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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.

Objective

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

Study Design

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.