Publications by authors named "Jeanne Miranda"

130 Publications

An Anti-Racist Approach to Achieving Mental Health Equity in Clinical Care.

Psychiatr Clin North Am 2020 09 7;43(3):451-469. Epub 2020 Jul 7.

Department of Psychiatry and Biobehavioral Sciences, UCLA, UCLA's Center for Health Services and Society, 10920 Wilshire Boulevard, Suite 300, Los Angeles, CA 90024, USA.

Racism is an important determinant of health and health disparities, but few strategies have been successful in eliminating racial discrimination from medical practice. This article proposes a novel antiracist approach to clinical care that acknowledges the racism shaping the clinical encounter and historical arc of racial oppression embedded in health care. Although preliminary, this approach can be easily implemented into clinical care and may reduce the harm done by racism. It could also serve as a template for antiracist service provision in other sectors, such as education and law enforcement.
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http://dx.doi.org/10.1016/j.psc.2020.05.002DOI Listing
September 2020

A critical review of current evidence on multiple types of discrimination and mental health.

Am J Orthopsychiatry 2020 30;90(3):374-390. Epub 2020 Jan 30.

Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles.

Little is known about people who experience multiple types of discrimination (e.g., racism and heterosexism). While some work suggests that multiply discriminated groups are at higher risk for poor mental health, other studies propose that they may develop resilience against additional kinds of discrimination. We conducted a review of published studies on the relationship between multiple types of discrimination and mental health to critically examine evidence in support of broad risk and resilience models. Using PRISMA guidelines, we identified 40 studies that met our inclusion criteria. Typically, studies examined either whether experiencing multiple discrimination was related to poorer mental health, or whether one kind of discrimination was more predictive of poor mental health. Studies generally showed support for the risk model, with multiple forms of discrimination associated with higher risk for depression symptoms. Furthermore, both racism and heterosexism uniquely predicted symptoms of depression, although initial evidence suggested that only heterosexism predicted suicidality among lesbian, gay, bisexual, transgender, and queer (LGBTQ) racial/ethnic minorities. Findings on multiple discrimination and other mental health problems (e.g., anxiety, posttraumatic stress disorder [PTSD], distress, and substance use) were mixed. The current evidence suggests that multiply discriminated groups exhibit higher risk for some mental health problems, particularly depression symptoms. However, methodological problems abound in this literature (e.g., correspondence between study sample and types of discrimination assessed), which limits our ability to draw clear conclusions about multiple discrimination. We propose that to further our understanding of how multiple kinds of discrimination may affect mental health, studies must remedy these and other issues. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/ort0000441DOI Listing
November 2020

Resilience Against Depression Disparities (RADD): a protocol for a randomised comparative effectiveness trial for depression among predominantly low-income, racial/ethnic, sexual and gender minorities.

BMJ Open 2019 10 22;9(10):e031099. Epub 2019 Oct 22.

Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, California, USA.

Introduction: Depression is the leading cause of adult disability and common among sexual and gender minority (SGM) adults. The current study builds on findings showing the effectiveness of depression quality improvement (QI) and delivery of cognitive behavioural therapy (CBT) skills provided by community health workers in reducing depression. Depression QI approaches across healthcare and social/community services in safety-net settings have shown improvements in mental wellness, mental health quality of life and depression over 12 months. Further, a randomised study showed improved depression among low-income racial/ethnic minorities enrolled in a CBT-informed resiliency class (Building Resilience and Increasing Community Hope (B-RICH)). The current protocol describes a comparativeness effectiveness study to evaluate whether predominantly low-income, SGM racial/ethnic minority adults randomised to a CBT-informed resiliency class have improvements in depressive symptoms over and above community-engaged QI resources and training only.

Methods And Analysis: The study approached three clusters of four to five programs serving predominantly SGM and racial/ethnic minority communities in the USA: two clusters in Los Angeles, California, and one in New Orleans, Louisiana. Clusters are comprised of one primary care, one mental health and two to three community agencies (eg, faith-based, social services/support, advocacy). All programs received depression QI training. The current study employed a community-partnered participatory research model to adapt the CBT-informed resiliency class, B-RICH+, to SGM communities. Study participants were screened and recruited in person from participating programs, and will complete baseline, 6- and 12-month survey follow-ups. Participants were depressed adults (8-item Patient Health Questionnaire ≥10; ≥18 years of age) who provided contact information. Enrolled participants were individually randomised to B-RICH+ or depression QI alone. Primary outcomes are depressive symptoms; secondary outcomes are mental health quality of life, mental wellness and physical health quality of life. Data collection for this study is ongoing.

Ethics And Dissemination: The current study was approved by the UCLA Institutional Review Board. Study findings will be disseminated through scientific publications and community conferences.

Trial Registration Number: https://clinicaltrials.gov/ct2/show/NCT02986126.
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http://dx.doi.org/10.1136/bmjopen-2019-031099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6830623PMC
October 2019

The Pilot Study: A Diabetes Management Intervention for Latino Caregiving Dyads.

Diabetes Educ 2019 10 21;45(5):507-519. Epub 2019 Aug 21.

Oregon State University, College of Public Health and Human Sciences, Corvallis, Oregon.

Purpose: The purpose of this study was to design a culturally sensitive dyad-level diabetes intervention to improve glycemic control for older Latino adults with type 2 diabetes.

