-partnered cluster-randomized comparative effectiveness trial of community engagement and planning or resources for services to address depression disparities

BACKGROUND

Depression contributes to disability and there are ethnic/racial disparities in access and outcomes of care. Quality improvement (QI) programs for depression in primary care improve outcomes relative to usual care, but health, social and other community-based service sectors also support clients in under-resourced communities. Little is known about effects on client outcomes of strategies to implement depression QI across diverse sectors.

OBJECTIVE

To compare the effectiveness of Community Engagement and Planning (CEP) and Resources for Services (RS) to implement depression QI on clients' mental health-related quality of life (HRQL) and services use.

DESIGN

Matched programs from health, social and other service sectors were randomized to community engagement and planning (promoting inter-agency collaboration) or resources for services (individual program technical assistance plus outreach) to implement depression QI toolkits in Hollywood-Metro and South Los Angeles.

PARTICIPANTS

From 93 randomized programs, 4,440 clients were screened and of 1,322 depressed by the 8-item Patient Health Questionnaire (PHQ-8) and providing contact information, 1,246 enrolled and 1,018 in 90 programs completed baseline or 6-month follow-up.

MEASURES

Self-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use.

RESULTS

CEP was more effective than RS at improving mental HRQL, increasing physical activity and reducing homelessness risk factors, rate of behavioral health hospitalization and medication visits among specialty care users (i.e. psychiatrists, mental health providers) while increasing depression visits among users of primary care/public health for depression and users of faith-based and park programs (each p < 0.05). Employment, use of antidepressants, and total contacts were not significantly affected (each p > 0.05).

CONCLUSION

Community engagement to build a collaborative approach to implementing depression QI across diverse programs was more effective than resources for services for individual programs in improving mental HRQL, physical activity and homelessness risk factors, and shifted utilization away from hospitalizations and specialty medication visits toward primary care and other sectors, offering an expanded health-home model to address multiple disparities for depressed safety-net clients.

Increasing equity of access to high-quality mental health services in primary care: a mixed-methods study

Background

Evidence-based interventions exist for common mental health problems. However, many people are unable to access effective care because it is not available to them or because interactions with caregivers do not address their needs. Current policy initiatives focus on supply-side factors, with less consideration of demand.

Aim and objectives

Our aim was to increase equity of access to high-quality primary mental health care for underserved groups. Our objectives were to clarify the mental health needs of people from underserved groups; identify relevant evidence-based services and barriers to, and facilitators of, access to such services; develop and evaluate interventions that are acceptable to underserved groups; establish effective dissemination strategies; and begin to integrate effective and acceptable interventions into primary care.

Methods and results

Examination of evidence from seven sources brought forward a better understanding of dimensions of access, including how people from underserved groups formulate (mental) health problems and the factors limiting access to existing psychosocial interventions. This informed a multifaceted model with three elements to improve access: community engagement, primary care quality and tailored psychosocial interventions. Using a quasi-experimental design with a no-intervention comparator for each element, we tested the model in four disadvantaged localities, focusing on older people and minority ethnic populations. Community engagement involved information gathering, community champions and focus groups, and a community working group. There was strong engagement with third-sector organisations and variable engagement with health practitioners and commissioners. Outputs included innovative ways to improve health literacy. With regard to primary care, we offered an interactive training package to 8 of 16 practices, including knowledge transfer, systems review and active linking, and seven agreed to participate. Ethnographic observation identified complexity in the role of receptionists in negotiating access. Engagement was facilitated by prior knowledge, the presence of a practice champion and a sense of coproduction of the training. We developed a culturally sensitive well-being intervention with individual, group and signposting elements and tested its feasibility and acceptability for ethnic minority and older people in an exploratory randomised trial. We recruited 57 patients (57% of target) with high levels of unmet need, mainly through general practitioners (GPs). Although recruitment was problematic, qualitative data suggested that patients found the content and delivery of the intervention acceptable. Quantitative analysis suggested that patients in groups receiving the well-being intervention improved compared with the group receiving usual care. The combined effects of the model included enhanced awareness of the psychosocial intervention among community organisations and increased referral by GPs. Primary care practitioners valued community information gathering and access to the Improving Access to Mental Health in Primary Care (AMP) psychosocial intervention. We consequently initiated educational, policy and service developments, including a dedicated website.

Conclusions

Further research is needed to test the generalisability of our model. Mental health expertise exists in communities but needs to be nurtured. Primary care is one point of access to high-quality mental health care. Psychosocial interventions can be adapted to meet the needs of underserved groups. A multilevel intervention to increase access to high-quality mental health care in primary care can be greater than the sum of its parts.

