description of momcare: culturally relevant treatment services for perinatal depression nancy k....
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Description of MOMcare:Description of MOMcare:Culturally Relevant Treatment Services Culturally Relevant Treatment Services
for Perinatal Depressionfor Perinatal Depression
Nancy K. Grote, Ph.D. Nancy K. Grote, Ph.D. Research Associate ProfessorResearch Associate Professor
School of Social Work, University of WashingtonSchool of Social Work, University of Washington
Acknowledgement
NIMH R01 MH084897NIMH R01 MH084897
Horizons Foundation, Seattle, WAHorizons Foundation, Seattle, WA
Co-investigator (Wayne Katon, M.D.) and MOMCare Co-investigator (Wayne Katon, M.D.) and MOMCare teamteam
Expectant moms in public health system of Seattle Expectant moms in public health system of Seattle and King County, WAand King County, WA
OverviewOverviewOverviewOverview
MOMCare – What is it?MOMCare – What is it?
Depression during the perinatal period and Depression during the perinatal period and underutilization of mental health servicesunderutilization of mental health services
Evidence on barriers to care and poverty, stress, and Evidence on barriers to care and poverty, stress, and depression depression
Culturally relevant enhancements to Interpersonal Culturally relevant enhancements to Interpersonal Psychotherapy (IPT) -- e.g., case managementPsychotherapy (IPT) -- e.g., case management
MOMCare design, outcomes, and sample descriptionMOMCare design, outcomes, and sample description
MOMCare: A 5-year Randomized Effectiveness TrialMOMCare: A 5-year Randomized Effectiveness Trial
220 pregnant women on Medicaid220 pregnant women on Medicaid
3 depression care specialists (DCSs) cover 10 public health centers 3 depression care specialists (DCSs) cover 10 public health centers trained in engagement session, culturally relevant IPT-B, and trained in engagement session, culturally relevant IPT-B, and pharmacotherapy (in collaboration with OB provider & team M.D.s)pharmacotherapy (in collaboration with OB provider & team M.D.s)
MOMCare DCS screens for MOMCare DCS screens for
inclusion criteriainclusion criteria: : >> 18 years old; 12-32 weeks gestation; 18 years old; 12-32 weeks gestation; major depression or dysthymia; access to a phone; English major depression or dysthymia; access to a phone; English speakingspeaking
exclusion criteria exclusion criteria – schizophrenia, bipolar disorder, substance – schizophrenia, bipolar disorder, substance abuse/dependence during the past 3 months, acute suicidality, abuse/dependence during the past 3 months, acute suicidality, severe intimate partner violencesevere intimate partner violence
Major or Minor Depression during PregnancyMajor or Minor Depression during Pregnancy
Prevalence ratesPrevalence rates: :
1 out of 10 middle- or upper-income women 1 out of 10 middle- or upper-income women (Gotlib et al., 1989)(Gotlib et al., 1989)
1 out of 4-5 women living in poverty 1 out of 4-5 women living in poverty (Hobfall et al., 1995; Scholle et al., 2002)(Hobfall et al., 1995; Scholle et al., 2002)
Negatively affects development of fetus in uteroNegatively affects development of fetus in utero (Field, 2000;(Field, 2000; Lundy et al., 1999)Lundy et al., 1999) and may interfere with the attachment bond and may interfere with the attachment bond between mother and infantbetween mother and infant ((Murray & Cooper, 1997)Murray & Cooper, 1997)
Predicts postpartum depressionPredicts postpartum depression (O’Hara & Swain, 1996(O’Hara & Swain, 1996) ) and and subsequent maternal depressionsubsequent maternal depression (Kumar & Robson, 1984)(Kumar & Robson, 1984)
Underutilization of Mental Health ServicesUnderutilization of Mental Health Services
National Comorbidity Survey Replication National Comorbidity Survey Replication (Wang et al., 2005)(Wang et al., 2005)
* * nationally representative sample of 9282 adult respondentsnationally representative sample of 9282 adult respondents
* * most people with depression and other mental illnessmost people with depression and other mental illness remain either untreated (60%) or poorly treated (66%) remain either untreated (60%) or poorly treated (66%)
