Development and Pilot of a Portable Community-Based Intervention for LGBTQ+ Youth with Depression Symptoms.

OBJECTIVE: Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) youth experience known inequities in mental health outcomes, including depression and suicidality. The Promoting Wellbeing & Resilience (PWR) class is an interactive, developmentally tailored group that provides strength-based, practical skills to LGBTQ+ teenagers with depression. It is designed to be implemented by paraprofessionals to increase community-based access to care. METHOD: Investigators developed and piloted an eight-session cognitive-behavioral class for LGBTQ+ youth (N = 21) ages 12 to 17 (M = 14.8 years, 81% Caucasian, 57% gender diverse, 100% non-heterosexual) with depression symptoms. The youth received training in mood regulation, communication skills, stress management, and goal setting in a small group format (5-8 youth per group). Outcomes were youth-reported depression (primary), anxiety, and trauma symptoms at pre-treatment and post-treatment. Paired sample (dependent) one-tailed t-tests were used to examine treatment effects. Focus groups were also conducted with participants to assess satisfaction and collect qualitative feedback regarding class content and format. RESULT: The resilience class was associated with reductions in depression symptoms post-treatment (t(17) = 3.3, p = .002, d = 0.5) but not anxiety (t(17) = 1.8, p = .049, d = 0.3) or trauma symptoms (t(17) = 1.2, p = .118, d = 0.1). Completion rates for all group sessions were high (95%), and the majority (57%) of participants returned for an optional review session. CONCLUSION: Preliminary results suggest a manualized 8-week skills-based cognitive-behavioral group intervention designed to be delivered by paraprofessionals may be effective at reducing depression symptoms in actively depressed LGBTQ+ youth.

Understanding the characteristics of Latino individuals with first-time DUI offenses to facilitate effective interventions.

Literature shows that Latinos who drink are more likely to experience alcohol-related consequences and less likely to seek care for alcohol misuse than Whites. We aim to understand characteristics, consumption patterns, and openness to treatment among Latino first-time offenders driving under the influence. Latino participants were significantly younger (29.0 years) than non-Latinos (37.7 years). In adjusted models, Latino participants were significantly more likely than non-Latinos to binge drink, but there were no significant group differences in amount of alcohol consumed in a typical week. There was no significant difference in incidence of alcohol-related consequences, readiness to change drinking, and driving behaviors in this sample.

Life Events, Barriers to Care, and Outcomes Among Minority Women Experiencing Depression: A Longitudinal, Mixed-Method Examination.

ABSTRACT: The long-term course of depression is not well-understood among minority women. We assessed depression trajectory, barriers to depression care, and life difficulties among minority women accessing health and social service programs as part of the Community Partners in Care study. Data include surveys ( N = 339) and interviews ( n = 58) administered at 3-year follow-up with African American and Latina women with improved versus persistent depression. The majority of the sample reported persistent depression (224/339, 66.1%), ≥1 barrier to mental health care (226/339, 72.4%), and multiple life difficulties (mean, 2.7; SD, 2.3). Many barriers to care ( i.e. , related to stigma and care experience, finances, and logistics) and life difficulties ( i.e. , related to finances, trauma, and relationships) were more common among individuals reporting persistent depression. Results suggest the importance of past experiences with depression treatment, ongoing barriers to care, and negative life events as contributors to inequities in depression outcomes experienced by minority women.

Depression, Anxiety, and Suicide Risk among Ugandan Youth in Vocational Training.

The current study examines the prevalence of depression, anxiety, suicide risk, and PTSD in Ugandan youth (13-25 years) attending vocational training programs. Youth from five urban (n=224 females, 81 males) and four rural (n=153 females only) vocational training centers operated by a non-governmental organization completed demographic and mental health questionnaires. Nearly half of the youth reported moderate or severe depression and/or anxiety. More than half reported anxiety and depression-related impairment. Nearly a quarter of youth had considered or attempted suicide. More than half screened positive on the PC-PTSD screen. Rural female youth reported the most food insecurity (56.9%), trafficking (37.9%), severe depression (35.9%), depression-related impairment (56.9%), severe anxiety (26.1%), and anxiety-related impairment (55.6%). Results from this study suggest that Ugandan youth have exceedingly high rates of depression, anxiety, suicide risk, and probable PTSD. Rural female youth may be especially at risk. Relevant treatment interventions are needed that can be adapted to youth in vocational training centers.

