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Papers by Lingqi Tang

Research paper thumbnail of Sampling and Recruiting Community-Based Programs Using Community-Partnered Participation Research

Health promotion practice, Jan 18, 2015

The inclusion of community partners in participatory leadership roles around statistical design i... more The inclusion of community partners in participatory leadership roles around statistical design issues like sampling and randomization has raised concerns about scientific integrity. This article presents a case study of a community-partnered, participatory research (CPPR) cluster-randomized, comparative effectiveness trial to examine implications for study validity and community relevance. Using study administrative data, we describe a CPPR-based design and implementation process for agency/program sampling, recruitment, and randomization for depression interventions. We calculated participation rates and used cross-tabulation to examine balance by intervention status on service sector, location, and program size and assessed differences in potential populations served. We achieved 51.5% agency and 89.6% program participation rates. Programs in different intervention arms were not significantly different on service sector, location, or program size. Participating programs were not ...

Research paper thumbnail of Geographic variation in alcohol, drug, and mental health services utilization: What are the sources of the variation

The Journal of Mental Health Policy and Economics

Studies have documented geographic variation in health services utilization over a range of medic... more Studies have documented geographic variation in health services utilization over a range of medical, surgical, and psychiatric conditions. These geographic differences are of concern to policy makers, as they may represent either excessive levels of unnecessary care or inappropriately low utilization of necessary services. However, the sources of geographic variation are not well understood, and variation may not represent a quality problem, to the extent that geographic variation is due to sampling variability or variation in case-mix across sites. Our aim was to determine the extent to which geographic variation in assessment and treatment rates for alcohol, drug, and mental disorders (ADM) was due to variation in case-mix across sites and to quantify the amount of geographic variation after case-mix adjustment. We analyzed data from Healthcare for Communities, a nationally representative telephone survey of ADM disorders and treatment. We utilized fixed effects and random interce...

Research paper thumbnail of Erratum to: Community-Partnered Cluster-Randomized Comparative Effectiveness Trial of Community Engagement and Planning or Resources for Services to Address Depression Disparities

Journal of General Internal Medicine

Research paper thumbnail of Gender disparities in the treatment of late-life depression: qualitative and quantitative findings from the IMPACT trial

The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2006

The objectives of this study were to examine gender differences in recruitment, depression presen... more The objectives of this study were to examine gender differences in recruitment, depression presentation, and depression treatment history in a large effectiveness trial; and to use qualitative data to generate hypotheses about reasons for observed gender differences. Data from IMPACT, a multisite trial of a disease management program for late-life depression in primary care were used to examine gender differences quantitatively. Qualitative interviews were conducted with 30 key informants from IMPACT (referring physicians, depression care managers, and study recruiters) to learn more about challenges in recruiting and treating depressed older men and then analyzed thematically. Compared with older women, older men were significantly less likely to be referred to IMPACT, to endorse core depressive symptoms, and to have received prior depression treatment. Gender differences in prior depression treatment persisted after adjustment for covariates. Qualitative themes identified as impor...

Research paper thumbnail of Service Use and Outcomes Among Elderly Persons With Low Incomes Being Treated for Depression

Psychiatric Services, 2007

Older adults with low incomes rarely use mental health care, and untreated depression is a seriou... more Older adults with low incomes rarely use mental health care, and untreated depression is a serious problem in this population. This study examined whether a collaborative care model for depression in primary care would increase use of depression treatment and treatment outcomes for low-income elderly adults as well as for higher-income older adults. A multisite randomized clinical trial that included 1,801 adults aged 60 years and older who were diagnosed as having depression compared collaborative care for depression with treatment as usual in primary care. Participants were divided into groups by income definitions on the basis of criteria used by the U.S. Census Bureau and the U.S. Department of Housing and Urban Development (HUD). A total of 315 participants (18%) were living below the poverty level by the U.S. Census criteria, 261 (15%) were living below 30% of the area median income (AMI) (HUD criteria) but above poverty, 438 (24%) were living between 30% and 50% of the AMI, 327 (18%) were living between 50% and 80% of the AMI, and 460 (26%) were not poor. The income groups were compared on service use, satisfaction, depression severity, and physical health at baseline and at three, six, and 12 months after being randomly assigned to collaborative care or usual care. The benefits for low-income older adults were similar to those for middle- and higher-income older adults. At 12 months, intervention patients in all economic brackets had significantly greater rates of depression care for both antidepressant medication and psychotherapy, greater satisfaction, lower depression severity, and less health-related functional impairment than usual care participants. Lower-income older adults can experience benefits from collaborative management of depression in primary care similar to those of higher-income older adults, although they may require up to a year to reap physical health benefits.

Research paper thumbnail of Comorbid Depression and Substance Abuse Among Safety-Net Clients in Los Angeles: A Community Participatory Study

Psychiatric Services, 2014

Depression and substance abuse are common among low-income adults from racial-ethnic minority gro... more Depression and substance abuse are common among low-income adults from racial-ethnic minority groups who receive services in safety-net settings, although little is known about how clients differ by service setting. This study examined characteristics and service use among depressed, low-income persons from minority groups in underresourced communities who did and did not have a substance abuse history. The study used cross-sectional baseline client data (N=957) from Community Partners in Care, an initiative to improve depression services in Los Angeles County. Clients with probable depression (eight-item Patient Health Questionnaire) from substance abuse programs were compared with depressed clients with and without a history of substance abuse from primary care, mental health, and social and community programs. Sociodemographic, health status, and services utilization variables were examined. Of the 957 depressed clients, 217 (23%) were from substance abuse programs; 269 (28%) clients from other sectors had a substance abuse history, and 471 (49%) did not. Most clients from substance abuse programs or with a substance abuse history were unemployed and impoverished, lacked health insurance, and had high rates of arrests and homelessness. They were also more likely than clients without a substance abuse history to have depression or anxiety disorders, psychosis, and mania and to use emergency rooms. Clients with depression and a substance abuse history had significant psychosocial stressors and high rates of service use, which suggests that communitywide approaches may be needed to address both depression and substance abuse in this safety-net population.

