Mental Health Service Use, Barriers, and Service Preferences During COVID-19 among Low-Income Housing and Market-Rate Housing Residents of Harlem in New York City

This study examined the differences in mental health service use, barriers, and service preferences among 393 low-income housing (LIH) and market-rate housing (MRH) Harlem residents in New York City. One-third (34.6%) endorsed the need for professional support for psychological issues, 27.2% and 15.8% reported using counseling services and psychotropic medication, with no differences between housing types. LIH residents (21.6-38.8%) reported significantly higher use of all types of mental health resources (e.g., websites, anonymous hotlines, self-help tools) compared with MRH residents (16.1-26.4%). Eighty-six percent reported barriers to mental health access, with LIH residents reporting more than double the barriers. Particularly, LIH residents reported greater difficulty getting time off work (34.1% vs. 14%), lack of health insurance (18.7% vs. 9.8%), lack of trust in mental health providers (14.6% vs. 4.7%), and stigma (12.2% vs. 5.1%) compared with MRH residents. Residents most preferred places of services were health clinics and houses of worship; provided by healthcare and mental health providers; and services delivered in-person and phone-based counseling. In contrast, residents least preferred getting support at mental health clinics; from family/friends; and by the Internet. No differences were found between service preferences by housing type. LIH residents reported higher use of mental health services and resources, but they face significantly more barriers to mental health care, suggesting a need to address specific barriers. Preferences for mental health services suggest a need for expanding mental health services to different settings given the low preference for services to be delivered at mental health clinics.

Mental Health Concerns During COVID-19: An Observational Study Among a Predominantly Black Community in New York City

PURPOSE

This study examined the prevalence of mental health concerns and its association with COVID-19, selected social determinants of health, and psychosocial risk factors in a predominantly racial/ethnic minoritized neighborhood in New York City.

METHODS

Adult Harlem residents (N = 393) completed an online cross-sectional survey from April to September 2021. The Patient Health Questionnaire (PHQ-4) and the Post-Traumatic Stress Disorder (PC-PTSD) were used to evaluate mental health concerns. Poisson regression with robust variance quantified the associations of interests via prevalence ratios (PR) and 95% confidence intervals (CI).

RESULTS

Two-thirds (66.4%) of the residents reported experiencing mental health concerns, including PTSD (25.7%), depression (41.2%), and anxiety (48.1%). Residents with low-income housing status (PR = 1.16; 95% CI 1.01, 1.34), alcohol misuse (PR = 1.68; 95% CI 1.40, 2.01), food insecurity (PR = 1.23; 95% CI 1.07, 1.42), exposure to interpersonal violence (PR = 1.33; 95% CI 1.08, 2.65), and experience of discrimination (PR = 1.53, 95% CI 1.23-1.92) were more likely to report mental health concerns. Better community perception of the police (PR = 0.97, 95% CI 0.95, 0.99) was associated with fewer mental health concerns. No associations were observed for employment insecurity, housing insecurity, or household COVID-19 positivity with mental health concerns.

CONCLUSIONS

This study showed a high prevalence of mental health concerns in a low-income racial/ethnic minoritized community, where COVID-19 and social risk factors compounded these concerns. Harlem residents face mental health risks including increased financial precarity, interpersonal violence, and discrimination exposure. Interventions are needed to address these concurrent mental health and psychosocial risk factors, particularly in racial/ethnic minoritized residents.

Substance Use Patterns and Their Association with Depression and Social Factors During COVID-19 Among Harlem Residents in New York City

This study aimed to identify the prevalence of substance use before and during COVID-19; and examined its association with depression and social factors among 437 residents from the neighborhood of Harlem in Northern Manhattan, New York City. Over a third of respondents reported using any substance before COVID-19, and initiating/increasing substance use during COVID-19. The most common substances used before COVID-19 and initiated/increased during COVID-19 were smoking (20.8% vs. 18.3%), marijuana (18.8% vs. 15.3%), and vaping (14.2% and 11.4%). The percentages of any hard drug use were 7.3% and 3.4%, respectively. After adjustment, residents with mild (Prevalence Ratio [PR] = 2.86, 95% CI 1.65, 4.92) and moderate (PR = 3.21, 95% CI 1.86, 5.56) symptoms of depression, and housing insecurity (PR = 1.47, 95% CI 1.12, 1.91) had at least a 47% greater probability of initiating and/or increasing substance use. Conversely, respondents with employment insecurity (PR = 0.71, 95% CI 0.57, 0.88) were 29% less likely to report such patterns. No association was found between substance use initiation and/or increase and food insecurity. High prevalence of substance use during COVID-19 may lead residents to turn to substance use as a coping mechanism for psychosocial stressors. Thus, it is essential to provide accessible and culturally sensitive mental health and substance use services.

