Race, Ethnicity, and Gender: Lessons for Culturally Appropriate Care Models for Depression

1
Race, Ethnicity, and Gender Lessons for
Culturally Appropriate Care Models for Depression

• Lisa A. Cooper, MD, MPH
• Professor of Medicine, Epidemiology and Health
  Policy Management
• Welch Center for Prevention, Epidemiology
  Clinical Research
• Johns Hopkins University

2
Overview

• Case presentation
• Epidemiology of depression
• Race, ethnicity, gender, and depression care
• Review of selected studies
• Patient attitudes and preferences
• Patient-clinician communication
• Strategies to improve depression care
• Standard quality improvement
• Patient-centered and culturally-tailored models
• Implications for clinical care, health
  professional education, future research, and
  health policy

3
55-year old African American woman with depression

• History of Present Illness
• Mrs. S. is a 55 year old married African American
  woman feeling down off and on for at least 6
  months. Recently feeling tired and overwhelmed
  and not sleeping right.
• Past Medical History
• Acid reflux, sometimes its so bad I get chest
  pains.
• No history of treatment for depression.
• Medication
• Prevacid for acid reflux
• Family History
• No history of depression or other psychiatric
  illnesses.

4
55-year old African American woman with
depression, contd

• Social History
• Habits She does not drink alcohol, smoke or use
  illicit drugs.
• Occupation She runs a housing program. Work is
  hectic, someones always in crisis or needs
  something. I cant even get 2 minutes to myself.
• Family Her husband had a stroke 2 years ago.
• He has some mobility back now but he still
  depends on me a lot, even when he could do things
  for himself.
• Ive been going through some problems in my
  marriage since my husband became ill.
• Social She belongs to a womens group at her
  church. I have a very supportive family but its
  difficult to ask for help. My husband expects me
  to always be there for him.

5
55-year old African American woman with
depression, contd

• Her thoughts about depression
• I think Ive been in a depressed state for
  awhile. I started writing in a journal, my church
  group suggested it. I tend to get down at the end
  of the year, in the winter. This year in
  particular was bad.
• Treatment by the doctor
• Joan was prescribed antidepressant meds at her
  last visit. I didn't like how that Paxil made me
  feel. I was feeling drained, not myself. I took
  it for about a week and just felt worse so I cut
  the pills in half and tried that for a couple of
  weeks. I still couldn't function. I didn't tell
  Dr. Morales.
• I'm not opposed to counseling but right now I
  think I'm doing much better and getting support
  from the ladies in my group. I'm trying to do
  things on my own.
• What should she do?

6
Major Depressive Disorder

• A very common and serious medical condition that
  affects 5 of the population at any time
• Affects women at twice the rate it affects men
• Is most common in persons aged 18 - 44 years
• Affects persons of various educational, social
  class, and ethnic backgrounds at similar rates
• Leads to functional impairment and worsens
  physical health (e.g., cardiovascular disease)
• Increases risk of mortality from suicide

7
Treatment of Depression in Primary Care Settings

• Most individuals with depression in the U.S. who
  seek care receive their mental health care in
  primary care settings Wang 2000, Kessler 2005
• Treatment of depression in primary care remains
  suboptimal
• Under-recognition of mental illness is common
  Perez-Stable 1990, Balsa 2005
• Primary care physicians use lower doses of
  antidepressants and for shorter periods of time
  than guidelines recommend Katon 1992,
  Magruder-Habib 1989

8
Racial and Ethnic Disparities in Mental Health
Care

• African Americans and Hispanics use specialty
  mental health services at half the rate of whites
  Vernon 1982, Sussman 1987, Hough 1987, Scheffler
  1989, Gallo 1995
• Attrition from psychotherapy and pharmaco-therapy
  is higher for ethnic minorities than whites Wells
  1994, Brown 1999
• Disparities in mental health care not explained
  by differences in education or health insurance
  Padgett 1994, Charbonneau 2003

9
Racial and Ethnic Disparities in Mental Health
Care

• Use of outpatient mental health services in
  primary care settings has increased for African
  Americans and Hispanics Cooper-Patrick 1999, Vega
  1999
• However, ethnic minorities are less likely to be
  recognized as depressed, receive
  guideline-concordant care in primary care
  settings, or to be referred to mental health
  specialists Wang 2000, Borowsky 2000, Harman
  2001, Young 2001, Miranda 2004, Leo 1998

