Depression Program's Benefits May Not Reach Minority Patients

During the past several decades, a concept of delivering depression treatment at the primary care level has taken hold in the United States. It is usually referred to as collaborative care or depression care management (DCM).

DCM programs include a primary care physician, a psychiatrist, and an individual defined as a care manager. The care manager serves as a pivot for the system. He or she will meet in the office with the patient, offer education about depression, follow up by phone, monitor medication adherence and side effects, troubleshoot any problem, and coordinate care with the primary care physician (Psychiatric News, April 3, 2009).

More than 30 studies of the DCM model have shown that such programs improve patients' adherence to treatment, outcomes, and satisfaction with care. Furthermore, in addition to numerous small-scale DCM projects, there are a few large-scale implementations of the DCM concept around the United States, notably in Minnesota and Washington (Psychiatric News, March 6, 2009).

But questions have been raised about whether DCM programs help reduce the disparities in depression treatment and outcomes that are known to exist between less- and better-educated patients and between whites and minority patients. Yuhua Bao, Ph.D., an assistant professor of public health at Weill Cornell Medical College, and her colleagues conducted a study to find out.

The verdict, they reported in the June Archives of General Psychiatry, was mixed.

Bao and her colleagues used the PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) system as the basis for their study. The PROSPECT study had shown that DCM in 20 primary care practices reduced depression and suicidal ideation in 214 older depressed primary care patients.

The researchers broke down the outcomes for the 214 subjects according to educational level independent of race or ethnicity and then according to race or ethnicity independent of educational level. As they explained in their paper, "Although patients with a lower educational level were disproportionately of ethnic minority (and vice versa), there was still substantial variation in race/ethnicity in each education group (and variation in educational achievement in each racial/ethnic group) to conduct such analyses."

They found that the DCM intervention had a larger and more lasting effect in less-educated patients than it did in better-educated ones.

For example, at month 12, the intervention had increased the rate of adequate antidepressant use by 14 percent in the no-college group, but had had no statistically significant effect on this factor in the college-educated group.

In contrast, the intervention had benefitted ethnic-minority patients less than non-Hispanic white ones. For example, at month 4, the intervention had raised the rate of adequate antidepressant use to a similar extent in minority patients and white patients. But starting at month 8, the intervention effect became null in minority patients, whereas it remained strong in white patients, leading to a minority-white difference in intervention effects of -17 percentage points at month 12 and -19 percentage points at month 24.

The researchers thus noted that "the intervention narrowed or closed the gap between education groups in antidepressant use and depressive symptoms ... but did not mitigate ethnic disparities in either outcome."

So, how can the DCM programs be modified to make them more effective for minorities? "First, designers of the implementation need to think about how to best involve family members of minority patients," Bao told Psychiatric News. "This may include an assessment of family and social support of the patient at the beginning of the program, strengthened education of family members, and identifying critical moments in the treatment process to enlist family members' help." In addition, she noted, clinicians should "allow patients ample room to express, rather than simply dismiss, their beliefs [about depression].... Once trust is established, clinicians can then work with the patients to adjust their beliefs in the direction that benefits treatment adherence and outcomes."

She emphasized as well that "more intensive effort may be needed ... to keep minority patients engaged in treatment and follow-up. An area for future research would be to identify the critical points of intervention to help reduce premature dropout of minority patients," which, as the study found, happens frequently.

The study was funded by the National Institutes of Health and a Pfizer Scholar's Grant in Health Policy.