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Treatment of Depression and PTSD in Primary Care Clinics Serving Uninsured Low-Income Mostly Latina/o Immigrants:
A Naturalistic Prospective Evaluation
Stacey Kaltman Georgetown University School of Medicine
Maria Rosa Watson and Marcela Campoli Primary Care Coalition of Montgomery County,
Silver Spring, Maryland
Adriana Serrano, Nicholas Talisman, and Laura Kirkpatrick
Georgetown University School of Medicine
Mihriye Mete MedStar Health Research Institute, Hyattsville, Maryland, and
Georgetown University School of Medicine
Bonnie L. Green Georgetown University School of Medicine
Objectives: Uninsured immigrants to the United States are psychologically vulnerable due to limited access to mental health services. Latina/o immigrants from Central and South America are further at risk due to high levels of trauma exposure, both in their country of origin and their adopted country. Effective behavioral interventions in primary care are needed to address this services gap for common trauma-related mental disorders, including depression and posttraumatic stress disorder (PTSD). A naturalistic prospective study compared depression and PTSD outcomes for uninsured primary care patients, mostly Latina/o immigrants, in clinics with distinct models for integrating behavioral health services. One clinic had a collaborative care program, that is, a multicomponent, system-level intervention with the goals of facilitating increased screen- ing, improving diagnostic accuracy, increasing uptake of evidence-based treatment, and utilizing measurement-based treatment to target. The other had colocated services, with an on-site therapist. Method: One hundred thirty-eight patients with presumptive depression were interviewed at baseline. Follow-up data were collected 8 months later. Care received between the two assessments was ascertained by chart review. Results: There was a significant decrease in depression symptoms regardless of clinic. Factors associated with improved depression outcomes included absence of comorbid PTSD and lack of additional trauma exposures. Although there was overall improvement in PTSD, there was significantly more improvement in the collaborative care clinic. Conclusions: Results suggest that both models were effective for depression and PTSD; however, the collaborative care model had added benefits for those patients with PTSD.
Keywords: Latino/a, immigrant, depression, PTSD, collaborative cares
There is increasing awareness of the need for effective and efficient treatment strategies for common mental disorders (e.g., depression and anxiety) in primary care settings. This is particu-
larly true for low-income, uninsured minority populations that experience significant mental health care disparities (Ault-Brutus & Alegría, 2018; Cook, McGuire, & Miranda, 2007; Lê Cook,
This article was published Online First February 28, 2019. Stacey Kaltman, Department of Psychiatry, Georgetown University
School of Medicine; Maria Rosa Watson and Marcela Campoli, Primary Care Coalition of Montgomery County, Silver Spring, Maryland; Adriana Serrano, Nicholas Talisman, and Laura Kirkpatrick, Department of Psy- chiatry, Georgetown University School of Medicine; Mihriye Mete, MedStar Health Research Institute, Hyattsville, Maryland, and Depart- ment of Psychiatry, Georgetown University School of Medicine; Bon- nie L. Green, Department of Psychiatry, Georgetown University School of Medicine.
Maria Rosa Watson is now an independent consultant, Silver Spring, Maryland. Marcela Campoli is now at Department of Psychiatry, George- town University School of Medicine. Nicolas Talisman is now at Depart-
ment of Psychology, George Washington University. Laura Kirkpatrick is now at Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania.
Funding for this study was provided by the National Institute of Mental Health (Grant R24MH080809; primary investigator: Green). The effort and support of the following individuals is acknowledged: Steve Galen, Elise Riley, Susan Pankratz, Edwin Velis, Marlene Printz, the clinicians and staff at the two study clinics, and additional study interviewers: Karen Orozco, Michelle Pilligua, and Maryen Vemuri.
Correspondence concerning this article should be addressed to Stacey Kaltman, Department of Psychiatry, Georgetown University Medical Cen- ter, 2115 Wisconsin Avenue, NW, Suite 120, Washington, DC 20007. E-mail: [email protected]
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Cultural Diversity and Ethnic Minority Psychology © 2019 American Psychological Association 2019, Vol. 25, No. 4, 579–589 1099-9809/19/$12.00 http://dx.doi.org/10.1037/cdp0000251
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Trinh, Li, Hou, & Progovac, 2017; Safran et al., 2009). Census projections suggest that by 2060, the number of Latina/os in the United States will grow to approximately 119 million, representing 29% of the United States population (Colby & Ortman, 2014). Central and South Americans are the third and fourth largest groups of Latina/os in the United States (López & Patten, 2015).
