Community-Partnered Cluster-Randomized Comparative Effectiveness Trial of Community Engagement and Planning or Resources for Services to Address Depression Disparities
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.
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.
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.
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.
Self-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use.
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).
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.
- Insel, TR, Charney, DS (2003) Research on major depression. JAMA 289: pp. 3167-8 CrossRef
- Kessler, R, Chiu, W, Demler, O, Merikangas, K, Walters, E (2005) Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62: pp. 617-27 CrossRef
- Williams, DR, Gonzalez, HM, Neighbors, H, Nesse, R, Abelson, JM, Sweetman, J (2007) Prevalence and distribution of major depressive disorder in African Americans, Caribbean blacks, and non-Hispanic whites: results from the National Survey of American Life. Arch Gen Psychiatry 64: pp. 305-15 CrossRef
- Miranda, J, Duan, N, Sherbourne, C, Schoenbaum, M, Lagomasino, I, Jackson-Triche, M (2003) Improving care for minorities: can quality improvement interventions improve care and outcomes for depressed minorities? Results of a controlled randomized trial. Health Serv Res 38: pp. 613-30 CrossRef
- Schulberg, HC, Raue, PJ, Rollman, BL (2002) The effectiveness of psychotherapy in treating depressive disorders in primary care practice: clinical and cost perspectives. Gen Hosp Psychiatry 24: pp. 203-12 CrossRef
- Turner, EH, Rosenthal, R (2008) Efficacy of antidepressants. BMJ 336: pp. 516-7 CrossRef
- Dwight-Johnson, M, Sherbourne, CD, Liao, D, Wells, KB (2000) Treatment preferences among depressed primary care patients. J Gen Intern Med 15: pp. 527-34 CrossRef
- Miranda, J, Chung, JY, Green, BL, Krupnick, J, Siddique, J, Revicki, DA (2003) Treating depression in predominantly low-income young minority women. JAMA 290: pp. 57-65 CrossRef
- Katon, W, Korff, M, Lin, E, Walker, E, Simon, GE, Bush, T (1995) Collaborative management to achieve treatment guidelines. JAMA 273: pp. 1026-31 CrossRef
- Gilbody, S, Bower, P, Fletcher, J, Richards, D, Sutton, AJ (2006) Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med 166: pp. 2314 CrossRef
- Areán, PA, Ayalon, L, Hunkeler, E, Lin, EHB, Tang, L, Harpole, L (2005) Improving depression care for older, minority patients in primary care. Med Care 43: pp. 381 CrossRef
- Wells, KB, Sherbourne, C, Schoenbaum, M, Ettner, S, Buan, N, Miranda, J (2004) Five-year impact of quality improvement for depression: results of a group-level randomized controlled trial. Arch Gen Psychiatry 61: pp. 378-86 CrossRef
- U.S. Department of Health and Human Services. New freedom commission on mental health: achieving the promise: transforming mental health in America. Final report. Rockville, MD: USDHHS; 2003. Report No.: SMA-03—3832.
- Alegría, M, Canino, G, Ríos, R, Vera, M, Calderón, J, Rusch, D (2002) Inequalities in use of specialty mental health services among Latinos, African Americans, and non-Latino whites. Psychiatr Serv 53: pp. 1547-55 CrossRef
- Marmot, MG, Wilkinson, RG (2006) Social determinants of health. Oxford University Press, USA
- Smedley BD, Syme SL. Promoting health: intervention strategies from social and behavioral research. Washington, D.C.: National Academies Press; 2000.
