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A Randomized Trial of Collaborative Depression Care in Obstetrics and Gynecology Clinics: Socioeconomic Disadvantage and Treatment Response
Wayne Katon, M.D.; Joan Russo, Ph.D.; Susan D. Reed, M.D., M.P.H.; Carmen A. Croicu, M.D.; Evette Ludman, Ph.D.; Anna LaRocco, M.S.W., M.P.H.; Jennifer L. Melville, M.D., M.P.H.
Am J Psychiatry 2014;:. doi:10.1176/appi.ajp.2014.14020258
View Author and Article Information

The authors report no financial relationships with commercial interests.

Supported by NIMH grant R01-MH085668.

Clinicaltrials.gov identifier: NCT 01096316.

From the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle; the Departments of Obstetrics and Gynecology and Psychiatry and Behavioral Sciences, Harborview Medical Center, Seattle; Northwest Women’s Healthcare, Seattle; and Group Health Research Institute, Seattle.

Address correspondence to Dr. Katon (wkaton@uw.edu).

Copyright © 2014 by the American Psychiatric Association

Received February 27, 2014; Revised April 30, 2014; Revised June 06, 2014; Accepted June 16, 2014.

Abstract

Objective  The authors evaluated whether an obstetrics-gynecology clinic-based collaborative depression care intervention is differentially effective compared with usual care for socially disadvantaged women with either no health insurance or with public coverage compared with those with commercial insurance.

Method  The study was a two-site randomized controlled trial with an 18-month follow-up. Women were recruited who screened positive (a score of at least 10 on the Patient Health Questionnaire–9) and met criteria for major depression or dysthymia. The authors tested whether insurance status had a differential effect on continuous depression outcomes between the intervention and usual care over 18 months. They also assessed differences between the intervention and usual care in quality of depression care and dichotomous clinical outcomes (a decrease of at least 50% in depressive symptom severity and patient-rated improvement on the Patient Global Improvement Scale).

Results  The treatment effect was significantly associated with insurance status. Compared with patients with commercial insurance, those with no insurance or with public coverage had greater recovery from depression symptoms with collaborative care than with usual care over the 18-month follow-up period. At the 12-month follow-up, the effect size for depression improvement compared with usual care among women with no insurance or with public coverage was 0.81 (95% CI=0.41, 0.95), whereas it was 0.39 (95% CI=–0.08, 0.84) for women with commercial insurance.

Conclusions  Collaborative depression care adapted to obstetrics-gynecology settings had a greater impact on depression outcomes for socially disadvantaged women with no insurance or with public coverage compared with women with commercial insurance.

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FIGURE 1. Depression Outcomes Over 18-Month Follow-Up for Women Receiving a Collaborative Care Intervention or Usual Care, by Insurance Statusa

a HSCL-20=Hopkins Symptom Checklist 20-item depression scale.

*p<0.001. **p<0.01.

FIGURE 2. Differences in Percent of Patients With ≥50% Reduction in Depression Score From Baseline Over 18-Month Follow-Up, Between Women Receiving a Collaborative Care Intervention and Those Receiving Usual Care, by Insurance Statusa

a HSCL-20=Hopkins Symptom Checklist 20-item depression scale. Differences were computed as percent of patients in the intervention group with a reduction of at least 50% in depression score from baseline minus percent of patients in the usual-care group with such a reduction.

FIGURE 3. Differences in Percent of Patients Reporting “Much Improved” or “Very Much Improved” From Baseline Over 18-Month Follow-Up, Between Women Receiving a Collaborative Care Intervention and Those Receiving Usual Care, by Insurance Statusa

a Improvement ratings were assessed with the Patient Global Improvement Scale. Differences were computed as percent of patients in the intervention group reporting this level of improvement minus percent of patients in the usual-care group reporting this level of improvement.

Anchor for Jump
TABLE 1.Baseline Demographic and Clinical Characteristics of Women Receiving a Collaborative Care Intervention or Usual Care, by Insurance Status
Table Footer Note

a Depression, dysthymia, and panic disorder were diagnosed with the Mini International Neuropsychiatric Interview.

Anchor for Jump
TABLE 2.Quality of Care and Clinical Outcomes Among Women Receiving a Collaborative Care Intervention and Those Receiving Usual Care, by Insurance Statusa
Table Footer Note

a HSCL-20=Hopkins Symptom Checklist 20-item depression scale.

Table Footer Note

*p<0.05. **p<0.01. ***p<0.001.

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