Primary Care Providers' Perspectives on Prescribing Antidepressant Medication to Latino Immigrant Patients: A Preliminary Study.

Latinos in the United States are less likely to take antidepressants than non-Latino whites, and more likely to prefer depression treatment in primary care. This preliminary study comprised focus groups (2) with primary care providers (12) serving uninsured immigrant Latinos regarding their experiences prescribing and counseling patients about antidepressants. Barriers and challenges included health literacy, language barriers, and illiteracy; perceived stigma; patients' concerns about addiction, polypharmacy, and adverse effects; time constraints of office visits; and difficulty discussing comorbid posttraumatic stress disorder. Messages providers try to share with patients included allowing time for medications to work, taking medications daily as prescribed, mechanisms of action, weighing risks versus benefits, and flexible options for treatment. Providers' recommendations for improving this process included better low-literacy, culturally appropriate written materials with pictures or videos discussing depression. More research is needed to understand patients' and providers' needs in optimizing counseling about antidepressants, particularly regarding underserved and at-risk US populations.

Treatment of depression and PTSD in primary care clinics serving uninsured low-income mostly Latina/o immigrants: A naturalistic prospective evaluation.

OBJECTIVES: Uninsured immigrants to the United States are psychologically vulnerable due to limited access to mental health services. Latina/o immigrants from Central and South America are further at risk due to high levels of trauma exposure, both in their country of origin and their adopted country. Effective behavioral interventions in primary care are needed to address this services gap for common trauma-related mental disorders, including depression and posttraumatic stress disorder (PTSD). A naturalistic prospective study compared depression and PTSD outcomes for uninsured primary care patients, mostly Latina/o immigrants, in clinics with distinct models for integrating behavioral health services. One clinic had a collaborative care program, that is, a multicomponent, system-level intervention with the goals of facilitating increased screening, improving diagnostic accuracy, increasing uptake of evidence-based treatment, and utilizing measurement-based treatment to target. The other had colocated services, with an on-site therapist. METHOD: One hundred thirty-eight patients with presumptive depression were interviewed at baseline. Follow-up data were collected 8 months later. Care received between the two assessments was ascertained by chart review. RESULTS: There was a significant decrease in depression symptoms regardless of clinic. Factors associated with improved depression outcomes included absence of comorbid PTSD and lack of additional trauma exposures. Although there was overall improvement in PTSD, there was significantly more improvement in the collaborative care clinic. CONCLUSIONS: Results suggest that both models were effective for depression and PTSD; however, the collaborative care model had added benefits for those patients with PTSD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Knowledge and Preferences Regarding Antidepressant Medication Among Depressed Latino Patients in Primary Care.

US Latinos are less likely to utilize mental health services than non-Latino whites and to take antidepressant medications. This mixed-method study followed a subset (N = 28) of a research sample of depressed Latino immigrant primary care patients, who took depression medication, with a telephone interview to study their knowledge about and experiences with antidepressant medications. Most (82%) reported taking medication for 2 months or more, and 75% reported feeling better, whereas more than half reported side effects. Most (61%) agreed that antidepressants are generally safe and helpful in treating depression (68%); however, many believed they could be addictive (39%). Fifty percent of patients who discontinued their medication did not inform their providers. Twelve of the 28 patients also participated in focus groups about interactions with providers and made suggestions for conveying information about antidepressants. Patients suggested videos as a format to disseminate medication information because they do not require written comprehension. Other patient recommendations are presented.

Impact of Collaborative Care for Underserved Patients with PTSD in Primary Care: a Randomized Controlled Trial.