Immigrants from Central and South America, while understud- ied, may warrant particular focus, given their high level of expo- sure to traumatic experiences (Fortuna, Porche, & Alegría, 2008; Kaltman, Hurtado de Mendoza, Gonzales, Serrano, & Guarnaccia, 2011). Trauma exposure is a significant risk factor for common mental disorders, including depression and posttraumatic stress disorder (PTSD; Hovens et al., 2010; Schell & Marshall, 2008). Further, trauma and PTSD predict medical morbidity (Burg et al., 2017; Schnurr, Wachen, Green, & Kaltman, 2014; Wolf & Schnurr, 2016), and the sequelae of trauma exposure are costly to health care systems (Eekhout, Geuze, & Vermetten, 2016; Walker et al., 2003). PTSD and depression often co-occur; when they do, treat- ment of depression is more complicated and may take longer to achieve remission (Campbell et al., 2007; Green et al., 2006; Hegel et al., 2005).
The research on the mental health of Latina/os in the United States, specifically the prevalence of depression and PTSD, has yielded inconsistent findings in comparisons with non-Latino Whites, with studies alternatively finding higher, lower, and equiv- alent prevalence of disorder (Alegría et al., 2013; González, Tar- raf, Whitfield, & Vega, 2010; Jimenez, Alegría, Chen, Chan, & Laderman, 2010; Pole, Best, Metzler, & Marmar, 2005; Roberts, Gilman, Breslau, Breslau, & Koenen, 2011). This inconsistency may be, in part, derived from the fact that Latina/os are not a singular group, but rather are from diverse countries with different contextual factors and influences (Alegría, Mulvaney-Day, et al., 2007). Complexity is also derived from length of time spent in the United States (Alegría, Mulvaney-Day, et al., 2007; Alegría, Srib- ney, Woo, Torres, & Guarnaccia, 2007). Other factors that have been found to influence the mental health of Latina/os in the United States include: family support and conflict; exposure to discrimination, and perceived neighborhood safety (Alegría, Shrout, et al., 2007; Cook, Alegría, Lin, & Guo, 2009).
One finding that is clear is that Latina/os in the United States experience significant mental health disparities related to access to care and mental health outcomes (Blanco et al., 2007; Cook et al., 2007; Jimenez, Cook, Bartels, & Alegría, 2013; Lê Cook, Man- ning, & Alegría, 2013; McGuire & Miranda, 2008; United States Department of Health and Human Services, 2001). Latina/os are more likely to be uninsured, compared with non-Latino Whites as well as other minority groups (Alegría et al., 2006: DeNavas-Walt, Proctor, & Lee, 2005), and those with a mental disorder are less likely to utilize mental health services. When they do seek care, Latina/os often delay treatment and are more likely to receive inadequate and lower quality care, compared with non-Latino Whites (Alegría et al., 2002; Young, Klap, Sherbourne, & Wells, 2001).
Research suggests that Latina/os in the United States often prefer to seek mental health care for common trauma-related mental disorders in primary care clinics (Eisenman et al., 2008; Kaltman, Hurtado de Mendoza, Gonzales, & Serrano, 2014). There are a number of existing models for integrating mental health care into the primary care setting (Collins, Hewson, Munger, & Wade,
2010; National Council for Behavioral Health, 2003). One specific model with a strong evidence base is the collaborative care model (Katon et al., 1997; Unützer et al., 2002). Collaborative care is a multicomponent, system-level intervention with the goals of facil- itating increased screening and accurate diagnosis, and increased uptake of evidence-based treatment (medications, psychotherapy or both; Bower, Gilbody, Richards, Fletcher, & Sutton, 2006; Katon et al., 1995). In this model, a patient-centered team includes a care manager, often a nurse or social worker, who facilitates communication between the patient, primary care provider, and a consulting psychiatrist. The primary care provider assumes respon- sibility for the patient’s mental health care, the care manager provides supportive services (e.g., assessment, care coordination, regular follow-up contact with the patient, psychoeducation), and a psychiatrist provides consultation to the team via regular meet- ings with the care manager, rarely providing direct service to patients.
Multiple reviews of collaborative care for depression have shown that this specific care delivery model is effective in im- proving depression symptoms, increasing adherence to care, and increasing patient satisfaction (Gerrity, Corson, & Dobscha, 2007; Gilbody, Bower, Fletcher, Richards, & Sutton, 2006; Gilbody, Whitty, Grimshaw, & Thomas, 2003; Neumeyer-Gromen, Lam- pert, Stark, & Kallischnigg, 2004; Sighinolfi et al., 2014; Thota et al., 2012). This is likely due to a number of important character- istics of the collaborative care model, including a patient-centered care team, focus on population-based care, measurement-based treatment to target, evidence-based care, and accountable care (AIMS Center, 2013). Collaborative care is effective in reducing PTSD symptoms as well (Fortney et al., 2015; Meredith et al., 2016).
The collaborative care model holds particular promise for the treatment of uninsured or underinsured populations that do not have access to specialty mental health care. Toward this end, a network of community clinics in the greater Washington, DC metropolitan area began an implementation of collaborative care in 2005. The network of clinics serves an uninsured population, many of whom are underresourced immigrants from Central and South America. A number of adaptations to the collaborative care model were necessitated by characteristics of the target patient population (Kaltman, Pauk, & Alter, 2011). Because of the high level of trauma exposure in the clinic populations, the model included an assessment of trauma exposure as well as multiple disease targets, including depression, PTSD, and generalized anxiety disorder. In addition to the care manager who performs many essential func- tions in a traditional collaborative care program, a family support worker was added to the intervention team to help address pa- tients’ basic needs related to housing, employment, and legal issues, and to increase patient engagement.
