In a partnership between CHPIR, Duke University’s Center for Health Policy and Infectious Diseases Clinic, and the Department of Psychiatry and Infectious Diseases Clinic at UNC at Chapel Hill, SLAM DUNC integrates a depression treatment and brief medication adherence counseling intervention into clinical care at four HIV clinics, employing randomized controlled trials to assess whether, relative to usual care, the intervention leads to improved HIV medication adherence. The depression treatment intervention uses a model known as Measurement-Based Care which equips Care Coordinators with systematic measurement tools, a decision algorithm, and psychiatric backup and trains them to provide decision support to HIV clinicians to implement, monitor, and adjust antidepressant therapy.

In 2012, SLAM DUNC acquired three new team members, Scotty Elliott (Depression Care Manager at Duke ID clinic), Elise Nelson (Interviewer), Marcus Hawley (Interviewer), in addition to expanding to a fourth site at the Northern Outreach Clinic in Henderson, NC. Here, 89 of the 133 active participants have successfully completed the study.

SLAM DUNC staff—Assistant Professor, Dr. Brian Pence; Project Coordinator, Quinn Williams; and Associate Professor, Dr. Nathan Theilman—disseminated their research findings by publishing two peer-reviewed articles with one currently in press, as well as through two presentations of SLAM DUNC research at the 7^th International Conference on HIV Treatment Adherence in Miami, FL.

Publications and Presentations

• Pence BW, O’Donnell JK, Gaynes BN.  “The depression treatment cascade in primary care: A public health perspective.”  Current Psychiatry Reports. 2012; 14(4): 328-35.  PMCID: PMC3410049.

ABSTRACT: Major depressive disorder (MDD) is common and costly. Primary care remains a major access point for depression treatment, yet the successful clinical resolution of depression in primary care is uncommon. The clinical response to depression suffers from a “treatment cascade”: the affected individual must access health care, be recognized clinically, initiate treatment, receive adequate treatment, and respond to treatment. Major gaps currently exist in primary care at each step along this treatment continuum. We estimate that 12.5% of primary care patients have had MDD in the past year; of those with MDD, 47% are recognized clinically, 24% receive any treatment, 9% receive adequate treatment, and 6% achieve remission. Simulations suggest that only by targeting multiple steps along the depression treatment continuum (e.g. routine screening combined with collaborative care models to support initiation and maintenance of evidence-based depression treatment) can overall remission rates for primary care patients be substantially improved.

• Pence BW, Gaynes BN, Williams Q, Modi R, Adams J, Quinlivan EB, Heine A, Thielman N, Mugavero MJ. “Assessing the effect of Measurement-Based Care depression treatment on HIV medication adherence and health outcomes: Rationale and design of the SLAM DUNC Study.” Contemporary Clinical Trials:33(4):828-38, 2012. PMCID: PMC3361555.

ABSTRACT: Depression affects 20-30% of people living with HIV/AIDS (PLWHA) in the U.S. and predicts greater sexual risk behaviors, lower antiretroviral (ARV) medication adherence, and worse clinical outcomes. Yet little experimental evidence addresses the critical clinical question of whether depression treatment improves ARV adherence and clinical outcomes in PLWHA with depression. The Strategies to Link Antidepressant and Antiretroviral Management at Duke, UAB, and UNC (SLAM DUNC) Study is a randomized clinical effectiveness trial funded by the National Institute for Mental Health. The objective of SLAM DUNC is to test whether a depression treatment program integrated into routine HIV clinical care affects ARV adherence. PLWHA with depression (n=390) are randomized to enhanced usual care or a depression treatment model called Measurement-Based Care (MBC). MBC deploys a clinically supervised Depression Care Manager (DCM) to provide evidence-based antidepressant treatment recommendations to a non-psychiatric prescribing provider, guided by systematic and ongoing measures of depressive symptoms and side effects. MBC has limited time requirements and the DCM role can be effectively filled by a range of personnel given appropriate training and supervision, enhancing replicability. In SLAM DUNC, MBC is integrated into HIV care to support HIV providers in antidepressant prescription and management. The primary endpoint is ARV adherence measured by unannounced telephone-based pill counts at 6 months with follow-up to 12 months and secondary endpoints including viral load, health care utilization, and depressive severity. Important outcomes of this study will be evidence of the effectiveness of MBC in treating depression in PLWHA and improving HIV-related outcomes.

• Pence BW, O’Donnell JK, Gaynes BN.  “Falling through the cracks: the gaps between depression prevalence, diagnosis, treatment, and response in HIV care.” AIDS 26(5):656-8, 2012. Presented at 7^th International Conference on HIV Treatment Adherence, Miami, FL, June 2012.
• Quinn Williams, MSW; Brian Pence, PhD, MPH; Julie Adams MD, MPH; Amy Heine, MSN, FNP; Bradley Gaynes, MD, MPH. “Monthly assessments of stressful life events in HIV patients participating in an adherence trial” Presented at 7^thInternational Conference on HIV Treatment Adherence, Miami, FL, June 2012.