BACKGROUND: The effectiveness of collaborative care of mental health problems is clear for depression and growing but mixed for anxiety disorders, including posttraumatic stress disorder (PTSD). We know little about whether collaborative care can be effective in settings that serve low-income patients such as Federally Qualified Health Centers (FQHCs). OBJECTIVE: We compared the effectiveness of minimally enhanced usual care (MEU) versus collaborative care for PTSD with a care manager (PCM). DESIGN: This was a multi-site patient randomized controlled trial of PTSD care improvement over 1 year. PARTICIPANTS: We recruited and enrolled 404 patients in six FQHCs from June 2010 to October 2012. Patients were eligible if they had a primary care appointment, no obvious physical or cognitive obstacles to participation, were age 18-65 years, planned to continue care at the study location for 1 year, and met criteria for a past month diagnosis of PTSD. MAIN MEASURES: The main outcomes were PTSD diagnosis and symptom severity (range, 0-136) based on the Clinician-Administered PTSD Scale (CAPS). Secondary outcomes were medication and counseling for mental health problems, and health-related quality of life assessed at baseline, 6 months, and 12 months. KEY RESULTS: Patients in both conditions improved similarly over the 1-year evaluation period. At 12 months, PTSD diagnoses had an absolute decrease of 56.7% for PCM patients and 60.6% for MEU patients. PTSD symptoms decreased by 26.8 and 24.2 points, respectively. MEU and PCM patients also did not differ in process of care outcomes or health-related quality of life. Patients who actually engaged in care management had mental health care visits that were 14% higher (p < 0.01) and mental health medication prescription rates that were 15.2% higher (p < 0.01) than patients with no engagement. CONCLUSIONS: A minimally enhanced usual care intervention was similarly effective as collaborative care for patients in FQHCs.

Academic Readiness among Young Children Treated for Brain Tumors: A Multisite, Prospective, Longitudinal Trial.

BACKGROUND: Young children treated for central nervous system (CNS) malignancies are at high risk for difficulties with academic functioning due to increased vulnerability of the developing brain and missed early developmental opportunities. Extant literature examining academics in this population is limited. We investigated academic readiness, its clinical and demographic predictors, and its relationship with distal academic outcomes among patients treated for CNS tumors during early childhood. METHODS: Seventy patients with newly diagnosed CNS tumors were treated on a prospective, longitudinal, multisite study with chemotherapy, with or without photon or proton irradiation. Patients underwent assessments of academic skills at baseline, six months, one year, and then annually for five years. Assessments measured academic readiness and academic achievement in reading and math. RESULTS: Mixed linear models revealed slowed development of academic readiness skills over time. Socioeconomic status (SES) was predictive of academic readiness at all time points. Other demographic (eg, age at treatment) and clinical (eg, shunt status, treatment exposure) variables were not predictive of academic readiness. Distal reading difficulties were proportionally greater than normative expectations while math difficulties did not differ. Academic readiness was predictive of distal academic outcomes in reading and math. CONCLUSIONS: Treatment for CNS malignancies in early childhood appears to slow development of academic readiness skills, with SES predictive of risk. Academic readiness skills were predictive of subsequent academic achievement. A disproportionate number of long-term survivors performed below age-based expectations in reading. These findings suggest the need for monitoring and interventions targeting early academic skills in this population.

A randomized clinical trial comparing Interpersonal Psychotherapy with Prolonged Exposure for the treatment of PTSD in veterans.

Trauma-focused therapies are recommended as first-line treatments for posttraumatic stress disorder (PTSD), but many veterans do not complete or sufficiently respond to these treatments. Interpersonal Therapy (IPT) is a non-trauma focused approach that directly addresses the interpersonal and social impairments associated with PTSD. This two-site randomized controlled equivalence trial compared IPT with Prolonged Exposure (PE) in improving PTSD symptoms and interpersonal functioning in 109 veterans with PTSD. Secondary outcomes included functioning and quality of life. We hypothesized that IPT would be statistically equivalent to PE in reducing PTSD symptoms, and superior to PE in improving interpersonal functioning and secondary outcomes of work and social adjustment and quality of life. PTSD symptom severity decreased significantly in both treatments from pre- to post-treatment. Although IPT improved as much as PE and treatments did not differ significantly, the 95 % confidence interval for the difference between the groups did not fall completely within the margin of equivalence. IPT was not superior to PE in improvement in interpersonal functioning or on secondary outcomes. Findings from multi-level linear mixed models using longitudinal data (posttreatment, three and six month follow up) for the primary outcomes of PTSD and interpersonal functioning were consistent with the post-treatment analyses. Although statistically inconclusive in terms of equivalence, the comparable reduction in PTSD symptoms slightly favoring IPT suggests that IPT is an acceptable alternative to gold-standard trauma-focused treatments for veterans with PTSD.