* the unmet need for mental health services were highest * the unmet need for mental health services were highest for those with for those with low incomes, racial/ethnic minoritieslow incomes, racial/ethnic minorities, the , the elderly, and rural respondentselderly, and rural respondents
* minimally adequate treatment (APA guidelines):* minimally adequate treatment (APA guidelines):8 sessions of psychotherapy (at least 30 minutes a session)8 sessions of psychotherapy (at least 30 minutes a session)2 months of medication & at least 4 check-ups2 months of medication & at least 4 check-ups
Practical Barriers to CarePractical Barriers to Care
Costs – 40% African Americans and 52% Hispanics Costs – 40% African Americans and 52% Hispanics lack health insurance in the USlack health insurance in the US (US Census Bureau, (US Census Bureau, 2003)2003)
AccessAccess Inconvenient or inaccessible clinic Inconvenient or inaccessible clinic locationslocations Limited clinic hoursLimited clinic hours Transportation problemsTransportation problems
Competing ObligationsCompeting Obligations Child care and social networkChild care and social network Loss of pay for missing workLoss of pay for missing work Time inTime in dealing with chronic stressorsdealing with chronic stressors
Psychological Barriers to CarePsychological Barriers to Care Public Stigma and Internalized StigmaPublic Stigma and Internalized Stigma
Stigmatizing treatment settingsStigmatizing treatment settings
Previous negative experiences with Previous negative experiences with treatment, including therapist characteristicstreatment, including therapist characteristics
Childhood trauma (abuse and neglect)Childhood trauma (abuse and neglect)
Burden of depressionBurden of depression
Cultural Barriers to Care: Cultural Barriers to Care: The Culture of RaceThe Culture of Race
Clinicians may fail to appreciate the personal Clinicians may fail to appreciate the personal resources that minority women with low incomes resources that minority women with low incomes have relied on to cope with stress.have relied on to cope with stress.
Spirituality and religion are often important Spirituality and religion are often important psychological coping mechanisms and sources of psychological coping mechanisms and sources of resilience in Latina and African American women.resilience in Latina and African American women.
(Mays, Caldwell, & Jackson, 1996; Miranda et (Mays, Caldwell, & Jackson, 1996; Miranda et al., 1996) al., 1996)
Cultural Barriers to Care: Cultural Barriers to Care: The Culture of PovertyThe Culture of Poverty
““No one can understand what my depression is No one can understand what my depression is like ‘til they have walked in my shoes and had no like ‘til they have walked in my shoes and had no money.”money.”
““My therapist seemed overwhelmed by all my My therapist seemed overwhelmed by all my practical problems, so how could she help me?”practical problems, so how could she help me?”
““I don’t see how just talking about something can I don’t see how just talking about something can change it. How is me talking about losing my job change it. How is me talking about losing my job going to get me another job?”going to get me another job?”
Physiological Needs: to have enough FOOD, water, and satisfy sex drives
Safety Needs: to feel secure, SAFE, and out of danger,to have A PLACE TO LIVE and SLEEP (BED)
Belongingness and Love Needs: to affiliate with others; to be accepted and belong
Esteem Needs: to achieve, be confident, gain approval and
recognition
The need to fulfill one’s
unique potential
Basic Needs
Psychological Needs
Self-Actualization Needs
Maslow’s Hierarchy of Needs, 1979Maslow’s Hierarchy of Needs, 1979
Study of acute stress, chronicStudy of acute stress, chronic stress, and depressive stress, and depressive symptoms symptoms
(Grote, Bledsoe, Larkin, & Brown, 2007)(Grote, Bledsoe, Larkin, & Brown, 2007)
How can we better understand and engage in How can we better understand and engage in treatment women living in poverty who have multiple treatment women living in poverty who have multiple stressors, but few financial or social resources to stressors, but few financial or social resources to deal with them? deal with them?