Alcohol Misuse, Binge Drinking, and their Associations with Psychosocial Factors during COVID-19 among Harlem Residents in New York City

This study examined alcohol misuse and binge drinking prevalence among Harlem residents, in New York City, and their associations with psycho-social factors such as substance use, depression symptom severity, and perception of community policing during COVID-19. An online cross-sectional study was conducted among 398 adult residents between April and September 2021. Participants with a score of at least 3 for females or at least 4 for males out of 12 on the Alcohol Use Disorders Identification Test were considered to have alcohol misuse. Binge drinking was defined as self-reporting having six or more drinks on one occasion. Modified Poisson regression models were used to examine associations. Results showed that 42.7% used alcohol before COVID-19, 69.1% used it during COVID-19, with 39% initiating or increasing alcohol use during COVID-19. Alcohol misuse and binge drinking prevalence during COVID-19 were 52.3% and 57.0%, respectively. Higher severity of depression symptomatology, history of drug use and smoking cigarettes, and experiencing housing insecurity were positively associated with both alcohol misuse and binge drinking. Lower satisfaction with community policing was only associated with alcohol misuse, while no significant associations were found between employment insecurity and food insecurity with alcohol misuse or binge drinking. The findings suggest that Harlem residents may have resorted to alcohol use as a coping mechanism to deal with the impacts of depression and social stressors during COVID-19. To mitigate alcohol misuse, improving access to mental health and substance use disorder services, and addressing public safety through improving relations with police could be beneficial.

Implementation of a Community-Partnered Research Suicide-Risk Management Protocol: Case Study From Community Partners in Care

OBJECTIVE

Suicidality is common among participants in clinical trials and health services research, but approaches to suicide risk assessment and mitigation vary widely. Studies involving vulnerable populations with limited access to care raise additional ethical concerns. The authors applied a community-partnered approach to develop and implement a suicide-risk management protocol (SRMP) in a depression study in an underresourced setting in Los Angeles.

METHODS

Using a community-partnered participatory research framework, the authors designed and adapted the SRMP. Qualitative data regarding SRMP implementation included notes from SRMP development meetings and from study clinicians conducting outreach calls to study participants. Analyses included baseline and 6- and 12-month telephone survey data from 1,018 enrolled adults with moderate to severe depressive symptoms (8-item Patient Health Questionnaire score ≥10), of whom 48% were Black and 40% Latino.

RESULTS

Community stakeholders prioritized a robust SRMP to ensure participant safety. Features included rapid telephone outreach by study clinicians in all cases of reported recent suicidality and expedited treatment access. Using a suicidality timeframe prompt of "in the past 2 weeks," endorsement of suicidality was common (15% at baseline, 32% cumulative). Midway through the study, the SRMP was modified to assess for present suicidality, which reduced the frequency of clinician involvement. Overall, 318 outreach calls were placed, with none requiring an emergency response. Treatment referrals were provided in 157 calls, and outreach was well received.

CONCLUSIONS

SRMP implementation in research involving underresourced and vulnerable communities merits additional considerations. Partnering with community stakeholders can facilitate the development of acceptable and feasible SRMP procedures.