Methods: This study used a pretest-posttest noncontrol group design. The intervention was developed from formative research with Mexican-origin caregiving dyads. The curriculum was adapted from 2 randomized trials of community interventions specifically designed for Latino older adults with type 2 diabetes. The curriculum consisted of communication skill-building exercises and dyad decision making on lifestyle changes to improve the older adult's blood glucose levels. Thirty-two community-dwelling dyads completed a 6-week program of one-on-one sessions with a trained program facilitator. Main outcomes were feasibility and acceptability of the program. The authors assessed feasibility by examining participant burden and retention and acceptability by participant exit interviews. Although underpowered for outcomes, A1C, health status, and dyadic communication were also assessed to evaluate whether trends suggested the effectiveness of the intervention.

Results: Most participants viewed as an acceptable program and wanted the program expanded in terms of length and scope. All outcomes showed improvement from baseline through 6 months postintervention.

Conclusions: Results show that is acceptable to Mexican-origin caregiving dyads and is a promising approach for effectively controlling type 2 diabetes among older Latino adults who have a family caregiver.
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http://dx.doi.org/10.1177/0145721719866619DOI Listing
October 2019

Developing and evaluating a lay health worker delivered implementation intervention to decrease engagement disparities in behavioural parent training: a mixed methods study protocol.

BMJ Open 2019 07 18;9(7):e028988. Epub 2019 Jul 18.

Psychology, University of California Los Angeles, Los Angeles, California, USA.

Introduction: Behavioural parent training (BPT) programmes are effective in preventing and treating early-onset conduct problems and child maltreatment. Unfortunately, pervasive mental health service disparities continue to limit access to and engagement in these interventions. Furthermore, challenges with parental engagement can impede the successful implementation of evidence-based practices (EBPs) in community settings that serve low-income, ethnic minority families. Lay health workers (LHWs)-individuals without formal mental health training-represent an important workforce to increase engagement, as they are members of the communities they serve. However, the mobilisation of LHWs has not been well studied as an implementation strategy to extend the reach or effectiveness of EBPs in the USA. LHW-delivered implementation interventions that specifically support the engagement of Latinx parents in evidence-based BPT programmes have the potential to improve clinical and implementation outcomes.

Methods And Analysis: A community-partnered approach will use the Quality Implementation Framework (QIF) to tailor and implement an LHW-delivered implementation intervention that aims to promote Latinx parent engagement in BPT programmes. Steps from the QIF will guide study activities to (1) conduct a mixed methods needs assessment to fit the implementation intervention to the local context, (2) adapt LHW-delivered implementation strategies to promote parent access to and engagement in Parent-Child Interaction Therapy and (3) conduct a hybrid effectiveness-implementation pilot trial to examine the feasibility, acceptability and preliminary effectiveness of the LHW implementation intervention at increasing engagement.

Ethics And Dissemination: Study procedures have been approved by the Institutional Review Board at the University of California, Santa Barbara. Results will be shared with the community-advisory group, at community-based meetings for other stakeholders involved in the pilot project, and submitted for publication in peer-reviewed journals.
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http://dx.doi.org/10.1136/bmjopen-2019-028988DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6661633PMC
July 2019

Depression Remission From Community Coalitions Versus Individual Program Support for Services: Findings From Community Partners in Care, Los Angeles, California, 2010-2016.

Am J Public Health 2019 06;109(S3):S205-S213

Armen C. Arevian, Jeanne Miranda, and Lingqi Tang are with the Jane and Terry Semel Institute for Neuroscience and Human Behavior and the Center for Health Services and Society, University of California Los Angeles (UCLA), Los Angeles, CA. At the time of the study, Felica Jones and Loretta Jones were with Healthy African American Families II, Los Angeles. Cathy D. Sherbourne is with RAND Corporation, Santa Monica, CA.

To explore effects of coalitions (Community Engagement and Planning [CEP]) versus technical assistance (Resources for Services [RS]) for depression collaborative care and the effects of social determinants on long-term remission outcomes. We randomized 95 health care and community programs in Los Angeles County, California, to CEP or RS. In 2010, 1246 depressed (Patient Health Questionnaire [PHQ-8] ≥ 10) adults enrolled and were invited for baseline and 6-, 12-, and 36-month surveys. Of 598 3-year completers, 283 participated at 4 years (2016). We examined effects of CEP versus RS, social factors (e.g., family income, food insecurity) on time to and periods in clinical (PHQ-8 < 10) and community-defined (PHQ-8 < 10 or PHQ-2 < 3; mental health composite score [MCS-12] > 40, or mental wellness) remission during the course of 3 years, and at 4 years. We found that CEP versus RS increased 4-year depression remission and, for women, community-defined remission outcomes during the course of 3 years. Social factors and clinical factors predicted remission. At 4 years, CEP was more effective than RS at increasing depression remission. Coalitions may improve 4-year depression remission, while addressing social and clinical factors associated with depression may hold potential to enhance remission.
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http://dx.doi.org/10.2105/AJPH.2019.305082DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6595525PMC
June 2019

The symptom-specific efficacy of antidepressant medication vs. cognitive behavioral therapy in the treatment of depression: results from an individual patient data meta-analysis.

World Psychiatry 2019 Jun;18(2):183-191

Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.