Sample of 97 African American and 97 White Sample of 97 African American and 97 White Ob/Gyn patients with low incomesOb/Gyn patients with low incomes
Definition of acute stress -- a Definition of acute stress -- a time-limited event time-limited event requiring a certain degree of life change)requiring a certain degree of life change)
Chronic Stressors of Living in PovertyChronic Stressors of Living in Poverty ( (many represent continuing demanding conditions many represent continuing demanding conditions
that do that do notnot change) change)
trying to get landlord to make repairstrying to get landlord to make repairs living in a neighborhood with high crime living in a neighborhood with high crime living in a violent neighborhood living in a violent neighborhood living in an excessively noisy neighborhood living in an excessively noisy neighborhood trying to make ends meet/running out of money trying to make ends meet/running out of money unable to afford a car unable to afford a car being the only parent being the only parent being on welfare, being unemployedbeing on welfare, being unemployed being approached/spoken to disrespectfully by being approached/spoken to disrespectfully by
someone discriminating against yousomeone discriminating against you
Chronic Stress Amplifies the Chronic Stress Amplifies the Effects of Acute Stress on Effects of Acute Stress on
Depressive SymptomsDepressive Symptoms(Grote, Bledsoe, Larkin & Brown, 2007)(Grote, Bledsoe, Larkin & Brown, 2007)
0
5
10
15
20
25
30
35
LowAcuteStress
HighAcuteStress
High Chronic Stress
Low Chronic Stress
Depressive Symptoms
Introduction: What is Interpersonal Introduction: What is Interpersonal Psychotherapy (IPT)?Psychotherapy (IPT)?
Introduction: What is Interpersonal Introduction: What is Interpersonal Psychotherapy (IPT)?Psychotherapy (IPT)?
Time-limited (12-16 weeks) individual psychotherapy Time-limited (12-16 weeks) individual psychotherapy for depressionfor depression
Structured, manualized treatment that has been used Structured, manualized treatment that has been used in research protocols in research protocols
Demonstrated efficacy in general and for antenatal Demonstrated efficacy in general and for antenatal depression depression (Grote et al., 2004; Spinelli, 1997(Grote et al., 2004; Spinelli, 1997) and postpartum ) and postpartum depression depression (O’Hara et al., 2000)(O’Hara et al., 2000)
Therapists and patients like it: “it makes sense”Therapists and patients like it: “it makes sense”
Introduction: The bio-psycho-social Introduction: The bio-psycho-social formulation of depressionformulation of depression
Expansion of IPT focus on current interpersonal functioning to address the chronic stressors of living in or near poverty.
IPT Cultural Enhancements to Promote IPT Cultural Enhancements to Promote Treatment Engagement and RetentionTreatment Engagement and Retention
Engagement Session Engagement Session before rx to address barriers to before rx to address barriers to care – practical, psychological, and cultural (manualized)care – practical, psychological, and cultural (manualized)
IPT-B -- Full course of IPT in 8 vs. 16 sessions IPT-B -- Full course of IPT in 8 vs. 16 sessions (Swartz, Frank, (Swartz, Frank,
& Shear, 2002) & Shear, 2002) and maintenance IPTand maintenance IPT
Enhancement to IPT-B relevant to culture of poverty Enhancement to IPT-B relevant to culture of poverty – – personalized case management for chronic economic personalized case management for chronic economic problems problems (i.e., FOOD, BED, housing, job training, baby supplies)(i.e., FOOD, BED, housing, job training, baby supplies)
Enhancements to IPT-B relevant to culture of Enhancements to IPT-B relevant to culture of race/ethnicity race/ethnicity (Bernal et al., 1995)(Bernal et al., 1995)
The Pre-Treatment Engagement SessionThe Pre-Treatment Engagement Session (Grote, Swartz, Zuckoff , Bledsoe et al., 2007)(Grote, Swartz, Zuckoff , Bledsoe et al., 2007)
First Part (45 minutes) -- We asked about:First Part (45 minutes) -- We asked about: HER STORYHER STORY: her perception of her depression experience (stigma): her perception of her depression experience (stigma)
and the acute & and the acute & chronic stressors of living in poverty chronic stressors of living in poverty linked with her depressionlinked with her depression HER STRENGTHS HER STRENGTHS and and cultural coping mechanisms, e.g., spirituality, cultural coping mechanisms, e.g., spirituality,
familialismfamilialism WHAT SHE DOES NOT WANT WHAT SHE DOES NOT WANT -- previous negative experiences with mental -- previous negative experiences with mental
