Community-Based Participatory Research Conceptual Model: Community Partner Consultation and Face Validity.

A national community-based participatory research (CBPR) team developed a conceptual model of CBPR partnerships to understand the contribution of partnership processes to improved community capacity and health outcomes. With the model primarily developed through academic literature and expert consensus building, we sought community input to assess face validity and acceptability. Our research team conducted semi-structured focus groups with six partnerships nationwide. Participants validated and expanded on existing model constructs and identified new constructs based on "real-world" praxis, resulting in a revised model. Four cross-cutting constructs were identified: trust development, capacity, mutual learning, and power dynamics. By empirically testing the model, we found community face validity and capacity to adapt the model to diverse contexts. We recommend partnerships use and adapt the CBPR model and its constructs, for collective reflection and evaluation, to enhance their partnering practices and achieve their health and research goals.

Long-term effectiveness of collaborative depression care in older primary care patients with and without PTSD symptoms.

OBJECTIVE: Depressed patients with comorbid post-traumatic stress disorder (PTSD) are more functionally impaired and may take longer to respond to depression treatment than patients without PTSD. This study examined the long-term effects of PTSD on depression severity, treatment response, and health care costs among older adults. METHODS: Patients were recruited from 18 primary care clinics in five states. A total of 1801 patients aged 60 years or older with major depression or dysthymia were randomized to Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care or usual care. The study included 191 (10.6%) subjects who screened positive for PTSD. Depression severity, assessed by the Hopkins Depression Symptom Checklist, was used to estimate depression-free days (DFDs) over 24 months. Total health care costs included inpatient, outpatient, and pharmacy costs. RESULTS: Depressed patients with PTSD had higher depression severity than patients without PTSD symptoms at baseline. Over 2 years, intervention patients with PTSD symptoms had relatively the same benefits from collaborative care (99 more DFDs than usual care patients) as patients without PTSD (108 more DFDs than usual care) (p = 0.85). Total health care costs did not differ significantly for depressed patients with and without PTSD symptoms. CONCLUSION: Depressed older adults with PTSD symptoms were more depressed at baseline, but collaborative care (compared to usual care) produced similar improvements in depression severity in both groups. This reduction of depression symptoms was observed for up to 12 months after the intervention ended, suggesting that long-term improvements in depression are possible with collaborative care in patients with and without PTSD symptoms.

Prevalence of psychiatric illnesses in older ethnic minority adults.

OBJECTIVES: To compare lifetime and 12-month prevalence of psychiatric disorders in a nationally representative sample of older Latino, Asian, African-American, and Afro-Caribbean adults with that of older non-Latino white adults. DESIGN: Cross-sectional study conducted in 2001 through 2004. SETTING: Urban and rural households in the contiguous United States. PARTICIPANTS: Two thousand three hundred seventy-five community-dwelling residents aged 60 and older living in noninstitutional settings. Data are from the National Institutes of Mental Health Collaborative Psychiatric Epidemiological Studies. METHODS: The World Mental Health Composite International Diagnostic Interview assessed lifetime and 12-month psychiatric disorders. Bayesian estimates compared psychiatric disorder prevalence rates of ethnic and racial groups. RESULTS: Older non-Latino whites exhibited a greater prevalence on several lifetime diagnoses than older Asian, African-American, and Afro-Caribbean respondents. Older Latinos did not differ from older non-Latino whites on any lifetime diagnosis and had higher 12-month rates of any depressive disorder. No differences were observed in the 12-month diagnoses between older non-Latino whites and the other racial and ethnic minority groups. Older immigrant Latinos had higher lifetime rates of dysthymia and generalized anxiety disorder (GAD) than U.S.-born Latinos. Older immigrant Asians had higher lifetime rates of GAD than U.S.-born Asians. Older immigrant Latinos had higher 12-month rates of dysthymia than older U.S.-born Latinos. CONCLUSION: Caution should be taken when generalizing the protective effects of ethnicity into old age. Older Asians and African-Americans exhibited lower prevalence rates of some psychiatric disorders, whereas older Latinos exhibited rates equal to those of older non-Latino whites. Also, the protective effect of nativity seems to vary according to age, psychiatric disorder, and ethnicity.

Research article: Antidepressant use among Asians in the United States.

OBJECTIVES: We examined the prevalence and predictors of past-year antidepressant use in a nationally representative sample of Asian Americans and non-Latino Whites. METHODS: Analyses of 12-month antidepressant medication use were based on data from the Collaborative Psychiatric Epidemiology Surveys that surveyed Asian (Chinese, Filipino, Vietnamese, and others; N=2,284) and non-Latino White (N=6,696) household residents ages 18 years and older in the 48 contiguous United States and Hawaii. RESULTS: Prevalence rates for 12-month antidepressant use for Asians with major depression ranged from 8.7% among Vietnamese to 17% among Chinese respondents. Compared to non-Latino Whites (32.4%), all Asians (10.9%) meeting criteria for 12-month depressive and anxiety disorders, but especially Filipinos (8.8%) were less likely to report past-year antidepressant use. CONCLUSIONS: We found disparities in past-year antidepressant use among all the examined major Asian groups meeting criteria for 12-month depressive and anxiety disorders. These disparities were not explained by mental health need or socioeconomic factors that enable access to care.