A recent individual patient data meta-analysis showed that antidepressant medication is slightly more efficacious than cognitive behavioral therapy (CBT) in reducing overall depression severity in patients with a DSM-defined depressive disorder. We used an update of that dataset, based on seventeen randomized clinical trials, to examine the comparative efficacy of antidepressant medication vs. CBT in more detail by focusing on individual depressive symptoms as assessed with the 17-item Hamilton Rating Scale for Depression. Five symptoms (i.e., "depressed mood" , "feelings of guilt" , "suicidal thoughts" , "psychic anxiety" and "general somatic symptoms") showed larger improvements in the medication compared to the CBT condition (effect sizes ranging from .13 to .16), whereas no differences were found for the twelve other symptoms. In addition, network estimation techniques revealed that all effects, except that on "depressed mood" , were direct and could not be explained by any of the other direct or indirect treatment effects. Exploratory analyses showed that information about the symptom-specific efficacy could help in identifying those patients who, based on their pre-treatment symptomatology, are likely to benefit more from antidepressant medication than from CBT (effect size of .30) versus those for whom both treatments are likely to be equally efficacious. Overall, our symptom-oriented approach results in a more thorough evaluation of the efficacy of antidepressant medication over CBT and shows potential in "precision psychiatry" .
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http://dx.doi.org/10.1002/wps.20630DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502416PMC
June 2019

Community Engagement and Planning versus Resources for Services for Implementing Depression Quality Improvement: Exploratory Analysis for Black and Latino Adults.

Ethn Dis 2019 18;29(2):277-286. Epub 2019 Apr 18.

Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine and the Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA; Department of Health Policy and Management, Fielding School of Public Health; RAND Health Program; Greater Los Angeles Veteran Affairs Health Care System, Los Angeles CA.

Objective: Racial/ethnic minorities experience disparities in depression1 and there is a paucity of evidence-based interventions to improve depression care access and outcomes. Community Partners in Care (CPIC) is a community-partnered study of depression care quality improvement (QI) in under-resourced, urban communities: Community Engagement and Planning (CEP) for multi-sector coalitions, and Resources for Services (RS) for program technical assistance.2 CEP demonstrated benefits for the overall CPIC study population; effects for Black and Latino sub-populations are unknown.

Methods: This sub-analysis examines outcomes for 409 Latino and 488 Black (non-Latino) adults recruited from 90 programs who completed baseline or 6-month follow-up. Regression analyses were used to estimate CEP vs RS intervention effects on primary (Mental Health Related Quality of Life [MHRQL], Patient Health Questionnaire-9 [PHQ-9]) and community-prioritized (mental wellness, physical activity, risk for homelessness) outcomes at 6-months.

Results: Baseline characteristics did not differ significantly by intervention in either group. In the adjusted analysis for Black adults, CEP resulted in decreased odds of poor MHRQL (OR: .62, 95% CI=.41-.94, P=.028) with a trend for reducing homelessness risk (OR: .60, .35-1.05, P=.69). For Latino adults, CEP resulted in greater probability of mental wellness (OR: 1.81, 1.05-3.13, P=.034) and a trend for increased physical activity (OR: 1.52, .93-2.49, P=.091).

Conclusions: Exploratory analyses of CEP for depression quality improvement suggests significant 6-month benefits in mental health outcomes for Black and Latino participants and trends for improvement in community-prioritized outcomes for both groups. Findings may inform research in multi-sector coalitions to promote equity in depression care.
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http://dx.doi.org/10.18865/ed.29.2.277DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6478049PMC
June 2020

Community Interventions to Promote Mental Health and Social Equity.

Curr Psychiatry Rep 2019 03 29;21(5):35. Epub 2019 Mar 29.

Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.

Purpose Of Review: We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions.

Recent Findings: There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.
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http://dx.doi.org/10.1007/s11920-019-1017-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6440941PMC
March 2019

Structural Interventions to Reduce and Eliminate Health Disparities.

Am J Public Health 2019 01;109(S1):S72-S78

Arleen F. Brown is with General Internal Medicine and Health Services Research, University of California Los Angeles (UCLA) and Olive View-UCLA Medical Center, Los Angeles, CA. Grace X. Ma is with Center for Asian Health, Fox Chase Cancer Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA. Jeanne Miranda is with the Department of Psychiatry and Biobehavioral Sciences, Jonathan and Karin Fielding School of Public Health, UCLA. Eugenia Eng is with the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Dorothy Castille is with the National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD. Teresa Brockie is with Community Public Health Nursing, Johns Hopkins School of Nursing, Johns Hopkins Bloomberg Center for American Indian Health, Baltimore, MD. Patricia Jones is with Division of Clinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health. Collins O. Airhihenbuwa is with Health Policy and Behavioral Sciences, Global Research Against Noncommunicable Diseases, Georgia State School of Public Health, Atlanta, GA. Tilda Farhat is with the Office of Science Policy, Planning, Analysis, Reporting and Data; National Institute on Minority Health and Health Disparities. Lin Zhu is with the Center for Asian Health, Lewis Katz School of Medicine, Temple University. Chau Trinh-Shevrin is with the Department of Population Health, New York University School of Medicine, New York, NY. Tilda Farhat is also a Guest Editor for this supplement issue.

Health disparities research in the United States over the past 2 decades has yielded considerable progress and contributed to a developing evidence base for interventions that tackle disparities in health status and access to care. However, health disparity interventions have focused primarily on individual and interpersonal factors, which are often limited in their ability to yield sustained improvements. Health disparities emerge and persist through complex mechanisms that include socioeconomic, environmental, and system-level factors. To accelerate the reduction of health disparities and yield enduring health outcomes requires broader approaches that intervene upon these structural determinants. Although an increasing number of innovative programs and policies have been deployed to address structural determinants, few explicitly focused on their impact on minority health and health disparities. Rigorously evaluated, evidence-based structural interventions are needed to address multilevel structural determinants that systemically lead to and perpetuate social and health inequities. This article highlights examples of structural interventions that have yielded health benefits, discusses challenges and opportunities for accelerating improvements in minority health, and proposes recommendations to foster the development of structural interventions likely to advance health disparities research.
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http://dx.doi.org/10.2105/AJPH.2018.304844DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6356131PMC
January 2019

Promoting Enrollment in Parenting Programs Among a Filipino Population: A Randomized Trial.