Depression at the Intersection of Race/Ethnicity, Sexual Orientation, and Income.

The current study uses an intersectional framework to examine subgroup differences in the prevalence of depression among a community sample of predominantly low-income, racial/ethnic and sexual minority adults. Between May 2017-June 2018, participants (N=1753) were recruited from and screened for depression in community organizations that predominantly serve sexual minority clients based in Los Angeles, California and New Orleans, Louisiana. Twenty-six percent of people screened for study eligibility met criteria for depression (Patient Health Questionnaire-8≥10). As is true in higher-resourced populations, bisexual (Odds Ratio; OR: 1.50; 95% Confidence Interval; CI: 1.08, 2.09) and queer/questioning (OR: 1.86; 95% CI: 1.08, 3.19) individuals were more likely to be depressed than heterosexual and lesbian/ gay individuals. These differences remained even when accounting for income. No differences in depression were observed between lesbian/gay and heterosexual adults. In terms of racial differences, bisexual Black (OR: .47; 95% CI: 0.21, 1.04) and Hispanic (OR: .51; 95% CI: 0.23, 1.12) adults were marginally less likely to be depressed than bisexual White adults. No racial differences emerged across other sexual orientations. Differences across some sexual minority subgroups may be race-specific, suggesting that intersectional frameworks may be the best way to understand how multiple marginalization affects different subgroups.

Depression Remission From Community Coalitions Versus Individual Program Support for Services: Findings From Community Partners in Care, Los Angeles, California, 2010-2016.

Objectives. To explore effects of coalitions (Community Engagement and Planning [CEP]) versus technical assistance (Resources for Services [RS]) for depression collaborative care and the effects of social determinants on long-term remission outcomes. Methods. We randomized 95 health care and community programs in Los Angeles County, California, to CEP or RS. In 2010, 1246 depressed (Patient Health Questionnaire [PHQ-8] ≥ 10) adults enrolled and were invited for baseline and 6-, 12-, and 36-month surveys. Of 598 3-year completers, 283 participated at 4 years (2016). We examined effects of CEP versus RS, social factors (e.g., family income, food insecurity) on time to and periods in clinical (PHQ-8 < 10) and community-defined (PHQ-8 < 10 or PHQ-2 < 3; mental health composite score [MCS-12] > 40, or mental wellness) remission during the course of 3 years, and at 4 years. Results. We found that CEP versus RS increased 4-year depression remission and, for women, community-defined remission outcomes during the course of 3 years. Social factors and clinical factors predicted remission. Conclusions. At 4 years, CEP was more effective than RS at increasing depression remission. Public Health Implications. Coalitions may improve 4-year depression remission, while addressing social and clinical factors associated with depression may hold potential to enhance remission.

Structural Interventions to Reduce and Eliminate Health Disparities.

Health disparities research in the United States over the past 2 decades has yielded considerable progress and contributed to a developing evidence base for interventions that tackle disparities in health status and access to care. However, health disparity interventions have focused primarily on individual and interpersonal factors, which are often limited in their ability to yield sustained improvements. Health disparities emerge and persist through complex mechanisms that include socioeconomic, environmental, and system-level factors. To accelerate the reduction of health disparities and yield enduring health outcomes requires broader approaches that intervene upon these structural determinants. Although an increasing number of innovative programs and policies have been deployed to address structural determinants, few explicitly focused on their impact on minority health and health disparities. Rigorously evaluated, evidence-based structural interventions are needed to address multilevel structural determinants that systemically lead to and perpetuate social and health inequities. This article highlights examples of structural interventions that have yielded health benefits, discusses challenges and opportunities for accelerating improvements in minority health, and proposes recommendations to foster the development of structural interventions likely to advance health disparities research.

Community Interventions to Promote Mental Health and Social Equity.

PURPOSE OF REVIEW: We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions. RECENT FINDINGS: There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.

