Comparing Long-Term Outcomes of Two Collaborative Care Approaches for People with Depression

This project has results

Abstracts

Public Abstract

Download this abstract: English (pdf) | Español (pdf) | Audio Recording (mp3)

What was the research about?

Depression is a health problem that causes people to feel sad and hopeless and to have low energy. People usually get treatment in healthcare settings, such as clinics. In communities with few resources, people may also get help in community settings, such as social services agencies or churches. Collaborative care approaches bring together healthcare and community programs to help people with depression.

In an earlier study, researchers compared two collaborative care approaches:

  • Coalition. In this approach, the research team invited healthcare and community program leaders to two-hour planning meetings twice a month for four months. With the help of the coalition, the leaders customized treatment resources to their community’s culture and trained program staff. The coalition gave trainings through conferences, webinars, and site visits. Training topics included depression therapy and care management. The coalition also shared online and written resources.
  • Technical assistance or TA. In this approach, a team of experts offered program staff 12 online trainings on topics such as team building and depression therapy. The experts also visited primary care groups to talk about how to treat depression. They shared online and written resources.

After one year, the coalition approach led to more improvement in people’s mental health quality of life and fewer nights in the hospital than the TA approach.

In this study, the research team compared the two approaches for three years.

What were the results?

After three years, the two approaches didn’t differ in people’s depression or mental health quality of life. Compared with people in programs assigned to the TA approach, people in programs assigned to the coalition approach

  • Showed more improvement in physical health quality of life
  • Averaged fewer nights in the hospital for mental health problems

Who was in the study?

The study included 980 adults with depression who completed the first survey for the earlier study. Of these, 46 percent were African American, 41 percent were Latino, and 9 percent were white. The average age was 45, and 58 percent were women. In addition, 74 percent of the people had incomes below the poverty line. Also, 54 percent were homeless or at risk for long-term homelessness. All people in the study attended a healthcare or community program. They lived in South Los Angeles and Hollywood-Metro Los Angeles.

What did the research team do?

In the earlier study, researchers assigned healthcare and community programs to one of the two collaborative care approaches by chance. Then, the team recruited people with depression who were receiving services from these programs.

In this study, the research team looked at people who completed surveys at the start of the study and three years later. People who have depression and other community members worked with the research team to design and carry out the study and suggest topics for future studies.

What were the limits of the study?

The study took place in two mostly African American and Latino communities in the Los Angeles area. Results may differ in other areas. Because many people in the study were homeless, the team couldn’t reach everyone to give them the final survey. Results may be different if everyone took the survey.

Future research could look at how to support coalition approaches over time.

How can people use the results?

Healthcare and community programs can use the results to help people with depression living in communities with few resources.

Professional Abstract

Objective

To compare the long-term effectiveness of two collaborative care interventions for adults with depression in underresourced communities

Study Design

Design Elements Description
Design Randomized controlled trial
Population 980 people with depression from 89 mental health service programs in Los Angeles County
Interventions/
Comparators
  • Community Engagement and Planning
  • Resources for Services
Outcomes

Primary: depression and mental health-related quality of life

Secondary: physical health-related quality of life, behavioral health-related hospitalization nights
Timeframe 3-year follow-up for primary outcomes

This extension study of a randomized controlled trial examined the long-term outcomes of two interventions to enhance collaborative care for adults with depression in healthcare and other community service settings. The study included community sites such as primary care clinics, agencies specializing in mental health and substance use disorder, social services agencies, faith-based groups, and community centers in the South Los Angeles and Hollywood-Metro Los Angeles communities.

In the previous study, the research team randomly assigned healthcare and community programs to one of two interventions and recruited adults with depression who received services from these programs. The two interventions were

  • Community Engagement and Planning, or coalition approach. Programs formed local coalitions, co-chaired by study and community leaders. Each coalition invited program administrators to two-hour meetings bimonthly for four months to plan how to disseminate intervention resources across the diverse programs in this intervention. Adapting resources to local culture, the coalition provided trainings to program staff through online and written resources, conferences, webinars, and site visits.
  • Resources for Services, or technical assistance approach. An expert, interdisciplinary team provided technical assistance to individual programs through webinars, site visits, and online and written resources. This team offered programs 12 webinars using a train-the-trainer model, with site visits for primary care providers. Topics included team building, case management, and clinical assessment and treatments.

