Improving Primary Care Treatment for Depression Creates Long-Lasting Improvements for Minority Patients

A program to improve the way primary care medical practices treat depression created significant benefits for African American and Latino patients that continued five years after the year-long program began, according to a RAND Corporation study issued today.

Minority patients treated in medical practices that adopted an evidence-based improvement effort called Partners in Care were significantly less likely to exhibit symptoms of depression than peers who received standard medical care, according to the study in the April edition of the Archives of General Psychiatry.

Among all participants, the interventions caused a small overall improvement in depression outcomes. But the improvements seen among minority patients were large enough to erase the disparities in depression outcomes seen between minority patients and their white peers in standard care.

Five years after patients enrolled in the programs, the prevalence of probable depressive disorder was 10 to 20 percentage points lower among African American and Latino patients who visited intervention practices than for peers who visited standard-care clinics.

Among whites, the interventions caused a drop of only 2 to 4 percentage points. The difference in response to the interventions for minorities and whites was significant, showing that the outcome disparity was reduced or overcome.

“These findings provide a hopeful message: An initial improved care experience can have lasting benefits overall and among minorities, while reducing disparities in outcomes of care between minority and white patients,” said psychiatrist Kenneth Wells, the study's principal investigator. “These interventions significantly improved health in the long run, for historically underserved minority groups at risk for poor health outcomes. ”

The study fielded two different versions of the interventions—one that especially supported use of psychotherapy for depression and one that especially supported medication management for depression, although patients could have either type of treatment in both interventions.

The strongest improvements for minorities were observed in the intervention with special resources for psychotherapy. But both interventions improved quality of care, or reduced unmet need for appropriate treatment, among minorities.

The study by researchers from RAND Health and UCLA is the first to examine very-long-term outcomes of practice-based quality improvement programs designed to improve primary care for depression.

The study assigned 46 primary care practices across different sites in the United States to either their usual care for depression or to programs that provided education for providers and patients about depression treatments. It provided resources to make it easier to get the treatments—either medications or psychotherapy—if necessary.

Previous RAND studies of the Partners in Care program have shown that after two years patients treated under the program improved significantly, experiencing fewer “depression burden days” and achieving a higher rate of employment than patients who received usual care. Those studies also found that African Americans and Latinos were most at risk of receiving poor quality care for depression and having poor clinical outcomes, yet they also strongly benefited from the interventions in the first year, when the interventions were active.

The latest study found that minorities continued to benefit from the intervention even five years after the start of the program. In fact, their improvement at five years was the largest outcome improvement found in the study at any time period.

Whites tended to do well five years after the intervention period, regardless of the type of practice program they were in. However, the minority groups had good outcomes only if they were in intervention practices instead of practices that made no changes in depression treatment, researchers found.

Among those treated in practices that offered usual care, about 56 percent of minorities and 36 percent of whites had a probable depressive disorder at the end of the five-year follow-up period.

However, among those treated in practices that offered improved care, the outcomes improved for minorities. About 45 percent of minorities had a probable depressive disorder under the intervention with extra resources to support medication management, while it was down to 36 percent under the intervention with extra resources to support psychotherapy.

In addition to providing education to providers and patients, the medication resource intervention supported nurses to help with medication follow-up for 6 to 12 months.

The psychotherapy resource intervention reduced the co-pay for patients to see local therapists trained in a form of psychotherapy for depression developed at the Depression Clinic of San Francisco General Hospital.

The control practices received written copies of national guidelines, but no other special programs or resources from the study.

“The interventions supported good medical practice and allowed patients and their doctors to make their own decisions after receiving up-to-date information and encouragement to try treatment,” Wells said.

In addition, the researchers thought that the particularly favorable outcomes for minorities in the psychotherapy resource intervention could be due to minorities perceiving that intervention as more culturally appropriate. For example, the authors previously found that African American and Latino patients tended to prefer psychotherapy over medication as a treatment for depression even at the beginning of the study.

The study followed 991 patients for five years who initially received primary care in community-based, public and private managed care practices in areas of California, Texas, Colorado, Maryland, and Minnesota. The programs were designed by the research team, but implemented and monitored by the practices according to their own goals and resources, to assure that they were feasible in today’s cost-conscious healthcare environment.

The study follows on the heels of national calls for improvements in the quality of care for chronic diseases and for reductions in medical errors by the Institute of Medicine and policy and research agencies, as well as national calls for approaches to reduce health disparities.

“Quality of health care tends to be poorer for minority populations, but it hasn't been clear what to do about the problem. Our study offers one promising approach that can improve long-run clinical outcomes and quality of life for Latinos and African Americans who suffer from depression,” said Dr. Jeanne Miranda, a professor of Psychiatry and Biobehavioral Sciences at UCLA and leader of the study’s psychotherapy resource intervention.

Miranda was the senior science editor for a U.S. Surgeon General supplemental report on mental health of minorities that was published in 2001. She noted that few studies in any area of mental health have demonstrated approaches that practices can follow to reduce mental health outcome disparities that can result from differential treatment.

The Partners in Care depression treatment improvement program has been widely distributed to medical practices across the country and the materials are available free on the RAND Web site. In addition, researchers published a book for the lay public that provides education about depression and summarizes the principles in the intervention (“Beating Depression: The Journey to Hope,” McGraw-Hill, 2002, Jackson-Triche, Wells, and Minnium).

The five-year outcome study was funded by the National Institute of Mental Health, and original two-year study was funded by the federal Agency for Healthcare Quality and Research, the National Institute of Mental Health, and the MacArthur Foundation.

Other authors of the study are: Cathy Sherbourne and Michael Schoenbaum of RAND; Susan Ettner, Naihua Duan and Dr. Jurgen Unutzer of the David Geffen UCLA School of Medicine; and Dr. Lisa Rubenstein of RAND, the UCLA School of Medicine and the Veterans Administration Greater Los Angeles Healthcare System.

RAND Health is the nation’s largest independent health policy research organization, with a broad research portfolio that focuses on health care quality, costs, and delivery, among other topics.