A qualitative evaluation of barriers to care for trauma-related mental health problems among low-income minorities in primary care.

This study aimed to identify barriers and facilitators of mental health care for patients with trauma histories via qualitative methods with clinicians and administrators from primary care clinics for the underserved. Individual interviews were conducted, followed by a combined focus group with administrators from three jurisdictions; there were three focus groups with clinicians from each clinic system. Common themes were identified, and responses from groups were compared. Administrators and clinicians report extensive trauma histories among patients. Clinician barriers include lack of time, patient resistance, and inadequate referral options; administrators cite reimbursement issues, staff training, and lack of clarity about the term trauma. A key facilitator is doctor-patient relationship. There were differences in perceived barriers and facilitators at the institutional and clinical levels for mental health care for patients with trauma. Importantly, there is agreement about better access to and development of trauma-specific interventions. Findings will aid the development and implementation of trauma-focused interventions embedded in primary care.

Attachment and health care relationships in low-income women with trauma histories: a qualitative study.

Few studies have examined the relationship between low-income, traumatized women and their health care providers. In this study we interviewed 23 women from primary care and social service settings for the underserved about trauma, attachment, psychiatric symptoms, and reports of their interactions with primary care providers. Nearly all reported trauma exposure, and 17% had current posttraumatic stress disorder. About half were categorized as Unresolved with regard to attachment state of mind. Analyses of a health experiences interview showed that women with Unresolved attachment reported significantly more negative interactions with providers. Attachment may play a role in the relationship between trauma and health care interactions with providers, indicating the need for further study of this relationship and suggesting intervention strategies to help both parties contribute to a more collaborative process.

Using latent variable modeling and multiple imputation to calibrate rater bias in diagnosis assessment.

We present an approach that uses latent variable modeling and multiple imputation to correct rater bias when one group of raters tends to be more lenient in assigning a diagnosis than another. Our method assumes that there exists an unobserved moderate category of patient who is assigned a positive diagnosis by one type of rater and a negative diagnosis by the other type. We present a Bayesian random effects censored ordinal probit model that allows us to calibrate the diagnoses across rater types by identifying and multiply imputing 'case' or 'non-case' status for patients in the moderate category. A Markov chain Monte Carlo algorithm is presented to estimate the posterior distribution of the model parameters and generate multiple imputations. Our method enables the calibrated diagnosis variable to be used in subsequent analyses while also preserving uncertainty in true diagnosis. We apply our model to diagnoses of posttraumatic stress disorder (PTSD) from a depression study where nurse practitioners were twice as likely as clinical psychologists to diagnose PTSD despite the fact that participants were randomly assigned to either a nurse or a psychologist. Our model appears to balance PTSD rates across raters, provides a good fit to the data, and preserves between-rater variability. After calibrating the diagnoses of PTSD across rater types, we perform an analysis looking at the effects of comorbid PTSD on changes in depression scores over time. Results are compared with an analysis that uses the original diagnoses and show that calibrating the PTSD diagnoses can yield different inferences.

Treatment of complex PTSD: results of the ISTSS expert clinician survey on best practices.

