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.