Pediatrics 2019 02;143(2)

Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California.

Background And Objectives: Evidence-based parenting programs prevent the onset and escalation of youth conduct problems. However, participation rates in such programs are low among hard-to-reach populations, including Filipino individuals. Compared with other ethnic groups, Filipino adolescents have significant mental health disparities. We evaluated the effectiveness of a theory-based, culturally tailored video versus a usual-care mainstream video on enrollment in an evidence-based parenting program among Filipino caregivers of children ages 6 to 12 years and tested theoretical mediators of intervention effect.

Methods: We randomly assigned 215 Filipino participants to view either a theory-based, culturally tailored video based on the Health Belief Model and Theory of Planned Behavior or a control video. The primary outcome was actual enrollment in an evidence-based parenting intervention. Mediators (knowledge and perceived susceptibility) were modeled as latent variables in a structural equation model.

Results: After the intervention, participants in the intervention group had significantly higher knowledge of Filipino adolescent behavioral health disparities and higher perceived susceptibility to adolescent risky sexual activity and illegal drug use. Controlling for child sex, parents in the intervention group had significantly greater odds of actual enrollment in the Incredible Years program (odds ratio = 2.667; 95% confidence interval: 1.328-5.354; = .006). The intervention effects were mediated by increased knowledge and perceived susceptibility.

Conclusions: Results demonstrated the effectiveness of a theory-based, culturally tailored intervention aimed at increasing participation of a hard-to-engage population in parenting interventions. Videos that include parents and health professionals with whom audiences can identify can be used to produce shifts in knowledge and behavior.
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http://dx.doi.org/10.1542/peds.2018-0553DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6361353PMC
February 2019

The Consequences of Family Separation at the Border and Beyond.

J Am Acad Child Adolesc Psychiatry 2019 01;58(1):139-140

University of California, Los Angeles Center for Health Services and Society. Electronic address:

The Trump administration's decision to separate young children from their parents who cross the border illegally or seek asylum generated a strong response from medical and mental health organizations. The National Academies of Sciences, Engineering and Medicine outlined the known harms to such separations.
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http://dx.doi.org/10.1016/j.jaac.2018.09.429DOI Listing
January 2019

Community Partnering for Behavioral Health Equity: Public Agency and Community Leaders' Views of its Promise and Challenge.

Ethn Dis 2018 6;28(Suppl 2):397-406. Epub 2018 Sep 6.

Center for Health Services and Society, University of California, Los Angeles, David Geffen School of Medicine, Department of Psychiatry & Biobehavioral Sciences; UCLA Division of Child and Adolescent Psychiatry, Los Angeles, CA.

Objective: To understand potential for multi-sector partnerships among community-based organizations and publicly funded health systems to implement health improvement strategies that advance health equity.

Design: Key stakeholder interviewing during HNI planning and early implementation to elicit perceptions of multi-sector partnerships and innovations required for partnerships to achieve system transformation and health equity.

Setting: In 2014, the Los Angeles County (LAC) Board of Supervisors approved the Health Neighborhood Initiative (HNI) that aims to: 1) improve coordination of health services for behavioral health clients across safety-net providers within neighborhoods; and 2) address social determinants of health through community-driven, public agency sponsored partnerships with community-based organizations.

Participants: Twenty-five semi-structured interviews with 49 leaders from LAC health systems, community-based organizations; and payers.

Results: Leaders perceived partnerships within and beyond health systems as transformative in their potential to: improve access, value, and efficiency; align priorities of safety-net systems and communities; and harness the power of communities to impact health. Leaders identified trust as critical to success in partnerships but named lack of time for relationship-building, limitations in service capacity, and questions about sustainability as barriers to trust-building. Leaders described the need for procedural innovations within health systems that would support equitable partnerships including innovations that would increase transparency and normalize information exchange, share agenda-setting and decision-making power with partners, and institutionalize partnering through training and accountability.

Conclusions: Leaders described improving procedural justice in public agencies' relationships with communities as key to effective partnering for health equity.
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http://dx.doi.org/10.18865/ed.28.S2.397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128347PMC
October 2019

Maintaining Internal Validity in Community Partnered Participatory Research: Experience from the Community Partners in Care Study.

Ethn Dis 2018 6;28(Suppl 2):357-364. Epub 2018 Sep 6.

UCLA Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA.

Objective: With internal validity being a central goal of designed experiments, we seek to elucidate how community partnered participatory research (CPPR) impacts the internal validity of public health comparative-effectiveness research.

Methods: Community Partners in Care (CPIC), a study comparing a community-coalition intervention to direct technical assistance for disseminating depression care to vulnerable populations, is used to illustrate design choices developed with attention to core CPPR principles. The study-design process is reviewed retrospectively and evaluated based on the resulting covariate balance across intervention arms and on broader peer-review assessments. Contributions of the CPIC Council and the study's design committee are highlighted.

Results: CPPR principles contributed to building consensus around the use of randomization, creating a sampling frame, specifying geographic boundaries delimiting the scope of the investigation, grouping similar programs into pairs or other small blocks of units, collaboratively choosing random-number-generator seeds to determine randomized intervention assignments, and addressing logistical constraints in field operations. Study protocols yielded samples that were well-balanced on background characteristics across intervention arms. CPIC has been recognized for scientific merit, has drawn attention from policymakers, and has fueled ongoing research collaborations.

