In work published in the July 2 issue of the Journal of the American Medical Association, the researchers found that medication and cognitive behavioral psychotherapy (CBT) treatments are effective options for young Latinas and African-American women. The study was funded by the National Institute of Mental Health; the principal investigator was Jeanne Miranda, Ph.D., previously at Georgetown and now at UCLA.
"Minority enrollment in mental health research is extremely low, so before this study, we could not feel confident that any one particular treatment would be acceptable or effective," said Joyce Chung, M.D., clinical associate professor of psychiatry at Georgetown University Medical Center and one of the Georgetown investigators. "We now have solid evidence that, when delivered in accessible, innovative ways, standard treatments can significantly alleviate their illness."
Although the landmark U.S. Surgeon General's 2001 "Mental Health: Culture, Race, Ethnicity" noted that people with the lowest socioeconomic status are about two to three times more likely than those in a higher social strata to have a mental disorder, no Latinos and only 27 African Americans participated in the 3,860 patient study which led to the 1993 American Psychiatric Association's guidelines for the treatment of depression. The Georgetown-UCLA study is the first confirmation that these guidelines are appropriate for low-income minority women.
The researchers followed 267 primarily working poor Latina and African-American women diagnosed with major depression, and randomly assigned each to one of three different treatment arms: antidepressant medication, group CBT, or referrals to local community providers. Women treated with medication (paroxetine, sold as Paxil, or buproprion, sold as Wellbutrin SR) fared the best, significantly reducing their depression symptoms and improving their ability to function socially. Women who received CBT also saw much improvement in their symptoms, although slightly less than those on medication. The women referred to local providers gained little benefit as 78 percent of this group did not attend even one treatment session in the community. Race did not affect treatment response.
During the randomized, five-year WECare (Women Entering Care) study, mental health services were made easily accessible to the predominantly low-income participants. Over 16,000 women from four counties in the Washington D.C. area who had not previously sought mental health treatment were screened for major depression. Most women were approached while attending county-run Women, Infants and Children (WIC) food subsidy programs and Title X family planning clinics.
Once enrolled in the study, women were provided with babysitting and transportation assistance in order to attend treatment sessions, bilingual clinicians and materials for Spanish speakers, and intensive outreach efforts that aided their ability to remain in the trial and receive care.
Participants averaged slightly under 30 years of age and almost half were married or living with a partner. Over one-third of the women had not graduated from high school or received a GED. Woman in this study had, on average, two or more children, and nearly two-thirds of the study participants lacked health insurance, including public insurance such as Medicaid. Sixty percent lived at or below the federal poverty guidelines. Over one-third reported having been raped and/or abused as a child, and nearly one-half had experienced domestic violence.
"There is no question that more needs to be done to understand what poor young women are struggling with, and how we can best help them," said Dr. Chung. "The majority of these women work incredibly hard but don't have enough money for health insurance, have children whose needs they put before their own, and live in less than ideal situations. The competing demands and pressures are extreme. We have a responsibility to fix the health care system in a way that makes care accessible, compassionate, and ultimately effective. This study gives us a blueprint for improving the quality of mental health services for poorer women."
"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 is the first to let providers know that treating depression in women with what may appear to be overwhelming life problems results in significant improvement in the way these women feel and function."
Dr. Chung and her Georgetown colleagues Dr. Bonnie Green and Dr. Janice Krupnick continue to study mental health in low-income women. These research studies include treatments for posttraumatic stress disorder as well as longitudinal studies of battered women and adolescent substance abuse and depression, all targeting economically disadvantaged groups. The Department of Psychiatry has also established the Center for Mental Health Outreach whose mission is to provide mental health services and expertise for underserved populations in collaboration with community based service providers in the greater Washington, DC area.
The UCLA Neuropsychiatric Institute is an interdisciplinary research and education institute devoted to the understanding of complex human behavior, including the genetic, biological, behavioral and sociocultural underpinnings of normal behavior, and the causes and consequences of neuropsychiatric disorders.
Online resources:
- Georgetown University Medical Center: http://gumc.georgetown.edu/
- UCLA Neuropsychiatric Institute: http://www.npi.ucla.edu
Georgetown University Medical Center is an internationally recognized academic medical center with a three-part mission of research, teaching and patient care (through our partnership with MedStar Health). Our mission is carried out with a strong emphasis on public service and a dedication to the Catholic, Jesuit principle of cura personalis--or "care of the whole person." The Medical Center includes the School of Medicine and the School of Nursing and Health Studies, both nationally ranked, and the world renowned Lombardi Cancer Center.
Journal
JAMA