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12-Month Outcomes of Community Engagement Versus Technical Assistance to Implement Depression Collaborative Care: A Partnered, Cluster, Randomized, Comparative Effectiveness TrialCommunity Engagement Versus Technical Assistance in Depression Care

Bowen Chung, MD, MSHS*; Michael Ong, MD, PhD; Susan L. Ettner, PhD; Felica Jones, AA; James Gilmore, MBA; Michael McCreary, MPP; Cathy Sherbourne, PhD; Victoria Ngo, PhD; Paul Koegel, PhD; Lingqi Tang, PhD; Elizabeth Dixon, PhD; Jeanne Miranda, PhD; Thomas R. Belin, PhD; and Kenneth B. Wells, MD, MPH*
[+] Article, Author, and Disclosure Information

* Former Robert Wood Johnson Foundation Clinical Scholar.

This article is part of the Annals supplement “RWJF Clinical Scholars in Pursuit of the Value Proposition: Evaluations of Low-Cost Innovations for Prevention and Management of Conditions.” The Robert Wood Johnson Foundation provided funding for publication of this supplement. Carol M. Mangione, MD, MPH (co-director of the RWJF Clinical Scholars Program at the University of California, Los Angeles); Jaya K. Rao, MD, MHS (Annals Deputy Editor); and Christine Laine, MD, MPH (Annals Editor in Chief), served as editors for this supplement.


From Harbor-UCLA Medical Center/Los Angeles Biomedical Research Institute, Torrance; Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, Greater Los Angeles Veterans Affiars Healthcare System, UCLA Fielding School of Public Health, Healthy African American Families II, and School of Nursing at UCLA, Los Angeles; RAND Corporation, Santa Monica; and Behavioral Health Services, Gardena, California.

Note: Drs. Chung and Wells are affiliated with the RAND Corporation, and the work described herein was performed through their roles at RAND.

Acknowledgment: The authors thank the Los Angeles programs, providers, staff, and clients who participated; and the RAND Survey Research Group and community members who conducted client data collection. They also thank Loretta Jones for her study leadership and vision; Esmeralda Pulido, Ana Ramos, Rosie Cardenas, and Liz Lizaola for project management support; Lily Zhang for statistical programming support; Ira Lesser, Charles Grob, and Christina Wang for support at Harbor-UCLA/Los Angeles Biomedical Research Institute; UCLA Clinical and Translational Science Institute for analyses and manuscript preparation support; and Paul Steinberg, Marcia Meldrum, and David Miklowitz for support during manuscript revisions. The authors also thank the 25 participating agencies of the Council and their representatives: QueensCare Health and Faith Partnership; COPE Health Solutions; UCLA Center for Health Services and Society; Cal State University Dominquez Hills; RAND; Healthy African American Families II; Los Angeles Urban League; Los Angeles Christian Health Centers; Los Angeles County Department of Mental Health and West Central Mental Health Center; Homeless Outreach Program/Integrated Care System; National Alliance on Mental Illness Urban Los Angeles; Behavioral Health Services; Avalon Carver Community Center; USC Keck School of Medicine Department of Psychiatry and Behavioral Sciences; Kaiser Watts Counseling and Learning Center; People Assisting the Homeless; Children's Bureau; Saban Free Clinic; New Vision Church of Jesus Christ; Jewish Family Services of Los Angeles; St. John's Well Child and Family Center; Charles Drew University of Medicine and Science; City of Los Angeles Department of Recreation and Parks; To Help Everyone Clinic; and QueensCare Family Clinics.

Grant Support: By the National Institute of Mental Health (awards R01MH078853, P30MH082760, and P30MH068639), the Robert Wood Johnson Foundation (award 64244), California Community Foundation, National Library of Medicine (award G08LM011058), and the National Institutes of Health/National Center for Advancing Translational Science for the UCLA Clinical and Translational Science Institute (award UL1TR000124).

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-3011.

Reproducible Research Statement:Study protocol: Available at http://hss.semel.ucla.edu/documents/CPIC_Protocol_Dec2012.pdf. Statistical code and data set: Available from Dr. Tang (e-mail, lqtang@ucla.edu).

Requests for Single Reprints: Bowen Chung, MD, MSHS, Department of Psychiatry, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 498, Torrance, CA 90509; e-mail, bchung@mednet.ucla.edu.

Current Author Addresses: Dr. Chung: Department of Psychiatry, Harbor-UCLA Medical Center, 1000 West Carson Street, Box 498, Torrance, CA 90509.

Dr. Ong: Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Box 957394, 10940 Wilshire Boulevard, Suite 700, Los Angeles, CA 90095-7394.

Dr. Ettner: Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Box 951736, 911 Broxton Plaza, Los Angeles, CA 90095-1736.

Ms. Jones: Healthy African American Families II, 4305 Degnan Boulevard, Suite 105, Los Angeles, CA 90008.

Mr. Gilmore: Behavioral Health Services, 15519 Crenshaw Boulevard, Gardena, CA 90249.