Conclusions: Creative and collaborative fulfillment of CPPR principles reinforced the internal validity of CPIC, strengthening the study's scientific rigor by engaging complementary areas of knowledge and expertise among members of the investigative team.
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http://dx.doi.org/10.18865/ed.28.S2.357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128339PMC
October 2019

12-Month Cost Outcomes of Community Engagement Versus Technical Assistance for Depression Quality Improvement: A Partnered, Cluster Randomized, Comparative-Effectiveness Trial.

Ethn Dis 2018 6;28(Suppl 2):349-356. Epub 2018 Sep 6.

Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Bio-behavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Objective: To compare community engagement and planning (CEP) for coalition support to implement depression quality improvement (QI) to resources for services (RS) effects on service-use costs over a 12-month period.

Design: Matched health and community programs (N=93) were cluster-randomized within communities to CEP or RS.

Setting: Two Los Angeles communities.

Participants: Adults (N=1,013) with depressive symptoms (Patient Health Questionnaire (PHQ-8) ≥10); 85% African American and Latino.

Interventions: CEP and RS to support programs in depression QI.

Main Outcome Measures: Intervention training and service-use costs over 12 months.

Results: CEP planning and training costs were almost 3 times higher than RS, largely due to greater CEP provider training participation vs RS, with no significant differences in 12-month service-use costs.

Conclusions: Compared with RS, CEP had higher planning and training costs with similar service-use costs.
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http://dx.doi.org/10.18865/ed.28.S2.349DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128344PMC
October 2019

Community Partners in Care: 6- and 12-month Outcomes of Community Engagement versus Technical Assistance to Implement Depression Collaborative Care among Depressed Older Adults.

Ethn Dis 2018 6;28(Suppl 2):339-348. Epub 2018 Sep 6.

Center for Health Services and Society, Semel Institute for Neuroscience and Human Behavior, Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA.

Objective: Community Partners in Care, a community-partnered, cluster-randomized trial with depressed clients from 95 Los Angeles health and community programs, examined the added value of a community coalition approach (Community Engagement and Planning [CEP]) versus individual program technical assistance (Resources for Services [RS]) to implement depression collaborative care in underserved communities. This exploratory subanalysis examines 6- and 12-month outcomes among CPIC participants aged >50 years.

Design: Community-partnered, cluster-randomized trial conducted between April 2010 and March 2012.

Setting: Hollywood-Metropolitan (HM) and South Los Angeles (SLA) Service Planning Areas (SPAs), Los Angeles, California.

Participants: 394 participants aged >50 years with depressive symptoms (8-item Patient Health Questionnaire score ≥ 10).

Intervention: A community-partnered multi-sector coalition approach (Community Engagement and Planning [CEP]) vs individual program technical assistance (Resources for Services [RS]) to implement depression collaborative care.

Main Outcome Measures: Depressive symptoms (PHQ-8 score), mental health-related quality of life (MHRQL), community-prioritized outcomes including mental wellness, homelessness risk and physical activity, and services utilization.

Results: At 6 months, CEP was more effective than RS at improving MHRQL and mental wellness among participants aged >50 years; no differences were found in the effects of CEP vs RS on other outcomes. No significant outcome differences between CEP and RS were found at 12 months.

Conclusions: A multisector community coalition approach may offer additional benefits over individual program technical assistance to improve outcomes among depressed adults aged >50 years living in underserved communities.
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http://dx.doi.org/10.18865/ed.28.S2.339DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128340PMC
October 2019

Comparative Effectiveness of Coalitions Versus Technical Assistance for Depression Quality Improvement in Persons with Multiple Chronic Conditions.

Ethn Dis 2018 6;28(Suppl 2):325-338. Epub 2018 Sep 6.

Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, Semel Institute, Department of Health Policy and Management, Fielding School of Public Health at UCLA; RAND Health Program, Los Angeles CA.

Significance: Prior research suggests that Community Engagement and Planning (CEP) for coalition support compared with Resources for Services (RS) for program technical assistance to implement depression quality improvement programs improves 6- and 12-month client mental-health related quality of life (MHRQL); however, effects for clients with multiple chronic medical conditions (MCC) are unknown.

Objective: To explore effectiveness of CEP vs RS in MCC and non-MCC subgroups.

Design: Secondary analyses of a cluster-randomized trial.

Setting: 93 health care and community-based programs in two neighborhoods.

Participants: Of 4,440 clients screened, 1,322 depressed (Patient Health Questionnaire, PHQ8) provided contact information, 1,246 enrolled and 1,018 (548 with ≥3 MCC) completed baseline, 6- or 12-month surveys.

Intervention: CEP or RS for implementing depression quality improvement programs.

Outcomes And Analyses: Primary: depression (PHQ9 <10), poor MHRQL (Short Form Health Survey, SF-12<40); Secondary: mental wellness, good physical health, behavioral health hospitalization, chronic homelessness risk, work/workloss days, services use at 6 and 12 months. End-point regressions were used to estimate intervention effects on outcomes for subgroups with ≥3 MCC, non-MCC, and intervention-by-MCC interactions (exploratory).

Results: Among MCC clients at 6 months, CEP vs RS lowered likelihoods of depression and poor MHRQL; increased likelihood of mental wellness; reduced work-loss days among employed and likelihoods of ≥4 behavioral-health hospitalization nights and chronic homelessness risk, while increasing faith-based and park community center depression services; and at 12 months, likelihood of good physical health and park community center depression services use (each P<.05). There were no significant interactions or primary outcome effects for non-MCC.

Conclusions: CEP was more effective than RS in improving 6-month primary outcomes among depressed MCC clients, without significant interactions.
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http://dx.doi.org/10.18865/ed.28.S2.325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128327PMC
October 2019

Evaluation of the Mental Health Services Act in Los Angeles County: Implementation and Outcomes for Key Programs.