Research paper thumbnail of Effectiveness of collaborative care in addressing depression treatment preferences among low-income Latinos

Psychiatric services (Washington, D.C.), 2010

This study assessed treatment preferences among low-income Latino patients in public-sector prima... more This study assessed treatment preferences among low-income Latino patients in public-sector primary care clinics and examined whether a collaborative care intervention that included patient education and allowed patients to choose between medication, therapy, or both would increase the likelihood that patients received preferred treatment. A total of 339 Latino patients with probable depressive disorders were recruited; participants completed a baseline conjoint analysis preference survey and were randomly assigned to receive the intervention or enhanced usual care. At 16 weeks, a patient survey assessed depression treatment received during the study period. Logistic regression models were constructed to estimate treatment preferences, examine patient characteristics associated with treatment preferences, and examine patient characteristics associated with a match between stated preference and actual treatment received. The conjoint analysis preference survey showed that patients pr...

Research paper thumbnail of Impact of comorbid panic and posttraumatic stress disorder on outcomes of collaborative care for late-life depression in primary care

The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2005

Comorbid anxiety disorders may result in worse depression treatment outcomes. The authors evaluat... more Comorbid anxiety disorders may result in worse depression treatment outcomes. The authors evaluated the effect of comorbid panic disorder and posttraumatic stress disorder (PTSD) on response to a collaborative-care intervention for late-life depression in primary care. A total of 1,801 older adults with depression were randomized to a collaborative-care depression treatment model versus usual care and assessed at baseline, 3, 6, and 12 months, comparing differences among participants with comorbid panic disorder (N=262) and PTSD (N=191) and those without such comorbid anxiety disorders. At baseline, patients with comorbid anxiety reported higher levels of psychiatric and medical illness, greater functional impairment, and lower quality of life. Participants without comorbid anxiety who received collaborative care had early and lasting improvements in depression compared with those in usual care. Participants with comorbid panic disorder showed similar outcomes, whereas those with co...

Research paper thumbnail of Applying permutation tests with adjustment for covariates and attrition weights to randomized trials of health-services interventions

Statistics in Medicine, 2009

Using a health-services study as an illustrative example of longitudinal randomized field researc... more Using a health-services study as an illustrative example of longitudinal randomized field research with the potential for participants to be lost to follow-up, we apply a permutation test where the treatment indicator variable is randomly permuted in the context of regression models with covariates and attrition weighting. The test is applied to a multi-site randomized intervention trial of a quality-improvement program for adolescent depression treatment in primary-care settings, in which regression models were used to assess intervention effects with weights used to adjust for attrition bias. The foundation and motivation for this approach to the analysis are considered with attention to the demands associated with implementing such a strategy. The results from the permutation tests were qualitatively similar to the results obtained from conventional parametric models, and in fact suggested that the significance level from the conventional t-test was understated in this application.

Research paper thumbnail of A comparison of imputation methods in a longitudinal randomized clinical trial

Statistics in Medicine, 2005

It is common for longitudinal clinical trials to face problems of item non-response, unit non-res... more It is common for longitudinal clinical trials to face problems of item non-response, unit non-response, and drop-out. In this paper, we compare two alternative methods of handling multivariate incomplete data across a baseline assessment and three follow-up time points in a multi-centre randomized controlled trial of a disease management programme for late-life depression. One approach combines hot-deck (HD) multiple imputation using a predictive mean matching method for item non-response and the approximate Bayesian bootstrap for unit non-response. A second method is based on a multivariate normal (MVN) model using PROC MI in SAS software V8.2. These two methods are contrasted with a last observation carried forward (LOCF) technique and available-case (AC) analysis in a simulation study where replicate analyses are performed on subsets of the originally complete cases. Missing-data patterns were simulated to be consistent with missing-data patterns found in the originally incomplete cases, and observed complete data means were taken to be the targets of estimation. Not surprisingly, the LOCF and AC methods had poor coverage properties for many of the variables evaluated. Multiple imputation under the MVN model performed well for most variables but produced less than nominal coverage for variables with highly skewed distributions. The HD method consistently produced close to nominal coverage, with interval widths that were roughly 7 per cent larger on average than those produced from the MVN model.

Research paper thumbnail of The importance of social context: Neighborhood stressors, stress-buffering mechanisms, and alcohol, drug, and mental health disorders

Social Science & Medicine, 2007

This study examines the relationship among neighborhood stressors, stress-buffering mechanisms, a... more This study examines the relationship among neighborhood stressors, stress-buffering mechanisms, and likelihood of alcohol, drug, and mental health (ADM) disorders in adults from 60 US communities (n=12,716). Research shows that larger support structures may interact with individual support factors to affect mental health, but few studies have explored buffering effects of these neighborhood characteristics. We test a conceptual model that explores effects of neighborhood stressors and stress-buffering mechanisms on ADM disorders. Using Health Care for Communities with census and other data, we found a lower likelihood of disorders in neighborhoods with a greater presence of stress-buffering mechanisms. Higher neighborhood average household occupancy and churches per capita were associated with a lower likelihood of disorders. Cross-level interactions revealed that violence-exposed individuals in high crime neighborhoods are vulnerable to depressive/ anxiety disorders. Likewise, individuals with low social support in neighborhoods with high social isolation (i.e., low average household occupancy) had a higher likelihood of disorders. If replicated by future studies using longitudinal data, our results have implications for policies and programs targeting neighborhoods to reduce ADM disorders.

Research paper thumbnail of How Quality Improvement Interventions for Depression Affect Stigma Concerns Over Time: A Nine-Year Follow-Up Study

Psychiatric Services, 2009

Objective-To examine the long-term impact of two quality improvement interventions for depression... more Objective-To examine the long-term impact of two quality improvement interventions for depression on stigma concerns in primary care compared to usual care.