The current study was a naturalistic prospective study of this adapted collaborative care program in a primary care clinic that serves primarily poor and uninsured immigrants from Central and South America. The treatment received and mental health out- comes (depression, PTSD) of patients in the adapted collaborative care were compared with those of patients in another network clinic that served a similar patient population and had an on-site therapist (75% of a full time equivalent) to provide mental health services. While several randomized controlled trials have demon- strated the effectiveness of psychotherapy for depression in pri-
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580 KALTMAN ET AL.
mary care (Linde et al., 2015; Schulberg, Raue, & Rollman, 2002), we are unaware of any studies that have examined the real-world effectiveness of having a therapist as part of the clinic staff as a model of care for meeting the mental health needs of the clinic population. It was unclear whether employing a therapist in the absence of the added structure of a psychotherapy trial (e.g., diagnostic rigor, use of manualized treatments) would yield the same results.
The current study was originally designed to compare a clinic with the collaborative care model to a clinic without integrated behavioral health care. At the time of study implementation, how- ever, each clinic in the network had some form of behavioral health treatment available. The clinic with an on-site therapist was chosen as the comparison clinic because of the sharp distinction between the two models of care integration and the similarity between the two patient populations. The clinic with an on-site therapist provided psychotherapy to as many patients as time allowed, using the therapist’s best judgment as to what psycho- therapy strategies to employ. In contrast, the collaborative care clinic had a focus on serving the clinic’s population of patients with depression and/or PTSD. This was done through screening and diagnostic assessment, care management, use of evidence- based interventions, including pharmacotherapy algorithms and behavioral activation (e.g., Dimidjian et al., 2006; Jakupcak, Wag- ner, Paulson, Varra, & McFall, 2010), and frequent symptom assessment to ensure treatment to target.
The study was intended to address the following research ques- tions: (a) were patients in the adapted collaborative care program more likely to achieve improved depression and PTSD outcomes than patients in the clinic with an on-site therapist?, (b) were patients in the adapted collaborative care program more likely to receive satisfactory care than patients in the clinic with an on-site therapist?, and (c) what additional factors were associated with improved depression and PTSD at both clinic sites? We hypoth- esized that patients in the collaborative care program would be both more likely to experience improved depression and PTSD outcomes and to receive satisfactory care as compared with pa- tients in the clinic with an on-site therapist.
Method
Study Design
This study identified patients with presumptive depression in two primary care clinics that serve uninsured patients with the two models of service delivery described above. Study participants were assessed at baseline and then again at approximately eight months. A comprehensive chart review identified treatment that occurred in the interval between the two assessments.
Setting
The study was conducted in partnership with two primary care clinics in the same clinic system that serves low-income, uninsured communities in the greater Washington, DC metropolitan area. The majority of patients served by the two clinics were monolin- gual Spanish-speaking immigrants. The collaborative care clinic served approximately 2,700 unduplicated patients per year and the on-site therapist clinic served approximately1,200 patients.
Participants
Participants were a convenience sample of patients receiving primary care, between the ages of 18 –70, who met presumptive criteria for depression based on having a Patient Health Questionnaire-9 (PHQ-9; Kroenke, Spitzer, & Williams, 2001) score �10, the cutoff for a moderate level of symptoms. Ex- clusion criteria included: (a) apparent incoherence, disorienta- tion, or other impaired mental status at the time of recruitment; (b) documented substance abuse or dependence within the last 6 months; (c) bipolar disorder or schizophrenia; and (d) suicidal intent at the time of recruitment.
A total of 681 patients were screened over a period of 7 months. Of these, 278 (41%) screened positive on the Patient Health Questionnaire-2 (PHQ-2). Of those who screened positive with the PHQ-2, 260 consented to participate in the study and be screened further with the PHQ-9. One hundred ninety-eight met depression inclusion criteria based on baseline PHQ-9 assessment, of which five patients were deemed ineligible due to cognitive impairment, other serious mental illness (e.g., schizophrenia, bipolar disorder), or having previously participated in the study.
There was a significant difference in the baseline depression screen-in rate by clinic, with 48.5% screening positive at the on-site therapist clinic and 35.8% at the collaborative care clinic (�2(1) � 10.95, p � .0001). With 55 participants lost to follow up, the final sample, with baseline and follow-up data, comprised 138 participants (72% follow up rate). Ten of these individuals had missing data for the follow-up assessment of PTSD.
Individuals lost to follow up were more likely to be male (�2(1) � 6.31, p � .05), never married (�2(3) � 17.07, p � .01), and employed (�2(2) � 25.76, p � .0001). Those lost to follow up also had higher PHQ-9 scores, t(191) � 2.03, p � .05. Although statistically significant, the difference represented only a 1.2-point difference on the PHQ-9. Those lost to follow up did not differ by clinic on demographics or baseline values.