Rand Health Q 2018 Aug 2;8(1). Epub 2018 Aug 2.

Los Angeles County used Mental Health Services Act (MHSA) funds to greatly expand access to Full-Service Partnership (FSP) services and offer new prevention and early intervention (PEI) services. This study examines the reach of key MHSA-funded activities and what the impact of those activities has been, with a focus on PEI programs for children and transition-age youth (TAY) and FSP programs for children, TAY, and adults. The evaluation found evidence that the Los Angeles County Department of Mental Health (LAC DMH) is reaching the highly vulnerable population it seeks to reach with its FSP and youth PEI programs. Furthermore, those reached by the programs experience improvements in their mental health and life circumstances. Refining data collection will enable more-thorough evaluation of processes of care and would inform the program's quality-improvement efforts.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6075804PMC
August 2018

Case Study of Resilient Baton Rouge: Applying Depression Collaborative Care and Community Planning to Disaster Recovery.

Int J Environ Res Public Health 2018 06 8;15(6). Epub 2018 Jun 8.

Department of Medicine, Tulane University School of Medicine, 1430 Tulane Ave. SL-16 New Orleans, LA 70112, USA.

Background: Addressing behavioral health impacts of major disasters is a priority of increasing national attention, but there are limited examples of implementation strategies to guide new disaster responses. We provide a case study of an effort being applied in response to the 2016 Great Flood in Baton Rouge.

Methods: Resilient Baton Rouge was designed to support recovery after major flooding by building local capacity to implement an expanded model of depression collaborative care for adults, coupled with identifying and responding to local priorities and assets for recovery. For a descriptive, initial evaluation, we coupled analysis of documents and process notes with descriptive surveys of participants in initial training and orientation, including preliminary comparisons among licensed and non-licensed participants to identify training priorities.

Results: We expanded local behavioral health service delivery capacity through subgrants to four agencies, provision of training tailored to licensed and non-licensed providers and development of advisory councils and partnerships with grassroots and government agencies. We also undertook initial efforts to enhance national collaboration around post-disaster resilience.

Conclusion: Our partnered processes and lessons learned may be applicable to other communities that aim to promote resilience, as well as planning for and responding to post-disaster behavioral health needs.
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http://dx.doi.org/10.3390/ijerph15061208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6025623PMC
June 2018

Recruiting Filipino Immigrants in a Randomized Controlled Trial Promoting Enrollment in an Evidence-Based Parenting Intervention.

J Immigr Minor Health 2019 Apr;21(2):324-331

University of California, Los Angeles, Los Angeles, CA, USA.

Filipinos, the second largest Asian subgroup in the U.S., experience significant youth behavioral health disparities but remain under-represented in health research. We describe lessons learned from using the Matching Model of Recruitment to recruit 215 Filipinos to participate in a large, randomized controlled trial of a culturally tailored video aimed at increasing enrollment in the Incredible Years® Parent Program. We recruited participants from schools, churches, clinics, community events, and other community-based locations. Facilitators of participation included: partnership with local community groups, conducting research in familiar settings, building on existing social networks, and matching perspectives of community members and researchers. Findings suggest recruitment success occurs when there is a match between goals of Filipino parents, grandparents and the research community. Understanding the perspectives of ethnic minority communities and effectively communicating goals of research studies are critical to successful recruitment of hard-to-reach immigrant populations in randomized controlled trials.
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http://dx.doi.org/10.1007/s10903-018-0755-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6240407PMC
April 2019

A Preliminary Exploration of the Barriers to Delivering (and Receiving) Exposure-Based Cognitive Behavioral Therapy for Anxiety Disorders in Adult Community Mental Health Settings.

Community Ment Health J 2018 10 9;54(7):899-911. Epub 2018 Mar 9.

Department of Psychiatry and Biobehavioral Sciences, University of California-Los Angeles, Los Angeles, USA.

Despite the effectiveness of exposure-based cognitive behavioral therapy (CBT) for anxiety disorders, few individuals in need receive this treatment, particularly in community mental health settings serving low-income adults. The present study took a preliminary step to understand these barriers by conducting a series of key informant interviews and focus groups among patients, providers, clinical administrators, and policy makers. Several themes emerged as barriers to the delivery of exposure-based CBT in these settings, including therapist training and compentency issues, logistical issues, and funding stream issues. Clinical implications and future research that can build from these data are discussed.
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http://dx.doi.org/10.1007/s10597-018-0252-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6129437PMC
October 2018

Stakeholder Perceptions of the Barriers to Receiving and Delivering Exposure-Based Cognitive Behavioral Therapy for Anxiety Disorders in Adult Community Mental Health Settings.

Community Ment Health J 2019 01 5;55(1):83-99. Epub 2018 Mar 5.

Department of Psychiatry and Biobehavioral Sciences, University of California-Los Angeles, Los Angeles, CA, USA.

CBT is considered the first-line treatment for anxiety disorders, particularly when it involves gradual confrontation with feared stimuli (i.e., exposure); however, delivery of CBT for anxiety disorders in real-world community clinics is lacking. This study utilized surveys we developed with key stakeholder feedback (patient, provider, and administrator) to assess patient and provider/administrator perceptions of the barriers to delivering (or receiving) CBT for anxiety disorders. Providers/administrators from two counties in California (N = 106) indicated lack of training/competency as primary barriers. Patients in one large county (N = 42) reported their own symptoms most often impacted treatment receipt. Both groups endorsed acceptability of exposure but indicated that its use in treatment provided/received had been limited. Implications and recommendations are discussed.
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http://dx.doi.org/10.1007/s10597-018-0250-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6123294PMC
January 2019

Lay Health Worker Involvement in Evidence-Based Treatment Delivery: A Conceptual Model to Address Disparities in Care.

