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.

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.

Depression among Latina immigrant mothers separated from their children.

OBJECTIVE: Latinas who immigrate to the United States and leave their children in their homelands may experience psychological consequences of this separation. This study examined whether immigrant Latinas who were separated from their children differed in rates of probable major depression from those who lived with their children and from those who did not have any children. METHODS: Data were obtained between March 1997 and May 2002 from women in Women, Infants, and Children programs that target low-income pregnant and postpartum women and their children (up to five years of age), women in county-run Title X family planning clinics, women in pediatric clinics for low-income families, and women who were living in a subsidized-housing project or attending programs for county welfare recipients. Latinas in this study were all immigrants to the United States. The women were screened for major depressive disorders with the Primary Care Evaluation of Mental Disorders. RESULTS: A total of 5,122 Latina immigrants were screened. Overall, 11.7 percent of the sample screened positive for major depression. The rates of depression were 11.4 percent for women who lived with their children, 10.9 percent for those who did not have children, and 18.1 for those who were not living with their children. When the analyses controlled for demographic differences, the odds of depression for immigrant Latinas who were separated from their children were 1.52 times as great as the odds for those whose children were currently living with them (p=.02). Odds of depression were similar among women who lived with their children and those who did not have children. CONCLUSIONS: Separation from children during immigration may lead to increased risk of depression for immigrant Latinas. Health care clinicians who treat young immigrant women should pay close attention to signs of depression among women who have left children with relatives in their homelands.

Depression prevalence in disadvantaged young black women--African and Caribbean immigrants compared to US-born African Americans.

BACKGROUND: Research with Mexican Americans suggests that immigrants have lower rates of mental disorders than U. S.-born Mexican Americans. We examine the prevalence of depression, somatization, alcohol use and drug use among black American women, comparing rates of disorders among U. S.-born, Caribbean-born, and African-born subsamples. METHODS: Women in Women, Infants and Children (WIC) programs, county-run Title X family planning clinics, and low-income pediatric clinics were interviewed using the PRIME-MD. In total, 9,151 black women were interviewed; 7,965 were born in the U. S., 913 were born in Africa, and 273 were born in the Caribbean. RESULTS: Controlling for other predictors, U.S.-born black women had odds of probable depression that were 2.94 times greater than the African-born women (p<0.0001, 95% CI: 2.07, 4.18) and 2.49 times greater than Caribbean-born women (p<0.0016, 95% CI: 1.41, 4.39). Likelihood of somatization did not differ among women who were U. S. born, African born, or Caribbean born. Rates of alcohol and drug problems were exceedingly low among all three groups, with less than 1% of the women reporting either alcohol or drug problems. CONCLUSIONS: These results mirror similar findings for Mexican immigrant as compared with American-born Mexican Americans. The findings suggest that living in the U. S. might increase depression among poor black women receiving services in county entitlement clinics. Further research with ethnically validated instruments is needed to identify protective and risk factors associated with depression in immigrant and U. S.-born poor black women.

Five-year impact of quality improvement for depression: results of a group-level randomized controlled trial.

BACKGROUND: Quality improvement (QI) programs for depressed primary care patients can improve health outcomes for 6 to 28 months; effects for longer than 28 months are unknown. OBJECTIVE: To assess how QI for depression affects health outcomes, quality of care, and health outcome disparities at 57-month follow-up. DESIGN: A group-level randomized controlled trial. SETTING: Forty-six primary care practices in 6 managed care organizations. PATIENTS: Of 1356 primary care patients who screened positive for depression and enrolled in the trial, 991 (73%, including 451 Latinos and African Americans) completed 57-month telephone follow-up. INTERVENTIONS: Clinics were randomly assigned to usual care or to 1 of 2 QI programs supporting QI teams, provider training, nurse assessment, and patient education, plus resources to support medication management (QI-meds) or psychotherapy (QI-therapy) for 6 to 12 months. MAIN OUTCOME MEASURES: Probable depressive disorder in the previous 6 months, mental health-related quality of life in the previous 30 days, primary care or mental health specialty visits, counseling or antidepressant medications in the previous 6 months, and unmet need, defined as depressed but not receiving appropriate care. RESULTS: Combined QI-meds and QI-therapy, relative to usual care, reduced the percentage of participants with probable disorder at 5 years by 6.6 percentage points (P =.04). QI-therapy improved health outcomes and reduced unmet need for appropriate care among Latinos and African Americans combined but provided few long-term benefits among whites, reducing outcome disparities related to usual care (P =.04 for QI-ethnicity interaction for probable depressive disorder). CONCLUSIONS: Programs for QI for depressed primary care patients implemented by managed care practices can improve health outcomes 5 years after implementation and reduce health outcome disparities by markedly improving health outcomes and unmet need for appropriate care among Latinos and African Americans relative to whites; thus, equity was improved in the long run.