The average age of the sample of 138 participants was 47.6 (SD � 12.2) years. More than 80% (84.8) were women, and 51.4% were married/living with a partner. The majority of the sample was Latina/o (94.2%) and 89.9% were monolingual Spanish speakers. Of those who were foreign-born (94.2%), 66.2% had been in the United States 10 years or more. The most frequently represented countries of origin were: El Salvador (40.6%), Guatemala (18.1%), Honduras (8.0%) and Mexico (8.0%). Sixty percent had completed less than a high school education and 58.0% were working part- or full-time. Table 1 presents participant demographics by clinic. Participants in the on-site therapist clinic were significantly more likely to be women, married/living together, foreign-born, and Latina/o than those in the collaborative care clinic, which served a slightly more diverse immigrant population.
Procedures
Patients were approached in clinic waiting rooms by bilingual/ bicultural research assistants and asked for verbal assent to be screened for a study; once in a more private section of the recep- tion area, the study goals were described. Patients who agreed were screened in Spanish or English, as preferred, using the PHQ-2 (Kroenke, Spitzer, & Williams, 2003) to determine preliminary eligibility. Patients who scored �4 were invited to participate further. A formal informed consent process included permission
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581TREATMENT OF DEPRESSION AND PTSD
for both baseline and follow-up interviews and a medical record review. Patients were administered a baseline interview that con- firmed eligibility using the PHQ-9 and included assessments of demographic variables, trauma exposure, and PTSD symptoms. Most participants chose the Spanish version of the assessments and were interviewed by bilingual/bicultural research assistants. If patients continued to meet study criteria for presumptive depres- sion at the baseline assessment, defined as a PHQ-9 score �10, their primary care providers were informed of the assessment results related to depression and PTSD symptoms for appropriate follow-up and provision of services.
For the follow-up assessment, participants were contacted by phone to schedule a telephone assessment an average of 8.2 (SD � 1.6) months following their baseline interviews, and follow-up timeframe did not differ significantly by clinic. The target time frame for the follow-up assessment was 6–9 months. This window was chosen to allow sufficient time for the interventions to have a sustained impact, and to reach as many participants as possible, given the mobility of the patient population. Participants were compensated with a $20 gift card to a local grocery store for each assessment completed. The Georgetown University Institutional Review Board and the primary care clinics’ review committees approved all study procedures.
At the time of the study, both clinics were in a transition phase from a paper record to an electronic health record. A clinic ad- ministrator from each site extracted data from the clinic’s elec- tronic health record based on a list of variables related to mental health treatment during the study period. Data were then linked to participants’ study IDs and given to the research team with per- sonal identifiers removed. For the collaborative care clinic, a study team member was also able to review that program’s additional records for collaborative care specific activities. This component of the data collection occurred at the time of the follow-up inter- view.
Because the treatment models at the two clinics were distinct in scope and in services offered, a strategy was needed to be able to compare the adequacy of care regardless of the treatment model. Thus, we defined satisfactory care separately for each clinic, in line with its treatment model. For the collaborative care clinic, satisfactory care was defined as participation in the collaborative care program—evidenced by an intake evaluation, presentation in the team meeting, and one or more services, including medication
management, therapy, and/or follow-up assessment. Individuals treated with antidepressant medication for at least 2 months out- side of the collaborative care program, a practice that some of the providers were comfortable with given their ongoing participation with the collaborative care program, were also deemed to meet the threshold of satisfactory care. For the on-site therapist clinic, satisfactory care for therapy was defined as having three or more sessions—based on a meta-analysis that suggested that brief psy- chotherapy for depression and anxiety in primary care could be effective when delivered in as few as three sessions (Cape, Whit- tington, Buszewicz, Wallace, & Underwood, 2010). For both sites, a course of antidepressant medication of at least 2 months was selected based on patient distribution, with at least 75% of those who took medications having taken it for at least 2 months, a reasonable amount of time for the medication to have an effect.
Measures
All assessments were administered in an interview format. This was done to maximize understanding by participants regardless of literacy level. Demographic variables included: age, gender, edu- cation level, marital status, employment status, self-reported in- come, country of origin, and years living in the United States.
Current depression symptoms were assessed using the PHQ-9, a brief assessment of depression typically used in primary care settings (Kroenke et al., 2001). The PHQ-9 has adequate reliabil- ity, convergent validity, discriminant validity, and sensitivity to change (Cameron, Crawford, Lawton, & Reid, 2008; Kroenke et al., 2001; Löwe, Kroenke, Herzog, & Grafe, 2004; Martin, Rief, Klaiberg, & Braehler, 2006). The reliability and validity of the Spanish version of the PHQ-9 has also been previously established (Diez-Quevedo, Rangil, Sanchez-Planell, Kroenke, & Spitzer, 2001; Wulsin, Somoza, & Heck, 2002). Presumptive depression was defined by a score �10. Cronbach’s alpha for this sample was 0.45.