Health care utilization and its costs for depressed veterans with and without comorbid PTSD symptoms.

OBJECTIVE: This study examined health care utilization and costs of care among Veterans Affairs (VA) patients with depression and with or without symptoms of comorbid posttraumatic stress disorder (PTSD). METHODS: Cross-sectional comparisons of health care utilization and costs were conducted with VA administrative data for a sample of veterans from a randomized trial of collaborative care depression treatment in ten VA primary care clinics across five states. Patients with depression or dysthymia were included in the study, and those who were acutely suicidal or had probable bipolar disorder were excluded. The sample of 606 patients was mainly male, white, and aged 55 or older. Health care utilization, costs, and medication data from VA administrative databases were analyzed over 12 months. RESULTS: Patients with depression and PTSD (screen score > or =3) were more emotionally distressed, had more frequent mental health specialty visits (6.91 versus 1.68, p<.001), more total outpatient visits (26.16 versus 19.94, p<.001), and correspondingly higher outpatient mental health care costs over the previous 12 months compared with depressed patients without PTSD. Antidepressants were prescribed to a higher proportion of depressed patients with PTSD (61% versus 40%). CONCLUSIONS: Patients with PTSD and depression had greater utilization of specialty mental health treatments and antidepressant medications and higher mental health care costs in the previous 12 months than depressed patients without PTSD. As military personnel return from Iraq, both VA and non-VA health care providers need to plan for an increase in outpatient mental health services and costs, particularly among depressed veterans who also have PTSD.

Dual use of VA and non-VA services among primary care patients with depression.

BACKGROUND: Depression treatment requires close monitoring to achieve optimal, long-term control. Use of multiple sources of health care can affect coordination and continuity of treatment for depression. OBJECTIVES: To assess levels of non-Veterans Health Administration (VA) use among depressed primary care patients by service type and examine patient factors associated with non-VA use. DESIGN: Cross-sectional comparison of dual and VA-only users among depressed primary care patients. Depression was defined as PHQ-9 >or=10. SUBJECTS: Five hundred fifty depressed patients from the baseline sample of a group-randomized trial of collaborative care for depression in ten VA primary care practices. MEASUREMENTS: VA and non-VA outpatient utilization for physical and emotional health problems in the prior 6 months, patient demographics, and co-morbid conditions. All measures were self-reported and obtained at the baseline interview. RESULTS: Overall, 46.8% of VA depressed primary care patients utilized non-VA care. Dual users were more likely to use acute care services (emergency room or inpatient), especially for physical health problems. Dual users of physical health services had more total visits, but fewer VA visits than VA-only users, while dual users of emotional health services had fewer total and VA visits. Factors associated with dual use were urban clinic location, having other insurance coverage, and dissatisfaction with physical health care in general. CONCLUSIONS: Almost half of depressed primary care patients used non-VA care, with most of their non-VA use for physical rather than emotional health problems. Care management strategies for depressed patients should include communication and coordination with non-VA providers.

Prevalence of depression-PTSD comorbidity: implications for clinical practice guidelines and primary care-based interventions.

BACKGROUND: Compared to those with depression alone, depressed patients with posttraumatic stress disorder (PTSD) experience more severe psychiatric symptomatology and factors that complicate treatment. OBJECTIVE: To estimate PTSD prevalence among depressed military veteran primary care patients and compare demographic/illness characteristics of PTSD screen-positive depressed patients (MDD-PTSD+) to those with depression alone (MDD). DESIGN: Cross-sectional comparison of MDD patients versus MDD-PTSD+ patients. PARTICIPANTS: Six hundred seventy-seven randomly sampled depressed patients with at least 1 primary care visit in the previous 12 months. Participants composed the baseline sample of a group randomized trial of collaborative care for depression in 10 VA primary care practices in 5 states. MEASUREMENTS: The Patient Health Questionnaire-9 assessed MDD. Probable PTSD was defined as a Primary Care PTSD Screen > or = 3. Regression-based techniques compared MDD and MDD-PTSD+ patients on demographic/illness characteristics. RESULTS: Thirty-six percent of depressed patients screened positive for PTSD. Adjusting for sociodemographic differences and physical illness comorbidity, MDD-PTSD+ patients reported more severe depression (P < .001), lower social support (P < .001), more frequent outpatient health care visits (P < .001), and were more likely to report suicidal ideation (P < .001) than MDD patients. No differences were observed in alcohol consumption, self-reported general health, and physical illness comorbidity. CONCLUSIONS: PTSD is more common among depressed primary care patients than previously thought. Comorbid PTSD among depressed patients is associated with increased illness burden, poorer prognosis, and delayed response to depression treatment. Providers should consider recommending psychotherapeutic interventions for depressed patients with PTSD.