title: Economic inequalities in the effectiveness of a primary care intervention for depression and suicidal ideation.
abstract: BACKGROUND
  Economic disadvantage is associated with depression and suicide. We sought to determine whether economic disadvantage reduces the effectiveness of depression treatments received in primary care.
  
  
  METHODS
  We conducted differential-effects analyses of the Prevention of Suicide in Primary Care Elderly: Collaborative Trial, a primary-care-based randomized, controlled trial for late-life depression and suicidal ideation conducted between 1999 and 2001, which included 514 patients with major depression or clinically significant minor depression.
  
  
  RESULTS
  The intervention effect, defined as change in depressive symptoms from baseline, was stronger among persons reporting financial strain at baseline (differential effect size = -4.5 Hamilton Depression Rating Scale points across the study period [95% confidence interval = -8.6 to -0.3]). We found similar evidence for effect modification by neighborhood poverty, although the intervention effect weakened after the initial 4 months of the trial for participants residing in poor neighborhoods. There was no evidence of substantial differences in the effectiveness of the intervention on suicidal ideation and depression remission by economic disadvantage.
  
  
  CONCLUSIONS
  Economic conditions moderated the effectiveness of primary-care-based treatment for late-life depression. Financially strained individuals benefited more from the intervention; we speculate this was because of the enhanced treatment management protocol, which led to a greater improvement in the care received by these persons. People living in poor neighborhoods experienced only temporary benefit from the intervention. Thus, multiple aspects of economic disadvantage affect depression treatment outcomes; additional work is needed to understand the underlying mechanisms.
authors.affiliation: Department of Society, Human Development and Health, Harvard School of Public Health, Boston, MA, USA. sgilman@hsph.harvard.edu.
authors.forename: Stephen E
authors.initials: SE
authors.lastname: Gilman
authors.forename: Garrett M
authors.initials: GM
authors.lastname: Fitzmaurice
authors.forename: Martha L
authors.initials: ML
authors.lastname: Bruce
authors.forename: Thomas
authors.initials: T
authors.lastname: Ten Have
authors.forename: M Maria
authors.initials: MM
authors.lastname: Glymour
authors.forename: Hannah
authors.initials: H
authors.lastname: Carliner
authors.forename: George S
authors.initials: GS
authors.lastname: Alexopoulos
authors.forename: Benoit H
authors.initials: BH
authors.lastname: Mulsant
authors.forename: Charles F
authors.initials: CF
authors.lastname: Reynolds
authors.forename: Alex
authors.initials: A
authors.lastname: Cohen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003863:Depression / Q000191:economics / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D054624:Health Status Disparities; D054625:Healthcare Disparities; D006801:Humans; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011203:Poverty / Q000523:psychology*; D011204:Poverty Areas; D011320:Primary Health Care / Q000379:methods / Q000592:standards; D059020:Suicidal Ideation; D013405:Suicide / Q000191:economics; D016896:Treatment Outcome; D000092864:Suicide Prevention