Research paper thumbnail of Cost-Effectiveness of Quality Improvement Programs for Patients With Subthreshold Depression or Depressive Disorder

Psychiatric Services, 2007

This study explored the cost-effectiveness of quality-improvement interventions for depression in... more This study explored the cost-effectiveness of quality-improvement interventions for depression in primary care, relative to usual care, among patients with subthreshold depression or depressive disorder. A total of 746 primary care patients in managed care organizations with 12-month depressive disorder and 502 with current depressive symptoms but no disorder (subthreshold depression) participated in a group-level randomized controlled trial initiated between June 1996 and March 1997. Matched clinics were randomly assigned to enhanced usual care or one of two quality improvement interventions that provided education to manage depression over time and resources to facilitate access to medication management or psychotherapy for six to 12 months. The cost-effectiveness ratio for the pooled intervention groups versus usual care was 2,028forpatientswithsubthresholddepression(952,028 for patients with subthreshold depression (95% confidence interval [CI]=-2,028forpatientswithsubthresholddepression(9517,225 to 21,282)and21,282) and 21,282)and53,716 for those with depressive disorder (CI=$14,194 to $93,238), by using a measure of quality-adjusted life years (QALY) based on the 12-Item Short Form Health Survey. Similar results were obtained when alternative QALY measures were used. Although precision was limited, even the upper limit of the 95% CIs suggests that such interventions are as cost-effective for patients with subthreshold depression as are many widely used medical therapies. Despite lack of evidence for efficacy of treatments for subthreshold depression, disease management programs that support clinical care decisions over time for patients with subthreshold depression or depressive disorder can yield cost-effectiveness ratios comparable to those of widely adopted medical therapies. Achieving greater certainty about average cost-effectiveness would require a much larger study.

Research paper thumbnail of The Cumulative Effects of Quality Improvement for Depression on Outcome Disparities Over 9 Years

Medical Care, 2007

Quality improvement (QI) programs for depression can improve outcomes of care and reduce outcome ... more Quality improvement (QI) programs for depression can improve outcomes of care and reduce outcome disparities; but cumulative effects on mental health outcome disparities have seldom been evaluated. To estimate cumulative effects over many years of short-term QI programs for depression in primary care on mental health outcome disparities, and to develop an interpretation for annualized, cumulative mental health outcome scores. : We conducted a group-level, randomized controlled trial in 6 US healthcare organizations. The QI programs supported provider and patient education in depression treatment and resources for medication management (QI-Meds) or access to evidence-based psychotherapy (QI-Therapy). Sites were selected to oversample minorities. Results were extrapolated to 1188 initially enrolled and living patients depressed at baseline. Psychologic well-being (MHI-5) estimated as cumulative outcomes and outcome disparities (minority-whites) over 9 years, and annualized. Across analyses there was a significant interaction of intervention status and ethnicity [lowest F(2,160) = 4.96, P = 0.008]. QI-therapy improved cumulative outcomes among minorities (mean, 37.92-44.29 MHI-5 points) and reduced outcome disparities for the whole sample relative to usual care (UC) (by mean, 39.44-59.01 MHI-5 points) and relative to QI-Meds (by mean, 53.90-74.41 MHI-5 points), lowest t(103) = 3.12, P = 0.002. By comparison, UC patients who lost a loved one in the year after baseline had lower psychologic well being by 6.18 MHI-5 scale points compared with similar UC patients without such a loss [t(15)=2.52, P = 0.02]. QI programs incorporating support for evidence-based psychotherapy offer an approach to substantially reduce cumulative outcome disparities for depressed primary care patients.

Research paper thumbnail of Reducing Suicidal Ideation in Depressed Older Primary Care Patients

Journal of the American Geriatrics Society, 2000

OBJECTIVES: To determine the effect of a primary carebased collaborative care program for depress... more OBJECTIVES: To determine the effect of a primary carebased collaborative care program for depression on suicidal ideation in older adults.

Research paper thumbnail of Depression Treatment in a Sample of 1,801 Depressed Older Adults in Primary Care

Journal of the American Geriatrics Society, 2000

To examine rates and predictors of lifetime and recent depression treatment in a sample of 1,801 ... more To examine rates and predictors of lifetime and recent depression treatment in a sample of 1,801 depressed older primary care patients Cross sectional survey data collected from 1999 to 2001 as part of a treatment effectiveness trial. Eighteen primary care clinics belonging to eight organizations in five states. One thousand eight hundred one clinic users aged 60 and older who met diagnostic criteria for major depression or dysthymia. Lifetime depression treatment was defined as ever having received a prescription medication, counseling, or psychotherapy for depression. Potentially effective recent depression treatment was defined as 2 or more months of antidepressant medications or four or more sessions of counseling or psychotherapy for depression in the past 3 months. The mean age +/- standard deviation was 71.2 +/- 7.5; 65% of subjects were women. Twenty-three percent of the sample came from ethnic minority groups (12% were African American, 8% were Latino, and 3% belonged to other ethnic minorities). The median household income was $23,000. Most study participants (83%) reported depressive symptoms for 2 or more years, and most (71%) reported two or more prior depressive episodes. About 65% reported any lifetime depression treatment, and 46% reported some depression treatment in the past 3 months, although only 29% reported potentially effective recent depression treatment. Most of the treatment provided consisted of antidepressant medications, with newer antidepressants such as selective serotonin reuptake inhibitors constituting the majority (78%) of antidepressants used. Most participants indicated a preference for counseling or psychotherapy over antidepressant medications, but only 8% had received such treatment in the past 3 months, and only 1% reported four or more sessions of counseling. Men, African Americans, Latinos, those without two or more prior episodes of depression, and those who preferred counseling to antidepressant medications reported significantly lower rates of depression care. The findings suggest that there is considerable opportunity to improve care for older adults with depression. Particular efforts should be focused on improving access to depression care for older men, African Americans, Latinos, and patients who prefer treatments other than antidepressants.

