Context Impoverished minority women experience a higher burden from depression
than do white women because they are less likely to receive appropriate care.
Little is known about the effectiveness of guideline-based care for depression
with impoverished minority women, most of whom do not seek care.
Objective To determine the impact of an intervention to deliver guideline-based
care for depression compared with referral to community care with low-income
and minority women.
Design, Setting, and Participants A randomized controlled trial conducted in the Washington, DC, suburban
area from March 1997 through May 2002 of 267 women with current major depression,
who attended county-run Women, Infants, and Children food subsidy programs
and Title X family planning clinics.
Outcomes Hamilton Depression Rating Scale measured monthly from baseline through
6 months; instrumental role functioning (Social Adjustment Scale) and social
functioning (Short Form 36-Item Health Survey) measured at baseline and 3
and 6 months.
Interventions Participants were randomly assigned to an antidepressant medication
intervention (trial of paroxetine switched to bupropion, if lack of response)
(n = 88), a psychotherapy intervention (8 weeks of manual-guided cognitive
behavior therapy) (n = 90), or referral to community mental health services
(n = 89).
Results Both the medication intervention (P<.001)
and the psychotherapy intervention (P = .006) reduced
depressive symptoms more than the community referral did. The medication intervention
also resulted in improved instrumental role (P =
.006) and social (P = .001) functioning. The psychotherapy
intervention resulted in improved social functioning (P = .02). Women randomly assigned to receive medications were twice
as likely (odds ratio, 2.04; 95% confidence interval, 0.98-4.27; P = .057) to achieve a Hamilton Depression Rating Scale score of 7
or less by month 6 as were those referred to community care.
Conclusions Guideline-concordant care for major depression is effective for these
ethnically diverse and impoverished patients. More women engaged in a sufficient
duration of treatment with medications compared with psychotherapy, and outcome
gains were more extensive and robust for medications.