1. Home>
2. Specialties>
3. Psychiatry>
4. Summary and Comment

Depression Treatments Work in Disadvantaged Patients

Antidepressants and CBT prove effective for low-income minority women who also receive help in overcoming logistical and psychological barriers to care.

We do not know whether depression treatments, tested as efficacious among largely middle-income, white patients, are also effective in low-income, minority populations that may receive worse mental healthcare and among whom depression may be more prevalent and severe. In a landmark 6-month study, 267 young, low-income, minority women were randomized to receive nurse-supervised paroxetine treatment, psychotherapist-delivered cognitive-behavioral therapy, or facilitated referral to community mental healthcare services (controls).

Women were recruited from community social-service and healthcare programs for low-income pregnant and postpartum women and their young children. To engage the active-treatment group in care, researchers conducted intensive outreach (9-10 telephone calls/person) and provided subsidies for transportation and child care. Although only 17% of controls attended one community care appointment and 9% attended 4 appointments, 75% of the paroxetine group received guideline-concordant medication treatment and 45% of CBT patients underwent at least 4 CBT sessions. Compared with the control condition, medication (at 3 and 6 months) and CBT (at 6 months) significantly reduced depressive symptoms and improved social functioning; medication improved instrumental-role functioning at 6 months. Medication was superior to CBT for improving symptoms and functioning at 6 months, although only measures of functioning were significantly different in a post-hoc analysis of those who received quality care. Approximately half of the participants had post-traumatic stress disorder, but PTSD diagnosis was unrelated to outcome.

Comment: These results document the effectiveness of antidepressant treatments in low-income, minority women who receive help in overcoming logistical and psychological barriers to care. Paroxetine may have been superior to CBT because medication took less time to administer or because nurses were better at outreach than therapists were. The extremely low utilization of community care by controls, even after study personnel made appointments and encouraged attendance, suggests that the poor quality of care among disadvantaged populations results from multiple barriers to care, not just lack of insurance. Sampling from the community rather than from established primary care clinics is novel and suggests the benefits of further community-oriented treatment studies.

— Peter Roy-Byrne, MD

Published in Journal Watch Psychiatry September 3, 2003

Citation(s):

Miranda J et al. Treating depression in predominantly low-income young minority women: A randomized controlled trial. JAMA 2003 Jul 2; 290:57-65.

• Original article (Subscription may be required)
• Medline abstract (Free)