Study registration

Current Controlled Trials ISRCTN68572159.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

A randomized controlled trial of combined exercise and psycho-education for low-SES women: short- and long-term outcomes in the reduction of stress and depressive symptoms

Exercise may have both a preventive and a therapeutic impact on mental health problems. The Exercise without Worries intervention aims to reduce stress and depressive symptoms in low-SES women by means of a group-based program combining physical exercise and psycho-education. Between September 2005 and May 2008, 161 Dutch low-SES women with elevated stress or depressive symptom levels were randomly assigned to the combined exercise/psycho-education intervention (EP), exercise only (E) or a waiting list control condition (WLC). The E condition provided low to moderate intensity stretching, strength, flexibility, and body focused training as well as relaxation, while the EP program integrated the exercise with cognitive-behavioral techniques. Depressive symptoms (CES-D) and perceived stress (PSS) were measured before and immediately after the intervention and at 2, 6 and 12 month follow-up. Multilevel linear mixed-effects models revealed no differential patterns in reduction of CES-D or PSS scores between the EP, E and WLC groups on the short (post-test and 2 month follow-up) or long term (6 and 12 months follow-up). Depressive symptom outcomes were moderated by initial depressive symptom scores: women from the EP and E groups with fewer initial symptoms benefited from participation on the short term. Further, women in the EP and E groups with the lowest educational level reported more stress reduction at post-test than women with higher educational levels. In the overall target population of low-SES women, no indications were found that the Exercise without Worries course reduced depressive symptom and stress levels on the short or long term. The findings do suggest, however, that exercise alone or in combination with psycho-education may be a viable prevention option for certain groups of disadvantaged women. Especially those low-SES women with less severe initial problems or those with low educational attainment should be targeted for future depression prevention practice.

Parenting enhancement, interpersonal psychotherapy to reduce depression in low-income mothers of infants and toddlers: a randomized trial

BACKGROUND

Depressive symptoms and clinical depression are highly prevalent in low-income mothers and negatively affect their infants and toddlers.

OBJECTIVES

The aim of this study was to test interpersonal psychotherapy combined with parenting enhancement on depressive symptoms and parenting behavior, compared with an equal attention-control condition.

METHODS

Mothers (n = 226) of Early Head Start infants and toddlers from the southeastern and northeastern United States were randomized to the intervention delivered in-home by psychiatric mental health advanced practice nurses or an equal attention-control condition delivered by generalist nurses. Rigorous clinical depressive symptom and depression assessments and videotaped, coded mother-child interactions were used as baseline and 14-, 22-, and 26-week postintervention measures.

RESULTS

Both the intervention and control groups had significantly reduced Hamilton Rating Scale for Depression scores at each subsequent time point compared with baseline (p < .0001). However, only mothers receiving the intervention showed a significant increase in positive involvement with their child, as measured by closeness, positive effect, affection, and warm touch at T4 (t = 2.22, df = 156, p < .03).

DISCUSSION

Both intervention and control conditions resulted in symptom reduction, but only the intervention mothers showed significant interaction changes with their child, an essential step in reducing the negative child outcomes associated with maternal depressive symptoms. Results suggest that a combination of generalist and specialist nurses could be used to treat depressive symptoms in these mothers. Further study with longer postintervention observation is needed to see if, over time, the intervention led to longer-lasting symptom reduction.

Poverty and mental health: how do low-income adults and children fare in psychotherapy?

Poverty is associated with an increased risk for psychological problems. Even with this increased risk for mental health problems and need for care, many low-income adults and families do not receive treatment because of logistical, attitudinal, and systemic barriers. Despite significant barriers to obtaining care, research suggests that low-income individuals show significant benefit from evidence-based mental healthcare. In this article, we review the link between poverty and mental health, common barriers to obtaining mental health services, and treatment studies that have been conducted with low-income groups. Finally, we discuss the implications of the research reviewed and offer recommendations for clinicians working with low-income children or adults, highlighting the importance of evidence-based care, extensive outreach, and empathic respect.

Comparative effectiveness of medication versus cognitive-behavioral therapy in a randomized controlled trial of low-income young minority women with depression

OBJECTIVE

To examine whether there are latent trajectory classes in response to treatment and whether they moderate the effects of medication versus psychotherapy.