Trauma exposure was assessed with a set of five questions that addressed whether the patient had been exposed to physical vio- lence, sexual violence, emotional abuse, had witnessed violence, or experienced any other extreme situation not covered by the previous questions. An example of a question is “Have you ever been physically attacked, like being hit, kicked, or beaten up?” The questions were already being utilized by the collaborative care
Table 1 Demographic Characteristics by Clinic
Variable Collaborative care
clinic (n � 65) On-site therapist clinic (n � 73)
Age in years, M (SD) 47.7 (12.8) 47.6 (11.8) Gender: Female, n (%) 50 (76.9) 67 (91.8)�
Marital status: Married/living together, n (%) 23 (35.4) 48 (65.8)�
Ethnicity: Latina/o, n (%) 58 (89.2) 72 (98.6)��
Nativity: Foreign born, n (%) 58 (89.2) 72 (98.6)�
Time in United States: Less than 10 years, n (%) 23 (35.4) 21 (28.8) Education: Less than high school education, n
(%) 36 (55.4) 47 (64.4)
Employment status: Employed full- or part-time, n (%)
37 (56.9) 43 (58.9)
� p � .01. �� p � .001.
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clinic as part of the ongoing program’s intake evaluation (Kaltman, Pauk, et al., 2011). The emotional abuse question was added based on prior research with the same immigrant community, which highlighted the frequency of this type of exposure (Kaltman, Hurtado de Mendoza, et al., 2011). This measure was pilot tested with patients in the same study clinics using standard cognitive testing techniques to ensure comprehension by the target patient population. If the participants answered one or more of the trauma exposure questions in the affirmative, they were considered trauma exposed and were assessed for PTSD symptoms.
Current PTSD symptomatology was evaluated with the PTSD Checklist for DSM–IV (PCL, Weathers, Litz, Herman, Huska, & Keane, 1993) among only those participants who endorsed at least one trauma exposure. Respondents rated how much they were bothered in the past month by each of the PTSD symptoms included in the Diagnostic and Statistical Manual of Mental Dis- orders (4th ed.; DSM–IV; American Psychiatric Association, 1994) diagnosis on a 5-point Likert-type scale ranging from 1 (Not at all) to 5 (Extremely). The PCL has good reliability with struc- tured interviews for PTSD (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996). It has been used in studies of Latina/o immi- grants (Eisenman, Gelberg, Liu, & Shapiro, 2003) and a psycho- metric study demonstrated general measurement equivalence across English- and Spanish-language versions (Marshall, 2004). Pre- sumptive PTSD was defined by a score �30 (Veterans Affairs (VA) National Center for PTSD, 2014. Change in PTSD symp- toms from baseline to follow-up assessment was measured using a subset of six PCL items with good sensitivity and specificity with the longer version, and high correlations with the longer total score (Lang & Stein, 2005). Cronbach’s alpha for this sample was 0.87 for the full PCL and 0.67 for the PCL-6.
A comprehensive chart review was completed for all patients included in the follow-up data set, employing the electronic med- ical record (EMR) of each clinic. The chart data abstraction was implemented by an EMR officer at each clinic organization at the time of the follow-up telephone interview and spanned 1 year prior to that time, to include the baseline phase of the study. The variables collected included: medical visits, behavioral health vis- its, psychotropic medications utilization, and medical conditions. Data specific to the collaborative care program were also collected, including intake evaluation, presentation at the team meeting with the consulting psychiatrist, medication management, reassessment of depression and/or PTSD symptoms, and visits with the family support worker. EMR data were available for 98% of the patients in the final sample, with three patients not having available chart data for review.
Data Analysis
Data collected in person at the onset of the study, via a computer-assisted phone interview at 8-month follow up, and via medical record abstraction were joined together into a spreadsheet where data were deidentified and password protected. Personal identifiers with the corresponding study identification number were stored separately in a locked cabinet. The deidentified patient data were imported into Stata 14 (StataCorp, 2015) for statistical analysis.
T-test comparisons of means (for continuous variables) for two independent groups and frequency distribution Pearson chi-square
(for categorical variables) were conducted to compare sociodemo- graphic and mental health variables at baseline. Analyses also compared (a) the final sample that completed follow up to the sample of participants lost to follow up, and (b) the patients in the two clinic sites.
For each of the outcome measures studied (i.e., PHQ-9 and PCL-6), independent-samples t tests were used to compare the clinics at baseline. The differences between the clinics over time were estimated for each outcome measure using linear mixed models, which included: a dummy variable for time, a dummy variable for clinic, and their interaction. These models were also adjusted by age, trauma experienced between baseline and follow up, and satisfactory care. Predicted margins were computed for each model to illustrate the differences over time and between clinics. The PTSD model was conducted on the 91 patients that met criteria for PTSD at baseline. Ten of these participants had missing data for PTSD at follow up. This was due to an error in procedures that happened periodically through the study. We were unable to find anything systematic to explain why this happened (i.e., it was unrelated to time within the study, interviewer, etc.).