- Thomas, SB, Quinn, SC, Butler, J, Fryer, CS, Garza, MA (2011) Toward a fourth generation of disparities research to achieve health equity. Annu Rev Public Health 32: pp. 399-416 CrossRef
- Coppock, DL, Desta, S, Tezera, S, Gebru, G (2011) Capacity building helps pastoral women transform impoverished communities in Ethiopia. Science 334: pp. 1394-8 CrossRef
- Tripathy, P, Nair, N, Barnett, S, Mahapatra, R, Borghi, J, Rath, S (2010) Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: a cluster-randomised controlled trial. Lancet 375: pp. 1182-92 CrossRef
- Chung, B, Jones, L, Jones, A, Corbett, C, Booker, T, Wells, K (2009) Using community arts events to enhance collective efficacy and community engagement to address depression in an African American community. Am J Public Health 99: pp. 237 CrossRef
- Dobransky-Fasiska, D, Nowalk, M, Pincus, H, Castillo, E, Lee, B, Walnoha, A (2010) Public-academic partnerships: improving depression care for disadvantaged adults by partnering with non-mental health agencies. Psychiatr Serv 61: pp. 110 CrossRef
- Patel, V, Weiss, HA, Chowdhary, N, Naik, S, Pednekar, S, Chatterjee, S (2010) Effectiveness of an intervention led by lay health counsellors for depressive and anxiety disorders in primary care in Goa, India (MANAS): a cluster randomised controlled trial. Lancet 376: pp. 18-31 CrossRef
- Bluthenthal, R, Jones, L, Fackler-Lowrie, N, Ellison, M, Booker, T, Jones, F (2006) Witness for Wellness: preliminary findings from a community-academic participatory research mental health initiative. Ethn Dis 16: pp. S18-34
- Chung, B, Dixon, EL, Miranda, J, Wells, K, Jones, L (2010) Using a community partnered participatory research approach to implement a randomized controlled trial: planning Community Partners in Care. J Health Care Poor Underserved 21: pp. 780-95 CrossRef
- Jones, L, Wells, K (2007) Strategies for academic and clinician engagement in community-participatory partnered research. JAMA 297: pp. 407-10 CrossRef
- Jones, L, Wells, K, Norris, K, Meade, B, Koegel, P (2009) The vision, valley, and victory of community engagement. Ethn Dis 19: pp. S6
- Wells, KB, Sherbourne, C, Schoenbaum, M, Duan, N, Meredith, L, Unützer, J (2000) Impact of disseminating quality improvement programs for depression in managed primary care. JAMA 283: pp. 212 CrossRef
- Wennerstrom, A, Vannoy, SD, Allen, C (2011) Community-based participatory development of a community health worker mental health outreach role to extend collaborative care in post-Katrina New Orleans. Ethn Dis 21: pp. S1-45
- Unützer, J, Katon, W, Callahan, CM, Williams, JW, Hunkeler, E, Harpole, L (2002) Collaborative care management of late-life depression in the primary care setting. JAMA 288: pp. 2836-45 CrossRef
- Hepner, KA, Miranda, JM, Woo, SM, Watkins, KE, Lagomasino, IT, Wiseman, SH (2011) Building recovery by improving goals, habits, and thoughts (BRIGHT): A group cognitive behavioral therapy for depression in clients with co-occurring alcohol and drug use problems-Group Leader’s Manual. RAND Corporation, Santa Monica, Calif
- Ell, K, Xie, B, Quon, B, Quinn, DI, Dwight-Johnson, M, Lee, PJ (2008) Randomized controlled trial of collaborative care management of depression among low-income patients with cancer. J Clin Oncol 26: pp. 4488-96 CrossRef
- Asarnow, JR, Jaycox, LH, Duan, N, LaBorde, AP, Rea, MM, Murray, P (2005) Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics. JAMA 293: pp. 311-9 CrossRef
- Rubenstein, LV (2000) Improving Depression Outcomes in Primary Care: A User’s Guide to Implementing the Partners in Care Approach. RAND Corporation, Santa Monica, CA