Research paper thumbnail of Determinants of Early Reductions in Drinking in Older At-Risk Drinkers Participating in the Intervention Arm of a Trial to Reduce At-Risk Drinking in Primary Care

Journal of the American Geriatrics Society, 2010

OBJECTIVES: To describe differences between older atrisk drinkers, as determined using the Comorb... more OBJECTIVES: To describe differences between older atrisk drinkers, as determined using the Comorbidity Alcohol Risk Evaluation Tool, who reduced drinking and those who did not after an initial intervention and to determine factors associated with early reductions in drinking. DESIGN: Secondary analyses of data from a randomized controlled trial. SETTING: Seven primary care sites. PARTICIPANTS: Subjects randomized to the intervention group who completed the first health educator call approximately 2 weeks after enrollment (n 5 239). INTERVENTION: Personalized risk reports, booklets on alcohol-associated risks, and advice from physicians, followed by a health educator call. MEASURMENTS: Reductions in number of alcoholic drinks. RESULTS: Thirty-nine percent of the sample had reduced drinking within 2 weeks of receiving the initial intervention. According to the final multiple logistic regression model, those who were concerned about alcohol-related risks (odds ratio (OR) 5 2.03, 95% confidence interval (CI) 5 1.01-4.07), read through the educational booklet (OR 5 2.97, 95% CI 5 1.48-5.95), or perceived that their physicians discussed risks and advised changing drinking behaviors (OR 5 4.1, 95% CI 5 2.02-8.32) had greater odds of reducing drinking by the first health educator call. CONCLUSION: Concern about risks, reading educational material, and perception of physicians providing advice to reduce drinking were associated with early reductions in alcohol use in older at-risk drinkers. Understanding these factors will enable development of better intervention strategies to reduce unhealthy alcohol use. J Am Geriatr Soc 58:227-233, 2010.

Research paper thumbnail of Quality of Publicly-Funded Outpatient Specialty Mental Health Care for Common Childhood Psychiatric Disorders in California

Journal of the American Academy of Child & Adolescent Psychiatry, 2005

Objective: To describe the documented adherence to quality indicators for the outpatient care of ... more Objective: To describe the documented adherence to quality indicators for the outpatient care of attention-deficit/hyperactivity disorder, conduct disorder, and major depression for children in public mental health clinics and to explore how adherence varies by child and clinic characteristics. Method: A statewide, longitudinal cohort study of 813 children ages 6.0-16.9 years with at least 3 months of outpatient care, drawn from 4,958 patients in 62 mental health clinics in California from August 1, 1998, through May 31, 1999. The main outcome was documented adherence to quality indicators based on scientific evidence and clinical judgment, assessed by explicit medical record review. Results: Relatively high adherence was recorded for clinical assessment (78%-95%), but documented adherence to quality indicators related to service linkage, parental involvement, use of evidence-based psychosocial treatment, and patient protection were moderate to poor (74.1%-8.0%). For children prescribed psychotropic medication, 28.3% of the records documented monitoring of at least one clinically indicated vital sign or laboratory study. Documented adherence to quality indicators varied little by child demographics or clinic factors. Conclusion: Efforts to improve care should be directed broadly across clinics, with documentation of safe practices, particularly for children prescribed psychotropic medication, being of highest priority. J. Am. Acad. Child Adolesc. Psychiatry, 2005;44(2):130-144. Key Words: quality of care, child mental health attention-deficit/hyperactivity disorder, psychotropic medication, safety.

Research paper thumbnail of Community-Partnered Cluster-Randomized Comparative Effectiveness Trial of Community Engagement and Planning or Resources for Services to Address Depression Disparities

Journal of General Internal Medicine, 2013

BACKGROUND: Depression contributes to disability and there are ethnic/racial disparities in acces... more BACKGROUND: Depression contributes to disability and there are ethnic/racial disparities in access and outcomes of care. Quality improvement (QI) programs for depression in primary care improve outcomes relative to usual care, but health, social and other community-based service sectors also support clients in under-resourced communities. Little is known about effects on client outcomes of strategies to implement depression QI across diverse sectors. OBJECTIVE: To compare the effectiveness of Community Engagement and Planning (CEP) and Resources for Services (RS) to implement depression QI on clients' mental health-related quality of life (HRQL) and services use. DESIGN: Matched programs from health, social and other service sectors were randomized to community engagement and planning (promoting inter-agency collaboration) or resources for services (individual program technical assistance plus outreach) to implement depression QI toolkits in Hollywood-Metro and South Los Angeles. PARTICIPANTS: From 93 randomized programs, 4,440 clients were screened and of 1,322 depressed by the 8item Patient Health Questionnaire (PHQ-8) and providing contact information, 1,246 enrolled and 1,018 in 90 programs completed baseline or 6-month follow-up. MEASURES: Self-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use.

Research paper thumbnail of Community-Partnered Evaluation of Depression Services for Clients of Community-Based Agencies in Under-Resourced Communities in Los Angeles

Journal of General Internal Medicine, 2013

As medical homes are developing under health reform, little is known regarding depression service... more As medical homes are developing under health reform, little is known regarding depression services need and use by diverse safety-net populations in under-resourced communities. For chronic conditions like depression, primary care services may face new opportunities to partner with diverse community service providers, such as those in social service and substance abuse centers, to support a collaborative care model of treating depression. To understand the distribution of need and current burden of services for depression in under-resourced, diverse communities in Los Angeles. Baseline phase of a participatory trial to improve depression services with data from client screening and follow-up surveys. Of 4,440 clients screened from 93 programs (primary care, mental health, substance abuse, homeless, social and other community services) in 50 agencies, 1,322 were depressed according to an eight-item Patient Health Questionnaire (PHQ-8) and gave contact information; 1,246 enrolled and 981 completed surveys. Ninety-three programs, including 17 primary care/public health, 18 mental health, 20 substance abuse, ten homeless services, and 28 social/other community services, participated. Comparisons by setting in 6-month retrospective recall of depression services use. Depression prevalence ranged from 51.9 % in mental health to 17.2 % in social-community programs. Depressed clients used two settings on average to receive depression services; 82 % used any setting. More clients preferred counseling over medication for depression treatment. Need for depression care was high, and a broad range of agencies provide depression care. Although most participants had contact with primary care, most depression services occurred outside of primary care settings, emphasizing the need to coordinate and support the quality of community-based services across diverse community settings.

