Depression has negative effects on patient self-care and social stress management. The negative effects of depression disproportionately affect low-income Latino patients with chronic medical illness.
To evaluate the effectiveness of A Helping Hand (AHH; Programa Mano Amiga in Primary Care) for patients with depressive symptoms and comorbid medical illness.
Patients with significant depressive symptoms (9-item Patient Health Questionnaire score ≥10) and coexisting diabetes or heart disease were randomized to AHH or usual care (UC) in 3 Los Angeles County Department of Health Services (LAC-DHS) safety-net clinics that were implementing patient-centered medical home (PCMH) models. The AHH intervention supported patients, families, and care providers by facilitating self-care management skills and activating patient communication with clinic medical providers. Community based, bilingual promotoras delivered the intervention in 6 weekly in-person or telephone sessions, followed by 3 monthly booster sessions. From April 2014 to May 2015, we screened 1957 and enrolled 348 depressed patients, of whom 296 (85%) had diabetes, 14 (4%) had heart disease, and 38 (11%) had both diseases. All participants received care management materials and community resource information. An interviewer blind to intervention assignment assessed outcomes at 6 and 12 months. Baseline and outcome data include depression, mental health assessments, treatment receipt, comorbid illness self-care, social relationships, and environmental stressor assessments.
Study participants were predominantly female (85%), Latino (99%), and born outside of the United States (91%). Overall study retention rate was 70% (121 AHH and 121 UC). Baseline characteristics did not vary significantly between retained and attrition groups. Half of AHH patients received 4 or more promotora sessions. Promotoras made 12 referrals to LAC-DHS providers and 154 referrals to community resources (most frequently requested community services: community/senior/wellness center, 88 occurrences; transportation, 33; food bank, 25). During the trial period, LAC-DHS activated health care improvements, including adding community health workers into UC clinics. Depression outcomes did not vary significantly between intervention and usual care groups (UC as the reference group; at 6 months: mean difference = 0.01; 95% CI, −1.3 to 1.3; at 12 months: mean difference = −1.1; 95% CI, −2.5 to 0.2); however, we found significant improvements in most assessed physical and mental health outcomes for each study group.
No significant differences existed in primary depression outcomes between the AHH intervention and the PCMH usual care study groups.
The challenges were to maximize intervention attendance and minimize study attrition given the high representation of immigrant, Spanish-speaking, safety-net population in the sample. The effects of the intervention were confounded by major quality improvement initiatives in the participating clinics. Future work is needed to provide a more definitive test of the AHH promotora model, while addressing these potential confounders.