10
Gender and Depression Care

• Literature on gender and depression care limited
• Large study of depressed primary care patients
  shows little evidence of gender disparities
  except women less likely to be counseled about
  anxiety and alcohol or drug use Chan 2006
• The associations of shared decision-making and
  guideline-concordant care with patient
  satisfaction and depression resolution are
  similar among men and women Clever 2006, Swanson
  2007

11
Access to Health Care for Racial and Ethnic
Groups
Modified From Access to Health Care in America
(1993, Millman M, ed). Cooper LA, Hill MN, and
Powe NR. JGIM 2002 477-486
12
Patient Attitudes and Preferences Regarding
Treatment of Depression

• Design Qualitative study using focus groups
• Study Subjects
• Patients African Americans and Whites, 18 years
  or older with recent depressive episode
• Professionals physicians and social workers
  involved in care of general medical patients

Cooper-Patrick L et al, JGIM 199712431-438
13
Conduct of Focus Groups

• Three groups two patient groups
  (African-American and White) one professional
  group
• Groups led by trained moderator 90 minutes each
• Discussions audio taped and transcribed verbatim
• Focus group questions addressed
• Depression experience/help-seeking behaviors
• Treatment preferences
• Perceived barriers to mental health care

14
Content Analysis

• Two investigators independently reviewed
  transcripts and mark comments
• Third investigator adjudicated differences
• Comments separated into categories with thematic
  labels
• Themes and comments sent to two other
  investigators for independent second review
• Final taxonomy developed by consensus

15
Sample Comments Made by Patients in Depression
Focus Groups
Spirituality

• I did pray a lot. Im a Christian, and I would
  pray and pray and find verses of scripture.
• African-American male, age 30

Cooper-Patrick L et al, JGIM 199712431-438
16
Sample Comments Made by Patients in Depression
Focus Groups
Stigma

• And I didnt want anyone to know that I was
  taking this prescription. I just didnt want to
  feel like I was crazy.
• African-American female, age 53

Cooper-Patrick L et al, JGIM 199712431-438
17
Sample Comments Made by Patients in Depression
Focus Groups
Patient-provider relationships

• This guy my doctor was just a plain old nice
  guy, you knowhe was very, very sharpI thought,
  whatever this guy tells me for the most part, if
  it sounds sensible, Ill give it a try.
• male, age 28

Cooper-Patrick L et al, JGIM 199712431-438
18
Sample Comments Made by Patients in Depression
Focus Groups
Attributes of treatment Medicines

• If its gonna make me feel good, make me feel
  good right away so I can get up and start doing
  what I want to do. I dont want it to take a
  long time to kick in.
• female, age 41

Cooper-Patrick L et al, JGIM 199712431-438
19
Patients Opinions Regarding the Importance of
Various Aspects of Depression Care

• Design cross-sectional survey to prioritize
  items derived from focus groups
• Patients 76 adults (49 white, 27 AA) aged 18-64
  years
• Setting Urban primary care clinics
• Data Collection demographics, past mental health
  treatment, mental health status, opinions about
  various aspects of depression care
• Instruments Importance Questionnaire, Center
  for Epidemiologic Studies Depression Scale (CES-D)

Cooper LA et al, Gen Hosp Psychiatry
200022163-173
20
Importance Questionnaire

• Patients were
• Given a brief description of symptoms of major
  depression
• Told that depression is treatable and given the
  major types of treatment
• Asked to rate the importance of each item on a
  5-point scale of not at all important to
  extremely important for good quality depression
  care
• Items were grouped by category/theme

21
Data Analysis

• Ranking of items by mean score and rating item
  extremely important (EI)
• Items selected for inclusion in Patient Attitudes
  and Ratings of Care for Depression (PARC-D)
  instrument based on importance ratings
• Reliability and validity testing of scales
• Comparisons between AAs and Whites

22
Most Important Aspects of Depression Care to
Patients

• 1. Health provider interpersonal skills
• 2. Treatment effectiveness
• 3. Treatment problems
• 4. Patient education, information, and
  understanding
• 5. Intrinsic spirituality (African Americans)
• 6. Financial access
• 7. Primary care provider recognition of
  depression

Cooper LA et al, Gen Hosp Psychiatry
200022163-173
23
African Americans rate spirituality as more
important in depression care than whites
All p-values lt0.05
Cooper LA et al, Journal of General Internal
Medicine 200116634-638
24
Acceptability of Depression Treatment Among
Primary Care Patients