Adolescents' family obligation and activities in rural and urban Vietnam: Implications for social change

This study examined how urbanisation may modify adolescents' values and activities concerning family obligation by surveying 572 adolescents (M_age  = 15.75, SD = .73) in rural and urban Vietnam. Compared with their rural peers, urban adolescents reported a stronger sense of family obligation but spent less time actually engaging in family assistance, findings that were partly explained by urban households' less financial hardship and higher parental education levels. As expected, stronger family obligation values were associated with greater family assistance activities across rural and urban Vietnam. However, stronger family obligation values were associated with more study hours only in urban Vietnam, indicating that urbanisation may broaden the meaning of family obligation to encompass the academic domain. Additionally, weaker family obligation values were associated with more employment hours only in rural Vietnam, suggesting that rural adolescents with little attachment to the traditional value of family obligation may pursue autonomy through employment outside the home. In traditionally familistic societies undergoing urbanisation, family obligation may take on different meaning depending on adolescents' ecological settings that construct cultural values and behavioural norms.

Effects of Family Obligation Values and Autonomy Support on Internalizing Symptoms of Vietnamese-American and European-American Adolescents

OBJECTIVES

Although negotiation of family relatedness and personal autonomy is a key developmental task of adolescence, what is most adaptive for adolescents may vary across cultures. The purpose of the present study was to examine whether relations between family obligation values and adolescent internalizing symptoms may vary as a function of the level of parental autonomy support perceived by the adolescent, and to assess the extent to which such associations vary by ethnic group.

METHODS

The study included 614 adolescents (Mean age = 15.57 years, 50% male) from Vietnamese-American (55%) and European-American (45%) backgrounds. Adolescents reported their: (a) family obligation values to (a1) respect, (a2) provide current assistance, and (a3) provide future support to the family, (b) perceived maternal and paternal autonomy support, and (c) internalizing symptoms.

RESULTS

Effects of family obligation values differed across the three subdomains as a function of maternal autonomy support and ethnic group. Family obligation values to respect the family (a1, above) were related to lower levels of internalizing symptoms for both Vietnamese- and European-American adolescents who received high levels of maternal autonomy support. Ethnic differences emerged such that only among Vietnamese-American adolescents, there was a negative relation between current assistance values (a2, above) and internalizing symptoms among adolescents with high maternal autonomy support.

CONCLUSIONS

Overall, findings highlight the importance for parents to nurture adolescents' family obligation values while also promoting their autonomy development.

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.

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.

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 Community-Partnered, Participatory, Cluster-Randomized Study of Depression Care Quality Improvement: Three-Year Outcomes

OBJECTIVE

Community Partners in Care, a community-partnered, cluster-randomized trial with depressed clients from 93 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]) for implementing depression quality improvement in underserved communities. CEP was more effective than RS in improving mental health-related quality of life, reducing behavioral health hospitalizations, and shifting services toward community-based programs at six months. At 12 months, continued evidence of improvement was found. This study examined three-year outcomes.

METHODS

Among 1,004 participants with depression who were eligible for three-year follow-up, 600 participants from 89 programs completed surveys. Multiple regression analyses estimated intervention effects on poor mental health-related quality of life and depression, physical health-related quality of life, behavioral health hospital nights, and use of services.

RESULTS

At three years, no differences were found in the effects of CEP versus RS on depression or mental health-related quality of life, but CEP had modest effects in improving physical health-related quality of life and reducing behavioral health hospital nights, and CEP participants had more social- and community-sector depression visits and greater use of mood stabilizers. Sensitivity analyses with longitudinal modeling reproduced these findings but found no significant differences between groups in change from baseline to three years.

CONCLUSIONS

At three years, CEP and RS did not have differential effects on primary mental health outcomes, but CEP participants had modest improvements in physical health and fewer behavioral health hospital nights.

Comparative Effectiveness of Two Models of Depression Services Quality Improvement in Health and Community Sectors

OBJECTIVE

The effectiveness of community coalition building and program technical assistance was compared in implementation of collaborative care for depression among health care and community sector clients.

METHODS

In under-resourced communities, within 93 programs randomly assigned to coalition building (Community Engagement and Planning) or program technical assistance (Resources for Services) models, 1,018 clients completed surveys at baseline and at six, 12, or 36 months. Regression analysis was used to estimate intervention effects and intervention-by-sector interaction effects on depression, mental health-related quality of life, and community-prioritized outcomes and on services use.

RESULTS

For outcomes, there were few significant intervention-by-sector interactions, and stratified findings suggested benefits of coalition building in both sectors. For services use, at 36 months, increases were found for coalition building in primary care visits, self-help visits, and appropriate treatment for community clients and in community-based services use for health care clients.

