Postpartum Depression Study Presentation to AMH

Multidisciplinary Model of Nurse Midwife Administered Psychotherapy for Postpartum Depression (5R21MH86610-2)

Bobbie Posmontier PI, PhD, CNM, PMHNP-BCAssistant Professor Drexel UniversityRichard Neugebauer, PhD, Columbia University, Co-IScott Stuart, MD, University of Iowa, Co-I

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.Session # I5October _29_, 20111:30 PM

Collaborative Family Healthcare Association 12th Annual ConferenceFaculty DisclosureWe have not had any relevant financial relationships during the past 12 months.

Acknowledgement: Funding though the National Institute of Mental Health 5R21MH86610-2

This should match your response on the Faculty Disclosure form from CE CentralCollaborative Family Healthcare Association 12th Annual ConferenceNeed/Practice Gap & Supporting ResourcesOnly 20-25% of childbearing women receive care for postpartum depression due to barriers such as insurance coverage, financial barriers, transportation, stigma, fears of entering the mental health system, lack of qualified mental health professionals, and competing childcare demands.

Holopainen (2002); Whitton, et al (1996); Huang, et al 2007; Dennis & Chung-Lee (2006); Anderson, et al (2006); Boyd et al (2006); Beck (2002)

What is the scientific basis for this talk?

Collaborative Family Healthcare Association 12th Annual ConferenceObjectivesDescribe the current barriers to postpartum depression treatment

Describe a novel interdisciplinary approach to decreasing the access gap for postpartum depression treatment

Describe the current challenges experienced and progress to date

Collaborative Family Healthcare Association 12th Annual ConferenceProblemPPD affects 6.5% to 30% of all childbearing womenOnly 20% to 25 % receive treatment. Major barriers StigmaRetelling story to unknown providerCompeting childcare responsibilitiesFinancial/insuranceTransportationFragmentation servicesMost studies focus on treatment by mental health professionalsSpecific AimsEvaluate among women with PPD recruited between 6 and 24 weeks postpartum:Feasibility, acceptability, and safety telephone IPT provided by nurse midwives in collaboration with a mental health teamEfficacy of IPT administered by nurse midwives inImproving the general level of maternal functioningSpecific improvement in marital adjustment Increase in maternal infant bonding

InnovationUsing Nurse Midwives (NMC) in Primary Care to fill treatment gapMultidisciplinary/CollaborativeConnection with mental health systemBuild on established relationships to improve engagement/retention

InnovationUtilize telephone to address maternal time and childcare constraints. Reduce costsManualize intervention for other advanced practice nurses for full-scale RCT

MethodsRCT pilot studyExperimental group receives NMC IPT intervention Control group receives treatment as usual (TAU) or wait listNMC recruits women with depressive symptoms at their six-week postpartum check-ups at nine national sites in USScreen EPDS 10Sociodemographic, health historyStructured interview for depressionAssessments/Diagnosis- baseline, 4 weeks, 8 weeks, 12 weeks by PMHNP

Treatment:Interpersonal PsychotherapyBriefEvidence based 30 years experience with PPDEffectiveCan be taught to lay peopleHelps to improve depression related toRoleInterpersonal disputesInterpersonal DeficitsGriefCurrent Recruitment PopulationOB practices from AZ, DC, MA, NJ, PA, TX, ~9922 womenAZ-240 diverse low income 50% PPDDC 2400 diverse low income 30% PPDMA 2400 middle income 12-18%PPDNJ- 742 low income 8% PPDPA - 1200 middle income 15% PPDPA 1440 middle income women 15% PPDPA - 720 diverse low income 40% PPDTX -780 diverse low income 6% PPDPower analysis 130 women with 65 randomized to each group

12-week post-randomization (n = 55)8-week post-randomization end IPT (n = 56)4-week post-randomization (n = 59)Treatment as Allocated (n = 65)IPT Intervention (n = 65)8-week post-randomization (n = 59)4-week post-randomization (n =61) Treatment as Allocated (n =65)

Treatment as Usual (n = 65)Assess for Eligibility (n =221)Excluded (refused) (n = 79)Decline Assess (n = 399)Randomization of enrolled participants (n = 130)EPDS 10 (n =644)Screening at 6 weeks postpartum (n = 9,922)Training subjects (n = 24)Estimated Flow12-week post-randomization (n = 52)Instruments MINI International Neuropsychiatric InterviewHamilton Rating Scale for Depression (HRSD)Dyadic Adjustment Scale (DAS) Mother-to-Infant Bonding Scale (MIBS)Social Support Questionnaire (SSQ)Global Assessment of Functioning (GAF)Client Satisfaction Questionnaire (CSQ)Question on acceptability (patients, NMC)Dropout Survey

Inclusion6 to 24 weeks postpartum 18 years and older English-speakingAccess to a telephoneConsents to enter the trialDiagnosis of Major Depression with the MINI Neuropsychiatric Interview (MINI)Score of 10 on the Edinburgh Postnatal Depression Scale Current use of antidepressant medication is allowed