Research paper thumbnail of Sampling and Recruiting Community-Based Programs Using Community-Partnered Participation Research

Health promotion practice, Jan 18, 2015

The inclusion of community partners in participatory leadership roles around statistical design i... more The inclusion of community partners in participatory leadership roles around statistical design issues like sampling and randomization has raised concerns about scientific integrity. This article presents a case study of a community-partnered, participatory research (CPPR) cluster-randomized, comparative effectiveness trial to examine implications for study validity and community relevance. Using study administrative data, we describe a CPPR-based design and implementation process for agency/program sampling, recruitment, and randomization for depression interventions. We calculated participation rates and used cross-tabulation to examine balance by intervention status on service sector, location, and program size and assessed differences in potential populations served. We achieved 51.5% agency and 89.6% program participation rates. Programs in different intervention arms were not significantly different on service sector, location, or program size. Participating programs were not ...

Research paper thumbnail of Geographic variation in alcohol, drug, and mental health services utilization: What are the sources of the variation

The Journal of Mental Health Policy and Economics

Studies have documented geographic variation in health services utilization over a range of medic... more Studies have documented geographic variation in health services utilization over a range of medical, surgical, and psychiatric conditions. These geographic differences are of concern to policy makers, as they may represent either excessive levels of unnecessary care or inappropriately low utilization of necessary services. However, the sources of geographic variation are not well understood, and variation may not represent a quality problem, to the extent that geographic variation is due to sampling variability or variation in case-mix across sites. Our aim was to determine the extent to which geographic variation in assessment and treatment rates for alcohol, drug, and mental disorders (ADM) was due to variation in case-mix across sites and to quantify the amount of geographic variation after case-mix adjustment. We analyzed data from Healthcare for Communities, a nationally representative telephone survey of ADM disorders and treatment. We utilized fixed effects and random interce...

Research paper thumbnail of Erratum to: Community-Partnered Cluster-Randomized Comparative Effectiveness Trial of Community Engagement and Planning or Resources for Services to Address Depression Disparities

Journal of General Internal Medicine

Research paper thumbnail of Gender disparities in the treatment of late-life depression: qualitative and quantitative findings from the IMPACT trial

The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2006

The objectives of this study were to examine gender differences in recruitment, depression presen... more The objectives of this study were to examine gender differences in recruitment, depression presentation, and depression treatment history in a large effectiveness trial; and to use qualitative data to generate hypotheses about reasons for observed gender differences. Data from IMPACT, a multisite trial of a disease management program for late-life depression in primary care were used to examine gender differences quantitatively. Qualitative interviews were conducted with 30 key informants from IMPACT (referring physicians, depression care managers, and study recruiters) to learn more about challenges in recruiting and treating depressed older men and then analyzed thematically. Compared with older women, older men were significantly less likely to be referred to IMPACT, to endorse core depressive symptoms, and to have received prior depression treatment. Gender differences in prior depression treatment persisted after adjustment for covariates. Qualitative themes identified as impor...

Research paper thumbnail of Service Use and Outcomes Among Elderly Persons With Low Incomes Being Treated for Depression

Psychiatric Services, 2007

Older adults with low incomes rarely use mental health care, and untreated depression is a seriou... more Older adults with low incomes rarely use mental health care, and untreated depression is a serious problem in this population. This study examined whether a collaborative care model for depression in primary care would increase use of depression treatment and treatment outcomes for low-income elderly adults as well as for higher-income older adults. A multisite randomized clinical trial that included 1,801 adults aged 60 years and older who were diagnosed as having depression compared collaborative care for depression with treatment as usual in primary care. Participants were divided into groups by income definitions on the basis of criteria used by the U.S. Census Bureau and the U.S. Department of Housing and Urban Development (HUD). A total of 315 participants (18%) were living below the poverty level by the U.S. Census criteria, 261 (15%) were living below 30% of the area median income (AMI) (HUD criteria) but above poverty, 438 (24%) were living between 30% and 50% of the AMI, 327 (18%) were living between 50% and 80% of the AMI, and 460 (26%) were not poor. The income groups were compared on service use, satisfaction, depression severity, and physical health at baseline and at three, six, and 12 months after being randomly assigned to collaborative care or usual care. The benefits for low-income older adults were similar to those for middle- and higher-income older adults. At 12 months, intervention patients in all economic brackets had significantly greater rates of depression care for both antidepressant medication and psychotherapy, greater satisfaction, lower depression severity, and less health-related functional impairment than usual care participants. Lower-income older adults can experience benefits from collaborative management of depression in primary care similar to those of higher-income older adults, although they may require up to a year to reap physical health benefits.

Research paper thumbnail of Comorbid Depression and Substance Abuse Among Safety-Net Clients in Los Angeles: A Community Participatory Study

Psychiatric Services, 2014

Depression and substance abuse are common among low-income adults from racial-ethnic minority gro... more Depression and substance abuse are common among low-income adults from racial-ethnic minority groups who receive services in safety-net settings, although little is known about how clients differ by service setting. This study examined characteristics and service use among depressed, low-income persons from minority groups in underresourced communities who did and did not have a substance abuse history. The study used cross-sectional baseline client data (N=957) from Community Partners in Care, an initiative to improve depression services in Los Angeles County. Clients with probable depression (eight-item Patient Health Questionnaire) from substance abuse programs were compared with depressed clients with and without a history of substance abuse from primary care, mental health, and social and community programs. Sociodemographic, health status, and services utilization variables were examined. Of the 957 depressed clients, 217 (23%) were from substance abuse programs; 269 (28%) clients from other sectors had a substance abuse history, and 471 (49%) did not. Most clients from substance abuse programs or with a substance abuse history were unemployed and impoverished, lacked health insurance, and had high rates of arrests and homelessness. They were also more likely than clients without a substance abuse history to have depression or anxiety disorders, psychosis, and mania and to use emergency rooms. Clients with depression and a substance abuse history had significant psychosocial stressors and high rates of service use, which suggests that communitywide approaches may be needed to address both depression and substance abuse in this safety-net population.