• Methods cross-sectional telephone survey
• Patients 829 U.S. adult primary care patients
  with major depressive disorder by the CIDI
• Independent variable patient race/ethnicity
• Outcomes patient self-reported acceptability of
  antidepressant medications and counseling
• Analysis Logistic regression using weighted data

Cooper LA et al. Med Care 200341479-489
25
Quality Improvementfor Depression Project

• Hopkins Quality Improvement for Depression
  (HQID), Baltimore/Washington DC (Ford, PI)
• Mental Health Awareness Project (MHAP), Los
  Angeles, CA (Rubenstein, PI)
• Quality Enhancement by Strategic Teaming (QuEST),
  10 mid-western states (Rost, PI)
• Partners in Care Depression PORT (Wells, PI)

26
Views about depression differ among Whites,
Blacks, and Hispanics

• White AA Hisp
• n659 n97 n72
• I believe I need treatment 68 70 68
• Medications are effective 91 69 84
• Medications are addictive 34 56 51
• Counseling is as effective as meds 50 57 74
• Counseling brings up bad feelings 50 71 71
• Prayer heals depression 67 93 67
• Socially embarrassed 24 24 33
• Family would be disappointed 16 15 22
• Prefer same ethnicity/race provider 14 25 13

plt0.05, plt0.01, plt0.001 Cooper LA et al. Med
Care 200341479-489
27
African Americans and Hispanics find medications
less acceptable as treatment for depression
Counseling, Hispanics
3.26
Whites, reference group
0.63
0.44
0.30
Counseling, AAs
Meds, AAs Meds, Hispanics
adjusted for patient demographics, illness
factors, treatment experience, social support,
life events, QID site
Cooper LA et al. Med Care 200341479-489
28
Access to Health Care for Racial and Ethnic
Groups
Modified From Access to Health Care in America
(1993, Millman M, ed). Cooper LA, Hill MN, and
Powe NR. JGIM 2002 477-486
29
Patient-physician communication is related to
important outcomes

• Patient recall of information
• Patient adherence
• Patient satisfaction
• Clinical outcomes
• Glycemic control
• Blood pressure control
• Pain reduction
• Depression resolution

• Roter 1988, Greenfield 1988, Kaplan 1989, Kaplan,
  1995, Stewart 1998, Clever 2006

30
Ethnic minorities receive poorer interpersonal
health care than whites

• African Americans, Hispanics, and Asians report
• Lower levels of trust in physicians and hospitals
  Boulware 2003
• Less respectful treatment Johnson 2004
• Less participation in health care decisions
  Cooper-Patrick 1999
• Minorities experience poorer communication with
  physicians Johnson 2004
• The only exception is in race-concordant
  relationships (where the patient and doctor are
  the same race) Cooper-Patrick 1999, Cooper 2003

31
Women receive better interpersonal health care
than men

• Female patients receive more information, ask
  more questions, and have more partnership-building
  with physicians than male patients Kaplan 1995,
  McKinlay 1996
• Female physicians engage in more psychosocial
  talk, partnership building and have longer visits
  than male physicians Roter Hall 1993, 1998
• Studies of gender concordance (where patients and
  physicians are the same gender) show mixed
  results Roter 1999, Derose 2001, Schmittdiel 2000

32
Race, Gender, and Partnership in the
Patient-Physician Relationship

• Design Cross-sectional telephone survey
• Subjects 1816 adults (784 W, 814 AA, 218 Other)
  who had seen their MD (n65) within the past 2
  weeks
• Setting 32 primary care practices, large network
  style managed care organization in Washington
  D.C. area
• Predictor variables race and gender concordant
  or discordant status in patient-physician
  relationship
• Main Outcome patients ratings of their MDs
  participatory decision-making (PDM) style

Cooper-Patrick L et al, JAMA 1999282583-589
33
Measurement of Physicians Participatory
Decision-Making Style

• Patient is asked
• If there were a choice between treatments, how
  often would this doctor ask you to help make the
  decision?
• How often does this doctor make an effort to give
  you some control over your treatment?
• How often does this doctor ask you to take some
  of the responsibility for your treatment?

