Literacy education as treatment for depression in patients with limited literacy and depression: A randomized controlled trial

Background: Individuals with limited literacy and those with depression share many characteristics, including low self-esteem, feelings of worthlessness, and shame. Objective: To determine whether literacy education, provided along with standard depression treatment to adults with depression and limited literacy, would result in greater improvement in depression than would standard depression treatment alone. Design: Randomized clinical trial with patients assigned either to an intervention group that received standard depression treatment plus literacy education, or a control group that received only standard depression treatment. Participants: Seventy adult patients of a community health center who tested positive for depression using the 9-question Patient Health Questionnaire (PHQ-9) and had limited literacy based on the Rapid Estimate of Adult Literacy in Medicine (REALM). Measurements: Depression severity was assessed with PHQ-9 scores at baseline and at 3 follow-up evaluations that took place up to 1 year after study enrollment. Changes in PHQ-9 scores between baseline and follow-up evaluations were compared between the intervention and control groups. Results: The median PHQ-9 scores were similar in both the intervention and control groups at baseline (12.5 and 14, respectively). Nine-question Patient Health Questionnaire scores improved in both groups, but the improvement was significantly larger in the intervention group. The final follow-up PHQ-9 scores declined to 6 in the intervention group but only to 10 in the control group. Conclusions: There may be benefit to assessing the literacy skills of patients who are depressed, and recommending that patients with both depression and limited literacy consider enrolling in adult education classes as an adjuvant treatment for depression.