This study provides a summary of the results of an expert opinion survey initiated by the International Society for Traumatic Stress Studies Complex Trauma Task Force regarding best practices for the treatment of complex posttraumatic stress disorder (PTSD). Ratings from a mail-in survey from 25 complex PTSD experts and 25 classic PTSD experts regarding the most appropriate treatment approaches and interventions for complex PTSD were examined for areas of consensus and disagreement. Experts agreed on several aspects of treatment, with 84% endorsing a phase-based or sequenced therapy as the most appropriate treatment approach with interventions tailored to specific symptom sets. First-line interventions matched to specific symptoms included emotion regulation strategies, narration of trauma memory, cognitive restructuring, anxiety and stress management, and interpersonal skills. Meditation and mindfulness interventions were frequently identified as an effective second-line approach for emotional, attentional, and behavioral (e.g., aggression) disturbances. Agreement was not obtained on either the expected course of improvement or on duration of treatment. The survey results provide a strong rationale for conducting research focusing on the relative merits of traditional trauma-focused therapies and sequenced multicomponent approaches applied to different patient populations with a range of symptom profiles. Sustained symptom monitoring during the course of treatment and during extended follow-up would advance knowledge about both the speed and durability of treatment effects.

Rationale, design, and methods of a two-site randomized controlled trial: Comparative effectiveness of two treatments for posttraumatic stress disorder in veterans.

PTSD is associated with serious problems in interpersonal functioning, including higher rates of marital conflict and divorce, disrupted relationships with family and friends, estrangement from others and social isolation. Cognitive behavioral and trauma focused treatments are effective for treating PTSD symptoms, but a substantial proportion of individuals, particularly veterans, with PTSD, do not engage, complete, or fully respond to these treatments, and the effects of these treatments on interpersonal functioning are unknown. There is a critical need for alternative treatments with established efficacy, and for treatments that directly address problems in relationship functioning. Interpersonal Psychotherapy for PTSD (IPT-PTSD) is a promising candidate for such a treatment. This paper describes the rationale, design, and methods of the first randomized controlled equivalence trial comparing IPT-PTSD with a first-line gold standard treatment for PTSD (Prolonged Exposure; PE) in the treatment of PTSD in veterans. Both treatments include up to 12 weekly individual sessions. Assessments were conducted at baseline, following sessions four and eight, end of treatment, and 3 and 6 months post-treatment. Primary hypotheses are that IPT-PTSD will be statistically equivalent to PE in reducing the severity of PTSD symptoms, and superior to PE in improving interpersonal functioning. Secondary hypotheses propose that IPT will be superior to PE in improving overall social adjustment and quality of life, and in reducing suicidal ideation. Findings from this study have the potential to improve treatment options for veterans struggling with PTSD and interpersonal problems.

Predictors of Cognitive Performance Among Infants Treated for Brain Tumors: Findings From a Multisite, Prospective, Longitudinal Trial.

PURPOSE: Infants treated for CNS malignancies experience a significantly poorer response to treatment and are particularly at risk for neuropsychological deficits. The literature is limited and inconsistent regarding cognitive outcomes among this group. We investigated predictors of cognitive outcomes in children treated for brain tumors during infancy as part of a large, prospective, multisite, longitudinal trial. PATIENTS AND METHODS: One hundred thirty-nine infants with a newly diagnosed CNS tumor were treated with chemotherapy, with or without focal proton or photon radiation therapy (RT). Cognitive assessments were conducted at baseline, 6 months, 1 year, and then annually for 5 years. The median length of follow-up was 816 days (26.8 months). Neurocognitive testing included assessment of intellectual functioning (intellectual quotient [IQ]), parent ratings of executive functioning and emotional and behavioral functioning, and socioeconomic status. RESULTS: At baseline, IQ, parent-reported working memory, and parent-reported adaptive functioning were worse than normative expectations. Baseline cognitive difficulties were associated with younger age at diagnosis and lower socioeconomic status. Linear mixed models did not demonstrate a decline in IQ over time. There were increased parent-reported attention and executive problems over time. Increased concerns were related to supratentorial tumor location and CSF diversion. There were no differences in cognitive outcomes based on treatment exposure (chemotherapy-only v chemotherapy with RT and proton v photon focal RT). CONCLUSION: Even before adjuvant therapy, young children with brain tumors experience cognitive difficulties that can affect quality of life. Changes in cognitive functioning over time were dependent on tumor location and surgical factors rather than adjuvant therapy. These findings may serve to guide treatment planning and indicate targets for cognitive monitoring and intervention.