- Corbie-Smith, G, Thomas, SB, Williams, MV, Moody-Ayers, S (2001) Attitudes and beliefs of African Americans toward participation in medical research. J Gen Intern Med 14: pp. 537-46 CrossRef
- Gamble, VN (1997) Under the shadow of Tuskegee: African Americans and health care. Am J Public Health 87: pp. 1773-8 CrossRef
- Kataoka, SH, Zhang, L, Wells, KB (2002) Unmet need for mental health care among US children: variation by ethnicity and insurance status. Am J Psychiatry 159: pp. 1548-55 CrossRef
- Meredith, LS, Mendel, P, Pearson, M, Wu, SY, Joyce, G, Straus, JB (2006) Implementation and maintenance of quality improvement for treating depression in primary care. Psychiatr Serv 57: pp. 48-55 CrossRef
- Miller, FG, Rosenstein, DL (2003) The therapeutic orientation to clinical trials. New Engl J Med 348: pp. 1383-6 CrossRef
- Rubenstein, LV, Jackson-Triche, M, Unutzer, J, Miranda, J, Minnium, K, Pearson, ML (1999) Evidence-based care for depression in managed primary care practices. Health Aff 18: pp. 89-105 CrossRef
- Schoenbaum, M, Unützer, J, Sherbourne, C, Duan, N, Rubenstein, LV, Miranda, J (2001) Cost-effectiveness of practice-initiated quality improvement for depression. JAMA 286: pp. 1325-30 CrossRef
- Sherbourne, CD, Wells, KB, Duan, N, Miranda, J, Unutzer, J, Jaycox, L (2001) Long-term effectiveness of disseminating quality improvement for depression in primary care. Arch Gen Psychiatry 58: pp. 696 CrossRef
- Mental health: culture, race, and ethnicity—a supplement to mental health: a report of the Surgeon General. USDHHS, Rockville, MD
- UCLA-NPI/RAND Research Center on Managed Care for Psychiatric Disorders. Community Update. Los Angeles, CA: UCLA/RAND, 2000–04.
- Wagner, EH (2000) The role of patient care teams in chronic disease management. BMJ 320: pp. 569 CrossRef
- Wang, PS, Simon, GE, Kessler, RC (2008) Making the business case for enhanced depression care: the National Institute of Mental Health-Harvard Work Outcomes Research and Cost-effectiveness Study. J Occup Environ Med 50: pp. 468-75 CrossRef
- Wells, KB, Klap, R, Koike, A, Sherbourne, C (2001) Ethnic disparities in unmet need for alcoholism, drug abuse, and mental health care. Am J Psychiatry 158: pp. 2027-32 CrossRef
- Wells, KB, Sherbourne, CD, Miranda, J, Tang, L, Benjamin, B, Duan, N (2007) The cumulative effects of quality improvement for depression on outcome disparities over 9 years: results from a randomized, controlled group-level trial. Med Care 45: pp. 1052-9 CrossRef
- Zambrana, RE (1996) The role of Latino/Hispanic communities in health services research: strategies for a meaningful partnership. J Med Syst 20: pp. 317-28 CrossRef
- Khodyakov D, Shariff M, Dixon E, Mendel P, Chung B, Linski B, et al. An implementation evaluation of the community engagement and planning intervention in the CPIC depression care improvement trial. Community Ment Health J. In press.
- Los Angeles County Department of Health Services. LA County Department of Health Services Key Health Indicators. Los Angeles, CA, 2009.
- Murray, DM (1998) Design and analysis of group-randomized trials. Oxford University Press, USA
- Belin TR, Stockdale S, Tang L, Jones F, Jones A, Wright A, et al., eds. Developing a randomization protocol in a community-partnered participatory research project to reduce the burden of depression. Proceedings of the American Statistical Association Health Policy Statistics Section, Alexandria Virginia. 2010;5165–5171.
- Cohen J. Statistical power analysis for the behavioral sciences. Hillsdale, New Jersey: Lawrence Erlbaum; 1988.
- Kish, L (1965) Survey sampling. Wiley, New York
- Kroenke, K, Spitzer, RL (2002) The PHQ-9: a new depression diagnostic and severity measure. Psychiatr Ann 32: pp. 509-15
- Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Med Care. 1992;473–83.