Annu Rev Clin Psychol 2018 05 31;14:185-208. Epub 2018 Jan 31.

Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, California 90095, USA; email:

Mobilizing lay health workers (LHWs) to deliver evidence-based treatments (EBTs) is a workforce strategy to address mental health disparities in underserved communities. LHWs can be leveraged to support access to EBTs in a variety of ways, from conducting outreach for EBTs delivered by professional providers to serving as the primary treatment providers. This critical review provides an overview of how LHW-supported or -delivered EBTs have been leveraged in low-, middle-, and high-income countries (HICs). We propose a conceptual model for LHWs to address drivers of service disparities, which relate to the overall supply of the EBTs provided and the demand for these treatments. The review provides illustrative case examples that demonstrate how LHWs have been leveraged globally and domestically to increase access to mental health services. It also discusses challenges and recommendations regarding implementing LHW-supported or -delivered EBTs.
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http://dx.doi.org/10.1146/annurev-clinpsy-050817-084825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5940491PMC
May 2018

Community, Public Policy, and Recovery from Mental Illness: Emerging Research and Initiatives.

Harv Rev Psychiatry 2018 Mar/Apr;26(2):70-81

From the Center for Health Services and Society (Drs. Chung, Bromley, Kataoka, Young, Miranda, and Wells), Center for Social Medicine and Humanities (Drs. Braslow and Castillo), Division of Child and Adolescent Psychiatry (Dr. Kataoka), Department of Psychiatry and Biobehavioral Sciences (Dr. Greenberg), David Geffen School of Medicine, and School of Public Health (Drs. Miranda and Wells), University of California, Los Angeles; Los Angeles County Department of Mental Health (Dr. Castillo); RAND Corporation (Drs. Chung and Wells); Los Angeles Biomedical Research Institute (Dr. Chung); Healthy African American Families II (Dr. Chung); Health Services Research & Development Center of Innovation (Dr. Young), Desert Pacific MIRECC Health Services Unit (Drs. Bromley and Greenberg), VA Greater Los Angeles Healthcare System; Division of Behavioral Health Services and Policy Research, Department of Psychiatry, Columbia University College of Physicians and Surgeons (Drs. Essock and Dixon); New York State Psychiatric Institute (Drs. Essock and Dixon).

This commentary examines the roles that communities and public policies play in the definition and processes of recovery for adults with mental illness. Policy, clinical, and consumer definitions of recovery are reviewed, which highlight the importance of communities and policies for recovery. This commentary then presents a framework for the relationships between community-level factors, policies, and downstream mental health outcomes, focusing on macroeconomic, housing, and health care policies; adverse exposures such as crime victimization; and neighborhood characteristics such as social capital. Initiatives that address community contexts to improve mental health outcomes are currently under way. Common characteristics of such initiatives and select examples are discussed. This commentary concludes with a discussion of providers', consumers', and other stakeholders' roles in shaping policy reform and community change to facilitate recovery.
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http://dx.doi.org/10.1097/HRP.0000000000000178DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5843494PMC
March 2019

Long-Term Effects of Pre-Placement Risk Factors on Children's Psychological Symptoms and Parenting Stress Among Families Adopting Children From Foster Care.

J Emot Behav Disord 2017 Jun 28;25(2):67-81. Epub 2016 Jan 28.

University of California, Los Angeles, USA.

This exploratory longitudinal study examined behavioral outcomes and parenting stress among families with children adopted from foster care, taking into account environmental and biological risk factors. Child internalizing and externalizing problems and parenting stress were assessed in 82 adopted children and their families at 2 months post-placement, 12 months post-placement, and then yearly until 5 years post-placement. A history of abuse/neglect predicted significantly higher externalizing and internalizing problems at a borderline level of statistical significance. In the initial stages after placement, externalizing problems were significantly higher among children who were 4 years or older at placement versus those who were younger than 4, although differences were no longer significant 5 years post-placement. Statistical trends in parenting stress reflected reduced stress in the first 12 months followed by a plateau for parents who adopted older children and greater stress for parents who adopted younger children. Familiar limitations for observational cohort data apply. Nonetheless, the availability of longitudinal follow-up on a sizable sample of children adopted from foster care adds insight to the psychological dynamics for adoptive families and suggests that families of children adopted from the foster care system may have unique needs for ongoing support around behavioral issues.
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http://dx.doi.org/10.1177/1063426615621050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734114PMC
June 2017

Comparative Effectiveness of Two Models of Depression Services Quality Improvement in Health and Community Sectors.

Psychiatr Serv 2017 Dec 1;68(12):1315-1320. Epub 2017 Nov 1.

