Engaging Community Networks to Improve Depression Services: A Cluster-Randomized Trial of a Community Engagement and Planning Intervention.

This paper explores the effects of a group-randomized controlled trial, Community Partners in Care (CPIC), on the development of interagency networks for collaborative depression care improvement between a community engagement and planning (CEP) intervention and a resources for services (RS) intervention that provided the same content solely via technical assistance to individual programs. Both interventions consisted of a diverse set of service agencies, including health, mental health, substance abuse treatment, social services, and community-trusted organizations such as churches and parks and recreation centers. Participants in the community councils for the CEP intervention reflected a range of agency leaders, staff, and other stakeholders. Network analysis of partnerships among agencies in the CEP versus RS condition, and qualitative analysis of perspectives on interagency network changes from multiple sources, suggested that agencies in the CEP intervention exhibited greater growth in partnership capacity among themselves than did RS agencies. CEP participants also viewed the coalition development intervention both as promoting collaboration in depression services and as a meaningful community capacity building activity. These descriptive results help to identify plausible mechanisms of action for the CPIC interventions and can be used to guide development of future community engagement interventions and evaluations in under-resourced communities.

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.

Community-partnered evaluation of depression services for clients of community-based agencies in under-resourced communities in Los Angeles.

BACKGROUND: As medical homes are developing under health reform, little is known regarding depression services need and use by diverse safety-net populations in under-resourced communities. For chronic conditions like depression, primary care services may face new opportunities to partner with diverse community service providers, such as those in social service and substance abuse centers, to support a collaborative care model of treating depression. OBJECTIVE: To understand the distribution of need and current burden of services for depression in under-resourced, diverse communities in Los Angeles. DESIGN: Baseline phase of a participatory trial to improve depression services with data from client screening and follow-up surveys. PARTICIPANTS: Of 4,440 clients screened from 93 programs (primary care, mental health, substance abuse, homeless, social and other community services) in 50 agencies, 1,322 were depressed according to an eight-item Patient Health Questionnaire (PHQ-8) and gave contact information; 1,246 enrolled and 981 completed surveys. Ninety-three programs, including 17 primary care/public health, 18 mental health, 20 substance abuse, ten homeless services, and 28 social/other community services, participated. MAIN MEASURES: Comparisons by setting in 6-month retrospective recall of depression services use. KEY RESULTS: Depression prevalence ranged from 51.9 % in mental health to 17.2 % in social-community programs. Depressed clients used two settings on average to receive depression services; 82 % used any setting. More clients preferred counseling over medication for depression treatment. CONCLUSIONS: Need for depression care was high, and a broad range of agencies provide depression care. Although most participants had contact with primary care, most depression services occurred outside of primary care settings, emphasizing the need to coordinate and support the quality of community-based services across diverse community settings.

Assessing organizational readiness and change in community intervention research: framework for participatory evaluation.

This paper describes a study currently underway that uses a collaborative approach to assess organizational capacity to form partnerships around mental health and substance abuse care. Employing many of the principles of community-based participatory research, the study's primary objective is to collaboratively develop a conceptual understanding and generalizable, practical measures of organizational capacity. The intent of this collaborative approach is to increase the rigor and relevance of the assessment framework while strengthening the ability of health partnerships and stakeholders to understand and track community organizational capacity. The study investigators developed an initial model of community dissemination based on the research literatures on organizations and the diffusion of innovations. Through the collaborative process, the specific goals of the project shifted substantially to match the partnership interests and concerns of community agencies. One of the benefits of a collaborative approach has been to use researchers' academic knowledge to catalogue potential factors and the wealth of community coinvestigators' experiential knowledge of interagency dynamics to identify specific relevant dimensions of capacity. This initial exploratory study represents a first step toward developing a general approach to conceptualizing and tracking the organizational capacity of communities. The model and measurement framework may have wider applicability to capacities to partner around and implement a variety of health-related interventions within communities.

Training substance abuse treatment staff to care for co-occurring disorders.

Although co-occurring disorders have been associated with poorer substance abuse treatment outcomes and higher costs of care, few individuals with co-occurring disorders receive appropriate mental health care. This article describes the design and implementation of an intervention to improve the quality of mental health care provided in outpatient substance abuse treatment programs without requiring new treatment staff. The intervention focuses on individuals with affective and anxiety disorders and consists of three components: training and supervising staff, educating and activating clients, and linking with community resources. We evaluated three treatment programs (one intervention and two comparison) for the first component by having program staff complete both self-administered questionnaires and semistructured interviews. Staff knowledge and attitudes about co-occurring disorders, job satisfaction, and morale all indicated an improvement at the intervention relative to the comparison sites. The evaluation is still under way; results for implementation of the other two components and for outcomes will be reported later.

Septal perforation repair without intraoperative mucosal closure.

OBJECTIVES/HYPOTHESIS: To report a technique for septal perforation repair that does not rely on intraoperative mucosal closure of the perforation defect. STUDY DESIGN: Case series with prospective and retrospective data collection. METHODS: Nine patients received multilayer interposition grafts and no attempt at intraoperative mucosal closure for repair of septal perforations. Eight patients received multilayer interposition grafts consisting of temporoparietal fascia on one side, polydioxanone plate in the middle, and deep temporal fascia on the other side. One patient received a variant graft consisting of acellular dermal matrix, polydioxanone plate, and full-thickness temporal fascia. Silastic or silicone sheets were placed bilaterally for at least 12 weeks to protect the septum during healing. This technique was applied to a variety of challenging surgical candidates. RESULTS: The eight patients who received interposition grafts with bilateral temporal fascia had complete repair of septal perforation sites. The variant interposition graft had complete loss on the acellular dermal matrix side but good integration of temporal fascia on the contralateral side. CONCLUSIONS: This tension-free technique does not rely on intraoperative mucosal closure of the septal perforation. It has been used to successfully obtain complete repair in a variety of challenging surgical candidates when combined with temporal fascia autografts.

