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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