Results
Table 2 presents baseline and follow-up levels of depression and PTSD. No statistically significant differences between the clinics were observed on these variables at baseline. At baseline, the mean depression score for participants in both clinics fell within the upper limits of the moderate depression range on the PHQ-9 (moderate depression is defined as a score of 10–14). At follow up (see Table 2), 73.9% of participants in the collaborative care clinic and 68.5% in the on-site therapist clinic had reached the target of a PHQ-9 score �9 (odds ratio [collaborative care vs. on-site therapist] � 1.30, 95% CI [0.62, 2.73]).
Levels of trauma exposure were high, with 83.3% of partici- pants (n � 115) reporting one or more exposures. The most frequently reported trauma exposure was physical violence (51.5%), followed by emotional abuse (42.8%), sexual violence
Table 2 Baseline and Follow-Up Levels of Depression and PTSD by Clinic
Variables Collaborative care
clinic (n � 65) On-site therapist clinic (n � 73)
t test (rank sum) p value
PHQ-9 score Baseline 14.8 (3.6) 14.8 (4.1) .91 Follow up 5.9 (6.1) 7.2 (5.3) .20�
Full PCL score Baselinea 46.4 (14.2) 44.4 (15.1) .47
PCL-6b
Baseline 19.1 (4.7) 19.1 (4.4) .98 (n � 44) (n � 47)
Follow up 12.4 (5.9) 14.7 (5.5) .07�
(n � 38) (n � 43)
Note. PTSD � posttraumatic stress disorder; PHQ � Patient Health Questionnaire; PCL � PTSD Checklist for DSM–IV. a Full PCL scores are reported for participants reporting trauma exposure, n � 115. b PCL-6 scores are reported for participants meeting criteria for PTSD at baseline, n � 91. � p value of p � .05 based on nonparametric test.
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(34.8%), and witnessed violence (33.3%). It is noteworthy that 80 participants (58.0%) reported experiencing an extreme situation not covered by the specific exposures surveyed. Fifty-three par- ticipants (81.5%) at the collaborative care clinic and 62 partici- pants (84.9%) at the on-site therapist clinic reported exposure to trauma. Forty-four participants (67.7%) at the collaborative care clinic and 47 participants (64.4%) at the on-site therapist clinic met the cutoff for presumptive PTSD in civilian primary care clinics (score of 30 or higher; VA National Center for PTSD, 2014). For later/multivariate analyses, those without trauma exposure were excluded from PTSD analyses.
Table 3 presents treatment received by participants at each clinic, including medication only (2 months), three or more ther- apy visits, collaborative care services, and combinations of care. Significantly more participants in the collaborative care clinic received satisfactory care than at the on-site therapist clinic. Forty- eight percent of participants in the collaborative care clinic and 25.4% of the on-site therapist clinic received satisfactory care (�2(1) � 7.76, p � .01) as defined for their respective clinics.
In the multivariate model of PHQ-9 scores over time (Table 4), statistically significant effects were observed for time (an average decrease of 7.5, 95% CI [�8.8, �6.2]), new trauma exposure during the study period (higher average PHQ-9 by 2.2 for those with a new trauma experience, 95% CI [0.55, 3.86]), and having PTSD at the onset of the study (higher average PHQ-9 by 2.2 for those with PTSD at baseline, 95% CI [0.85, 3.55]). No effects were
observed for clinic or having received satisfactory care. No other interactions, including the Time � Clinic interaction, were statis- tically significant.
In the multivariate model of PCL-6 score over time, statistically significant effects were observed for age (average decrease in PCL-6 score for each year by 0.07, 95% CI [�0.14, �0.00]) and having moderate/severe depression (higher PCL-6 score by 4.5, 95% CI [3.0, 6.1]). The Time � Clinic interaction was significant (p � .006), with predictive margins indicating that patients in the collaborative care clinic experienced greater symptom reductions over time; that is a decrease of 2.0 in the PCL-6 score in the on-site therapist clinic (95% CI [�3.8, �0.2]) compared with a decrease of 5.2 in the collaborative care clinic (95% CI [�7.0, �3.4]), which resulted in a statistically lower follow-up PCL-6 mean score for the collaborative care clinic by 2.6 units (95% CI [�4.71, �0.53]). No other interactions tested were statistically significant (Table 4).
Discussion
This study was a naturalistic prospective evaluation of a collab- orative care program treating depression and PTSD in a clinic that serves uninsured patients, primarily immigrants from Central and South America. Receipt of treatment and mental health outcomes (depression and PTSD symptoms) among patients with depression in a clinic with a collaborative care program were compared with those of patients in a clinic with an on-site 75% of a full time equivalent therapist available. Patients at both study clinics, on average, experienced a significant decrease in depression and PTSD symptoms between the baseline and follow-up assessments. This finding is similar to a recent randomized controlled trial of collaborative care for PTSD in an underserved patient population (Meredith et al., 2016), in which patients in both the collaborative care arm and the “enhanced care as usual” arm improved.