Mr. McCreary and Drs. Tang, Miranda, and Wells: Center for Health Services and Society, Semel Institute for Neuroscience, Box 957082, 10920 Wilshire Boulevard, Suite 300, Los Angeles, CA 90095-7082.

Drs. Sherbourne, Ngo, and Koegel: RAND Corporation, 1776 Main Street, PO Box 2138, Santa Monica, CA 90407-2138.

Dr. Dixon: UCLA School of Nursing, Box 956919, 5-660 Factor, Los Angeles, CA 90095-6919.

Dr. Belin: UCLA School of Public Health, Department of Biostatistics, Box 951772, 51-267 CHS, Los Angeles, CA 90095-1772.

Author Contributions: Conception and design: B. Chung, M.K. Ong, S.L. Ettner, J. Gilmore, C.D. Sherbourne, V. Ngo, L. Tang, T.R. Belin, K.B. Wells.

Analysis and interpretation of the data: B. Chung, M.K. Ong, S.L. Ettner, J. Gilmore, M. McCreary, C.D. Sherbourne, L. Tang, J. Miranda, T.R. Belin, K.B. Wells.

Drafting of the article: B. Chung, M.K. Ong, M. McCreary, C.D. Sherbourne, P. Koegel, L. Tang, J. Miranda.

Critical revision of the article for important intellectual content: B. Chung, M.K. Ong, S.L. Ettner, F. Hones, C.D. Sherbourne, V. Ngo, P. Koegel, L. Tang, J. Miranda, T.R. Belin, K.B. Wells.

Final approval of the article: B. Chung, M.K. Ong, S.L. Ettner, F. Hones, J. Gilmore, C.D. Sherbourne, V. Ngo, P. Koegel, L. Tang, E. Dixon, J. Miranda, T.R. Belin, K.B. Wells.

Provision of study materials or patients: J. Gilmore, M. McCreary, V. Ngo, E. Dixon, K.B. Wells.

Statistical expertise: B. Chung, M.K. Ong, S.L. Ettner, L. Tang, J. Miranda, T.R. Belin.

Obtaining of funding: M.K. Ong, C.D. Sherbourne, K.B. Wells, B. Chung.

Administrative, technical, or logistic support: B. Chung, M.K. Ong, S.L. Ettner, J. Gilmore, M. McCreary, V. Ngo, P. Koegel, L. Tang, E. Dixon, K.B. Wells.

Collection and assembly of data: B. Chung, J. Gilmore, M. McCreary, C.D. Sherbourne, L. Tang, E. Dixon, K.B. Wells.


Ann Intern Med. 2014;161(10_Supplement):S23-S34. doi:10.7326/M13-3011
Text Size: A A A

Background: Depression collaborative care implementation using community engagement and planning (CEP) across programs improves 6-month client outcomes in minority communities, compared with technical assistance to individual programs (resources for services [RS]). However, 12-month outcomes are unknown.

Objective: To compare effects of CEP and RS on mental health–related quality of life (MHRQL) and use of services among depressed clients at 12 months.

Design: Matched health and community programs (n = 93) in 2 communities randomly assigned to receive CEP or RS. (ClinicalTrials.gov: NCT01699789).

Measurements: Self-reported MHRQL and services use at baseline, 6 months, and 12 months.

Setting: Los Angeles, California.

Patients: 1018 adults with depressive symptoms (8-item Patient Health Questionnaire score ≥10), 88% of whom were an ethnic minority.

Intervention: CEP and RS to implement depression collaborative care.

Measurements: The primary outcome was poor MHRQL (12-item mental health composite score ≤40) at baseline, 6 months, and 12 months; the secondary outcome was use of services at 12 months.

Results: At 6 months, the finding that CEP outperformed RS to reduce poor MHRQL was significant but sensitive to underlying statistical assumptions. At 12 months, some analyses suggested that CEP was advantageous to MHRQL, whereas others did not confirm a significant difference favoring CEP. The finding that CEP reduced behavioral health hospitalizations at 6 months was less evident at 12 months and was sensitive to underlying statistical assumptions. Other services use did not significantly differ between interventions at 12 months.

Limitation: Data are self-reported, and findings are sensitive to modeling assumptions.

Conclusion: In contrast to 6-month results, no consistent effects of CEP on reducing the likelihood of poor MHRQL and behavioral health hospitalizations were found at 12 months. Still, given the needs of underresourced communities, the favorable profile of CEP, and the lack of evidence-based alternatives, CEP remains a viable strategy for policymakers and communities to consider.

Primary Funding Source: National Institute of Mental Health, Robert Wood Johnson Foundation, California Community Foundation, National Library of Medicine, and National Institutes of Health/National Center for Advancing Translational Science for the UCLA Clinical and Translational Science Institute.

Figures

Grahic Jump Location
Figure.

Study flow diagram.

Five programs (2 in the RS group and 3 in the CEP group) had no clients with data for outcome analysis. CEP = community engagement and planning; RS = resources for services.

Grahic Jump Location

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