The Initiative for Decreasing Disparities in Depression

What is the most effective way to translate research findings, such as those summarized in the Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care and other published studies, into practice- and behavior altering information and interventions? One method has been to utilize continuing medical education activities to inform physicians and other practitioners of the latest evidence and advances in medical science. This approach has been more or less successful when used to educate about specific treatments or procedures, but what role can CME play when applied to broader subjects, such as helping to reduce racial and ethnic disparities in health and healthcare? Is it an effective tool for addressing a challenge that is created by such a wide range of contributing factors? Certainly, CME broadly applied has proven to be highly useful; an Agency for Healthcare Quality and Research review of CME effectiveness concluded that “CME appears to be effective at [promoting] the acquisition and retention of knowledge, attitudes, skills, behaviors and clinical outcomes.” However, the review also stipulated that more “research is needed to determine with any degree of certainty which types of media, techniques, and exposure volumes as well as what internal and external audience characteristics are associated with improvements in outcomes.” Educational outcomes research of this kind requires adequate multi-year funding by public and private sector organizations to determine whether given CME strategies and content are effective or not. Such funding can be hard to come by in health disparities research.

MDNG Physician Editor-in-Chief Robert Like, MD, says that long-term funding is always a concern, because educational programs that have focused on disparities in health and healthcare typically “only have a grant which is funded for one or two years, so it’s hard to find dramatic impacts from them.” This is exactly what happened with The Initiative for Decreasing Disparities in Depression (I3D).

I3D was developed by the University of Alabama at Birmingham (UAB), Vanderbilt University, and Indicia Medical Education, LLC, and received funding from Wyeth Pharmaceuticals for one year (January-December 2006). When Wyeth decided not to allocate additional money to continue the project, I3D could not proceed beyond its first stage of development. Don Moore, PhD, Director of Continuing Medical Education, Professor of Medical Education and Administration at Vanderbilt University School of Medicine, says, “Funding is always a tough issue and we just need to match a funder’s objectives with our objectives” for the I3D program. Moore says the program coordinators are always on the look out for funding to continue I3D.

Clinical outreach I3D was developed to find strategies and solutions that can enable physicians to better understand disparities in diagnosing and treating depression in diverse populations. With approximately 15 million Americans dealing with major depression each year, physicians must work to ensure they are as culturally competent in treating minority patients with depression as they are with every other disease. The I3D program participants viewed this issue as being especially important, because minorities who experience depression symptoms often first visit their primary care physician for help, if they choose to seek treatment at all.

The goal of I3D is to educate physicians on how to effectively treat minority patients with depression by decreasing disparities in detection, diagnosis, treatment, and management. Katie Crenshaw, JD, MSEd, Assistant Director of the Division of Continuing Medical Education at UAB, says, “It was our intent to arm primary care physicians with the kind of educational tools and resources they could use to diagnose, treat, and manage patients with depression in their everyday practice for a multitude of cultural groups.” To increase accessibility and uptake, the educational offerings I3D created were designed with convenience in mind, offering busy physicians several avenues through which they could participate, including satellite symposiums, online courses, and broad-range fax broadcasts sent right to the physician’s practice. “We provided a range of options for this kind of education, and the physicians were able to choose whichever vehicle that fit their lifestyle and practice the best,” says Crenshaw.

An innovative approach The I3D project sought to identify the most effective methods for educating primary care physicians on how to provide quality care to minority patients with symptoms of depression. Increasing primary care providers’ awareness of depression symptoms was a priority, because it was recognized that—although depression can be most effectively treated when it is diagnosed in its beginning stages—this is when depression tends to be overlooked the most. Clearly, a new educational approach was needed. “What we proposed was not only a different way of doing CME, but a different way of looking at a physician’s practice in terms of incorporating outreach into the normal approach of taking care of patients, which is crucial in mental health and depression, especially with ethnic and racial minorities due to the stigma involved related to mental health,” says Moore.

The I3D partners conceptualized what many believe is an innovative program for physicians. CME Advocate blogger Brian S. McGowan, PhD, wrote “From what I can tell, the I3D model should be recreated whenever possible… The planners and designers went above and beyond; not only did they plan and design [high-impact] certified CME addressing depression in the primary care setting, but they had the dedication and vision to understand the value of disseminating the lessons learned throughout the initiative to the broader CME audience.”

Another unique feature of I3D was that it took some of the money from the grant it received from Wyeth and used it to solicit proposals for projects and award grants to organizations and institutions with similar objectives as I3D. With no influence from Wyeth, the I3D coordinators convened an expert review panel that decided which proposals were worthy of receiving grant money. Among the programs that received grant money were “Initiative for Decreasing Disparities in Depression CME: Provider Self-Assessment CME Model Incorporating Cultural and Linguistic Competence in the Diagnosis and Treatment of Depression,” developed by Georgetown University (www. gucchdgeorgetown.net/I3D), and “Eliminating Disparities in Depression Care: Depression Treatment in Primary Care,” developed as a collaborative effort between the American Psychiatric Association and the National Alliance on Mental Illness.

It’s just the beginning…

Although I3D did not have the funding to continue for more than one year, it still accomplished a great deal, producing several resources designed to provide physicians with the tools and knowledge to more effectively detect, diagnose, treat, and manage depression in minority patients. Another notable aspect of the I3D project is that the principles and approaches on which it is based can be applied in a variety of clinical areas. To help in this area, the co-principal developers published an excellent summary of the project’s findings in a supplement for The Journal of Continuing Education in the Health Professions. Karen Overstreet, EdD, RPh, FACME, President of Indicia Medical Education, LLC says, “I think potentially, that the model we developed in relation to I3D, which was of course related to depression, can be used in other therapeutic areas where disparities are an important issue, like diabetes, cardiovascular disease, cancer, and any areas where healthcare disparities are prevalent.”

Disparities-focused CME is a relatively new field, and there is a need for further multi-method research to establish its effectiveness. Hopefully, pharmaceutical companies and other healthcare organizations will recognize the growing importance of this field, renew their commitment to educating physicians about disparities in health and healthcare, and use their resources to provide long-term funding to such projects as I3D.