Kaplan SH et al, Medical Care 1995331176-1187
Each item contributes 33.3 points. Maximum score
is 100 points.
34
Patient race, not gender, is related to
participatory decision-making
P0.007
P0.05
PDM scores range from 0-100. A higher score means
visit is more participatory. Cooper-Patrick L ,
JAMA 1999282583-589
35
Physician gender, not race, is related to
participatory decision-making
P0.03
Adjusted for patients age, race, gender,
education, marital status, health status, and
length of patient-physician relationship.
Cooper-Patrick L et al, JAMA 1999282583-9
36
Patients in race-concordant, not
gender-concordant, relationships rate their
physicians as more participatory
P-value NS
P0.02
Mean PDM Style Score
Adjusted for patients age, gender, education,
marital status, health status, length of the
patient-physician relationship, physician gender
(race concordant analysis) and physician race
(gender concordance analysis). Cooper-Patrick L,
JAMA 1999282583-589
37
Patient-Centered Communication, Ratings of Care
and Concordance of Patient and Physician Race

• Design cross-sectional study using pre-visit and
  post-visit surveys and audiotape analysis
• Setting urban primary care practices serving
  managed care and fee-for-service patients
• Participants 458 African American and white
  adult patients receiving care from 61 primary
  care physicians
• Patient recruitment 10 patients per MD
  recruited consecutively from waiting rooms

Cooper LA, Roter DL, Johnson RL, Ford DE,
Steinwachs DM, Powe NR. Ann Intern Med
2003139907-915
38
Measurement of Patient-Clinician Communication

• Content
• Biomedical exchange
• Psychosocial exchange
• Depression exchange
• Affect (Rapport-building)
• Emotional Talk - Negative talk
• Positive talk - Social talk
• Process
• Orientation (directions or instructions)
• Facilitation (includes partnership-building)

Roter Interaction Analysis System (RIAS) Roter
D, Larson S. Patient Educ Couns 200246243-51
39
Examples from Communication Categories

• Biomedical exchange
• Your blood pressure is 100 over 70.
• I was in the hospital last year for ulcers.
• Psychosocial exchange
• You really need to get out and meet more
  people.
• I guess every marriage has its ups and downs.
• Rapport-building exchange
• This must be very hard for you.
• I hope youll be feeling better soon.
• Facilitation and Partnership-building
• Do you follow me? How does that sound to you?

40
Examples of Depression Talk

• Physician
• It might just be a matter of getting you on the
  right amount of antidepressant medication.
• Maybewe should have you see a professional
  counselor to help you sort through some of these
  issues.
• Patient
• I am feeling tired all the time. I like to look
  on the bright side, but it seems like lately,
  its harder to do.
• Ive been taking Trazodone.

41
Measurement of Global Affect or Emotional Tone

• Coders are asked to rate overall emotional tone
  of the visit for clinicians and patients
• Physician positive affect (assertiveness
  interest responsiveness empathy) hurried
• Patient positive affect (assertiveness
  interest friendliness responsiveness
  empathy)
• Patient negative affect (anxiety, irritation,
  depression, and emotional distress)

All global affect dimensions are coded on a
numeric scale of 1-6 (1low/none, 6high).
42
The Patient-Centered Medical Interview

• Visit duration is longer
• Speech speed is lower
• Physicians are less verbally dominant
• doctor talk to patient talk ratio is close to 1
• Patient-centeredness ratio is high more
  psychosocial, emotional, and partnership talk
  than biomedical talk
• More positive emotional tone

43
Race-concordant visits are longer with more
positive patient emotional tone
plt0.05. Adjusted for patient age, race, gender,
and health status and physician gender and years
in practice.


Cooper LA et al, Ann Intern Med 2003139907-915
44
Patients in Race-Concordant Relationships Rate
Their Physicians Better



Mean Score/Probability
plt0.05, plt0.01 from GEE. Analyses adjusted for
patient gender, race, age, and health status,
physician gender, years in practice, and
patient-centered communication. Cooper LA
et al, Ann Intern Med 2003139907-915
45
Physicians are more verbally dominant and have
less positive emotional tone in visits with
African-American patients
Adjusted for patient age, gender, education
level, and self-rated health status and
physician gender, race, time since completing
training, and report of how well he/she knows
each patient. p-value from linear regression
with GEE. Patient and physician affect scores
are derived from audiotape coders impressions of
the overall emotional tone of the medical visit.
Johnson RL, Roter DL, Powe NR, Cooper LA. Am J
Public Health 2004 942084-2090.
46
Physicians engage in less depression talk and
rapport-building with depressed African Americans
P0.07
P0.04
P0.01
P0.30
Ghods BK, Roter D, Ford DE, Larson S, Arbelaez J,
Cooper LA. J Gen Intern Med 2008 Feb 8 Epub
ahead of print
47
Patient Race, Visit Length, and Coder Ratings of
Global Affect
plt0.05, plt0.01. Adjusted for patient age,
education and PCS-12 score
48
Physician Ratings of Patients Health Status
The sample size is lower than the total number of
patient participants because of physician
non-response to post-visit surveys.
49
Summary

