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Improvements are needed in treatment of depression in primary care and among minorities in specialty care

About 40 percent of depressed adults receive mental health care in primary care settings, where depressive disorders are as prevalent (5 to 9 percent) as many major chronic conditions such as diabetes. Yet primary care providers often are unaware of a patient's depression and consequently do not provide effective treatments. It has been suggested that mental health specialty services are not sufficiently responsive to the needs of minority patients and that professionals should be trained to provide more culturally sensitive programs.

The Partners in Care project is designed to partner mental health specialists with primary care physicians to improve primary care treatment of depression. This is a Patient Outcomes Research Team (PORT) project, which is supported by the Agency for Health Care Policy and Research (HS08349) and led by Kenneth B. Wells, M.D., M.P.H., of the University of California, Los Angeles. Two recent studies supported by the PORT are summarized here. The first study evaluates the cost-effectiveness of improving primary care for depression. The second study examines cultural issues in the treatment of ethnic minorities with mental health problems.

Wells, K.B. (1999). "The design of Partners in Care: Evaluating the cost-effectiveness of improving care for depression in primary care." Social Psychiatry and Psychiatric Epidemiology 34, pp. 20-29.

This study examines the cost-effectiveness of improving the quality of treatments for depression in 27,000 patients seen in primary care managed care practices for depression. The researchers randomized 46 primary care clinics from 6 managed care organizations to either basic quality improvement (QI) plus enhanced medication management; QI plus enhanced psychotherapy; and usual care. QI interventions included patient and provider education, nurse-assisted patient assessment, and resources to support appropriate medication management or access to cognitive behavioral therapy.

For QI an expert team received 2 days of training in assessing and treating depression, educating primary care clinicians, and conducting quality assurance meetings. Practice nurses were trained to educate patients using a brochure and videotape and to assess patients' depressive symptoms, functioning, and other factors. Physicians received a manual on detecting, assessing, and treating depression, which was based in part on the depression guideline published by AHCPR in 1993.

Studies showing the effectiveness of treatment models using a mental health specialist/primary care partnership to support effective antidepressant medication management or to provide brief cognitive therapy on referral strongly influenced the Partners in Care (PIC) QI approach. The goal of PIC was to study treatment effectiveness and this type of partnership on typical patients under usual care conditions, rather than the ideal conditions usually present in clinical trials. Dr. Wells concludes that studying depression treatment effects and QI in nonacademic settings is feasible but requires relaxation of experimental design features, such as blinding of patient or doctor to type of treatment.

Takeuchi, D.T., Uehara, E., and Maramba, G. (1999). "Cultural diversity and mental health treatment." In: The Sociology of Mental Health, A. Horwitz and T. Scheid, editors. New York: Oxford; pp. 550-565.

In this book chapter, the authors examine cultural issues in the treatment of ethnic minorities who have mental health problems. They note that ethnic minorities use less mental health services than whites, and that when minorities do use mental health services, they are less likely to drop out if their provider shares their language and ethnicity. The authors describe a number of culturally appropriate mental health programs. They note, however, that three recent trends in mental health services conflict with the goal of developing multicultural mental health service systems: endorsing etiologies of mental illness that stress biological over social and cultural causes; seeing culture as fixed, historical, and autonomous; and overlooking the substantial heterogeneity in socioeconomic status and stress-related life experiences within specific ethnic groups.

For instance, ethnic differences both within and between ethnic groups in these stressors—ranging from poverty, war-related physical and emotional trauma, and social role discontinuities—are substantial and warrant more careful attention by those who plan mental health services. Categories such as "Latino Americans" and "Native Americans" may conceal more than they reveal, note the authors.

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