CONCLUSIONS

Relative to program technical assistance, community coalition building benefited clients across sectors and shifted long-term utilization across sectors.

Effects of Depression Alleviation on Work Productivity and Income Among HIV Patients in Uganda

PURPOSE

Depression is common among people living with HIV, and it is associated with impaired work functioning. However, little research has examined whether depression alleviation improves work-related outcomes in this population, which is the focus of this analysis.

METHOD

A sample of 1028 depressed HIV clients in Uganda enrolled in a comparative trial of depression care models and were surveyed over 12 months. Serial regression analyses examined whether depression alleviation (measured by the nine-item Patient Health Questionnaire) was associated with change in self-reported weekly amount of hours worked and income earned, and whether these relationships were mediated by change in work-related self-efficacy.

RESULTS

Among those with major depression, depression alleviation was associated with nearly a doubling of weekly hours worked in bivariate analysis. The relationship between depression alleviation and hours worked was partially mediated by change in work self-efficacy among those with major depression, as well as those with minor depression, in multivariate regression analysis that controlled for demographic and health covariates. Depression alleviation was not significantly associated with change in weekly income.

CONCLUSION

These findings suggest that depression alleviation benefits work functioning at least in part through improved confidence to engage in work-related activities. Integration of depression care services into HIV care may be important for improving the economic well-being of people living with HIV.

Effects of Depression Alleviation on ART Adherence and HIV Clinic Attendance in Uganda, and the Mediating Roles of Self-Efficacy and Motivation

With depression known to impede HIV care adherence and retention, we examined whether depression alleviation improves these disease management behaviors. A sample of 1028 depressed HIV clients in Uganda enrolled in a cluster randomized controlled trial of two depression care models, and were surveyed over 12 months. Serial regression analyses examined whether depression alleviation was associated with self-reported antiretroviral therapy (ART) adherence and clinic attendance at month 12, and whether these relationships were mediated by self-efficacy and motivation. Among those with major depression, depression alleviation was associated with better ART adherence and clinic attendance at month 12; these relationships were fully mediated by self-efficacy at month 12, while adherence motivation partially mediated the relationship between depression alleviation and ART adherence. When both mediators were entered simultaneously, only self-efficacy was a significant predictor and still fully mediated the relationship between depression alleviation and adherence. These findings suggest that depression alleviation benefits both ART adherence and clinic attendance, in large part through improved confidence and motivation to engage in these disease management behaviors.

A Psychometric Study of the Modified Bridges for Newborns Screening Tool

Welcome Baby, a program that First 5 Los Angeles (First 5 LA) sponsors, provides new mothers with supportive services intended to create enriching environments for their children. To identify mothers in need of these services, First 5 LA employs hospital liaisons who administer a maternal risk assessment tool, the Modified Bridges for Newborns screening tool, during postpartum interviews of mothers. First 5 LA uses risk assessment scores from the Modified Bridges to classify mothers as low, moderate, or high risk; high-risk mothers are eligible for additional supportive services that are not available to low- and moderate-risk mothers. This article describes RAND Corporation work evaluating the psychometric characteristics of the Modified Bridges.

Community Engagement Compared With Technical Assistance to Disseminate Depression Care Among Low-Income, Minority Women: A Randomized Controlled Effectiveness Study

OBJECTIVES

To compare the effectiveness of a (CEP) versus a technical assistance approach (Resources for Services, or RS) to disseminate depression care for low-income ethnic minority women.

METHODS

We conducted secondary analyses of intervention effects for largely low-income, minority women subsample (n = 595; 45.1% Latino and 45.4% African American) in a matched, clustered, randomized control trial conducted in 2 low-resource communities in Los Angeles, California, between 2010 and 2012. Outcomes assessed included mental health, socioeconomic factors, and service use at 6- and 12-month follow-up.

RESULTS

Although we found no intervention difference for depressive symptoms, there were statistically significant effects for mental health quality of life, resiliency, homelessness risk, and financial difficulties at 6 months, as well as missed work days, self-efficacy, and care barriers at 12 months favoring CEP relative to RS. CEP increased use of outpatient substance abuse services and faith-based depression visits at 6 months.