Research paper thumbnail of Effectiveness of collaborative care in addressing depression treatment preferences among low-income Latinos

Psychiatric services (Washington, D.C.), 2010

This study assessed treatment preferences among low-income Latino patients in public-sector prima... more This study assessed treatment preferences among low-income Latino patients in public-sector primary care clinics and examined whether a collaborative care intervention that included patient education and allowed patients to choose between medication, therapy, or both would increase the likelihood that patients received preferred treatment. A total of 339 Latino patients with probable depressive disorders were recruited; participants completed a baseline conjoint analysis preference survey and were randomly assigned to receive the intervention or enhanced usual care. At 16 weeks, a patient survey assessed depression treatment received during the study period. Logistic regression models were constructed to estimate treatment preferences, examine patient characteristics associated with treatment preferences, and examine patient characteristics associated with a match between stated preference and actual treatment received. The conjoint analysis preference survey showed that patients pr...

Research paper thumbnail of Impact of comorbid panic and posttraumatic stress disorder on outcomes of collaborative care for late-life depression in primary care

The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry, 2005

Comorbid anxiety disorders may result in worse depression treatment outcomes. The authors evaluat... more Comorbid anxiety disorders may result in worse depression treatment outcomes. The authors evaluated the effect of comorbid panic disorder and posttraumatic stress disorder (PTSD) on response to a collaborative-care intervention for late-life depression in primary care. A total of 1,801 older adults with depression were randomized to a collaborative-care depression treatment model versus usual care and assessed at baseline, 3, 6, and 12 months, comparing differences among participants with comorbid panic disorder (N=262) and PTSD (N=191) and those without such comorbid anxiety disorders. At baseline, patients with comorbid anxiety reported higher levels of psychiatric and medical illness, greater functional impairment, and lower quality of life. Participants without comorbid anxiety who received collaborative care had early and lasting improvements in depression compared with those in usual care. Participants with comorbid panic disorder showed similar outcomes, whereas those with co...

Research paper thumbnail of Applying permutation tests with adjustment for covariates and attrition weights to randomized trials of health-services interventions

Statistics in Medicine, 2009

Using a health-services study as an illustrative example of longitudinal randomized field researc... more Using a health-services study as an illustrative example of longitudinal randomized field research with the potential for participants to be lost to follow-up, we apply a permutation test where the treatment indicator variable is randomly permuted in the context of regression models with covariates and attrition weighting. The test is applied to a multi-site randomized intervention trial of a quality-improvement program for adolescent depression treatment in primary-care settings, in which regression models were used to assess intervention effects with weights used to adjust for attrition bias. The foundation and motivation for this approach to the analysis are considered with attention to the demands associated with implementing such a strategy. The results from the permutation tests were qualitatively similar to the results obtained from conventional parametric models, and in fact suggested that the significance level from the conventional t-test was understated in this application.

Research paper thumbnail of A comparison of imputation methods in a longitudinal randomized clinical trial

Statistics in Medicine, 2005

It is common for longitudinal clinical trials to face problems of item non-response, unit non-res... more It is common for longitudinal clinical trials to face problems of item non-response, unit non-response, and drop-out. In this paper, we compare two alternative methods of handling multivariate incomplete data across a baseline assessment and three follow-up time points in a multi-centre randomized controlled trial of a disease management programme for late-life depression. One approach combines hot-deck (HD) multiple imputation using a predictive mean matching method for item non-response and the approximate Bayesian bootstrap for unit non-response. A second method is based on a multivariate normal (MVN) model using PROC MI in SAS software V8.2. These two methods are contrasted with a last observation carried forward (LOCF) technique and available-case (AC) analysis in a simulation study where replicate analyses are performed on subsets of the originally complete cases. Missing-data patterns were simulated to be consistent with missing-data patterns found in the originally incomplete cases, and observed complete data means were taken to be the targets of estimation. Not surprisingly, the LOCF and AC methods had poor coverage properties for many of the variables evaluated. Multiple imputation under the MVN model performed well for most variables but produced less than nominal coverage for variables with highly skewed distributions. The HD method consistently produced close to nominal coverage, with interval widths that were roughly 7 per cent larger on average than those produced from the MVN model.

Research paper thumbnail of The importance of social context: Neighborhood stressors, stress-buffering mechanisms, and alcohol, drug, and mental health disorders

Social Science & Medicine, 2007

This study examines the relationship among neighborhood stressors, stress-buffering mechanisms, a... more This study examines the relationship among neighborhood stressors, stress-buffering mechanisms, and likelihood of alcohol, drug, and mental health (ADM) disorders in adults from 60 US communities (n=12,716). Research shows that larger support structures may interact with individual support factors to affect mental health, but few studies have explored buffering effects of these neighborhood characteristics. We test a conceptual model that explores effects of neighborhood stressors and stress-buffering mechanisms on ADM disorders. Using Health Care for Communities with census and other data, we found a lower likelihood of disorders in neighborhoods with a greater presence of stress-buffering mechanisms. Higher neighborhood average household occupancy and churches per capita were associated with a lower likelihood of disorders. Cross-level interactions revealed that violence-exposed individuals in high crime neighborhoods are vulnerable to depressive/ anxiety disorders. Likewise, individuals with low social support in neighborhoods with high social isolation (i.e., low average household occupancy) had a higher likelihood of disorders. If replicated by future studies using longitudinal data, our results have implications for policies and programs targeting neighborhoods to reduce ADM disorders.

Research paper thumbnail of How Quality Improvement Interventions for Depression Affect Stigma Concerns Over Time: A Nine-Year Follow-Up Study

Psychiatric Services, 2009

Objective-To examine the long-term impact of two quality improvement interventions for depression... more Objective-To examine the long-term impact of two quality improvement interventions for depression on stigma concerns in primary care compared to usual care.

