Victoria K. Ngo

Community-Partnered Cluster-Randomized Comparative Effectiveness Trial of Community Engagement and Planning or Resources for Services to Address Depression Disparities

ABSTRACTBACKGROUNDDepression 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.OBJECTIVETo 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.DESIGNMatched 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.PARTICIPANTSFrom 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.MEASURESSelf-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use.RESULTSCEP 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).CONCLUSIONCommunity 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.

Providing Evidence-Based Practice to Ethnically Diverse Youths: Examples from the Cognitive Behavioral Intervention for Trauma in Schools (CBITS) Program.

At first glance, implementing evidence-based treatments for ethnically diverse youth may appear to raise some concerns. Do manualized treatments work for the diverse youth we see in our communities? Should clinicians only use culturally-specific treatments? Unfortunately, the literature is not definitive. Several studies have found that tailoring interventions for specific populations can increase their effectiveness1–5 while others have found that cultural adaptations of an intervention may actually dilute the effectiveness of the original treatment even though retention is improved.6 What appears to be important is to strike a balance between fidelity to evidence-based treatment and culturally-informed care. This paper provides illustrations from a school-community-academic partnership’s dissemination of the Cognitive-Behavioral Intervention for Trauma in Schools7 program to ethnically diverse communities nationwide. CBITS is an evidence-based intervention program initially developed for ethnic minority and immigrant youth exposed to trauma. CBITS was created to decrease the negative effects of trauma exposure in an ethnically and linguistically diverse group of primarily low-income children while being delivered in the real-world setting of schools. 8, 9 In a randomized controlled study, Mexican and Central American youth showed significant reduction in post-traumatic stress and depressive symptoms.10, 11 Similar positive effects have been found in dissemination evaluations of CBITS in other communities12, including urban African American13, Native American14, and rural communities.15 Although our CBITS partnership recommends program evaluations, we recognize that it is not always feasible for each community to do systematic evaluation for each adaptation or modification of CBITS. In delivering CBITS, we have confronted common issues that arise when trying to deliver an evidence-based intervention to youth from a broad range of ethnic and socioeconomic backgrounds. We present several examples of how we use community partnerships throughout all phases of dissemination, from program development, pre-implementation planning, to delivery of CBITS groups (see Figure 1). Community partnerships refer to collaboration between key stakeholders from the local school and its surrounding community including school personnel, parents, community organizations, faith-based groups, clinicians and researchers. This approach addresses contextual and cultural issues at every stage so that CBITS is tailored for each unique community. We have found this to be a promising model for reaching diverse and underserved populations and increasing community engagement.8, 16 Figure 1 Model for Using Community Partnerships to Provide Culturally-Sensitive Evidence-Based Treatment

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.

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. (

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.

Development of a Patient-Report Measure of Psychotherapy for Depression

Despite clear indications of need to improve depression treatment, practical tools that efficiently measure psychotherapy are not available. We developed a patient-report measure of psychotherapy for depression that assesses Cognitive Behavioral (CBT), Interpersonal (IPT), and Psychodynamic therapies. 420 patients with depression from a large managed behavioral health care organization completed the measure. The three subscales measuring CBT, IPT, and Psychodynamic Therapy showed good internal consistency, appropriate item-total correlations, and were supported by a 3-factor structure. Our results suggest that a patient questionnaire is a promising approach for assessing psychotherapy in quality improvement interventions.

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.

Adolescents’ Stigma Attitudes Toward Internalizing and Externalizing Disorders Cultural Influences and Implications for Distress Manifestations

This study examined predictors of stigma attitudes toward common youth emotional behavioral problems to test the hypothesis that interdependent cultural values would be associated with differential stigma toward externalizing versus internalizing disorders. Furthermore, we examined whether problem-specific stigma attitudes would predict adolescents’ own self-reported manifestations of distress. A total of 1,224 Vietnamese American and European American adolescents completed measures of social distance stigma attitudes in response to vignettes depicting youth with internalizing (depression, social anxiety, somatization) and externalizing (alcohol use, aggressive behaviors, delinquency) disorders. A subset of 676 youth also provided self-reports on their own adjustment prospectively over 6 months. Measurement models revealed clear separation of negatively correlated factors assessing stigma toward externalizing versus internalizing problems. Values related to family interdependence were significantly associated with greater tolerance of internalizing disorders and lower tolerance of externalizing disorders. Stigma toward internalizing disorders was associated with lower concurrent self-reported internalizing symptoms, whereas stigma toward externalizing symptoms was associated with lower concurrent externalizing symptoms and greater decreases in externalizing symptoms over time. The results of the study suggest that stigma attitudes are differentiated by problem type and may represent one cultural factor shaping distress manifestations

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.

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.