METHOD

Data come from a 1-year randomized controlled trial of 267 low-income, young (M = 29 years), minority (44% Black, 50% Latina, 6% White) women with current major depression randomized to antidepressants, cognitive-behavioral therapy (CBT), or referral to community mental health services. Growth mixture modeling was used to determine whether there were differential effects of medication versus CBT. Depression was measured via the Hamilton Depression Rating Scale (Hamilton, 1960).

RESULTS

We identified 2 latent trajectory classes. The first was characterized by severe depression at baseline. At 6 months, mean depression scores for the medication and CBT groups in this class were 13.9 and 14.9, respectively (difference not significant). At 12 months, mean depression scores were 16.4 and 11.0, respectively (p for difference = .04). The second class was characterized by moderate depression and anxiety at baseline. At 6 months, mean depression scores for the medication and CBT groups were 4.4 and 6.8, respectively (p for difference = .03). At 12 months, the mean depression scores were 7.1 and 7.8, respectively, and the difference was no longer significant.

CONCLUSIONS

Among depressed women with moderate baseline depression and anxiety, medication was superior to CBT at 6 months, but the difference was not sustained at 1 year. Among women with severe depression, there was no significant treatment group difference at 6 months, but CBT was superior to medication at 1 year.

A qualitative evaluation of barriers to care for trauma-related mental health problems among low-income minorities in primary care

This study aimed to identify barriers and facilitators of mental health care for patients with trauma histories via qualitative methods with clinicians and administrators from primary care clinics for the underserved. Individual interviews were conducted, followed by a combined focus group with administrators from three jurisdictions; there were three focus groups with clinicians from each clinic system. Common themes were identified, and responses from groups were compared. Administrators and clinicians report extensive trauma histories among patients. Clinician barriers include lack of time, patient resistance, and inadequate referral options; administrators cite reimbursement issues, staff training, and lack of clarity about the term trauma. A key facilitator is doctor-patient relationship. There were differences in perceived barriers and facilitators at the institutional and clinical levels for mental health care for patients with trauma. Importantly, there is agreement about better access to and development of trauma-specific interventions. Findings will aid the development and implementation of trauma-focused interventions embedded in primary care.

Group Interventions were not Effective for Female Turkish Migrants with Recurrent Depression - Recommendations from a Randomized Controlled Study

We tested group interventions for women with a Turkish migration background living in Austria and suffering from recurrent depression. N = 66 participants were randomized to: (1) Self-Help Groups (SHG), (2) Cognitive Behavior Therapy (CBT) Groups, and (3) a Wait-List (WL) Control condition. Neither SHG nor CBT were superior to WL. On an individual basis, about one third of the participants showed significant improvements with respect to symptoms of depression. Younger women, women with a longer duration of stay in Austria and those who had encountered a higher number of traumatic experiences, showed increased improvement of depressive symptoms. The results suggest that individual treatment by ethnic, female psychotherapists should be preferred to group interventions.

Public health nursing case management for women receiving temporary assistance for needy families: a randomized controlled trial using community-based participatory research

OBJECTIVES

We evaluated the effectiveness of a community-based participatory research-grounded intervention among women receiving Temporary Assistance for Needy Families (TANF) with chronic health conditions in increasing (1) health care visits, (2) Medicaid knowledge and skills, and (3) health and functional status.

METHODS

We used a randomized controlled trial design to assign 432 women to a public health nurse case management plus Medicaid intervention or a wait-control group. We assessed Medicaid outcomes pre- and posttraining; other outcomes were assessed at 3, 6, and 9 months.

RESULTS

Medicaid knowledge and skills improved (P < .001 for both). Intervention group participants were more likely to have a new mental health visit (odds ratio [OR] = 1.92; P = .007), and this likelihood increased in higher-risk subgroups (OR = 2.03 and 2.83; P = .04 and .006, respectively). Depression and functional status improved in the intervention group over time (P = .016 for both). No differences were found in routine or preventive care, or general health.

CONCLUSIONS

Health outcomes among women receiving TANF can be improved with public health interventions. Additional strategies are needed to further reduce health disparities in this population.

Implementation of collaborative depression management at community-based primary care clinics: an evaluation

OBJECTIVE

This study evaluated a large demonstration project of collaborative care of depression at community health centers by examining the role of clinic site on two measures of quality care (early follow-up and appropriate pharmacotherapy) and on improvement of symptoms (score on Patient Health Questionnaire-9 reduced by 50% or ≤ 5).

