Hybrid Effectiveness-Implementation Trial to Evaluate a Scalable, Peer-Delivered Intervention for Depression among People with Substance Use Disorder in a Certified Community Behavioral Health Clinic

Low-income, racial/ethnic minoritized individuals, especially people of color living in impoverished communities, have limited access to evidence-based interventions (EBIs) for mental health yet also experience greater psy- chiatric and medical comorbidities and poorer treatment outcomes compared to higher-income, White counter-

parts. Alarmingly, rates of major depressive disorder (MDD) and substance use disorder (SUD) have risen sig- nificantly for Black adults over the past two decades, particularly individuals living in poverty, resulting in dispro- portionately worsening clinical and functional outcomes. There is a pressing need to disseminate EBIs for MDD-

SUD that are acceptable, scalable and sustainable in traditionally underserved settings, including Certified Com- munity Behavioral Health Clinics (CCBHCs) which seek to expand access to services in socioeconomically dis- advantaged areas. Peer recovery specialists (PRSs), individuals in recovery from SUD, have promise for in-

creasing access to EBIs and are widely employed in CCBHCs; yet, few studies have evaluated the clinical ef- fectiveness, implementation, and cost-effectiveness of PRS-delivered EBIs, even as PRS models are rapidly scaling in the US. Preliminary data: PIs Felton and Magidson have led two open-label trials demonstrating the

feasibility, acceptability, and preliminary effectiveness of a PRS-delivered model (Peer Activate) to improve MDD and SUD outcomes among low-income, predominantly Black individuals in traditionally underserved areas. The team has shown that behavioral activation (BA), an EBI based on reinforcement theory and focused on sched-

uling of valued, adaptive behaviors is particularly suitable for PRS delivery and promising to address gaps in EBI access. Preliminary studies established the feasibility and acceptability of this approach; next steps are to con- duct a large-scale randomized trial to evaluate clinical and cost effectiveness, test potential modifiable mecha-

nisms of treatment effectiveness, and evaluate longer-term implementation. Methods: We propose to evaluate Peer Activate in a fully-powered randomized hybrid Type 1 effectiveness-implementation trial (n=200) in a his- torically underserved setting in Detroit, MI. Leveraging a well-established partnership with a community-based,

PRS-led CCBHC, we will compare Peer Activate to enhanced treatment as usual (ETAU; non-specific, PRS- delivered supportive care) on depressive symptoms (primary) and substance use (Aim 1), and evaluate potential mechanisms of this approach (environmental reward; Aim 2). Guided by the EPIS framework and Proctor’s

model, we will evaluate longer-term implementation outcomes (Aim 3), including cost effectiveness. A community advisory board will guide all aspects of the trial to promote the potential for sustainability. Impact: Our proposal is consistent with the goals of PAR-21-130, NIMH strategic objectives to develop innovative service delivery

models for low-income, Black individuals with mental health and SUD comorbidity, and NOT-MH-22-170 promo- tion of partnerships between academic institutions and CCBHCs. Findings have the potential to increase avail- ability of sustainable EBIs for mental health and SUD comorbidity in underserved communities.