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

Kenneth B Wells,Kenneth B Wells,Kenneth B Wells,Lingqi Tang,Bowen Chung,Bowen Chung,Bowen Chung,Thomas R Belin,Thomas R Belin,Susan Stockdale,Jim Gilmore,Elizabeth L Dixon,Jeanne Miranda,Loretta Jones,Esmeralda Ramos,Victoria K Ngo,Cathy Sherbourne,Susan Stockdale,Loretta Jones,Michael K Ong

doi:10.1007/s11606-013-2484-3

Abstract

ABSTRACTBACKGROUNDDepression 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.OBJECTIVETo 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.DESIGNMatched 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.PARTICIPANTSFrom 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.MEASURESSelf-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use.RESULTSCEP 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).CONCLUSIONCommunity 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.Electronic supplementary materialThe online version of this article (doi:10.1007/s11606-013-2484-3) contains supplementary material, which is available to authorized users.

Highlights

Electronic supplementary material The online version of this article contains supplementary material, which is available to authorized users.Received December 7, 2012 Revised February 27, 2013 Accepted April 22, 2013 Published online May 7, 2013Depressive symptoms and disorders are common in general populations and clients in healthcare settings, impact morbidity, and are priorities for comparative effectiveness research.[1,2] Depression is prevalent across cultural groups, yet African Americans may have more severe depression.[3]Ethnic minorities have worse access to depression care andWells et al.: Community-Partnered Engagement to Address Depression Disparities worse outcomes in primary care than white patients.[4]
We developed a Community-based participatory research (CBPR) approach to depression in under-resourced communities in Los Angeles[23] and used that experience to design Community Partners in Care (CPIC),[24] which examines the value of a community engagement and planning (CEP) intervention over and above resources for services (RS) for individual programs to implement depression Quality improvement (QI) programs across healthcare and community-based service sectors
Of 1,018 depressed clients, 57 % were female, 87 % were Latino and or African American; 43.6 % had less than a high school education, 73.6 % had income below poverty, 20 % worked and 54.1 % were uninsured

Summary

Introduction

Wells et al.: Community-Partnered Engagement to Address Depression Disparities worse outcomes in primary care than white patients.[4] Evidencebased treatments include psychotherapies such as Cognitive Behavioral Therapy (CBT) and antidepressant medication; but the latter has limited efficacy in mild depression.[5,6] Some minority groups prefer psychotherapy,[7] which is less available in under-resourced areas,[8] where depressed adults suffer from medical and social problems and seek support from diverse service 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. MEASURES: Self-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use

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