health care or health care or social service agencies social service agencies (self and sig. others)(self and sig. others) WHAT SHE WANTS WHAT SHE WANTS – from rx or a therapist – from rx or a therapist – does race matter?– does race matter? SUMMARYSUMMARY of practical, psychological, and cultural barriers – of practical, psychological, and cultural barriers –
transportation, child care, scheduling, stigma, depression burdentransportation, child care, scheduling, stigma, depression burden
Second Part (15 minutes) -- We provided:Second Part (15 minutes) -- We provided: PsychoeducationPsychoeducation about depression and treatment options – about depression and treatment options – inclusion inclusion of a case management component to deal with chronic stressorsof a case management component to deal with chronic stressors Problem-solving the barriers, Problem-solving the barriers, affirmation of strengths, and hope affirmation of strengths, and hope
Structure of Brief IPT (IPT-B) Structure of Brief IPT (IPT-B) (8 vs. 16 sessions)(8 vs. 16 sessions)
Initial PhaseInitial Phase (1-2 sessions (1-2 sessions))IPT Inventory includes IPT Inventory includes assessment of chronic stressors and assessment of chronic stressors and
relationships with social service agenciesrelationships with social service agenciesCase formulation of the interpersonal problem ares most linked with Case formulation of the interpersonal problem ares most linked with
the onset or exacerbation of the depressionthe onset or exacerbation of the depression
Middle PhaseMiddle Phase (5 sessions) (5 sessions)Choose only one interpersonal problem area:Choose only one interpersonal problem area:
Role transition, role dispute, complicated griefRole transition, role dispute, complicated griefChoose a “manageable” problem in 8 sessionsChoose a “manageable” problem in 8 sessionsBuild on existing cultural strengths and ways of copingBuild on existing cultural strengths and ways of coping
Behavioral activation (explicit weekly homework) with an Behavioral activation (explicit weekly homework) with an interpersonal and culturally relevant focus interpersonal and culturally relevant focus assessing needed assessing needed social services (e.g., housing, food banks, job training, free baby social services (e.g., housing, food banks, job training, free baby supplies)supplies)
TerminationTermination (1-2 sessions (1-2 sessions) ) -- -- Support self-efficacySupport self-efficacy
Swartz et al., 2004, Swartz et al., 2004, Psychiatric ServicesPsychiatric Services Grote et al., 2009, Grote et al., 2009, J of Contemporary PsychotherapyJ of Contemporary Psychotherapy
Cultural Enhancements to IPT-BCultural Enhancements to IPT-B(Grote et al., 2009, (Grote et al., 2009, Psychiatric ServicesPsychiatric Services, 60, 313-321), 60, 313-321)
Enhancements regarding culture of povertyEnhancements regarding culture of poverty: : facilitation of access to social services; convenient facilitation of access to social services; convenient public health setting, phone therapy; reminder phone callspublic health setting, phone therapy; reminder phone calls Enhancements related to culture of race/ethnicityEnhancements related to culture of race/ethnicity (based on Bernal et al., 1995)(based on Bernal et al., 1995) culturally sensitive, experienced cliniciansculturally sensitive, experienced clinicians incorporating cultural resources and strengthsincorporating cultural resources and strengths treatment setting served others from same racial/ethnic grouptreatment setting served others from same racial/ethnic group using stories from patient culture to support treatment goalsusing stories from patient culture to support treatment goals providing psychoeducation and treatment information providing psychoeducation and treatment information congruent with patient’s cultural preferences and values congruent with patient’s cultural preferences and values
e.g. therapy= a class; depression could be re-labeled “stress”e.g. therapy= a class; depression could be re-labeled “stress”
Use of Case Management (CM) ServicesUse of Case Management (CM) Services(Grote et al., 2009, (Grote et al., 2009, Psychiatric ServicesPsychiatric Services, 60, 313-321), 60, 313-321)
previous small RCT of IPT-B showed that 50% of pregnant previous small RCT of IPT-B showed that 50% of pregnant women on low-incomes received case management serviceswomen on low-incomes received case management services