Dr. Sherbourne, Dr. Koegel, Dr. Khodyakov, Dr. Ngo, Ms. Perlman, Ms. Lucas-Wright, and Dr. Wells are with RAND Health, RAND Corporation, Santa Monica, California. Dr. Wells, along with Dr. Bromley, Dr. Chung, Dr. Landry, and Dr. Miranda, is also with the Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles (UCLA). Dr. Bromley is also with the Desert Pacific Mental Illness Research, Education and Clinical Center, U.S. Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles. Dr. Aoki is with Los Angeles Christian Health Centers, Los Angeles. Dr. Belin is with the Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles. Dr. Dixon is with the School of Nursing, UCLA. Mr. Gilmore is with Behavioral Health Services, Los Angeles. Dr. Johnson is with the Department of Psychiatry, Kaiser Permanent of Southern California, Los Angeles. Ms. Jones, Ms. Williams, and Dr. Jones are with Healthy African American Families II, Los Angeles. Ms. Lizaola, Dr. Tang, and Ms. Zhang are with the Semel Institute Center for Health Services and Society, UCLA, Los Angeles. Ms. Mtume is with Shields for Families, Los Angeles. Dr. Ong is with the Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles. Ms. Pulido is with L.A. Care Health Plan, Los Angeles. Ms. Sauer, now retired, was with Jewish Family Services of Los Angeles at the time of this study. Ms. Whittington is with the Los Angeles County Department of Mental Health, Los Angeles, where Mr. Vidaurri was affiliated before his retirement.

Objective: The effectiveness of community coalition building and program technical assistance was compared in implementation of collaborative care for depression among health care and community sector clients.

Methods: In under-resourced communities, within 93 programs randomly assigned to coalition building (Community Engagement and Planning) or program technical assistance (Resources for Services) models, 1,018 clients completed surveys at baseline and at six, 12, or 36 months. Regression analysis was used to estimate intervention effects and intervention-by-sector interaction effects on depression, mental health-related quality of life, and community-prioritized outcomes and on services use.

Results: For outcomes, there were few significant intervention-by-sector interactions, and stratified findings suggested benefits of coalition building in both sectors. For services use, at 36 months, increases were found for coalition building in primary care visits, self-help visits, and appropriate treatment for community clients and in community-based services use for health care clients.

Conclusions: Relative to program technical assistance, community coalition building benefited clients across sectors and shifted long-term utilization across sectors.
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http://dx.doi.org/10.1176/appi.ps.201700170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5872839PMC
December 2017

Improving Depression Care for Adults With Serious Mental Illness in Underresourced Areas: Community Coalitions Versus Technical Support.

Psychiatr Serv 2018 02 16;69(2):195-203. Epub 2017 Oct 16.

Dr. Castillo, Dr. Tang, Dr. Chung, Dr. Miranda, and Dr. Wells are with the Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles. Dr. Shaner and Ms. Whittington are with the Los Angeles County Department of Mental Health. Ms. Jones is with Healthy African American Families II, Los Angeles.

Objective: Community Partners in Care (CPIC) was a group-randomized study of two approaches to implementing expanded collaborative depression care: Community Engagement and Planning (CEP), a coalition approach, and Resources for Services (RS), a technical assistance approach. Collaborative care networks in both arms involved health care and other agencies in five service sectors. This study examined six- and 12-month outcomes for CPIC participants with serious mental illness.

Methods: This secondary analysis focused on low-income CPIC participants from racial-ethnic minority groups with serious mental illness in underresourced Los Angeles communities (N=504). Serious mental illness was defined as self-reported severe depression (≥20 on the Patient Health Questionnaire-8) at baseline or a lifetime history of bipolar disorder or psychosis. Logistic and Poisson regression with multiple imputation and response weights, controlling for covariates, was used to model intervention effects.

Results: Among CPIC participants, 50% had serious mental illness. Among those with serious mental illness, CEP relative to RS reduced the likelihood of poor mental health-related quality of life (OR=.62, 95% CI=.41-.95) but not depression (primary outcomes); reduced the likelihood of having homelessness risk factors and behavioral health hospitalizations; increased the likelihood of mental wellness; reduced specialty mental health medication and counseling visits; and increased faith-based depression visits (each p<.05) at six months. There were no statistically significant 12-month effects.

Conclusions: Findings suggest that a coalition approach to implementing expanded collaborative depression care, compared with technical assistance to individual programs, may reduce short-term behavioral health hospitalizations and improve mental health-related quality of life and some social outcomes for adults with serious mental illness, although no evidence was found for long-term effects in this subsample.
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http://dx.doi.org/10.1176/appi.ps.201600514DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5794612PMC
February 2018

Bringing alcohol treatment to driving under the influence programs: Perceptions from first-time offenders.

Alcohol Treat Q 2017 20;35(2):113-129. Epub 2017 Mar 20.

Center for Health Services and Society, Department of Psychiatry and Biobehavioral Sciences, 10920 Wilshire Blvd. Suite 300, Los Angeles, CA 90024, USA.

Alcohol use disorders (AUDs) are common among first-time driving under the influence (DUI) offenders. Individuals with a DUI arrest may attend a DUI alcohol education program for license reinstatement. We evaluated the acceptability of cognitive behavioral treatment (CBT) for AUDs adapted for DUI programs. Participants (N=35) were enrolled in one of two DUI programs in Los Angeles and were an average of 34.5 (SD=11.9) years old; 66% male; 37.1% African American, 34.2% Hispanic/Latino(a), and 20% non-Hispanic White. We analyzed data from ten focus groups and 35 self-report surveys that evaluated the nine-session CBT group protocol. Overall, participants stated that the CBT philosophy was acceptable and helpful in thinking about how to prevent future DUIs. They also found the coping skills in the sessions relevant to other life events and decisions. Participants valued the personal disclosure and interactive role-play and group exercises embedded within each session stating that these exercises helped with group cohesion and self-disclosure. Data from satisfaction surveys showed that participants reported high satisfaction ratings on the overall session, session content, and session facilitator. Future studies are needed to evaluate whether evidence-based treatment within DUI programs may increase access to evidence-base care among at-risk individuals who may not otherwise seek treatment for their AUDs.
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http://dx.doi.org/10.1080/07347324.2017.1288484DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606326PMC
March 2017