Stakeholder Perceptions of the Barriers to Receiving and Delivering Exposure-Based Cognitive Behavioral Therapy for Anxiety Disorders in Adult Community Mental Health Settings.

CBT is considered the first-line treatment for anxiety disorders, particularly when it involves gradual confrontation with feared stimuli (i.e., exposure); however, delivery of CBT for anxiety disorders in real-world community clinics is lacking. This study utilized surveys we developed with key stakeholder feedback (patient, provider, and administrator) to assess patient and provider/administrator perceptions of the barriers to delivering (or receiving) CBT for anxiety disorders. Providers/administrators from two counties in California (N = 106) indicated lack of training/competency as primary barriers. Patients in one large county (N = 42) reported their own symptoms most often impacted treatment receipt. Both groups endorsed acceptability of exposure but indicated that its use in treatment provided/received had been limited. Implications and recommendations are discussed.

Lay Health Worker Involvement in Evidence-Based Treatment Delivery: A Conceptual Model to Address Disparities in Care.

Mobilizing lay health workers (LHWs) to deliver evidence-based treatments (EBTs) is a workforce strategy to address mental health disparities in underserved communities. LHWs can be leveraged to support access to EBTs in a variety of ways, from conducting outreach for EBTs delivered by professional providers to serving as the primary treatment providers. This critical review provides an overview of how LHW-supported or -delivered EBTs have been leveraged in low-, middle-, and high-income countries (HICs). We propose a conceptual model for LHWs to address drivers of service disparities, which relate to the overall supply of the EBTs provided and the demand for these treatments. The review provides illustrative case examples that demonstrate how LHWs have been leveraged globally and domestically to increase access to mental health services. It also discusses challenges and recommendations regarding implementing LHW-supported or -delivered EBTs.

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.

12-Month Cost Outcomes of Community Engagement Versus Technical Assistance for Depression Quality Improvement: A Partnered, Cluster Randomized, Comparative-Effectiveness Trial.

Objective: To compare community engagement and planning (CEP) for coalition support to implement depression quality improvement (QI) to resources for services (RS) effects on service-use costs over a 12-month period. Design: Matched health and community programs (N=93) were cluster-randomized within communities to CEP or RS. Setting: Two Los Angeles communities. Participants: Adults (N=1,013) with depressive symptoms (Patient Health Questionnaire (PHQ-8) ≥10); 85% African American and Latino. Interventions: CEP and RS to support programs in depression QI. Main Outcome Measures: Intervention training and service-use costs over 12 months. Results: CEP planning and training costs were almost 3 times higher than RS, largely due to greater CEP provider training participation vs RS, with no significant differences in 12-month service-use costs. Conclusions: Compared with RS, CEP had higher planning and training costs with similar service-use costs.

Community Partnering for Behavioral Health Equity: Public Agency and Community Leaders' Views of its Promise and Challenge.

Objective: To understand potential for multi-sector partnerships among community-based organizations and publicly funded health systems to implement health improvement strategies that advance health equity. Design: Key stakeholder interviewing during HNI planning and early implementation to elicit perceptions of multi-sector partnerships and innovations required for partnerships to achieve system transformation and health equity. Setting: In 2014, the Los Angeles County (LAC) Board of Supervisors approved the Health Neighborhood Initiative (HNI) that aims to: 1) improve coordination of health services for behavioral health clients across safety-net providers within neighborhoods; and 2) address social determinants of health through community-driven, public agency sponsored partnerships with community-based organizations. Participants: Twenty-five semi-structured interviews with 49 leaders from LAC health systems, community-based organizations; and payers. Results: Leaders perceived partnerships within and beyond health systems as transformative in their potential to: improve access, value, and efficiency; align priorities of safety-net systems and communities; and harness the power of communities to impact health. Leaders identified trust as critical to success in partnerships but named lack of time for relationship-building, limitations in service capacity, and questions about sustainability as barriers to trust-building. Leaders described the need for procedural innovations within health systems that would support equitable partnerships including innovations that would increase transparency and normalize information exchange, share agenda-setting and decision-making power with partners, and institutionalize partnering through training and accountability. Conclusions: Leaders described improving procedural justice in public agencies' relationships with communities as key to effective partnering for health equity.