CONCLUSIONS

Engaging health care and social community programs may offer modest improvements on key functional and socioeconomic outcomes, reduce care barriers, and increase engagement in alternative depression services for low-income, predominantly ethnic minority women.

Linkages between mental health need and help-seeking behavior among adolescents: Moderating role of ethnicity and cultural values

Risk of developing emotional and behavioral mental health problems increases markedly during adolescence. Despite this increasing need, most adolescents, particularly ethnic minority youth, do not seek professional help. Informed by conceptual models of health behavior, the current study examined how cultural values are related to help seeking among adolescents from 2 distinct racial/ethnic groups. Using a prospective survey design, 169 Vietnamese American and European American youth in 10th and 11th grade reported on their mental health need, as measured by emotional/behavioral mental health symptoms and stressful life events, with participants reporting on their help-seeking behavior at 6-month follow-up assessments. Multinomial logistic regression analyses indicated that mental health need interacted with cultural values and ethnicity to predict help-seeking behavior. Specifically, associations between symptoms and stressful life events, and help-seeking behavior were smaller among Vietnamese American adolescents, and among adolescents with strong family obligation values. These results underscore the complex sociocultural factors influencing adolescents' help-seeking behavior, which have important implications for engaging youth in needed mental health care.

Participation in Training for Depression Care Quality Improvement: A Randomized Trial of Community Engagement or Technical Support

OBJECTIVE

Community engagement and planning (CEP) could improve dissemination of depression care quality improvement in underresourced communities, but whether its effects on provider training participation differ from those of standard technical assistance, or resources for services (RS), is unknown. This study compared program- and staff-level participation in depression care quality improvement training among programs enrolled in CEP, which trained networks of health care and social-community agencies jointly, and RS, which provided technical support to individual programs.

METHODS

Matched programs from health care and social-community service sectors in two communities were randomly assigned to RS or CEP. Data were from 1,622 eligible staff members from 95 enrolled programs. Primary outcomes were any staff trained (for programs) and total hours of training (for staff). Secondary staff-level outcomes were hours of training in specific depression collaborative care components.

RESULTS

CEP programs were more likely than RS programs to participate in any training (p=.006). Within health care sectors, CEP programs were more likely than RS programs to participate in training (p=.016), but within social-community sectors, there was no difference in training by intervention. Among staff who participated in training, mean training hours were greater among CEP programs versus RS programs for any type of training (p<.001) and for training related to each component of depression care (p<.001) except medication management.

CONCLUSIONS

CEP may be an effective strategy to promote staff participation in depression care improvement efforts in underresourced communities.

Qualitative study of the influence of antidepressants on the psychological health of patients on antiretroviral therapy in Uganda

The study set out to explore how HIV-positive individuals conceptualise and describe depression and its manifestation in their lives, and how this may change over time in the context of antiretroviral therapy (ART) and antidepressant treatment. We conducted in-depth interviews using a semi-structured interview guide with 26 adult HIV-positive clients receiving ART in Uganda. We asked the participants to describe their depression and its impact on their general health, physical functioning and psychological wellbeing, as well as the influences of receiving ART or antidepressant treatment. Although depressive experience among the patients was largely described in terms of criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), some of the symptoms used to describe depression, such as 'thinking too much' or worrisome thoughts, did not fit into the DSM-IV criteria. The participants attributed their depression to news of the HIV diagnosis, a fear of dying, the potential socioeconomic consequences of their HIV infection on their family, ART side-effects and continued bad health. Their subjective reports indicated that the treatment of depression with antidepressants had made a positive impact on their general and psychological health. These findings highlight the need for models of HIV care that integrate mental health services and promote the diagnosis and treatment of depression in culturally sensitive ways so as to improve the quality of life and health outcomes for clients. However, keeping the particular study design in mind, these findings should be interpreted as preliminary.