- Sheehan, DV, Lecrubier, Y, Sheehan, KH, Amorim, P, Janavs, J, Weiller, E (1998) The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 59: pp. 22-33
- Wong, MD, Sarkisian, CA, Davis, C, Kinsler, J, Cunningham, WE (2007) The association between life chaos, health care use, and health status among HIV-infected persons. J Gen Intern Med 22: pp. 1286-91 CrossRef
- Apicello, J (2010) A paradigm shift in housing and homeless services: applying the population and high-risk framework to preventing homelessness. Open Health Serv Policy J 3: pp. 41-52 CrossRef
- Gundersen, C, Weinreb, L, Wehler, C, Hosmer, D (2003) Homelessness and food insecurity. J Hous Econ 12: pp. 250-72 CrossRef
- Sherbourne, CD, Edelen, MO, Zhou, A, Bird, C, Duan, N, Wells, KB (2008) How a therapy-based quality improvement intervention for depression affected life events and psychological well-being over time: a 9-year longitudinal analysis. Med Care 46: pp. 78 CrossRef
- Little RJA. Missing-data adjustments in large surveys. J Bus Econ Stat. 1988;287–96.
- Rubin, D (1987) Multiple imputation for nonresponse in surveys. Wiley, Hoboken, NJ CrossRef
- Lavori, PW, Dawson, R, Shera, D (1995) A multiple imputation strategy for clinical trials with truncation of patient data. Stat Med 14: pp. 1913-25 CrossRef
- Tang, L, Song, J, Belin, TR, Unützer, J (2005) A comparison of imputation methods in a longitudinal randomized clinical trial. Stat Med 24: pp. 2111-28 CrossRef
- Binder DA. On the variances of asymptotically normal estimators from complex surveys. Int Stat Rev. 1983;279–92.
- Graubard, BI, Korn, EL (2004) Predictive margins with survey data. Biometrics 55: pp. 652-9 CrossRef
- Kleinman, LC, Norton, EC (2009) What’s the risk? A simple approach for estimating adjusted risk measures from nonlinear models including logistic regression. Health Serv Res 44: pp. 288-302 CrossRef
- Dunn, OJ (1961) Multiple comparisons among means. J Am Stat Assoc 56: pp. 52-64 CrossRef
- Miranda, J, Green, BL, Krupnick, JL, Chung, J, Siddique, J, Belin, T (2006) One-year outcomes of a randomized clinical trial treating depression in low-income minority women. J Consult Clin Psychol 74: pp. 99 CrossRef
- Community-Partnered Cluster-Randomized Comparative Effectiveness Trial of Community Engagement and Planning or Resources for Services to Address Depression Disparities
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Journal of General Internal Medicine
Volume 28, Issue 10 , pp 1268-1278
- Cover Date
- Print ISSN
- Online ISSN
- Springer US
- Additional Links
- community partnered participatory research
- community-based participatory research
- Industry Sectors
- Kenneth B. Wells MD, MPH (1) (2) (3) (4)
- Loretta Jones MA (5) (6)
- Bowen Chung MD (1) (2) (7)
- Elizabeth L. Dixon RN, PhD (8)
- Lingqi Tang PhD (2) (4)
- Jim Gilmore MBA (9)
- Cathy Sherbourne PhD (1)
- Victoria K. Ngo PhD (1)
- Michael K. Ong MD (10)
- Susan Stockdale PhD (12) (2)
- Esmeralda Ramos BA (2)
- Thomas R. Belin PhD (11) (2)
- Jeanne Miranda PhD (2) (4)
- Author Affiliations
- 1. RAND Corporation, Santa Monica, CA, USA
- 2. David Geffen School of Medicine, Departments of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, CA, USA
- 3. Department of Healthy Policy and Management, UCLA Jonathan and Karin Fielding School of Public Health, Los Angeles, CA, USA
- 4. Center for Health Services and Society, UCLA Jane and Terry Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
- 5. Healthy African American Families II, Los Angeles, CA, USA
- 6. Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
- 7. Harbor-UCLA Medical Center, Torrance, CA, USA
- 8. QueensCare Health and Faith Partnership, Los Angeles, CA, USA
- 9. Behavioral Health Services, Gardena, CA, USA
- 10. Department of Medicine, David Geffen School of Medicine, UCLA Division of General Internal Medicine and Health Services Research, Los Angeles, CA, USA
- 12. Greater Los Angeles Veteran’s Affairs, Los Angeles, CA, USA
- 11. UCLA Johnathan and Karin Fielding School of Public Health, Department of Biostatistics, Los Angeles, CA, USA