Patient-Centered Depression Care in the Public Sector

OBJECTIVE(S): This project seeks to understand the depression treatment preferences and barriers to care of low-income Latino patients, medical providers, and system administrators in public sector primary care settings and to incorporate this information into locally relevant, sustainable depression treatment programs.

METHODS: The study takes place in 3 large public sector primary care centers. We first assess depression treatment preferences and resources of patients, providers, and administrators. Next, we conduct a randomized controlled trial of a standardized depression intervention at each clinic to provide consumers, clinicians, and administrators with a treatment exposure. Following the intervention, we examine whether stated preferences correspond to actual behaviors, and whether stated preferences change with treatment exposure and outcome. We examine provider and administrator preferences and attitudes before and after the intervention. Finally, we conduct a multi-stakeholder process to prioritize patient-oriented goals given practice and resource constraints.

FINDINGS / RESULTS: Of 1428 potential patient subjects that have been approached, 517 have been eligible and agreed to be screened. 145 (28%) were study eligible, of which117 (81% of eligible) enrolled in the study. Of the 102 subjects whose data is available for analysis, 91 (89%) are female, 45 (44%) are married, 64 (63%) are unemployed, 43 (42%) have < 6 years of education, 84 (83%) are Latino, and 76 (74%) have a yearly household income of < $15,000. Thirty-nine (38%) report lifetime counseling, 36 (35%) report lifetime use of medication for mental health problems, and 49 (48%) report perceived need for depression treatment. In the baseline conjoint analysis preference survey, subjects are significantly more likely to prefer treatment in the primary care vs. mental health setting. Preferences for treatment type and format are not significant in this preliminary analysis. Strategies to reduce barriers to depression care, such as bus passes and telephone appointments, significantly improve odds of treatment acceptance. Family involvement and format of educational materials are not currently significant. Cost is significant in treatment choice. Baseline assessments have been completed with 21 primary care clinicians. Of 17 physicians, 10 were general internists, 6 family practitioners, and 1 a medicine/pediatrics specialist. Nine of the 21 are board certified; 8 were resident physicians. Physicians saw or supervised the care of 58 patients on average per week, 33% of whom they estimated had depression. Providers perceive depression treatment as important in primary care but hindered by lack of time with patients, lack of linkage between mental health and primary care, competing demands of medical illness, and stigma about depression and medications. Providers prefer on-site collaborative depression care over current care. Several family practice physicians enjoy providing limited counseling themselves and indeed practice some principles of problem solving therapy and behavioral activation. Providers view addressing the psychosocial stressors and practical needs of their patients as an important component of depression care but perceive lack of motivation and energy from depression as a significant barrier to patient engagement in care.

STATUS: Patient subject recruitment and enrollment is actively underway in the three clinics. Baseline interviews with providers and administrators are being completed.

IMPACT: This study aims to improve depression care in public sector, primary care systems serving low-income minority patients by consulting constituents to make care more patient-centered and sustainable. In order to develop patient-centered care, it is essential to understand and accommodate patient treatment preferences that are clinically reasonable; including provider and administrator priorities in the design of depression interventions may lead to better implementation and greater sustainability. Our study will provide methods for assessing preferences for depression care and for tailoring the implementation of depression interventions to make them relevant to local populations and resources. These are critical steps for disseminating evidence-based practice strategies. Furthermore, information about how patient and provider preferences for care and perceptions of treatment barriers change after depression treatment can be used to develop more effective and targeted educational interventions. This study will provide valuable information for health care providers, administrators, and policy makers who aim to reduce disparities in depression care for low income and minority populations. The study also addresses needs to develop ways to integrate mental health services into primary care, to conduct effectiveness trials of depression care in "real world" public care systems, and to perform culturally sensitive research.