Research paper thumbnail of Cost-Effectiveness of Quality Improvement Programs for Patients With Subthreshold Depression or Depressive Disorder

Psychiatric Services, 2007

This study explored the cost-effectiveness of quality-improvement interventions for depression in... more This study explored the cost-effectiveness of quality-improvement interventions for depression in primary care, relative to usual care, among patients with subthreshold depression or depressive disorder. A total of 746 primary care patients in managed care organizations with 12-month depressive disorder and 502 with current depressive symptoms but no disorder (subthreshold depression) participated in a group-level randomized controlled trial initiated between June 1996 and March 1997. Matched clinics were randomly assigned to enhanced usual care or one of two quality improvement interventions that provided education to manage depression over time and resources to facilitate access to medication management or psychotherapy for six to 12 months. The cost-effectiveness ratio for the pooled intervention groups versus usual care was 2,028forpatientswithsubthresholddepression(952,028 for patients with subthreshold depression (95% confidence interval [CI]=-2,028forpatientswithsubthresholddepression(9517,225 to 21,282)and21,282) and 21,282)and53,716 for those with depressive disorder (CI=$14,194 to $93,238), by using a measure of quality-adjusted life years (QALY) based on the 12-Item Short Form Health Survey. Similar results were obtained when alternative QALY measures were used. Although precision was limited, even the upper limit of the 95% CIs suggests that such interventions are as cost-effective for patients with subthreshold depression as are many widely used medical therapies. Despite lack of evidence for efficacy of treatments for subthreshold depression, disease management programs that support clinical care decisions over time for patients with subthreshold depression or depressive disorder can yield cost-effectiveness ratios comparable to those of widely adopted medical therapies. Achieving greater certainty about average cost-effectiveness would require a much larger study.

Research paper thumbnail of The Cumulative Effects of Quality Improvement for Depression on Outcome Disparities Over 9 Years

Medical Care, 2007

Quality improvement (QI) programs for depression can improve outcomes of care and reduce outcome ... more Quality improvement (QI) programs for depression can improve outcomes of care and reduce outcome disparities; but cumulative effects on mental health outcome disparities have seldom been evaluated. To estimate cumulative effects over many years of short-term QI programs for depression in primary care on mental health outcome disparities, and to develop an interpretation for annualized, cumulative mental health outcome scores. : We conducted a group-level, randomized controlled trial in 6 US healthcare organizations. The QI programs supported provider and patient education in depression treatment and resources for medication management (QI-Meds) or access to evidence-based psychotherapy (QI-Therapy). Sites were selected to oversample minorities. Results were extrapolated to 1188 initially enrolled and living patients depressed at baseline. Psychologic well-being (MHI-5) estimated as cumulative outcomes and outcome disparities (minority-whites) over 9 years, and annualized. Across analyses there was a significant interaction of intervention status and ethnicity [lowest F(2,160) = 4.96, P = 0.008]. QI-therapy improved cumulative outcomes among minorities (mean, 37.92-44.29 MHI-5 points) and reduced outcome disparities for the whole sample relative to usual care (UC) (by mean, 39.44-59.01 MHI-5 points) and relative to QI-Meds (by mean, 53.90-74.41 MHI-5 points), lowest t(103) = 3.12, P = 0.002. By comparison, UC patients who lost a loved one in the year after baseline had lower psychologic well being by 6.18 MHI-5 scale points compared with similar UC patients without such a loss [t(15)=2.52, P = 0.02]. QI programs incorporating support for evidence-based psychotherapy offer an approach to substantially reduce cumulative outcome disparities for depressed primary care patients.

Research paper thumbnail of Reducing Suicidal Ideation in Depressed Older Primary Care Patients

Journal of the American Geriatrics Society, 2000

OBJECTIVES: To determine the effect of a primary carebased collaborative care program for depress... more OBJECTIVES: To determine the effect of a primary carebased collaborative care program for depression on suicidal ideation in older adults.

Research paper thumbnail of Depression Treatment in a Sample of 1,801 Depressed Older Adults in Primary Care

Journal of the American Geriatrics Society, 2000

To examine rates and predictors of lifetime and recent depression treatment in a sample of 1,801 ... more To examine rates and predictors of lifetime and recent depression treatment in a sample of 1,801 depressed older primary care patients Cross sectional survey data collected from 1999 to 2001 as part of a treatment effectiveness trial. Eighteen primary care clinics belonging to eight organizations in five states. One thousand eight hundred one clinic users aged 60 and older who met diagnostic criteria for major depression or dysthymia. Lifetime depression treatment was defined as ever having received a prescription medication, counseling, or psychotherapy for depression. Potentially effective recent depression treatment was defined as 2 or more months of antidepressant medications or four or more sessions of counseling or psychotherapy for depression in the past 3 months. The mean age +/- standard deviation was 71.2 +/- 7.5; 65% of subjects were women. Twenty-three percent of the sample came from ethnic minority groups (12% were African American, 8% were Latino, and 3% belonged to other ethnic minorities). The median household income was $23,000. Most study participants (83%) reported depressive symptoms for 2 or more years, and most (71%) reported two or more prior depressive episodes. About 65% reported any lifetime depression treatment, and 46% reported some depression treatment in the past 3 months, although only 29% reported potentially effective recent depression treatment. Most of the treatment provided consisted of antidepressant medications, with newer antidepressants such as selective serotonin reuptake inhibitors constituting the majority (78%) of antidepressants used. Most participants indicated a preference for counseling or psychotherapy over antidepressant medications, but only 8% had received such treatment in the past 3 months, and only 1% reported four or more sessions of counseling. Men, African Americans, Latinos, those without two or more prior episodes of depression, and those who preferred counseling to antidepressant medications reported significantly lower rates of depression care. The findings suggest that there is considerable opportunity to improve care for older adults with depression. Particular efforts should be focused on improving access to depression care for older men, African Americans, Latinos, and patients who prefer treatments other than antidepressants.