• African American patients report less favorable
  attitudes regarding depression treatment
• Racial disparities in patient-physician
  communication and physician recognition of
  depression exist
• To overcome disparities in depression care,
  studies should test the effectiveness of
• Physician communication skills training programs
  that emphasize recognition and rapport-building
• Culturally sensitive patient activation programs

50
Blacks Receiving Interventions for Depression and
Gaining Empowerment

• Design Randomized controlled trial
• Population 30 primary care providers and 250
  African American patients with depression
• Setting Urban, community-based clinics in
  Delaware, Maryland, and Washington DC
• Interventions
• Standard quality improvement program
  (disease-oriented provider academic detailing and
  patient case management)
• Patient-centered, culturally tailored program
  (provider communication skills training and
  patient case management focused on cultural
  issues)

Supported by AHRQ R01HS013645, 9/30/03-8/31/08
51
Bridge Study Outcomes

• Resolution of depression symptoms
• Functional status and disability days
• Guideline concordant depression care
• Health service utilization
• Patient ratings of care
• Patient-provider communication behaviors

Assessed at 6 and 12 months of
follow-up Assessed at baseline and after
provider intervention
52
Conceptual Framework for BRIDGE
BRIDGE Study Interventions
Provider Needs assessment CME lunch meetings
(2) Communication skills training Feedback from
case manager
Health Care System Psychiatric consultation Collab
orative care Feedback regarding patients
status Case manager encourages more follow-up and
appointments
Patient Needs assessment Education Activation Supp
ort Active follow-up
Process of Care
Outcomes
53
Study Design
Patient-Centered Intervention Physicians N15
Patient-Centered Intervention Patients N125
All clinicians are videotaped with a simulated
patient at baseline, then randomized
Standard Intervention Patients N125
Standard Intervention Physicians N15
Depression Care Manager contacts for active
follow-up up to 12 months
54
Clinical Sites Partners

• Baltimore Medical Surgical Associates
• Baltimore Medical System (BMSI)
• Johns Hopkins Community Physicians
• Sinai Hospital

• Henrietta Johnson Medical Center, DE Associates
• Westside Healthcare, DE

55
Recruitment

• Clinicians
• Via letter from medical director and PI
• CME credit and individualized feedback on
  communication style
• Organizations given incentive for MD/NP/PA
  participation in research (200/clinician)

• Patients
• Approached onsite by RA
• Screener administered and visit audio-taped
• Baseline interview completed by phone within 2
  weeks
• Assigned to care manager
• Monetary compensation
  (25 per interview3 75)

56
Primary Care Clinician Intervention Features
57
Examples of Provider Goals

• Improve recognition
• Evaluate depressed patients more thoroughly
  example, substance abuse, anxiety
• Assess suicidal ideation
• Change the antidepressant I usually use
• Identify patients cultural beliefs regarding
  depression and its treatment
• Elicit patients treatment preferences more often

58
Interactive CD-ROM
59
Patient Intervention Features
60
Standard Needs Assessment

• Depressive symptoms
• Associated conditions
• Functional Status/Activities affected
• Stressors
• Social Support
• Treatment preferences

61
Patient-Centered Intervention Needs Assessment

• Meaning of illness from patient perspective
• Perceptions of racial discrimination
• Literacy and language concerns
• Importance of spirituality in coping and care
• Specific treatment concerns regarding
  antidepressants or counseling
• Financial concerns
• Role of stigma
• Relationships with health professionals

62
Standard InterventionPatient Education Materials

• Brochure
• Book
• DVD

63
Patient-Centered Intervention Patient Education
Materials

• Brochure
• Book
• Videotape
• Prayer card
• Bridge Study calendar

only if patient is spiritually oriented and/or
receptive
64
Primary Care Clinician Enrollment(June 2004
March 2006)
108 Clinicians Contacted
9 No Response
99 Clinicians Responded
63 Refusals
36 Clinicians Randomized
27 Clinicians with patients enrolled in study
65
Demographic Characteristicsof Primary Care
Clinicians (N27)
66
Primary Care Clinician Elicitation of Depressive
Symptoms at Baseline
67
Primary Care Clinician Depression Proficiencies
at Baseline (N27)