At the follow-up assessment, more than 70% of participants at both clinics had a PHQ-9 score of less than 10 (73.9% of partic- ipants in the collaborative care clinic, 71.01% in the on-site ther- apist clinic), the treatment target typically used by collaborative care programs: a very positive outcome. This result is noteworthy, given the setting of underresourced clinics and the mostly unin- sured and impoverished patient population. Improvement in de-
Table 3 Treatment Received by Participants With Chart Review Data by Clinic
Variable Collaborative care
clinic (n � 64) On-site therapist clinic (n � 71)
Less than satisfactory care, n (%) 33 (51.6) 53 (74.6) Satisfactory care, n (%) 31 (48.4) 18 (25.4) Types of treatment received, n (% proportion of clinic total)
Medications only 3 (4.7) 6 (8.5) Collaborative care 17 (26.6) N/A Therapy only N/A 11 (15.5) Combined treatment 11 (17.2) 1 (1.4)
Note. N/A � not applicable.
Table 4 Linear Mixed Models Changes in Depression and PTSD
Variable PHQ-9 coefficient (95% CI) PCL-6 coefficient (95% CI)
Age �.02 [�.07, .03] �.07 [�.14, .00] New trauma 2.20 [.55, 3.55]�� �.19 [�2.20, 1.81] PTSD (baseline) 2.20 [.85, 3.55]��� N/A Depression (baseline) N/A 4.52 [2.96, 6.08]���
Received satisfactory care .83 [�.51, 2.17] �.17 [�1.84, 1.50] Time �7.49 [�8.82, 6.16]��� �1.98 [�3.77, �.19]]�
Clinic .02 [�1.54, 1.59] .58 [�1.41, 2.58] Time � Clinic �1.54 [�3.47, .39] �3.21 [�5.51, �.90]��
N observations 270 166 Wald �2(df) 311.2 (7) 135.85 (7) p value �.001 �.001
Note. PTSD � posttraumatic stress disorder; PHQ-9 � Patient Health Questionnaire; PCL-6 � PTSD Checklist for DSM–IV; CI � confidence interval; N/A � not applicable. � p � .05. �� p � .01. ��� p � .001.
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pression was not associated with clinic site/model, suggesting that both treatment models were effective.
The receipt of satisfactory care was not associated with im- provement in depression over time. However, significantly more participants in the collaborative care clinic received satisfactory care. This is similar to a recent study of collaborative care for depression for Latina/os in public-sector primary care clinics, which found that patients in the collaborative care arm were more likely to receive psychotherapy or antidepressant medication treat- ment than those in the enhanced usual care arm (Lagomasino et al., 2017). Services in the collaborative care clinic also tended to be more comprehensive, consistent with the treatment model there, as compared with the on-site therapist clinic, where patients tended to receive either therapy or medications, but rarely both. There are several possibilities as to why the receipt of satisfactory care did not confer better depression outcomes. First, the definition of satisfactory care, based on the relatively low levels of care ren- dered to this uninsured population, may not have been the right standard. However, other studies have found sustained effects for brief behavioral interventions in primary care clinics (Kaner et al., 2007; Ray-Sannerud et al., 2012), and additional research suggests that the greatest improvements in mental health interventions occur early in treatment (Haas, Hill, Lambert, & Morrell, 2002; Stiles et al., 2003). Second, it is possible that the added personal attention provided by a compassionate research staff member during the relatively intensive baseline assessment may have con- tributed to patient healing, again minimizing group differences. Third, a number of cases of depression may have resolved on their own, consistent with the cyclic nature of the disorder (Burcusa & Iacono, 2007).
Of note, more than half of the patients in both clinics received either no care or a level of care below the defined threshold of satisfactory care (52.3% in the collaborative care clinic and 72.6% in the on-site therapist clinic). This is consistent with a recent study of the reach of interventions that integrate behavioral health into primary care. In that study of 11 practices with integrated care models with a total of 24,906 patients, 41% of eligible patients received integrated services (Balasubramanian et al., 2015). The low level of care received in our clinics may be due to patient factors such as refusal or patients not being able to work within the clinic’s schedule for treatment, a realistic concern for the working poor. In addition, providers may have recommended a watch-and- wait approach prior to initiating care, or they may not have been able to address the identified mental health concern among the host of other health concerns that patients frequently present. Finally, especially within the on-site therapist clinic, there were capacity issues that may have prevented patients from having a thorough mental health evaluation or accessing mental health care.
