title: Community-partnered cluster-randomized comparative effectiveness trial of community engagement and planning or resources for services to address depression disparities.
abstract: BACKGROUND
  Depression 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.
  
  
  OBJECTIVE
  To 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.
  
  
  METHODS
  Matched 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.
  
  
  METHODS
  From 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.
  
  
  METHODS
  Self-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use.
  
  
  RESULTS
  CEP 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).
  
  
  CONCLUSIONS
  Community 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.
authors: RAND Corporation, Santa Monica, CA, USA, kwells@mednet.ucla.edu.
authors: Kenneth B
authors: KB
authors: Wells
authors: Loretta
authors: L
authors: Jones
authors: Bowen
authors: B
authors: Chung
authors: Elizabeth L
authors: EL
authors: Dixon
authors: Lingqi
authors: L
authors: Tang
authors: Jim
authors: J
authors: Gilmore
authors: Cathy
authors: C
authors: Sherbourne
authors: Victoria K
authors: VK
authors: Ngo
authors: Michael K
authors: MK
authors: Ong
authors: Susan
authors: S
authors: Stockdale
authors: Esmeralda
authors: E
authors: Ramos
authors: Thomas R
authors: TR
authors: Belin
authors: Jeanne
authors: J
authors: Miranda
mesh_terms: D000328:Adult; D003156:Community Mental Health Services / Q000458:organization & administration* / Q000592:standards / Q000706:statistics & numerical data; D057186:Comparative Effectiveness Research / Q000379:methods; D003299:Cooperative Behavior; D003863:Depression / Q000628:therapy*; D003866:Depressive Disorder / Q000628:therapy*; D005260:Female; D018166:Health Care Reform / Q000379:methods; D006285:Health Planning / Q000458:organization & administration; D006296:Health Services / Q000706:statistics & numerical data; D006301:Health Services Needs and Demand; D006302:Health Services Research / Q000379:methods; D054625:Healthcare Disparities; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007373:Interinstitutional Relations; D015141:Los Angeles; D008297:Male; D008507:Medically Underserved Area; D008875:Middle Aged; D018579:Patient Selection; D011569:Psychiatric Status Rating Scales; D011788:Quality of Life; D016037:Single-Blind Method; D012959:Socioeconomic Factors; D016896:Treatment Outcome
references: J Clin Psychiatry. 1998;59 Suppl 20:22-33;quiz 34-57
references: 9881538
references: J Consult Clin Psychol. 2006 Feb;74(1):99-111
references: 16551147
references: JAMA. 1995 Apr 5;273(13):1026-31
references: 7897786
references: Ethn Dis. 2006 Winter;16(1 Suppl 1):S18-34
references: 16681126
references: JAMA. 2000 Jan 12;283(2):212-20
references: 10634337
references: JAMA. 2005 Jan 19;293(3):311-9
references: 15657324
references: Community Ment Health J. 2014 Apr;50(3):312-24
references: 23625140
references: Med Care. 1992 Jun;30(6):473-83
references: 1593914
references: Arch Intern Med. 2006 Nov 27;166(21):2314-21
references: 17130383
references: Psychiatr Serv. 2006 Jan;57(1):48-55
references: 16399962
references: Science. 2011 Dec 9;334(6061):1394-8
references: 22158816
references: Health Serv Res. 2009 Feb;44(1):288-302
references: 18793213
references: Arch Gen Psychiatry. 2004 Apr;61(4):378-86
references: 15066896
references: J Med Syst. 1996 Oct;20(5):317-28
references: 9001997
references: Am J Psychiatry. 2002 Sep;159(9):1548-55
references: 12202276
references: J Occup Environ Med. 2008 Apr;50(4):468-75
references: 18404020
references: Psychiatr Serv. 2002 Dec;53(12):1547-55
references: 12461214
references: Arch Gen Psychiatry. 2001 Jul;58(7):696-703
references: 11448378
references: BMJ. 2008 Mar 8;336(7643):516-7
references: 18319297
references: Gen Hosp Psychiatry. 2002 Jul-Aug;24(4):203-12
references: 12100831
references: Arch Gen Psychiatry. 2005 Jun;62(6):617-27
references: 15939839
references: Med Care. 2005 Apr;43(4):381-90
references: 15778641
references: JAMA. 2001 Sep 19;286(11):1325-30
references: 11560537
references: N Engl J Med. 2003 Apr 3;348(14):1383-6
references: 12672867
references: Health Aff (Millwood). 1999 Sep-Oct;18(5):89-105
references: 10495595
references: Ethn Dis. 2011 Summer;21(3 Suppl 1):S1-45-51
references: 22352080
references: Lancet. 2010 Apr 3;375(9721):1182-92
references: 20207411
references: Arch Gen Psychiatry. 2007 Mar;64(3):305-15
references: 17339519
references: J Health Care Poor Underserved. 2010 Aug;21(3):780-95
references: 20693725
references: BMJ. 2000 Feb 26;320(7234):569-72
references: 10688568
references: J Clin Oncol. 2008 Sep 20;26(27):4488-96
references: 18802161
references: Lancet. 2010 Dec 18;376(9758):2086-95
references: 21159375
references: Health Serv Res. 2003 Apr;38(2):613-30
references: 12785564
references: JAMA. 2003 Jun 18;289(23):3167-8
references: 12813123
references: J Gen Intern Med. 2007 Sep;22(9):1286-91
references: 17597350
references: Am J Public Health. 1997 Nov;87(11):1773-8
references: 9366634
references: Am J Public Health. 2009 Feb;99(2):237-44
references: 19059844
references: Med Care. 2007 Nov;45(11):1052-9
references: 18049345
references: JAMA. 2002 Dec 11;288(22):2836-45
references: 12472325
references: JAMA. 2007 Jan 24;297(4):407-10
references: 17244838
references: JAMA. 2003 Jul 2;290(1):57-65
references: 12837712
references: Biometrics. 1999 Jun;55(2):652-9
references: 11318229
references: J Gen Intern Med. 2000 Aug;15(8):527-34
references: 10940143
references: Psychiatr Serv. 2010 Feb;61(2):110-2
references: 20123813
references: J Gen Intern Med. 1999 Sep;14(9):537-46
references: 10491242
references: Stat Med. 1995 Sep 15;14(17):1913-25
references: 8532984
references: Ethn Dis. 2009 Autumn;19(4 Suppl 6):S6-3-7
references: 20088076
references: Annu Rev Public Health. 2011;32:399-416
references: 21219164
references: Am J Psychiatry. 2001 Dec;158(12):2027-32
references: 11729020
references: Stat Med. 2005 Jul 30;24(14):2111-28
references: 15889392
references: Med Care. 2008 Jan;46(1):78-84
references: 18162859