ExclusionInfant complications requiring medical care beyond 6 weeks postpartum Infant birth defectsInfant being placed for adoption by 6 weeks postpartum Maternal mental retardationActive substance or alcohol abuse or dependenceActive suicidality, homicidality, or current psychosisDisabling pain that interferes with ADLsConcurrent serious medical co-morbiditiesProcedureNMC trainingTwo day IPT workshopHuman subjectsRecording softwareDropBoxAdministration EPDSIPT certificationRA trainingInstrumentsBlindedProcedureRecruitment over 18 monthsNMC screens all pts with EPDS at 6 week checkupNMC refers interested patients with EPDS 10Time commitment NMCs 2 hours per week (one hour therapy, one hour supervision), plus 30 minute monthly team meetingsPI calls patients, explains study, consents RA screen and diagnose PPDReferral suicidal, homicidal, beyond scope NMCProcedureRandomize to treatment vs. TAU(treatment as usual) or wait listEight weekly 50 minute telephone sessions over 12 weeksTAU referral to MH provider of NMC choiceTreatment- NMC sets up telephone appointmentsThree training patients, 7-8 post-training patientsNMC weekly telephone supervision with IPT supervisor$25 gift card for all patients

ProgressStudy began June 2010Original five NJ sitesProblemsOne CNM left her positionOne CNM did not seek permission from medical directorThree CNMs trained August 2010 including PIPI delivered intervention but disallowed by NIMHOne NMC dropped out due to personal problemsOne NMC major practice change but still in studyProgress24 women expressed interest

RefusalsConfidentialityDid not want to be in control group

Collected complete data on two women in the treatment group and one woman in the control group.

Another woman in treatment group did not complete treatment.

Two in progress

Premature to draw any conclusions with few subjects Just a peek .SubjT vs. CEPDS 0-30Ham-D0-50GAF0-100DAS0-150SS27-162 MIBS0-24CSQ8-321T18 to 10.518 to 1478 to 8099 to 99100 to 12523 to 19322C24 to 2030 to 1667 to 77116 to 104116 to 14022 to 20183T15 to 318 to 372 to 8387 to 89162 to 16224 to 2432ProgressNeeded to address provider problemSent mass email 4,415 CNMs through ACNM31,897 WHNP through AANP555 positive responses460 midwives95 NPsWomens healthPsychiatricFamily

Locations of RespondentsRepresented 45 states Washington DC, JapanAK, AL, AZ, CA, CO, CT, DE, DC, FL, GA, HI, IA, ID, IL, IN, KY, KS, LA, MA, ME, MD, MI, MO, MN, MT, NC, NE, NH, NM, NY, NV, NJ, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, WA, WI, WV, JapanQualitative Responses319 commented This is a particular area of interest of mine. We provided a 2 week post partum visit in attempt to capture woman at risk, until billing was a problem , Yet this visit was usually the most important of the entire pregnancy. Problem was also no referral available for people in need .Qualitative ResponsesI am curious if I am doing everything possible to help my patients.This is outstanding. New moms with PPD have very limited resources. In my 10 year practice as a midwife, I have called one patient every three hours every day / day and night for 5 days until I could get a psychologist to see her.These nurse midwives would serve their patients better by encouraging them to seek a fully-trained mental health professional.Qualitative ResponsesAfter participation in the study, will the APN have sufficient skills to continue to provide postpartum depression counseling within their own practice setting?I know this is primarily aimed toward nurse midwifes but I would love to participate if able.Military who has almost double the rates of the civilian population. I am starting my own practice because of the lack of response of the military to women's [mental] health care needs.Qualitative ResponsesDoes the psychotherapy training involve travel? What kind of time commitment does the training involve? Sounds like a wonderful study!Have been very interested in PPD for years - would love to participate. Live and work in rural area (for a health center) where transportation and availability of mental health providers are very real barriers for my patients.Qualitative ResponsesI am a new CNM and military wife living overseas in Okinawa, Japan. I am currently in the process of obtaining a job or volunteering with the Red Cross in order to provide patient care. I believe military families endure unique circumstances i which I have great empathy for. I hope to be able to serve these women in the near future, and welcome the opportunity to participate in your study if you desire.Qualitative ResponsesI am a CNS, certified by ANNC for the practice of adult psychiatric and mental health services. I have licensure to practice independent psychotherapy and collaborative-agreement prescribing in the state of Minnesota. I am writing with concern about midwives being "trained" for licensure in interpersonal psychotherapy. (Would you be concerned if I could get a "licensure" to deliever babies)?Qualitative ResponsesI have no official training in counseling and would like to extend my help beyond supportive listening. So, this training opportunity would be beneficial to both myself and my clients and their families.I AM so EXCITED that you are creating such a dynamic program. I happen to be a mother of four children who experienced PPD; I know first hand how PPD robs a family of their dreams.Qualitative ResponsesWe recognize that a CNM/PMHNP dual certified provider would be immensely helpful but that is a strategic goal not to be realized in our short term planning for this coming year due to budget and other pressing issues.I am very interested in this project both as a clinician and as a future researcher.I have felt inadequate in helping my pts with PP depression.Qualitative ResponsesI work mainly with Spanish speaking patients via interpreters and do not know if this setting is conducive to your study.This is something that is tremendously needed in our profession.Native Alaska women are not often outspoken, rather they are shy. We realize it takes awhile to build trust. Many providers come and go in Native healthcare, so when they connect, that person has deep meaning to the patient. We have no good program to handle postpartum depression, we are down now to one psychiatrist for 13,000 people. Progress10 CNMs chosen from national sites 7 still in studyOne IRB not approvedOne potential NMC became ill at trainingOne developed personal problemSecond training August 2011One NJ site still recruitingTotal 8 NMCs recruitingRecruitment for new NMCs started September 1, 2011Spoke to program officer at NIMH about ITT group

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