A high level of exposure to potentially traumatic events was observed in this study. More than 80% of participants in both clinics reported exposure to one or more of the potentially trau- matic events assessed. Among general primary care populations, studies have found a prevalence of trauma exposure between 57 and 88% (Alim et al., 2006; Gillespie et al., 2009; Holman, Silver, & Waitzkin, 2000; Liebschutz et al., 2007; McQuaid, Pedrelli, McCahill, & Stein, 2001; Norman et al., 2006), with studies of urban poor samples yielding the higher estimates. For the depres- sion outcome, experiencing additional trauma during the study period was associated with worse outcomes, which is not surpris-
ing, given the strong relationship between trauma exposure and a range of negative mental health outcomes (Creamer, Burgess, & McFarlane, 2001; Hovens et al., 2010; Kessler et al., 1999; Schell & Marshall, 2008). This finding highlights the importance of screening for trauma exposure in primary care.
Comorbid PTSD was observed in 68% of patients in the col- laborative care clinic and 64% in the on-site therapist clinic. Other studies have found the prevalence of PTSD among patients with depression to be closer to one third (Campbell et al., 2007; Gerrity et al., 2007; Green et al., 2006), much lower than what was observed in this sample. The higher prevalence of PTSD observed here is not surprising, given the high level of trauma exposure experienced by impoverished immigrants from Central and South America. Identifying and treating PTSD alongside depression is important because PTSD has been shown to complicate and lengthen the treatment of depression (Green et al., 2006; Hegel et al., 2005).
On average, patients in both clinics saw significant improve- ments in their PTSD symptoms. In contrast to the findings for depression, however, and consistent with the study hypothesis, patients in the collaborative care clinic evidenced more improved PTSD symptoms than those in the on-site therapist clinic. This finding suggests that for patients with comorbid depression and PTSD, the collaborative care model, especially one including a trauma focus, may result in improved outcomes.
A further finding of interest was the significantly differential screen-in rate observed in the two clinics: more participants in the on-site therapist clinic (48.5%) screened positive for depression than those in the collaborative care clinic (35.8%). One possible explanation for this finding given the roughly similar patient populations served by the two clinics is that more patients in the collaborative care clinic had already been identified and treated successfully for depression. Outreach screening is an important part of a collaborative care model and this result provides support for this systemic approach, which may identify more patients in need of care than other models of integrated care. However, other explanations (e.g., chance sampling differences) could account for the same finding, so further study is warranted.
As mentioned earlier, this sample also had a high proportion of patients with various chronic medical conditions (77%), which have the potential to impact mood and overall quality of life. Although this study did not focus on the relationship between mental health and coexisting chronic diseases, future studies should explore baseline depression levels and outcome improve- ment in relationship to conditions that impair general health.
Some study limitations warrant mention. First, only one clinic with each treatment model was evaluated. A study with multiple clinics randomized to each treatment model would allow for more rigorous analysis and generalizable findings. Second, this study was originally designed to compare a collaborative care program to a clinic without mental health services. However, this was not feasible by the time of study implementation. Fortunately for the patients, there were no longer any potential comparison clinics that did not have some component of mental health treatment. Third, both clinics were implementing electronic health records during the study period, increasing the likelihood that some treatment data may have been missing (missing data would most likely be ran- dom). The medical record review was also challenged by a lack of systematic and consistent documentation in the records. Fourth,
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there was a 28% loss to follow up and those lost to follow up differed in important ways from the original sample. However, given the multistage consenting process and multiple contacts required to participate in the study, we were encouraged that 72% of those recruited were able to fully participate. This rate of retention was similar to other studies of collaborative care pro- grams (Meredith et al., 2016).
In conclusion, this prospective study adds to the literature on integrating behavioral health into primary care, and specifically the collaborative care model, by examining the impact of a community- implemented collaborative care program for a particularly vulner- able and understudied patient population that is uninsured and ineligible for federally funded health programs. Our results suggest that both treatment models were effective for both depression and PTSD within a context of screening for these disorders. The similarity in findings in this study across the two treatment models does not provide support for adoption of one treatment model over the other. Clearly further research is needed. An additional re- search question for future studies could examine the costs of the two models as well as their cost effectiveness.
Our study did find added benefits of the collaborative care model for those patients with PTSD and appeared to be more effective in identifying patients in need of care. Key characteristics of the collaborative care model, including outreach screening, a focus on population management, and measurement-based treat- ment to target, as well as the adaptations made to the collaborative care program specific to this patient population, may all work together toward ameliorating the disparities that underserved groups such as Latina/o immigrants in the United States experi- ence with regard to access to and quality of mental health services.
Given the level of need for mental health care, particularly among uninsured and underserved patient populations, it is imper- ative to continue the discussion regarding the best models of integrated care and processes for identifying and treating common mental disorders in primary care, including trauma-related out- comes. Understanding the relationship between characteristics of the target patient population and the services offered, particularly with an understanding of the level of care needed to achieve an impact, will be important to support mental health care that is accessible, relevant, and effective.
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589TREATMENT OF DEPRESSION AND PTSD
- Treatment of Depression and PTSD in Primary Care Clinics Serving Uninsured Low-Income Mostly Lat ...
- Method
- Study Design
- Setting
- Participants
- Procedures
- Measures
- Data Analysis
- Results
- Discussion
- References