Ethnic Disparities in Trauma-Related Mental Illness: Is Ethnic Identity a Buffer?

Despite evidence that racial and ethnic characteristics influence the impact of traumatic exposure on psychological health, little is known about how race and ethnic identity can alter, and possibly protect against, the effects of trauma on the psychiatric diagnoses of women. Therefore, the present study examined the moderating role of race/ethnicity and ethnic identity in the link between trauma exposure and psychiatric diagnosis for African American and Caucasian college women. Participants were a sample of 242 women from the Mid-Atlantic region of the United States who self-identified as African American or Black (31%) and European American or Caucasian (69%; M age = 19.5 years). Interviews were conducted over the phone to screen for trauma, followed by longer in-person interviews. Each of the interviewers was supervised, and interviews were reviewed to control for quality. Regression analyses revealed that the number of traumatic events was a stronger predictor of lifetime psychiatric diagnoses for Caucasian women. In addition, ethnic identity served as a protective factor against trauma exposure among participants. The findings suggest that ethnic identity is a relevant buffer against potential psychiatric diagnoses as result of exposure to traumatic events for both Caucasian and African American women.

System factors affect the recognition and management of posttraumatic stress disorder by primary care clinicians.

BACKGROUND: Posttraumatic stress disorder (PTSD) is common with an estimated prevalence of 8% in the general population and up to 17% in primary care patients. Yet, little is known about what determines primary care clinician's (PCC's) provision of PTSD care. OBJECTIVE: To describe PCC's reported recognition and management of PTSD and identify how system factors affect the likelihood of performing clinical actions with regard to patients with PTSD or "PTSD treatment proclivity." DESIGN: Linked cross-sectional surveys of medical directors and PCCs. PARTICIPANTS: Forty-six medical directors and 154 PCCs in community health centers (CHCs) within a practice-based research network in New York and New Jersey. MEASUREMENTS: Two system factors (degree of integration between primary care and mental health services, and existence of linkages with other community, social, and legal services) as reported by medical directors, and PCC reports of self-confidence, perceived barriers, and PTSD treatment proclivity. RESULTS: Surveys from 47 (of 58) medical directors (81% response rate) and 154 PCCs (86% response rate). PCCs from CHCs with better mental health integration reported greater confidence, fewer barriers, and higher PTSD treatment proclivity (all P < 0.05). The PCCs in CHCs with better community linkages reported greater confidence, fewer barriers, higher PTSD treatment proclivity, and lower proclivity to refer patients to mental health specialists or to use a "watch and wait" approach (all P < 0.05). CONCLUSIONS: System factors play an important role in PCC PTSD management. Interventions are needed that restructure primary care practices by making mental health services more integrated and community linkages stronger.

PTSD in Latino patients: illness beliefs, treatment preferences, and implications for care.