METHODS

A quasi-experimental study examined data on the treatment of 2,821 patients aged 18 and older with depression symptoms between 2006 and 2009 at six community health organizations selected in a competitive process to implement a model of collaborative care. The model's key elements were use of a Web-based disease registry to track patients, care management to support primary care providers and offer proactive follow-up of patients, and organized psychiatric consultation.

RESULTS

Across all sites, a plurality of patients achieved meaningful improvement in depression, and in many sites, improvement occurred rapidly. After adjustment for patient characteristics, multivariate logistic regression models revealed significant differences across clinics in the probability of receiving early follow-up (range .34-.88) or appropriate pharmacotherapy (range .27-.69) and in experiencing improvement (.36 to .84). Similarly, after adjustment for patient characteristics, Cox proportional hazards models revealed that time elapsed between first evaluation and the occurrence of improvement differed significantly across clinics (p<.001).

CONCLUSIONS

Despite receiving similar training and resources, organizations exhibited substantial variability in enacting change in clinical care systems, as evidenced by both quality indicators and outcomes. Sites that performed better on quality indicators had better outcomes, and the differences were not attributable to patients' characteristics.

The effects of cognitive therapy versus 'treatment as usual' in patients with major depressive disorder

BACKGROUND

Major depressive disorder afflicts an estimated 17% of individuals during their lifetimes at tremendous suffering and costs. Cognitive therapy may be an effective treatment option for major depressive disorder, but the effects have only had limited assessment in systematic reviews.

METHODS/PRINCIPAL FINDINGS

Cochrane systematic review methodology, with meta-analyses and trial sequential analyses of randomized trials, are comparing the effects of cognitive therapy versus 'treatment as usual' for major depressive disorder. To be included the participants had to be older than 17 years with a primary diagnosis of major depressive disorder. Altogether, we included eight trials randomizing a total of 719 participants. All eight trials had high risk of bias. Four trials reported data on the 17-item Hamilton Rating Scale for Depression and four trials reported data on the Beck Depression Inventory. Meta-analysis on the data from the Hamilton Rating Scale for Depression showed that cognitive therapy compared with 'treatment as usual' significantly reduced depressive symptoms (mean difference -2.15 (95% confidence interval -3.70 to -0.60; P<0.007, no heterogeneity)). However, meta-analysis with both fixed-effect and random-effects model on the data from the Beck Depression Inventory (mean difference with both models -1.57 (95% CL -4.30 to 1.16; P = 0.26, I(2) = 0) could not confirm the Hamilton Rating Scale for Depression results. Furthermore, trial sequential analysis on both the data from Hamilton Rating Scale for Depression and Becks Depression Inventory showed that insufficient data have been obtained.

DISCUSSION

Cognitive therapy might not be an effective treatment for major depressive disorder compared with 'treatment as usual'. The possible treatment effect measured on the Hamilton Rating Scale for Depression is relatively small. More randomized trials with low risk of bias, increased sample sizes, and broader more clinically relevant outcomes are needed.

Exploring recruitment, willingness to participate, and retention of low-SES women in stress and depression prevention

Background

Recruitment, willingness to participate, and retention in interventions are indispensable for successful prevention. This study investigated the effectiveness of different strategies for recruiting and retaining low-SES women in depression prevention, and explored which sociodemographic characteristics and risk status factors within this specific target group are associated with successful recruitment and retention.

Methods

The process of recruitment, willingness to participate, and retention was structurally mapped and explored. Differences between women who dropped out and those who adhered to the subsequent stages of the recruitment and retention process were investigated. The potential of several referral strategies was also studied, with specific attention paid to the use of GP databases.

Results

As part of the recruitment process, 12.1% of the target population completed a telephone screening. The most successful referral strategy was the use of patient databases from GPs working in disadvantaged neighborhoods. Older age and more severe complaints were particularly associated with greater willingness to participate and with retention.

Conclusions

Low-SES women can be recruited and retained in public health interventions through tailored strategies. The integration of mental health screening within primary care might help to embed preventive interventions in low-SES communities.

A review of empirically supported psychological therapies for mood disorders in adults

BACKGROUND

The mood disorders are prevalent and problematic. We review randomized controlled psychotherapy trials to find those that are empirically supported with respect to acute symptom reduction and the prevention of subsequent relapse and recurrence.

METHODS

We searched the PsycINFO and PubMed databases and the reference sections of chapters and journal articles to identify appropriate articles.