The previous study found that the coalition approach was more effective than the technical assistance approach in improving mental health-related quality of life and reducing behavioral health hospitalizations at 6 and 12 months.

In this extension study, the research team compared the study outcomes for people in the two interventions at baseline and three years. The study included 980 clients with baseline surveys and 600 with three-year surveys. All clients were receiving services from 89 programs. Of these clients, 46% were African American, 41% were Latino, and 9% were white. The average age of participants at baseline was 45, and 58% were female. In addition, 74% of participants had incomes below the poverty line, and 54% were homeless or had two or more risk factors for chronic homelessness.

People who have depression and other community members worked with researchers to design and conduct the study and prioritize outcomes for future research.

Results

At three years, compared with people in programs assigned to the technical assistance approach, those in programs assigned to the coalition approach did not differ in depression or mental health quality of life. However, people in the coalition approach had improved physical health-related quality of life (difference in scores=1.2; 95% confidence interval [CI]: 0.2, 2.2) and fewer behavioral health-related hospitalization nights (incidence rate ratio=0.2; 95% CI: 0.1, 0.8) (both p<0.05).

Limitations

The study took place in two underresourced, mostly African American and Latino communities in Los Angeles County. Results may be different in other areas or with different populations. Many people in the study were homeless. As a result, the research team had difficulty contacting them for follow-up surveys, which limited response rates.

Conclusions and Relevance

Collaborative care approaches for depression show promise in improving the quality of health care in underresourced communities. In this extension study, the two collaborative care approaches did not differ in primary mental health outcomes at three years, but the coalition approach was more effective in improving physical health-related quality of life and reducing behavioral health-related hospitalization nights.

Future Research Needs

Future research could explore efforts to maintain long-term effects of collaborative care approaches on mental health outcomes and other outcomes important to adults with depression, such as physical health-related quality of life.

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments. 

Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:

  • Reviewers noted many places where the language of the draft report needed clarification. The researchers made the requested changes but noted that the complexity of the study and the need to explain the parent study of the PCORI-funded study meant that descriptions were lengthy.
  • Reviewers noted that the researchers did not measure how faithfully the intervention was actually implemented, which is a major limitation of the study. The researchers responded by describing how they measured how well the implementation of the interventions went.

Final Research Report

View this projects final research report.

Conflict of Interest Disclosures

View the COI disclosure form.

Journal Articles

Results of This Project

Psychiatric Services

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

Psychiatric Services

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

Psychiatric Services

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

Related Articles

Ethnicity & Disease

Stakeholder Perspectives on the Social Determinants of Mental Health in Community Coalitions

Ethnicity & Disease

Whole Person Care in Under-resourced Communities: Stakeholder Priorities at Long-Term Follow-Up in Community Partners in Care

Western Journal of Nursing Research

A Comparative Effectiveness Trial of Depression Collaborative Care: Subanalysis of Comorbid Anxiety

Health Promotion Practice

Sampling and Recruiting Community-Based Programs Using Community-Partnered Participation Research

Annals of Internal Medicine

12-month outcomes of community engagement versus technical assistance to implement depression collaborative care: a partnered, cluster, randomized, comparative effectiveness trial

Ces4Health.Info

Community Partners in Care (CPIC): Video Summary of Rationale, Study Approach / Implementation, and Client 6-month Outcomes

More on this Project  

PCORI Stories

Engaging Communities to Improve Depression Treatment
A coalition-based approach to care, bringing together clinicians and community members, helped people from low-income minority groups.

Fighting Depression with the Power of Community
Inner-city minority groups have reduced access to traditional treatment services for depression; a partnership in Los Angeles expands on existing community resources to improve access to evidence-based services in a community-wide strategy.

Project Details

Principal Investigator
Kenneth B. Wells, MD, MPH
Project Status
Completed; PCORI Public and Professional Abstracts Posted
Project Title
Long-Term Outcomes of Community Engagement to Address Depression Outcomes Disparities
Board Approval Date
December 2012
Project End Date
July 2018
Organization
University of California, Los Angeles
Year Awarded
2012
State
California
Year Completed
2018
Project Type
Research Project
Funding Announcement
Addressing Disparities
Conditions 
Mental/Behavioral Health
Depression
Project Budget
$2,342,615
DOI - Digital Object Identifier
10.25302/11.2018.CER.1845
Study Registration Information
HSRP20142268
NCT01699789
Page Last Updated: 
November 28, 2018