BACKGROUND: Little is known about how Latinos with post-traumatic stress disorder (PTSD) understand their illness and their preferences for mental health treatment. OBJECTIVE: To understand the illness beliefs and treatment preferences of Latino immigrants with PTSD. DESIGN: Semi-structured, face-to-face interviews. PARTICIPANTS: Sixty foreign-born, Latino adults recruited from five primary care centers in New York and New Jersey and screened for PTSD. APPROACH: Content analytic methods identified common themes, their range, and most frequent or typical responses. RESULTS: Participants identified their primary feelings as sadness, anxiety, nervousness, and fear. The most common feeling was "sad" (triste). Other words frequently volunteered were "angry" (enojada), "nervous" (nerviosa), and "scared" (miedo). Participants viewed their PTSD as impairing health and functioning. They ascribed their somatic symptoms and their general medical problems to the "stress" from the trauma and its consequences on their lives. The most common reason participants volunteered for their work and school functioning being impaired was their poor concentration, often due to intrusive thoughts. Most expressed their desire to receive mental health treatment, to receive it within their primary care center, and preferred psychotherapy over psychotropic medications. Among participants who did not report wanting treatment, most said it was because the trauma was "in the past." CONCLUSIONS: Clinicians may consider enquiring about PTSD in Latino patients who report feeling sad, anxious, nervous, or fearful. Our study suggests topics clinicians may include in the psychoeducation of patients with PTSD.

Group interpersonal psychotherapy for low-income women with posttraumatic stress disorder.

The aim of this study was to assess the efficacy of group interpersonal psychotherapy (IPT) for low-income women with chronic posttraumatic stress disorder (PTSD) subsequent to interpersonal trauma. Non-treatment-seeking predominantly minority women were recruited in family planning and gynecology clinics. Individuals with interpersonal trauma histories (e.g., assault, abuse, and molestation) who met criteria for current PTSD (N=48) were randomly assigned to treatment or a wait list. Assessments were conducted at baseline, treatment termination, and 4-month follow-up; data analysis used a mixed-effects regression approach with an intent-to-treat sample. The results showed that IPT was significantly more effective than the wait list in reducing PTSD and depression symptom severity. IPT participants also had significantly lower scores than waitlist individuals on four interpersonal functioning subscales: Interpersonal Sensitivity, Need for Social Approval, Lack of Sociability, and Interpersonal Ambivalence.

Validation of a Standardized Patient Checklist for Patient-Centered Communication: The G-PACER.

This study sought to validate the Georgetown PAtient-CEnteredness Rating Scale (G-PACER) standardized patient (SP) checklist as a measure of patient-centered communication in patient-provider interactions. Patient centeredness is associated with improved doctor-patient communication and better health outcomes. Simulated medical encounters using SPs are an important way to teach and evaluate provider communication skills, yet validated SP scales that focus on patient-centered communication are limited. Two versions of an SP checklist of provider interaction behaviors, the G-PACER, were developed as part of a training designed to improve relationships between providers and patients who have experienced trauma. Concurrent validity of the G-PACER was assessed with Roter Interaction Analysis System (RIAS) summary scores, particularly the patient-centeredness summary score. Item-total correlations were conducted to determine which items should be retained for future versions of the scale. Scores on the G-PACER were significantly correlated with the RIAS Patient-Centeredness score. Correlation analysis also revealed significant associations between G-PACER Total Score and RIAS Global Affect Ratings. The twelve-item version of the G-PACER performed at a commensurate level with the longer version; thus, it's use is recommended in future research. This study represents an important step in the development of reliable, valid, and efficient tools to add to those available for evaluating patient-provider interactions from the SP perspective.

An Internet-based writing intervention for PTSD in veterans: A feasibility and pilot effectiveness trial.

