Participants were randomly assigned an antidepressant, psychotherapy, or referral to a community mental health service provider. "Structured care reduces major depression in these diverse and impoverished patients," said lead author Jeanne Miranda, Ph.D., University of California at Los Angeles Neuropsychiatric Institute. "This study broadens the knowledge base by evaluating depression treatments among young, predominantly minority women. It is the first study to let providers know that treating depression in this population can significantly improve the ability of these women to feel and function."
Results show that low-income women in minority populations benefit from depression treatment when it is paired with intensive outreach and encouragement to support the interventions. Not only did women achieve lower levels of depressive symptoms, but they also gained higher levels of functioning in daily life.
Outreach support¾ including transportation, child care, and spending considerable time to gain the trust of these participants¾was an essential part of the study. Miranda and colleagues screened thousands of women for ethnicity, major depression, and exclusionary factors while they attended Women, Infants, and Children food subsidy programs and family planning clinics in four suburban counties near Washington, D.C.
Three cultural groups were recruited. Of the 276 women who met criteria, consented to treatment, and were randomized in the trial, 117 were black women, 134 were Latina women, and 16 were white women. The median age was 29.3, 60 percent lived at or below the federal guidelines for poverty, and 37.1 percent had not graduated from high school. The women had experienced extremely high rates of trauma exposure, including rape, child abuse, and domestic violence. High rates of post-traumatic stress disorder were also found.
Each month for six months, participants completed a version of a standard psychiatric measuring tool to compare depression symptom and functioning scores over time.
Women assigned to medication were treated with paroxetine for 6 months. If a patient did not tolerate the antidepressant or show a significant response, buproprion, an antidepressant with a different medical profile, was prescribed. Women assigned to psychotherapy were treated by experienced psychotherapists in 8 weekly cognitive behavioral therapy (CBT) sessions. The treatments were most often provided in or near the county clinic where the women were identified. CBT taught participants techniques to manage mood, disprove thinking that may keep them depressed, engage in pleasant activities, reverse self-defeating beliefs, and get social support from others.
Medications and psychotherapy were both significantly more effective in decreasing depressive symptoms than the community referral sample, which received little treatment. With community referral, researchers made appointments for care, but very few women attended the sessions.
Medications were more effective than no treatment at 6 months for reducing patients' depressive symptoms, improving home and work life, and increasing their ability to get along with others and engage in social activities. Psychotherapy was more effective than no treatment at 6 months for decreasing depressive symptoms and relating to others, but it did not improve home and work life.
The 88 women in the medication group were twice as likely as those referred to community care to achieve a significant reduction on depression rating scale scores.
Researchers believe that without outreach involving education, encouragement to comply with treatment, transportation, and childcare, few poor women are likely to receive appropriate depression treatment. Results suggest that treating depression in this population improves the functioning of these young women if they have tools to overcome barriers to care and receive treatment services.
NIMH is part of the National Institutes of Health (NIH), the Federal Government's primary agency for biomedical and behavioral research. NIH is a component of the U.S. Department of Health and Human Services.
Journal
JAMA