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May is National Mental Health Month. In recognition, this edition of our newsletter presents recent results from three RAND projects that also represent extensions of major, longer-term work in their respective areas—depression care, mental health care for servicemembers and veterans, and school-based interventions to help children cope with the effect of trauma.
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Improving Quality of Care for Depression in Primary Care Settings
Depression is a major cause of disability worldwide and imposes enormous costs on society each year in the form of high medical and drug bills and lost productivity. Yet research has consistently shown low rates of detection and quality of care for depression, especially in primary care settings, where patients are most likely to seek treatment. Rates are particularly low for members of underserved racial and ethnic minority groups. Partners in Care is a real-world trial examining whether primary care clinics can improve the quality of depression care and reduce disparities for minorities. A team of RAND researchers is conducting the first study to examine the long-term effects of quality improvement (QI) programs for depression in primary care. For the past nine years, the RAND team has followed more than 1,300 participants representing an ethnically diverse population—one-third are Latino, a group for whom depression treatment has rarely been studied. The interventions in this study were designed to help clinicians and patients make their own decisions about depression treatment, supported by the best available information. The interventions were available to patients for roughly one episode of depression, over a period of six to 12 months.
Over the first two years of follow-up, intervention patients had better depression outcomes, as well as greater employment, than patients receiving usual care. In addition, underserved minority patients improved more in their health outcomes under the intervention than did white patients, and by the five-year follow-up, disparities in outcomes for minorities in depression outcomes largely disappeared. The benefits of the intervention continued over the nearly full decade of follow-up for the whole study, especially for patients with access to evidence-based psychotherapy. The findings suggest that these QI programs improve care for all patients and that minority patients, especially, stand to benefit.
Improving Mental Health Care for Returning Veterans
Many of the 1.7 million military servicemembers who deployed to the conflicts in Iraq and Afghanistan may face mental health challenges. Invisible Wounds of War, a study conducted by RAND in 2008, found that an estimated 18.5 percent of returning veterans reported symptoms consistent with a diagnosis of post-traumatic stress disorder (PTSD) or depression. A large infusion of new funds into the Department of Defense (DoD) and Veterans Health Administration (VHA) in recent years has supported ongoing efforts to improve mental health care for veterans. However, many returning veterans also seek care in community settings as they rejoin civilian life. As part of the Invisible Wounds of War project, a RAND team published additional results identifying key challenges to the provision of mental health care that cut across community, VHA and DoD health care settings.
The study identified two major barriers to access. First, mental health specialty care for conditions such as PTSD and depression is not available in many parts of the country, especially rural areas. Second, many military servicemembers are reluctant to seek mental health care because of concerns that doing so may have negative career effects and because of skepticism about the effectiveness of treatment. The study also found gaps in the quality of care. In more than half of all cases, the treatment delivered did not meet recommended standards for care as supported by scientific evidence. This problem likely stems from the need for better training in evidence-based practices among the mental health specialty workforce. In addition, the study noted that organizational systems and tools that support quality improvement for mental health are not widely used in either the DoD or civilian health sectors.
To address these issues, the researchers suggest a coordinated national effort to improve care by expanding the availability of training for the treatment of combat-related mental disorders, promoting the development of health information and systems that support performance monitoring and quality improvement for mental health care, and providing technical assistance to states and communities to help them address veterans' mental health needs.
A Trauma Intervention for Students That School Personnel Can Deliver
Ten years ago, specialists from RAND, the Los Angeles Unified School District, and UCLA collaborated to develop the Cognitive-Behavioral Intervention for Trauma in Schools (CBITS). This school-based early intervention program aims to help the roughly one in four youngsters who are emotionally affected by exposure to violence, trauma, or maltreatment. Such experiences, whether caused by humans or nature, often manifest as learning difficulties and/or behavioral problems. CBITS can be used for diverse student groups, and its effectiveness is recognized by numerous national organizations. But the program is designed to be delivered by school mental health clinicians, putting it out of reach for many school budgets. With feedback from teachers, school counselors, clinicians, and national experts, the CBITS researchers adapted the program so that school personnel with no mental health training could deliver it. Called Support for Students Exposed to Trauma (SSET), the adaptation keeps the same cognitive-behavioral approach and group-session structure as CBITS, but the clinical aspects have been modified. SSET, for example, is based on the familiar lesson-plan format. Results from a two-year pilot test of SSET in two Los Angeles middle schools show that the program can be implemented successfully by teachers and school counselors to address violence-related post-traumatic stress disorder and depression, especially in low-income, urban students. Overall, students showed small reductions in trauma symptoms, with those having a high level of symptoms before taking SSET benefitting the most. Both students and parents reported good to high satisfaction with the program. Teachers reported small improvements in student behavior, but parents did not.
Given the promising pilot test results, a larger evaluation of SSET effectiveness is warranted. Until that time, the impact of this intervention is not fully known, but it does show promise. Schools interested in conducting SSET have access to the program manual (in press) as well as training resources.
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RESEARCHER PROFILE
Kenneth B. Wells
Kenneth B. Wells MD, MPH, is Senior Scientist at RAND; Professor-in-Residence of Psychiatry and Biobehavioral Sciences and of Health Services at UCLA Semel Institute & David Geffen School of Medicine and UCLA School of Public Health. Dr. Wells is the Principal Investigator of Partners in Care, a national study of quality improvement for depression in managed, primary care practices, and of Community Partners in Care, a randomized trial of community planning versus technical assistance to improve access to quality depression care in underserved communities in Los Angeles. He is the Co-Principal Investigator of a Red Cross initiative to expand delivery of evidence-based behavioral health services in New Orleans post-Katrina. Dr. Wells is CoDirector of the UCLA site of the Robert Wood Johnson Foundation's Clinical Scholars Program and Director of the Health Services Research Center of the Semel Institute.
Read more work by Dr. Wells »
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