Maintaining Internal Validity in Community Partnered Participatory Research: Experience from the Community Partners in Care Study.

Objective: With internal validity being a central goal of designed experiments, we seek to elucidate how community partnered participatory research (CPPR) impacts the internal validity of public health comparative-effectiveness research. Methods: Community Partners in Care (CPIC), a study comparing a community-coalition intervention to direct technical assistance for disseminating depression care to vulnerable populations, is used to illustrate design choices developed with attention to core CPPR principles. The study-design process is reviewed retrospectively and evaluated based on the resulting covariate balance across intervention arms and on broader peer-review assessments. Contributions of the CPIC Council and the study's design committee are highlighted. Results: CPPR principles contributed to building consensus around the use of randomization, creating a sampling frame, specifying geographic boundaries delimiting the scope of the investigation, grouping similar programs into pairs or other small blocks of units, collaboratively choosing random-number-generator seeds to determine randomized intervention assignments, and addressing logistical constraints in field operations. Study protocols yielded samples that were well-balanced on background characteristics across intervention arms. CPIC has been recognized for scientific merit, has drawn attention from policymakers, and has fueled ongoing research collaborations. Conclusions: Creative and collaborative fulfillment of CPPR principles reinforced the internal validity of CPIC, strengthening the study's scientific rigor by engaging complementary areas of knowledge and expertise among members of the investigative team.

Comparative Effectiveness of Coalitions Versus Technical Assistance for Depression Quality Improvement in Persons with Multiple Chronic Conditions.

Significance: Prior research suggests that Community Engagement and Planning (CEP) for coalition support compared with Resources for Services (RS) for program technical assistance to implement depression quality improvement programs improves 6- and 12-month client mental-health related quality of life (MHRQL); however, effects for clients with multiple chronic medical conditions (MCC) are unknown. Objective: To explore effectiveness of CEP vs RS in MCC and non-MCC subgroups. Design: Secondary analyses of a cluster-randomized trial. Setting: 93 health care and community-based programs in two neighborhoods. Participants: Of 4,440 clients screened, 1,322 depressed (Patient Health Questionnaire, PHQ8) provided contact information, 1,246 enrolled and 1,018 (548 with ≥3 MCC) completed baseline, 6- or 12-month surveys. Intervention: CEP or RS for implementing depression quality improvement programs. Outcomes and Analyses: Primary: depression (PHQ9 <10), poor MHRQL (Short Form Health Survey, SF-12<40); Secondary: mental wellness, good physical health, behavioral health hospitalization, chronic homelessness risk, work/workloss days, services use at 6 and 12 months. End-point regressions were used to estimate intervention effects on outcomes for subgroups with ≥3 MCC, non-MCC, and intervention-by-MCC interactions (exploratory). Results: Among MCC clients at 6 months, CEP vs RS lowered likelihoods of depression and poor MHRQL; increased likelihood of mental wellness; reduced work-loss days among employed and likelihoods of ≥4 behavioral-health hospitalization nights and chronic homelessness risk, while increasing faith-based and park community center depression services; and at 12 months, likelihood of good physical health and park community center depression services use (each P<.05). There were no significant interactions or primary outcome effects for non-MCC. Conclusions: CEP was more effective than RS in improving 6-month primary outcomes among depressed MCC clients, without significant interactions.

A Preliminary Exploration of the Barriers to Delivering (and Receiving) Exposure-Based Cognitive Behavioral Therapy for Anxiety Disorders in Adult Community Mental Health Settings.

Despite the effectiveness of exposure-based cognitive behavioral therapy (CBT) for anxiety disorders, few individuals in need receive this treatment, particularly in community mental health settings serving low-income adults. The present study took a preliminary step to understand these barriers by conducting a series of key informant interviews and focus groups among patients, providers, clinical administrators, and policy makers. Several themes emerged as barriers to the delivery of exposure-based CBT in these settings, including therapist training and compentency issues, logistical issues, and funding stream issues. Clinical implications and future research that can build from these data are discussed.

Mobilizing Community Health Workers to Address Mental Health Disparities for Underserved Populations: A Systematic Review.