Effectiveness of antidepressants and predictors of treatment response for depressed HIV patients in Uganda

Antidepressant medication is well established for the treatment of depression but little is known about its effectiveness for HIV populations in sub-Saharan Africa. This study examined the effectiveness of antidepressant treatment and predictors of treatment response among depressed HIV patients in Uganda. Data were obtained from two open-label trials in which 184 HIV patients were diagnosed with depression and started on antidepressants. Data at treatment baseline and month 6 were compared to assess treatment response, and baseline predictors of response were assessed. A total of 154 completed month 6, of whom 122 (79%) had responded to treatment and were no longer depressed (Patient Health Questionnaire-9, score < 5). Bivariate analysis found that education, CD4 count, general health functioning, physical health, pain, quality of life and social support variables were associated with antidepressant treatment response; however, only secondary education and social support independently predicted treatment response in logistic multiple regression analysis. Baseline depression severity was not associated with treatment response. In conclusion, antidepressants are effective in treating both moderate and more severe depression among persons living with HIV in Uganda, and education [OR (95% CI) = 4.33 (1.33-14.11)] and social support [OR (95% CI) = 1.54 (1.03-2.30)] were most predictive of treatment response.

Test of "Facilitation" vs. "Proximal Process" Moderator Models for the Effects of Multisystemic Therapy on Adolescents with Severe Conduct Problem

The present study identified moderators of Multisystemic Therapy's (MST) effects on adolescent conduct problems, considering facilitation and proximal process moderation models. The sample included 164 adolescents (mean age = 14.6 years; 83% male) randomly assigned to receive MST or services as usual; parent, youth, and teacher reports of adolescent functioning were obtained. A number of significant moderators were identified. Proximal process moderation patterns were identified (e.g., families with parents with lower levels of adaptive child discipline skills gained more from MST), but the majority of significant interactions showed a facilitation moderation pattern with, for instance, higher levels of adaptive functioning in families and parents appearing to facilitate MST (i.e., greater benefits from MST were found for these families). This facilitation pattern may reflect such families being more capable of and/or more motivated to use the resources provided by MST. It is suggested that factors consistently identified as facilitation moderators may serve as useful foci for MST's strength-based levers of change approach. Other implications of these findings for individualized treatment also are discussed.

The Vietnam Multicomponent Collaborative Care for Depression Program: Development of Depression Care for Low- and Middle-Income Nations

In this article, we discuss the Vietnam Multicomponent Collaborative Care for Depression Program, which was designed to provide evidence-based depression care services in low-resource, non-Western settings such as Vietnam. The article provides the program development background; the social, economic, and political context in which the program was developed; and the structure and content of the program and their underlying rationale in the context of rural Vietnam. Although the program was found to be acceptable, feasible, and effective in reducing depression outcomes, we did face challenges in implementation, which are outlined in this article. Key challenges included cultural factors (e.g., a lack of recognition of depression as a health-related entity amenable to professional treatment, relatively low levels of psychological mindedness useful for understanding of psychological interventions) and health system (e.g., lack of mental health specialists, overburdened health providers unfamiliar with behavioral interventions) factors. We discuss the strategies we employed to resolve these challenges and our successes and failures therein. We conclude with recommendations for others interested in implementing similar programs in low- and middle-income countries settings.

Impact of antidepressant therapy on cognitive aspects of work, condom use, and psychosocial well-being among HIV clients in Uganda

OBJECTIVE

Depression has been found to impede several health outcomes among people living with HIV, but little research has examined whether depression treatment mitigates this influence. We assessed the impact of antidepressant therapy on measures of work, condom use, and psychosocial well-being among depressed HIV clients in Uganda.

METHODS

Paired t-tests and McNemar tests were used to assess change in survey data collected from participants at initiation of antidepressant therapy (baseline) and 6 months later.

RESULTS

Ninety-five participants completed the 6-month assessment, of whom 82 (86%) responded to treatment (defined as Patient Health Questionnaire-9 score < 5). Among study completers, work functioning improved significantly, as did measures of self-efficacy related to condom use and work (as well as general self-efficacy), and internalized HIV stigma declined; however, actual engagement in work activity and consistent condom use did not show significant change. Similar findings were observed among treatment responders.

CONCLUSIONS

Antidepressant treatment benefits functional capacity, psychological well-being, and cognitive intermediary factors that may be essential for behavioral change related to work and condom use, but supplementary therapeutic strategies may be needed to impact more direct behavioral change.