The Duke Clergy Health Initiative (DCHI) is a seven-year program intended to improve the health and well-being of United Methodist clergy in North Carolina. This $12 million initiative has continued to obtain press due to the research of Assistant Research Professor and DCHI Research Director, Dr. Rae Jean Proeschold-Bell, and Research Scholar, Dr. Sara LeGrand. The Christian Century and North Carolina Health News interviewed Dr. Proeschold-Bell for a story on DCHI’s work in addressing the crisis in clergy health, while Philanthropy.com invited Proeschold-Bell’s insights on the importance of evaluating interventions in order to determine whether or not DCHI’s programs were ameliorating the health of clergy.

Beyond this publicity, the fruit of Drs. Proeschold-Bell and LeGrand’s research is three peer-reviewed articles produced with their other research colleagues at DCHI, examining how health interventions can be tailored to address clergy health (see abstracts below).

For more information the Duke Clergy Health Initiative, click here.

In the News

“Fit for Ministry: Addressing the crisis in clergy health” by Amy Frykholm, The Christian Century

“Who is Behind the Evaluation Curtain?” by Caroline Preston, Philanthropy.com

“Study Shows Ministers Sacrifice Their Own Health To Serve” by Rose Hoban, North Carolina Health News

“Forty percent of clergy were obese compared to 29 percent of comparable North Carolinians” – Dr. Rae Jean Proeschold-Bell

For more news stories on DCHI, please click here.

Publications and Presentations

• Miles, A., & Proeschold-Bell, R.J. (2012). “Overcoming the challenges of pastoral work?: Peer support groups and mental distress among United Methodist Church clergy.” Sociology of Religion: A Quarterly Review, DOI: 10.1093/socrel/srs055.

ABSTRACT: Clergy often face a great deal of occupational stress that in turn can lead to psychological distress. In recent years, denominations have been turning to peer support groups to combat these challenges, but little research exists regarding their effectiveness. This study explores the utility of peer support groups for reducing psychological distress among pastors by analyzing data from two waves of an ongoing study of United Methodist Church (UMC) clergy in North Carolina, as well as focus group data from the same population. Results indicate that participation in peer support groups had weakly beneficial direct and indirect relationships to psychological distress (measured as mentally unhealthy days, anxiety, and depression). Focus group data indicated that the weak results may be due to an interplay between varied group activities and differences in individual coping styles, which in turn lead to a mix of positive and negative group experiences. The results caution against assuming that peer groups are a uniformly effective solution to the occupational demands of pastoral work.

• Proeschold-Bell, R.J. & McDevitt, P.M. (2012). “An overview of the history and current status of clergy health.” Journal of Prevention & Intervention in the Community, 40(3), 177-179.
• Wallace A, Proeschold-Bell RJ, LeGrand S, James J, Swift R, Toole D, Toth M (2012). “Health programming for clergy: An overview of Protestant programs in the United States.” Pastoral Psychology, 61, 113-143.

ABSTRACT: The health of clergy is important, and clergy may find health programming tailored to them more effective. Little is known about existing clergy health programs. We contacted Protestant denominational headquarters and searched academic databases and the Internet. We identified 56 clergy health programs and categorized them into prevention and personal enrichment; counseling; marriage and family enrichment; peer support; congregational health; congregational effectiveness; denominational enrichment; insurance/strategic pension plans; and referral-based programs. Only 13 of the programs engaged in outcomes evaluation. Using the Socioecological Framework, we found that many programs support individual-level and institutional-level changes, but few programs support congregational-level changes. Outcome evaluation strategies and a central repository for information on clergy health programs are needed.

• Proeschold-Bell RJ, LeGrand S (2012). “Physical health functioning among United Methodist clergy.” Journal of Religion and Health, 51(3), 734-742.

ABSTRACT: United Methodist clergy have been found to have higher than average self-reported rates of obesity, diabetes, asthma, arthritis, and high blood pressure. However, health diagnoses differ from physical health functioning, which indicates how much health problems interfere with activities of daily living. Ninety-five percent (n = 1726) of all actively serving United Methodist clergy in North Carolina completed the SF-12, a measure of physical health functioning that has US norms based on self-administered survey data. Sixty-two percent (n = 1074) of our sample completed the SF-12 by self-administered formats. We used mean difference tests among self-administered clergy surveys to compare the clergy SF-12 Physical Composite Scores to US-normed scores. Clergy reported significantly better physical health composite scores than their gender- and age-matched peers, despite above average disease burden in the same sample. Although health interventions tailored to clergy that address chronic disease are urgently needed, it may be difficult to elicit participation given pastors’ optimistic view of their physical health functioning.