This systematic review evaluates efforts to date to involve community health workers (CHWs) in delivering evidence-based mental health interventions to underserved communities in the United States and in low- and middle-income countries. Forty-three articles (39 trials) were reviewed to characterize the background characteristics of CHW, their role in intervention delivery, the types of interventions they delivered, and the implementation supports they received. The majority of trials found that CHW-delivered interventions led to symptom reduction. Training CHWs to support the delivery of evidence-based practices may help to address mental health disparities. Areas for future research as well as clinical and policy implications are discussed.

Surviving Depression: Clinical Qualitative Analysis of Long-Term Survival for Ethnically Diverse, Depressed Patients.

Depression is persistent and recurrent across ethnic groups. Few narrative analyses of long-term outcomes for ethnically diverse adults with depression exist. We combined 9 years of quantitative data, qualitative interviews at 10 years, clinician ratings of outcomes, and a community discussion group with the objective of describing long-term recovery and survival of diverse primary care patients after an episode of depression. Nearly half of participants were found to be depressed at some time over a 10-year period, and most cases across ethnic groups were judged to need further treatment. The ethnically diverse community members that analyzed the transcripts emphasized assets that participants showed in surviving multiple life stresses. Different sex and ethnic/racial groups had different characteristics of engaging in care, with Latino women in particular raising concerns about care engagement, coping with stress, and long-term outcomes.

Community Partners in Care: 6-Month Outcomes of Two Quality Improvement Depression Care Interventions in Male Participants.

OBJECTIVE: Limited data exist on approaches to improve depression services for men in under-resourced communities. This article explores this issue using a sub-analysis of male participants in Community Partners in Care (CPIC). DESIGN: Community partnered, cluster, randomized trial. SETTING: Hollywood-Metropolitan and South Los Angeles, California. PARTICIPANTS: 423 adult male clients with modified depression (PHQ-8 score≥10). INTERVENTIONS: Depression collaborative care implementation using community engagement and planning (CEP) across programs compared with the more-traditional individual program, technical assistance (Resources for Services, RS). MAIN OUTCOME MEASURES: Depressive symptoms (PHQ-8 score), mental health-related quality of life (MHRQL), mental wellness, services utilization and settings. RESULTS: At screening, levels of probable depression were moderate to high (17.5%-47.1%) among men across services sectors. Intervention effects on primary outcomes (PHQ-8 score and MHRQL) did not differ. Men in CEP compared with RS had improved mental wellness (OR 1.85, 95% CI 1.00-3.42) and reduced hospitalizations (OR .40, 95% CI .16-.98), with fewer mental health specialty medication visits (IRR 0.33, 95% CI .15-.69), and a trend toward greater faith-based depression visits (IRR 2.89, 95% CI .99-8.45). CONCLUSIONS: Exploratory sub-analyses suggest that high rates of mainly minority men in under-resourced communities have high prevalence of depression. A multi-sector coalition approach may hold promise for improving community-prioritized outcomes, such as mental wellness and reduced hospitalizations for men, meriting further development of this approach for future research and program design.

Long-Term Effects of Pre-Placement Risk Factors on Children's Psychological Symptoms and Parenting Stress Among Families Adopting Children From Foster Care.

This exploratory longitudinal study examined behavioral outcomes and parenting stress among families with children adopted from foster care, taking into account environmental and biological risk factors. Child internalizing and externalizing problems and parenting stress were assessed in 82 adopted children and their families at 2 months post-placement, 12 months post-placement, and then yearly until 5 years post-placement. A history of abuse/neglect predicted significantly higher externalizing and internalizing problems at a borderline level of statistical significance. In the initial stages after placement, externalizing problems were significantly higher among children who were 4 years or older at placement versus those who were younger than 4, although differences were no longer significant 5 years post-placement. Statistical trends in parenting stress reflected reduced stress in the first 12 months followed by a plateau for parents who adopted older children and greater stress for parents who adopted younger children. Familiar limitations for observational cohort data apply. Nonetheless, the availability of longitudinal follow-up on a sizable sample of children adopted from foster care adds insight to the psychological dynamics for adoptive families and suggests that families of children adopted from the foster care system may have unique needs for ongoing support around behavioral issues.