Comparison of microtia reconstruction outcomes using rib cartilage vs porous polyethylene implant.

IMPORTANCE: Auricular reconstruction is a unique blend of cosmesis and functionality. The choice of the optimal framework material to use is an important decision for the patient with microtia. OBJECTIVE: To evaluate and compare the outcomes of reconstruction of microtia using porous polyethylene implants and rib cartilage grafts. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review from January 1, 2001, through December 31, 2012, at a tertiary academic institution. Thirty-five patients (36 ears) undergoing microtia repair were divided into groups using high-density porous polyethylene (17 ears), rib cartilage (17 ears), and both materials (2 ears). Only patients with completed repair were included in the analysis. EXPOSURES: Reconstructive surgery for microtia. MAIN OUTCOME AND MEASURES: We compared groups in terms of mean number of operations, age at treatment initiation, and complications (infection, extrusion, cartilage exposure, and pneumothorax). Photographs were graded by blinded observers to give each patient a score on protrusion, definition, shape, size, location, and color match. RESULTS: The cartilage group was older than the polyethylene group (mean age, 8.0 vs 6.9 years; P = .23). The mean number of operations was 4.88 for the cartilage group vs 3.35 for the polyethylene group (P = .004). Two patients in the polyethylene group had postoperative infections and implant extrusion and underwent subsequent reconstruction with cartilage grafts. Patients in the cartilage group had no infection or extrusion; 1 had a minor cartilage exposure. No patient had pneumothorax. Patients in the polyethylene group had significantly better grades for ear definition and size match, whereas those in the cartilage group had a significantly better color match. Patients in the cartilage group had better protrusion and location outcomes, although the difference was not significant. CONCLUSIONS AND RELEVANCE: Comparison of reconstruction with porous polyethylene implants and rib cartilage grafts showed neither material to be clearly superior. Polyethylene implants may achieve a better cosmetic outcome in the categories of ear definition, shape, and size with a higher risk for infection and extrusion. Patients in the cartilage group were older and underwent significantly more surgical procedures, which should factor into the decision on which technique to choose. LEVEL OF EVIDENCE: 3.

An effectiveness trial of group cognitive behavioral therapy for patients with persistent depressive symptoms in substance abuse treatment.

CONTEXT: Although depression frequently co-occurs with substance abuse, few individuals entering substance abuse treatment have access to effective depression treatment. OBJECTIVE: The Building Recovery by Improving Goals, Habits, and Thoughts (BRIGHT) study is a community-based effectiveness trial that compared residential substance abuse treatment with residential treatment plus group cognitive behavioral therapy for depression delivered by substance abuse treatment counselors. We hypothesized that intervention clients would have improved depression and substance use outcomes compared with those of clients receiving usual care. DESIGN: A nonrandomized controlled trial using a quasi-experimental intent-to-treat design in which 4 sites were assigned to alternate between the intervention and usual care conditions every 4 months for 2½ years. SETTING: Four treatment programs in Los Angeles County. PARTICIPANTS: We screened 1262 clients for persistent depressive symptoms (Beck Depression Inventory-II score >17). We assigned 299 clients to receive either usual care (n = 159) or usual care plus the intervention (n = 140). Follow-up rates at 3 and 6 months after the baseline interview were 88.1% and 86.2%, respectively, for usual care and 85.7% and 85.0%, respectively, for the intervention group. INTERVENTION: Sixteen 2-hour group sessions of cognitive behavioral therapy for depression. MAIN OUTCOME MEASURES: Change in depression symptoms, mental health functioning, and days of alcohol and problem substance use. RESULTS: Intervention clients reported significantly fewer depressive symptoms (P < .001 at 3 and 6 months) and had improved mental health functioning (P < .001 at 3 months and P < .01 at 6 months). At 6 months, intervention clients reported fewer drinking days (P < .05) and fewer days of problem substance use (P < .05) on days available. CONCLUSIONS: Providing group cognitive behavioral therapy for depression to clients with persistent depressive symptoms receiving residential substance abuse treatment is associated with improved depression and substance use outcomes. These results provide support for a new model of integrated care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01191788.

Access to medical care, use of preventive services, and chronic conditions among adults in substance abuse treatment.

OBJECTIVE: Few studies have examined access to a regular source of medical care and preventive medical care among adults being treated for substance abuse. This report describes the prevalence of a usual source of care, use of preventive care services, and self-reported chronic conditions among adults in a publicly funded substance abuse treatment program. METHODS: The investigators partnered with a large behavioral health organization in Los Angeles County to conduct an interviewer-administered survey during June 2008. RESULTS: A total of 254 clients completed the survey. Fifty percent reported having a usual source of medical care, and 70% reported at least one visit to a physician within the prior 12 months. Participants reported low receipt of most preventive care screening measures. Half had at least one chronic condition, with hypertension, asthma, and arthritis most often reported. CONCLUSIONS: Although this middle-aged sample with substantial medical need reported having access to care, receipt of preventive care was low and unaddressed health concerns were reported.