An independent randomized clinical trial of multisystemic therapy with non-court-referred adolescents with serious conduct problems

OBJECTIVE

Adolescent conduct problems exact serious social as well as personal costs, and effective treatments are essential. One of the most widely disseminated and effective programs for the treatment of serious conduct problems in adolescents is Multisystemic Therapy (MST). However, most evaluations of MST have involved the developers of MST. The purpose of the present study was to conduct an independent evaluation of MST, with non-court-referred adolescents with conduct problems.

METHOD

Participants were 164 adolescents ages 11-18 years who were recruited from self-contained behavior intervention classrooms in public schools. Adolescents and their families were randomly assigned to receive MST or services as usual. Outcome measures assessed conduct problems, school functioning, and court records of criminal behavior. Participants were followed for 18 months after baseline using parent, adolescent, and teacher reports; arrest data were collected for 2.5 years postbaseline.

RESULTS

Two of 4 primary outcome measures focused on externalizing problems showed significant treatment effects favoring MST. Several secondary and intervention targets pertaining to family functioning and parent psychopathology showed positive effects of MST, and no negative effects were identified.

CONCLUSIONS

Results provide some further support for the effectiveness of MST, although smaller effect sizes than previous studies also suggest the complexity of successful dissemination, particularly to non-court-referred populations.

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.

A qualitative analysis of the effects of depression and antidepressants on physical and work functioning among antiretroviral therapy clients in Uganda

Depression is common among people living with HIV/AIDS in sub-Saharan Africa. Yet, little is known about how depression influences physical health and socioeconomic well-being in the context of antiretroviral therapy (ART). Semistructured interviews with 40 adult HIV clients receiving ART in Uganda were conducted to assess experiences prior to and after HIV diagnosis and initiation of ART. Content analysis revealed themes that were suggestive of the following patterns: (1) functioning decreased after patients were diagnosed with HIV, but improved following ART, (2) depression is associated with lower physical health functioning and work status levels after both HIV diagnosis and ART, and (3) antidepressant medication is associated with better functioning compared with patients with depression not receiving depression treatment. These findings suggest that depression plays a role in the deleterious effects of HIV on functioning, and that antidepressant treatment provided alongside ART may serve to help individuals regain functioning, particularly employment. These findings highlight the potential value of integrating depression treatment into HIV care.

Grand challenges: Integrating mental health care into the non-communicable disease agenda

In the third article of a five-part series providing a global perspective on integrating mental health, Victoria Ngo and colleagues discuss the benefits and requirements of collaborative care models, where non-communicable disease and mental health care are integrated and provided in the primary care setting. Please see later in the article for the Editors' Summary

Partnered evaluation of a community engagement intervention: use of a kickoff conference in a randomized trial for depression care improvement in underserved communities

Community partnered research and engagement strategies are gaining recognition as innovative approaches to improving health care systems and reducing health disparities in underserved communities. These strategies may have particular relevance for mental health interventions in low income, minority communities in which there often is stigma and silence surrounding conditions such as depression and difficulty in implementing improved access and quality of care. At the same time, there is a relative dearth of evidence on the effectiveness of specific community engagement interventions and on the design, process, and context of these interventions necessary for understanding their implementation and generalizability. This article evaluates one of a number of community engagement strategies employed in the Community Partners in Care (CPIC) study, the first randomized controlled trial of the role of community engagement in adapting and implementing evidence-based depression care. We specifically describe the unique goals and features of a community engagement kickoff conference as used in CPIC and provide evidence on the effectiveness of this type of intervention by analyzing its impact on: 1) stimulating a dialog sense of collective efficacy, and opportunities for learning and networking to address depression and depression care in the community; 2) activating interest and participation in CPIC's randomized trial of two different ways to implement evidence-based quality improvement programs for depression across diverse community agencies; and 3) introducing evidence-based toolkits and collaborative care models to potential participants in both intervention conditions and other community members. We evaluated the effectiveness of the conference through a community-partnered process in which both community and academic project members were involved in study design, data collection and analysis. Data sources include participant conference evaluation forms (n = 187 over two conferences; response rate 59%) and qualitative observation field notes of each conference session. Mixed methods for the analysis consist of descriptive statistics of conference evaluation form ratings, as well as thematic analysis of evaluation form write-in comments and qualitative observation notes. Results indicate the effectiveness of this type of event for each of the three main goals, and provide insights into intervention implementation and use of similar community engagement strategies for other studies.