• Treatment of Depression
• Proficiency of clinicians who did
• Recommend counseling/
• referral or future referral 81
• Discussed psychotropic
• medication use 89
• Asked knowledge/ beliefs
• regarding depression 15
• Asked treatment/ concerns
• regarding depression 96
• Ask for commitment to plan 74

68
Primary Care ClinicianPost-Intervention
Proficiencies

• Standard Patient Centered
• (n31) (n25)
• Depression Proficiency elicited
  elicited
• gt 5 depression symptoms 63 81
• Depressed Mood 52 80
• Sleep disturbance 55 76
• Appetite or weight change 35 60
• Fatigue 26 36
• Suicidal Ideation 68 64
• Diminished interest 45 44
• Impaired concentration 29 28
• Psychomotor 10 12
• Guilt 13 8

plt0.05
69
Primary Care ClinicianPost-Intervention
Proficiencies

• Standard Patient Centered
• Depression Proficiency (n31) (n25)
• Asked knowledge/beliefs 0 4
• Asked treatment concerns 23 12
• Recommended counseling 77 64
• Discussed medication use 77 44
• Ask for commitment to plan 3 20

plt0.05
70
Patient Enrollment(October 2005 - August 2006)
1,486 patients Approached in waiting rooms
873 (59) Agreed to be screened
457 not depressed 46 getting SMH care 68 CAGE
positive
231 (26) Eligible by screener
22 Unable to locate
132 (90) Eligible by CIDI and randomized
71
Demographic Characteristics of Patients at
Baseline (n132)
72
Clinical Characteristics of Patients at Baseline
(n132)
73
Patients Treatment Preferences

• If you had to choose between taking
  antidepressant medicine daily for 6-9 months or
  going to counseling weekly for at least 3 months,
  which would you prefer?

74
Patient Attitudes and Ratings Towards Depression
Care
75
Satisfaction with Care and Trust in Providers
76
Patients Decision-making Preference
77
Patient Follow-up Status
78
Patient Intervention Contacts
Refused during initial call or at some point
during the 12 month intervention
79
Treatment status at 6 and 12 months by
intervention status
80
Depression status at 6 and 12 months by
intervention status
81
Conclusions

• Recruiting primary care clinicians and depressed
  African American patients from busy urban
  community-based clinics to participate in quality
  improvement interventions for depression is
  challenging, but feasible
• Both intervention approaches show similarly
  modest improvements in clinician assessment of
  depression and patient depression symptoms

82
Conclusions

• Standard QI approaches may lead to greater use of
  antidepressant medications among clinicians and
  their African American patients
• Patient-centered care may lead to greater
  long-term improvements in depression status
• We are conducting an 18-month follow-up
• Future analyses will focus on processes of care
  and patient experiences and make comparisons to
  clinical effects seen in other randomized trials

83
Implications

• Research Examine more links among clinician and
  patient attitudes, behaviors, and health
  outcomes
• Health Professional Education - employ
  patient-centered communication skills programs
  that emphasize rapport building and affective
  dimensions and enhance awareness of bias and
  intercultural skills
• Clinical Practice - implement patient activation
  programs improve scheduling, increase time to
  build rapport and develop continuity of care
• Policy - increase numbers of underrepresented
  ethnic minorities among health professionals
  parity in mental health coverage reimbursement
  for case management and collaborative care

84
Research and Clinical Team

• Principal Investigator
• Lisa A. Cooper, MD, MPH
• Co-Investigators
• Daniel E. Ford, MD, MPH
• James M. Gill, MD, MPH
• Susan Larson, MHS
• Annelle B. Primm, MD, MPH
• Debra L. Roter, DrPH
• Elias K. Shaya, MD
• Nae-Yuh Wang, PhD

• Research Program Coordinator
• Bri Ghods
• Depression Case Managers
• Karen Kemp, MSW
• Dawna McGlynn, LCSW-C
• Data Collection Unit
• Battelle Memorial Institute
• Other collaborators
• Junius Gonzales, MD
• Joseph Gallo, MD
• Charlotte Brown, PhD
• Jeanne Miranda, PhD