[Correction Notice: An Erratum for this article was reported in Vol 9(4) of Psychological Trauma: Theory, Research, Practice, and Policy (see record 2016-54154-001). In the article, the names of authors Adil Alaoui and Anas Belouali were misspelled as Adil Aloui and Anas Beloui respectively. All versions of this article have been corrected.] Objective: Veterans suffering from posttraumatic stress disorder (PTSD) may avoid or fail to follow through with a full course of face-to-face mental health treatment for a variety of reasons. We conducted a pilot effectiveness trial of an online intervention for veterans with current PTSD to determine the feasibility, safety, and preliminary effectiveness of an online writing intervention (i.e., Warriors Internet Recovery & EDucation [WIRED]) as an adjunct to face-to-face psychotherapy. Method: Veterans (N = 34) who had served in Iraq or Afghanistan with current PTSD subsequent to deployment-related trauma were randomized to Veterans Affairs (VA) mental health treatment as usual (TAU) or to treatment as usual plus the online intervention (TAU + WIRED). All research participants were recruited from the Trauma Services Program, VA Medical Center, Washington, DC. They completed baseline assessments as well as assessments 12 weeks and 24 weeks after the baseline assessment. The online intervention consisted of therapist-guided writing, using principles of prolonged exposure and cognitive therapy. The intervention was adapted from an evidence-based treatment used in The Netherlands and Germany for individuals who had been exposed to nonmilitary traumas. Results: In addition to showing that the online intervention was both feasible to develop and implement, as well as being safe, the results showed preliminary evidence of the effectiveness of the TAU + WIRED intervention in this patient population, with particular evidence in reducing PTSD symptoms of hyperarousal. Conclusion: With minor modifications to enhance the therapeutic alliance, this intervention should be tested in a larger clinical trial to determine whether this method of online intervention might provide another alternative to face-to-face treatment for veterans with PTSD. (PsycINFO Database Record

Cost-effectiveness of evidence-based pharmacotherapy or cognitive behavior therapy compared with community referral for major depression in predominantly low-income minority women.

BACKGROUND: Few clinical trials have evaluated interventions for major depressive disorder in samples of low-income minority women, and little is known about the cost-effectiveness of depression interventions for this population. OBJECTIVE: To evaluate the cost-effectiveness of pharmacotherapy or cognitive behavior therapy (CBT) compared with community referral for major depression in low-income minority women. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial was conducted in 267 women with current major depression. INTERVENTIONS: Participants were randomly assigned to pharmacotherapy (paroxetine hydrochloride or bupropion hydrochloride) (n = 88), CBT (n = 90), or community referral (n = 89). MAIN OUTCOME MEASURES: The main outcomes were intervention and health care costs, depression-free days, and quality-adjusted life years based on Hamilton Depression Rating Scale scores and Medical Outcomes Study 36-Item Short-Form Health Survey summary scores for 12 months. Cost-effectiveness ratios were estimated to compare incremental patient outcomes with incremental costs for pharmacotherapy relative to community referral and for CBT relative to community referral. RESULTS: Compared with the community referral group, the pharmacotherapy group had significantly lower adjusted mean Hamilton Depression Rating Scale scores from the 3rd month through the 10th month (P = .04 to P<.001) of the study, and the CBT group had significantly lower adjusted mean scores from the 5th month through the 10th month (P = .03 to P = .049). There were significantly more depression-free days in the pharmacotherapy group (mean, 39.7; 95% confidence interval, 12.9-66.5) and the CBT group (mean, 25.80; 95% confidence interval, 0.04-51.50) than in the community referral group. The cost per additional depression-free day was USD 24.65 for pharmacotherapy and USD 27.04 for CBT compared with community referral. CONCLUSIONS: Effective treatment for depression in low-income minority women reduces depressive symptoms but increases costs compared with community referral. The pharmacotherapy and CBT interventions were cost-effective relative to community referral for the health care system.

One-year outcomes of a randomized clinical trial treating depression in low-income minority women.

This study examines 1-year depressive symptom and functional outcomes of 267 predominantly lowincome, young minority women randomly assigned to antidepressant medication, group or individual cognitive- behavioral therapy (CBT), or community referral. Seventy-six percent assigned to medications received 9 or more weeks of guideline-concordant doses of medications; 36% assigned to psychotherapy received 6 or more CBT sessions. Intent-to-treat, repeated measures analyses revealed that medication (p=.001) and CBT (p=.02) were superior to community referral in lowering depressive symptoms across 1-year follow-up. At Month 12, 50.9% assigned to antidepressants, 56.9% assigned to CBT, and 37.1% assigned to community referral were no longer clinically depressed. These findings suggest that both antidepressant medications and CBT result in clinically significant decreases in depression for low-income minority women.