Building capacity for cognitive behavioral therapy delivery for depression in disaster-impacted contexts

Numerous challenges exist in implementing evidence-based practices, such as cognitive behavioral therapy, in resource poor, ethnic minority, and/or disaster-affected communities with disparities in mental health. Community-academic participatory partnerships are a promising approach to addressing disparities by implementing community-appropriate, evidence-based depression care. A community-academic collaborative was formed in New Orleans after Hurricane Katrina to expand resources for effective depression care, including cognitive behavioral therapy. In this article, we: 1) describe our model of building capacity to deliver cognitive behavioral therapy for depression in post-disaster community-based settings; 2) discuss the impact of this training program on therapist reported practice; and 3) share lessons learned regarding disseminating and sustaining evidence-based interventions in the context of a disaster impacted community. Using a mixed methods approach, we found that this model was feasible, acceptable, and disseminated knowledge about cognitive behavioral therapy in community settings. Over the course of two years, community providers demonstrated the feasibility of implementing evidence-based practice and potential for local community leadership. The lessons learned from this model of implementation may help address barriers to disseminating evidence-based interventions in other low-resource, disaster-impacted community settings.

Outcomes for youths from racial-ethnic minority groups in a quality improvement intervention for depression treatment

OBJECTIVE

This study examined racial-ethnic differences in the impact of the Youth Partners in Care quality improvement intervention. The intervention was designed to improve access to evidence-based depression care, primarily cognitive-behavioral therapy and medication, through primary care. Previous analyses have shown that the quality improvement intervention was associated with improved depression and quality-of-life outcomes at the end of the six-month intervention period.

METHODS

A randomized controlled trial comparing quality improvement and usual care for youths from diverse racial-ethnic groups from five health care organizations, including managed care, the public sector, and academic center clinics, was conducted. Depressed youths (N=325), who self-identified as black (N=59), Latino (N=224), and white (N=42), aged 13-21 years, were included in these analyses. To evaluate intervention effects within racial-ethnic groups, regression models were constructed, which adjusted for baseline and study site variation in depression symptoms, mental health status, satisfaction with mental health care, and mental health service utilization.

RESULTS

Differential intervention effects were found across racial-ethnic groups. Black youths in the intervention group experienced significant reductions in depression symptoms and had higher rates of use of specialty mental health care at the six-month follow-up. Among Latino youths, the intervention was associated with significantly greater satisfaction with care. Intervention effects were weak among white youths.

CONCLUSIONS

Quality improvement interventions may help to reduce disparities in mental health care for youths from racial-ethnic minority groups. (

Outcomes for youths from racial-ethnic minority groups in a quality improvement intervention for depression treatment

OBJECTIVE

This study examined racial-ethnic differences in the impact of the Youth Partners in Care quality improvement intervention. The intervention was designed to improve access to evidence-based depression care, primarily cognitive-behavioral therapy and medication, through primary care. Previous analyses have shown that the quality improvement intervention was associated with improved depression and quality-of-life outcomes at the end of the six-month intervention period.

METHODS

A randomized controlled trial comparing quality improvement and usual care for youths from diverse racial-ethnic groups from five health care organizations, including managed care, the public sector, and academic center clinics, was conducted. Depressed youths (N=325), who self-identified as black (N=59), Latino (N=224), and white (N=42), aged 13-21 years, were included in these analyses. To evaluate intervention effects within racial-ethnic groups, regression models were constructed, which adjusted for baseline and study site variation in depression symptoms, mental health status, satisfaction with mental health care, and mental health service utilization.

RESULTS

Differential intervention effects were found across racial-ethnic groups. Black youths in the intervention group experienced significant reductions in depression symptoms and had higher rates of use of specialty mental health care at the six-month follow-up. Among Latino youths, the intervention was associated with significantly greater satisfaction with care. Intervention effects were weak among white youths.

CONCLUSIONS

Quality improvement interventions may help to reduce disparities in mental health care for youths from racial-ethnic minority groups. (