Research paper thumbnail of Determinants of Early Reductions in Drinking in Older At-Risk Drinkers Participating in the Intervention Arm of a Trial to Reduce At-Risk Drinking in Primary Care

Journal of the American Geriatrics Society, 2010

OBJECTIVES: To describe differences between older atrisk drinkers, as determined using the Comorb... more OBJECTIVES: To describe differences between older atrisk drinkers, as determined using the Comorbidity Alcohol Risk Evaluation Tool, who reduced drinking and those who did not after an initial intervention and to determine factors associated with early reductions in drinking. DESIGN: Secondary analyses of data from a randomized controlled trial. SETTING: Seven primary care sites. PARTICIPANTS: Subjects randomized to the intervention group who completed the first health educator call approximately 2 weeks after enrollment (n 5 239). INTERVENTION: Personalized risk reports, booklets on alcohol-associated risks, and advice from physicians, followed by a health educator call. MEASURMENTS: Reductions in number of alcoholic drinks. RESULTS: Thirty-nine percent of the sample had reduced drinking within 2 weeks of receiving the initial intervention. According to the final multiple logistic regression model, those who were concerned about alcohol-related risks (odds ratio (OR) 5 2.03, 95% confidence interval (CI) 5 1.01-4.07), read through the educational booklet (OR 5 2.97, 95% CI 5 1.48-5.95), or perceived that their physicians discussed risks and advised changing drinking behaviors (OR 5 4.1, 95% CI 5 2.02-8.32) had greater odds of reducing drinking by the first health educator call. CONCLUSION: Concern about risks, reading educational material, and perception of physicians providing advice to reduce drinking were associated with early reductions in alcohol use in older at-risk drinkers. Understanding these factors will enable development of better intervention strategies to reduce unhealthy alcohol use. J Am Geriatr Soc 58:227-233, 2010.

Research paper thumbnail of Quality of Publicly-Funded Outpatient Specialty Mental Health Care for Common Childhood Psychiatric Disorders in California

Journal of the American Academy of Child & Adolescent Psychiatry, 2005

Objective: To describe the documented adherence to quality indicators for the outpatient care of ... more Objective: To describe the documented adherence to quality indicators for the outpatient care of attention-deficit/hyperactivity disorder, conduct disorder, and major depression for children in public mental health clinics and to explore how adherence varies by child and clinic characteristics. Method: A statewide, longitudinal cohort study of 813 children ages 6.0-16.9 years with at least 3 months of outpatient care, drawn from 4,958 patients in 62 mental health clinics in California from August 1, 1998, through May 31, 1999. The main outcome was documented adherence to quality indicators based on scientific evidence and clinical judgment, assessed by explicit medical record review. Results: Relatively high adherence was recorded for clinical assessment (78%-95%), but documented adherence to quality indicators related to service linkage, parental involvement, use of evidence-based psychosocial treatment, and patient protection were moderate to poor (74.1%-8.0%). For children prescribed psychotropic medication, 28.3% of the records documented monitoring of at least one clinically indicated vital sign or laboratory study. Documented adherence to quality indicators varied little by child demographics or clinic factors. Conclusion: Efforts to improve care should be directed broadly across clinics, with documentation of safe practices, particularly for children prescribed psychotropic medication, being of highest priority. J. Am. Acad. Child Adolesc. Psychiatry, 2005;44(2):130-144. Key Words: quality of care, child mental health attention-deficit/hyperactivity disorder, psychotropic medication, safety.

Research paper thumbnail of Community-Partnered Cluster-Randomized Comparative Effectiveness Trial of Community Engagement and Planning or Resources for Services to Address Depression Disparities

Journal of General Internal Medicine, 2013

BACKGROUND: Depression contributes to disability and there are ethnic/racial disparities in acces... more BACKGROUND: Depression contributes to disability and there are ethnic/racial disparities in access and outcomes of care. Quality improvement (QI) programs for depression in primary care improve outcomes relative to usual care, but health, social and other community-based service sectors also support clients in under-resourced communities. Little is known about effects on client outcomes of strategies to implement depression QI across diverse sectors. OBJECTIVE: To compare the effectiveness of Community Engagement and Planning (CEP) and Resources for Services (RS) to implement depression QI on clients' mental health-related quality of life (HRQL) and services use. DESIGN: Matched programs from health, social and other service sectors were randomized to community engagement and planning (promoting inter-agency collaboration) or resources for services (individual program technical assistance plus outreach) to implement depression QI toolkits in Hollywood-Metro and South Los Angeles. PARTICIPANTS: From 93 randomized programs, 4,440 clients were screened and of 1,322 depressed by the 8item Patient Health Questionnaire (PHQ-8) and providing contact information, 1,246 enrolled and 1,018 in 90 programs completed baseline or 6-month follow-up. MEASURES: Self-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use.

Research paper thumbnail of Community-Partnered Evaluation of Depression Services for Clients of Community-Based Agencies in Under-Resourced Communities in Los Angeles

Journal of General Internal Medicine, 2013

As medical homes are developing under health reform, little is known regarding depression service... more As medical homes are developing under health reform, little is known regarding depression services need and use by diverse safety-net populations in under-resourced communities. For chronic conditions like depression, primary care services may face new opportunities to partner with diverse community service providers, such as those in social service and substance abuse centers, to support a collaborative care model of treating depression. To understand the distribution of need and current burden of services for depression in under-resourced, diverse communities in Los Angeles. Baseline phase of a participatory trial to improve depression services with data from client screening and follow-up surveys. Of 4,440 clients screened from 93 programs (primary care, mental health, substance abuse, homeless, social and other community services) in 50 agencies, 1,322 were depressed according to an eight-item Patient Health Questionnaire (PHQ-8) and gave contact information; 1,246 enrolled and 981 completed surveys. Ninety-three programs, including 17 primary care/public health, 18 mental health, 20 substance abuse, ten homeless services, and 28 social/other community services, participated. Comparisons by setting in 6-month retrospective recall of depression services use. Depression prevalence ranged from 51.9 % in mental health to 17.2 % in social-community programs. Depressed clients used two settings on average to receive depression services; 82 % used any setting. More clients preferred counseling over medication for depression treatment. Need for depression care was high, and a broad range of agencies provide depression care. Although most participants had contact with primary care, most depression services occurred outside of primary care settings, emphasizing the need to coordinate and support the quality of community-based services across diverse community settings.