Working toward Wellness

In WtW, master’s-level clinicians--"care managers"--call individuals who were suffering from depression to encourage them to seek treatment, help them find and make appointments with mental health professionals, make sure that they were keeping appointments and taking prescribed medications, educate them about how depression would affect them and how treatment can help them, and provide support and counseling by telephone to individuals who were reluctant to seek treatment in the community. It was hypothesized that encouraging people to seek treatment and alleviate their depression would help more of them return to work or become more productive at jobs they already held.

2004-11-17

2007-10-31

Depression severity, employment

Depression severity was measured using the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) scale. Scores ranged from 0 to 25 and were classified as mild depression (scores of 6-10), moderate (11-15), severe (16-20), and very severe (21-25).

Employment was based on participant survey responses regarding work since entering the study and employment at the time of the survey.

Individuals who had children and who were receiving Medicaid in Rhode Island and were eligible for mental health services through United Behavioral Health were screened by telephone for depression. Those who were found to have depressive symptoms as defined by a clinical assessment using the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR) questionnaire and who agreed to participate were assigned to the study. Individuals scoring 6 or higher on the QIDS-SR questionnaire--which is defined as a mild or higher level of depression--were included in the study. The evaluation used a random assignment design, meaning that each study participant was randomly assigned to either a program group, which received the intervention’s mental health services, or a control group, which did not. Participants in the program group were eligible to receive telephone care management from master’s-level clinicians employed by United Behavioral Health (UBH). The control group received usual care that included referrals to mental health treatment providers in the community.

Randomization done by MDRC by computer.

individual

No

499 individuals

499 individuals

254 control, 245 program

This paper describes several additional analyses and results that go beyond the basic impact findings from the evaluation of the Working toward Wellness (WtW) program in Rhode Island. WtW was a one-year telephone care management intervention for depressed parents who were Medicaid recipients. To encourage individuals with depression to seek treatment from mental health professionals, the WtW program randomly assigned depressed Medicaid recipients to a program group, which had access to telephone care management for up to a year, or to a control group, which had access to the usual mental health services available to Medicaid recipients. Results from the study found that telephone care management modestly increased in-person treatment for depression during the year of the intervention but not after that point. No impacts on average depression severity were observed for the sample as a whole.

To understand which individuals showed reduced depression over time, the paper examines the relationship between participants’ characteristics and changes in depression scores from baseline to six months and to eighteen months. The results do not, however, suggest a clear means of targeting services like WtW to those who are least likely to improve on their own. Other than baseline depression severity, few participant characteristics were found to be associated with reduced depression over time. This suggests that most subgroups of participants could have benefited from a more effective intervention.

Also, because only about 40 percent of the study population participated in in-person mental health treatment, the paper examines which factors contributed to receiving treatment and the intensity of that treatment. The results suggest that a number of factors were associated with seeking mental health treatment. In particular, treatment occurred more frequently for those who were more severely depressed, those who were not working at baseline, white sample members, and those who had received treatment for depression prior to random assignment. This may suggest providing more resources and supports to encourage those groups to receive treatment who are least likely to participate, for whom the program might make a larger difference. It may also suggest excluding individuals with prior treatment for depression from future studies of similar interventions.

Lastly, because the eighteen-month results showed that there were significantly fewer program group members in the very severely depressed group, the paper investigates which baseline characteristics are associated with being very severely depressed at follow-up. It was found that although some characteristics are associated with having severe depression at follow-up, the impacts on depression severity for this high-risk subgroup are not statistically significant.

Kim, Sue, and Charles Michalopoulos. 2012. Investigating Depression Severity in the Working toward Wellness Study. OPRE Report 2012-03. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

http://www.mdrc.org/publication/investigating-depression-severity-working-toward-wellness-study

Although many public assistance recipients suffer from depression, few receive consistent treatment. This report presents 36-month results from a random assignment evaluation of a one-year program that provided telephonic care management to encourage depressed parents, who were Medicaid recipients in Rhode Island, to seek treatment from mental health professionals. Called “Working toward Wellness” (WtW), the program represents one of four strategies being studied in the Enhanced Services for the Hard-to-Employ Demonstration and Evaluation Project to improve employment for low-income parents who face serious barriers to employment. The project is sponsored by the Administration for Children and Families and the Office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services, with additional funding from the Department of Labor.

This report focuses on assessing the success of the program’s efforts to improve depression symptoms and work-related outcomes, two years after the end of the intervention. In WtW, master’s-level clinicians (“care managers”) telephoned the study participants in the program group to encourage them to seek treatment, to make sure that they were complying with treatment, and to provide telephonic counseling. The effects of the program are being studied by examining 499 depressed Medicaid recipients with children; these parents were randomly assigned to either the program group or the control group from November 2004 to October 2006.

Key Findings
-- WtW care managers used the telephone effectively to initiate engagement with people with depression to consider treatment. They contacted 91 percent of those assigned to the program group, and they averaged about nine contacts per client over the yearlong intervention.
-- WtW increased the use of mental health services while the intervention was running, but it did not help individuals sustain treatment after the intervention ended. Although the program group members were more likely to receive mental health treatment and to fill prescription medications for depression in the early phase of WtW, this effect disappeared after the one-year intervention ended.
-- Authorization procedures limited the capacity of WtW care managers to function as liaisons between clients and clinicians; care managers could not provide direct feedback to clinicians regarding WtW clients as they progressed in treatment. Such a collaborative approach was difficult to orchestrate in the case of WtW because the care managers worked for UBH while the community clinicians worked in a variety of settings outside UBH.
-- WtW did not have an effect on depression or employment outcomes at 36 months after the end of the intervention. At that point, despite some modest impacts on depression for subgroups in earlier follow-up periods, the overall distributions of depression levels between the program and the control groups are not significantly different. Since the 36-month impact on depression was minimal, it is not surprising that there were no differences in employment outcomes for the two groups.

Kim, Sue, Allen J. LeBlanc, Pamela Morris, Greg Simon, and Johanna Walter. 2011. Working toward Wellness: Telephone Care Management for Medicaid Recipients with Depression, Thirty-Six Months After Random Assignment. OPRE Report 2011-21. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

http://www.mdrc.org/publication/working-toward-wellness-1