• Proeschold-Bell RJ, LeGrand S, Wallace A, James J, Moore H, Swift R, Toole D (2012). “Tailoring health programming to clergy: Findings from a study of United Methodist clergy in North Carolina.” Journal of Prevention and Intervention in the Community, 40(3), 246-261.

ABSTRACT: Research indicating high rates of chronic disease among some clergy groups highlights the need for health programming for clergy. Like any group united by similar beliefs and norms, clergy may find culturally tailored health programming more accessible and effective. There is an absence of research on what aspects clergy find important for clergy health programs. We conducted 11 focus groups with United Methodist Church pastors and district superintendents. Participants answered open-ended questions about clergy health program desires and ranked program priorities from a list of 13 possible programs. Pastors prioritized health club memberships, retreats, personal trainers, mental health counseling, and spiritual direction. District superintendents prioritized for pastors: physical exams, peer support groups, health coaching, retreats, health club memberships, and mental health counseling. District superintendents prioritized for themselves: physical exams, personal trainers, health coaching, retreats, and nutritionists. Additionally, through qualitative analysis, nine themes emerged concerning health and health programs: (a) clergy defined health holistically, and they expressed a desire for (b) schedule flexibility, (c) accessibility in rural areas, (d) low cost programs, (e) institutional support, (f) education on physical health, and (g) the opportunity to work on their health in connection with others. They also expressed concern about (h) mental health stigma and spoke about (i) the tension between prioritizing healthy behaviors and fulfilling vocational responsibilities. The design of future clergy health programming should consider these themes and the priorities clergy identified for health programming.

• Miles, A., & Proeschold-Bell, R.J. (2012). “Are rural clergy worse off?: An examination of occupational conditions and pastoral experiences in a sample of United Methodist clergy.” Sociology of Religion: A Quarterly Review, 73(1), 23-45. DOI:10.1093/socrel/srr025.

ABSTRACT: Scholars have shown that clergy work can be stressful, and that these occupational strains can lead to negative physical and mental health outcomes. Despite the fact that nearly one-third of all congregations in the United States are rural, little work has examined how occupational conditions and clergy experiences might vary systematically by geographical context. This study uses recent data from United Methodist Church clergy in North Carolina to test extant depictions of rural ministry, which typically portray rural churches as challenging occupational settings. It finds that although rural clergy face several unique challenges (such as multichurch ministry and lower salaries), they report lower levels of several stressors and more positive experiences. These differences disappear once controls are added, suggesting that rural ministry per se is neither particularly harmful nor beneficial when compared with ministry in other settings.

• Adams, C. & Proeschold-Bell, R.J. “An Update on the Duke Clergy Health Initiative: Recent findings on clergy mental and physical health.” Presented at The Society for the Study of Psychology and Wesleyan Theology Annual Conference. Trevecca Nazarene University: Nashville, TN. February 2012.
• Adams, C. & Proeschold-Bell, R.J. “The Duke Clergy Health Initiative.” Presented at the Christian Association for Psychological Studies International Conference: Washington, D.C. (2012, March).
• Proeschold-Bell, R.J. “Leading a spirited life: Health disparities among clergy and their possible origins and solutions.” Presented at the East Carolina University Center for Health Disparities Fall 2012 Lecture Series, East Carolina University, Greenville, North Carolina. (2012, September).

2012 Accomplishments: TOP of Craven County, NC

CHPIR continues to partner with the Craven County Health Department (CCHD) in New Bern, NC to offer the Teen Outreach Project (TOP).  In 2012, Genevieve Ankeny Hunter (GV), a CHPIR project coordinator, brought on board Tova Hairston, a native of Craven County, as they successfully led a program that reached over one hundred youth, ages 11-17, in Craven County. The TOP curriculum not only provided these youth with an essential education on teen pregnancy and HIV/STD transmission, it also promoted essential abilities to reduce future risk behavior by focusing on three important tenants in youth development: a sense of purpose, life skills and healthy behaviors.

In order to develop their capacity to effectively educate the youth in Craven County as well as to promote their work in New Bern, NC, GV and Tova attended the NC Annual Teen Pregnancy Prevention Conference. Tova also participated in the National Teen Pregnancy Prevention Conference in Washington, D.C., while they both continued training in the TOP curricula. What’s more, GV and CHPIR faculty member, Rae Jean Proeschold-Bell, worked with other scholars to write the journal article, “The increasing impact of HIV infections, sexually transmitted diseases and viral hepatitis in Durham County, North Carolina: A call for coordinated and integrated services,” which was published in the North Carolina Medical Journal.”

Publications

• Kolman, M., DeCoster, M., Proeschold-Bell, R.J., Ankeny, G., Bartlett, J., & Seña, A.C. (2012). The increasing impact of HIV infections, sexually transmitted diseases and viral hepatitis in Durham County, North Carolina: A call for coordinated and integrated services. North Carolina Medical Journal, 72(6), 439-446.