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A Randomized Controlled Trial

Jeanne Miranda, PhD; Joyce Y. Chung, MD; Bonnie L. Green, PhD; Janice Krupnick, PhD; Juned Siddique, MS; Dennis A. Revicki, PhD; Tom Belin, PhD

JAMA. 2003;290:57-65.

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 buproprion, 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.

Author Affiliations: Health Services Research Center, University of California at Los Angeles Neuropsychiatric Institute (Drs Miranda and Belin, and Mr Siddique); Department of Psychiatry, Georgetown University Medical Center, Washington, DC (Drs Chung, Green, Krupnick, and Revicki); Center for Health Outcomes Research, MEDTAP International, Bethesda, Md (Dr Revicki); and Department of Biostatistics, University of California at Los Angeles School of Public Health (Dr Belin).

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