RESULTS

One hundred twenty-five studies were found evaluating treatment efficacy for the various mood disorders. With respect to the treatment of major depressive disorder (MDD), interpersonal psychotherapy (IPT), cognitive behavior therapy (CBT), and behavior therapy (BT) are efficacious and specific and brief dynamic therapy (BDT) and emotion-focused therapy (EFT) are possibly efficacious. CBT is efficacious and specific, mindfulness-based cognitive therapy (MBCT) efficacious, and BDT and EFT possibly efficacious in the prevention of relapse/recurrence following treatment termination and IPT and CBT are each possibly efficacious in the prevention of relapse/recurrence if continued or maintained. IPT is possibly efficacious in the treatment of dysthymic disorder. With respect to bipolar disorder (BD), CBT and family-focused therapy (FFT) are efficacious and interpersonal social rhythm therapy (IPSRT) possibly efficacious as adjuncts to medication in the treatment of depression. Psychoeducation (PE) is efficacious in the prevention of mania/hypomania (and possibly depression) and FFT is efficacious and IPSRT and CBT possibly efficacious in preventing bipolar episodes.

CONCLUSIONS

The newer psychological interventions are as efficacious as and more enduring than medications in the treatment of MDD and may enhance the efficacy of medications in the treatment of BD.

Treatment of depression in patients from ethnic minority groups in the Netherlands

This article presents the results of a large efficacy study comparing different forms of therapy for major depressive disorder (MDD), including interpersonal psychotherapy (IPT) and pharmacotherapy. Patients were randomized to either IPT, IPT in combination with anti-depressant medication, IPT in combination with pill-placebo or medication only. The primary outcome measure was the Hamilton Rating Scale for Depression (HAMD). Patients were treated for 12 to 16 weeks. Ratings were performed at baseline, after 6 weeks of treatment and at the end of treatment. Ethnic minority patients (EMP) had higher scores on the HAMD than non-EMP for every rating period. However, the rate of improvement was the same for EMP and non-EMP. The higher mean scores of EMP on the HAMD could not be explained as solely due to higher scores on somatic items of the rating scales. The attrition rate in EMP (45.9%) was significantly higher than in non-EMP (24.4%), even in the structured treatment format studied. The results suggest that standard antidepressant therapy, be it medication, psychotherapy or both, may be effective for depressed minority patients but therapists should focus on enhancing adherence to treatment.

Psychotherapeutic interventions for depressed, low-income women: a review of the literature

Low-income women have very high rates of depression and also face a number of unique barriers that can prevent them from seeking, accepting, engaging in, or benefiting from psychotherapy treatment. Untreated depression often leads to deleterious psychological consequences for these women and their children, and may also diminish a woman's ability to improve her economic circumstances. We reviewed the literature on psychotherapeutic interventions for depressed, low-income women, identifying a number of practical, psychological, and cultural barriers that often prevent them from engaging in psychotherapy. Next, we assessed the degree to which established intervention programs help women overcome these barriers. The data suggest that it is quite difficult to engage depressed, low-income women in psychotherapy, but that a number of standard psychotherapy approaches do show promise. However, we found that many of the currently available interventions fail to fully address the barriers that prevent this population from engaging in treatment. Moreover, the impact these interventions have on engagement and attrition rates or clinical improvements is often inadequately reported. We provide preliminary recommendations for clinicians who work with low-income women as well as suggestions for bolstering the literature base.

Collaborative care for depressed patients with chronic medical conditions: a randomized trial in Puerto Rico

OBJECTIVE

This study examined whether a collaborative care model for depression would improve clinical and functional outcomes for depressed patients with chronic general medical conditions in primary care practices in Puerto Rico.

METHODS

A total of 179 primary care patients with major depression and chronic general medical conditions were randomly assigned to receive collaborative care or usual care. The collaborative care intervention involved enhanced collaboration among physicians, mental health specialists, and care managers paired with depression-specific treatment guidelines, patient education, and follow-up. In usual care, study personnel informed the patient and provider of the diagnosis and encouraged patients to discuss treatment options with their provider. Depression severity was assessed with the Hopkins Symptom Checklist; social functioning was assessed with the 36-item Short Form.

RESULTS

Compared with usual care, collaborative care significantly reduced depressive symptoms and improved social functioning in the six months after randomization. Integration of collaborative care in primary care practices considerably increased depressed patients' use of mental health services.

CONCLUSIONS

Collaborative care significantly improved clinical symptoms and functional status of depressed patients with coexisting chronic general medical conditions receiving treatment for depression in primary care practices in Puerto Rico. These findings highlight the promise of the collaborative care model for strengthening the relationship between mental health and primary care services in Puerto Rico.