on average, they received 2 referrals to social serviceon average, they received 2 referrals to social service agenciesagencies
66% of those who received referrals reported successfully 66% of those who received referrals reported successfully following throughfollowing through
clinical observations: clinical observations: 1) focusing on CM took little time away from an IPT focus1) focusing on CM took little time away from an IPT focus 2) including CM made IPT more meaningful and relevant to2) including CM made IPT more meaningful and relevant to
the womenthe women
MOMcare DesignMOMcare Design
Eligible public health clients consent to be randomized to: Eligible public health clients consent to be randomized to:
MOMcare interventionMOMcare intervention (engagement PLUS choice of evidence-based brief (engagement PLUS choice of evidence-based brief IPT and/or anti-depressant IPT and/or anti-depressant medication plus case management)medication plus case management)
8 sessions acute rx BEFORE BIRTH and monthly maintenance 8 sessions acute rx BEFORE BIRTH and monthly maintenance sessions to 1 year postpartum sessions to 1 year postpartum
Care PlusCare Plus (the care they receive as a public health client – (the care they receive as a public health client – psychoeducation, treatment referral, and depression monitoring)psychoeducation, treatment referral, and depression monitoring)
MOMCare DCS delivers the intervention in the public health MOMCare DCS delivers the intervention in the public health center or by phonecenter or by phone
MomCare OutcomesMomCare Outcomes Effectiveness outcomes for MOMcare relative to Care Plus:Effectiveness outcomes for MOMcare relative to Care Plus:
1) Reduction in depression, improvement in social functioning 1) Reduction in depression, improvement in social functioning
2) Better maternal role functioning, e.g. maternal sensitivity and 2) Better maternal role functioning, e.g. maternal sensitivity and responsivity to infant cues at 6 and 12 months postpartumresponsivity to infant cues at 6 and 12 months postpartum
e.g. home observations of mother-infant interaction in collaboration e.g. home observations of mother-infant interaction in collaboration with Center for Infant Mental Health at UWwith Center for Infant Mental Health at UW
3) Infant – higher rates of secure attachment and better mental3) Infant – higher rates of secure attachment and better mental health outcomes at 12 months postpartumhealth outcomes at 12 months postpartum
Cost effectivenss outcomes – depression free days, more well-baby visits Cost effectivenss outcomes – depression free days, more well-baby visits and higher rates of immunizations and higher rates of immunizations
Effectiveness StudyEffectiveness StudyBrief Initial Screening by DCS
n=246
Eligible Pregnant Women (n=82)
Age > 18, MDD or Dysthymia
Enhanced Usual care in community (n=41)
Engage & IPT-B and/or anti-
depressant medication (n=41)
Diagnostic Screening – AFTER engagement
Usual care (n=42) IPT-B (n=42)
3-, 6-, 12- and 18-month follow-up assessments
Demographic Variables for Pregnant Study Participants (N=82)
Age in years 27 (18-43)
Marital status * Single/cohabiting 61%
Married 28%
Divorced/separated/widowed 11%
Race/ethnicity
White
Black
Hispanic
Asian/Hawaiian/Pac. Islander
Native Amer./Alaska native
Mixed race
61%
15.9%
19.5%
7.3%
2.4%
13.4%
* p<.05 MOMcare participants more likely to be married that Usual Care
Demographic Variables for Study Participants (N=82)
Education
Less than H.S.
H.S. degree/GED
Some college/vocational
College degree or higher
25.6%
21.9%
42.7%
9.8%
Employment
Full-time 12.2%
Part-time 19.5%
Unemployed 68.3%
Depression
PHQ-9 (moderate range)
SCL-20 (severe range)
Intervention Group
Choice of IPT-B alone
Choice of IPT-B & Medication
M = 16.84 (10-23)
M = 42.43 (26-62)
72% (n=28)
28% (n=11)
Conclusions about Culturally Relevant IPT-BConclusions about Culturally Relevant IPT-B
Preliminary findings on clinician-rated PHQ-9 depression Preliminary findings on clinician-rated PHQ-9 depression measure suggest that culturally relevant IPT-B measure suggest that culturally relevant IPT-B maymay ameliorate antenatal depression in MOMCare participants ameliorate antenatal depression in MOMCare participants (did not look at usual care yet)(did not look at usual care yet)
Observations:Observations:
Most women needed and have accepted CM services – increasing Most women needed and have accepted CM services – increasing evictions, homelessness, job loss, food insecurity evictions, homelessness, job loss, food insecurity
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