Transcript Work in Progress: “Feasibility of using brief

Description of MOMcare:
Culturally Relevant Treatment Services
for Perinatal Depression
Nancy K. Grote, Ph.D.
Research Associate Professor
School of Social Work, University of Washington
Acknowledgement

NIMH R01 MH084897

Horizons Foundation, Seattle, WA

Co-investigator (Wayne Katon, M.D.) and MOMCare
team

Expectant moms in public health system of Seattle
and King County, WA
Overview

MOMCare – What is it?

Depression during the perinatal period and
underutilization of mental health services

Evidence on barriers to care and poverty, stress, and
depression

Culturally relevant enhancements to Interpersonal
Psychotherapy (IPT) -- e.g., case management

MOMCare design, outcomes, and sample description
MOMCare: A 5-year Randomized Effectiveness Trial

220 pregnant women on Medicaid

3 depression care specialists (DCSs) cover 10 public health
centers trained in engagement session, culturally relevant IPTB, and pharmacotherapy (in collaboration with OB provider &
team M.D.s)

MOMCare DCS screens for
inclusion criteria: > 18 years old; 12-32 weeks gestation;
major depression or dysthymia; access to a phone; English
speaking
exclusion criteria – schizophrenia, bipolar disorder,
substance abuse/dependence during the past 3 months, acute
suicidality, severe intimate partner violence
Major or Minor Depression during Pregnancy

Prevalence rates:
1 out of 10 middle- or upper-income women (Gotlib et al., 1989)
1 out of 4-5 women living in poverty (Hobfall et al., 1995; Scholle et al., 2002)

Negatively affects development of fetus in utero (Field, 2000;
Lundy et al., 1999) and may interfere with the attachment bond
between mother and infant (Murray & Cooper, 1997)

Predicts postpartum depression (O’Hara & Swain, 1996) and
subsequent maternal depression (Kumar & Robson, 1984)
Underutilization of Mental Health Services

National Comorbidity Survey Replication (Wang et al., 2005)
* nationally representative sample of 9282 adult respondents
* most people with depression and other mental illness
remain either untreated (60%) or poorly treated (66%)
* the unmet need for mental health services were highest
for those with low incomes, racial/ethnic minorities, the
elderly, and rural respondents
* minimally adequate treatment (APA guidelines):
8 sessions of psychotherapy (at least 30 minutes a session)
2 months of medication & at least 4 check-ups
Practical Barriers to Care



Costs – 40% African Americans and 52% Hispanics
lack health insurance in the US (US Census Bureau, 2003)
Access
 Inconvenient or inaccessible clinic locations
 Limited clinic hours
 Transportation problems
Competing Obligations
 Child care and social network
 Loss of pay for missing work
 Time in dealing with chronic stressors
Psychological Barriers to Care

Public Stigma and Internalized Stigma

Stigmatizing treatment settings

Previous negative experiences with
treatment, including therapist
characteristics

Childhood trauma (abuse and neglect)

Burden of depression
Cultural Barriers to Care:
The Culture of Race

Clinicians may fail to appreciate the personal
resources that minority women with low incomes
have relied on to cope with stress.

Spirituality and religion are often important
psychological coping mechanisms and sources of
resilience in Latina and African American women.
(Mays, Caldwell, & Jackson, 1996; Miranda et al., 1996)
Cultural Barriers to Care:
The Culture of Poverty

“No one can understand what my depression is
like ‘til they have walked in my shoes and had no
money.”

“My therapist seemed overwhelmed by all my
practical problems, so how could she help me?”

“I don’t see how just talking about something can
change it. How is me talking about losing my job
going to get me another job?”
Maslow’s Hierarchy of Needs, 1979
Self-Actualization
Needs
Psychological
Needs
The need to
fulfill one’s
unique potential
Esteem Needs: to achieve, be
confident, gain approval and
recognition
Belongingness and Love Needs: to affiliate
with others; to be accepted and belong
Basic
Needs
Safety Needs: to feel secure, SAFE, and out of danger,
to have A PLACE TO LIVE and SLEEP (BED)
Physiological Needs: to have enough FOOD, water,
and satisfy sex drives
Study of acute stress, chronic
stress, and depressive symptoms
(Grote, Bledsoe, Larkin, & Brown, 2007)

How can we better understand and engage in
treatment women living in poverty who have multiple
stressors, but few financial or social resources to
deal with them?

Sample of 97 African American and 97 White
Ob/Gyn patients with low incomes

Definition of acute stress -- a time-limited event
requiring a certain degree of life change)
Chronic Stressors of Living in Poverty
(many represent continuing demanding conditions
that do not change)









trying to get landlord to make repairs
living in a neighborhood with high crime
living in a violent neighborhood
living in an excessively noisy neighborhood
trying to make ends meet/running out of money
unable to afford a car
being the only parent
being on welfare, being unemployed
being approached/spoken to disrespectfully by
someone discriminating against you
Chronic Stress Amplifies the Effects of
Acute Stress on Depressive Symptoms
(Grote, Bledsoe, Larkin & Brown, 2007)
Depressive Symptoms
35
30
25
20
High Chronic Stress
Low Chronic Stress
15
10
5
0
Low
Acute
Stress
High
Acute
Stress
Introduction: What is Interpersonal
Psychotherapy (IPT)?

Time-limited (12-16 weeks) individual psychotherapy
for depression

Structured, manualized treatment that has been used
in research protocols

Demonstrated efficacy in general and for antenatal
depression (Grote et al., 2004; Spinelli, 1997) and postpartum
depression (O’Hara et al., 2000)

Therapists and patients like it: “it makes sense”
Introduction: The bio-psycho-social
formulation of depression
Biology/Genetics
Social Context:
Relationships
Acute and Chronic
Stressors
Depressed
Individual
Psychological:
Cognitions
Attachment
Expansion of IPT focus on current interpersonal functioning to address the
chronic stressors of living in or near poverty.
IPT Cultural Enhancements to Promote
Treatment Engagement and Retention

Engagement Session before rx to address barriers to
care – practical, psychological, and cultural (manualized)

IPT-B -- Full course of IPT in 8 vs. 16 sessions (Swartz, Frank,
& Shear, 2002) and maintenance IPT

Enhancement to IPT-B relevant to culture of poverty –
personalized case management for chronic economic
problems (i.e., FOOD, BED, housing, job training, baby supplies)

Enhancements to IPT-B relevant to culture of
race/ethnicity (Bernal et al., 1995)
The Pre-Treatment Engagement Session

(Grote, Swartz, Zuckoff , Bledsoe et al., 2007)
First Part (45 minutes) -- We asked about:






HER STORY: her perception of her depression experience (stigma)
and the acute & chronic stressors of living in poverty linked with her
depression
HER STRENGTHS and cultural coping mechanisms, e.g., spirituality,
familialism
WHAT SHE DOES NOT WANT -- previous negative experiences with
mental health care or social service agencies (self and sig. others)
WHAT SHE WANTS – from rx or a therapist – does race matter?
SUMMARY of practical, psychological, and cultural barriers –
transportation, child care, scheduling, stigma, depression burden
Second Part (15 minutes) -- We provided:


Psychoeducation about depression and treatment options – inclusion
of a case management component to deal with chronic stressors
Problem-solving the barriers, affirmation of strengths, and hope
Structure of Brief IPT (IPT-B) (8 vs. 16 sessions)

Initial Phase (1-2 sessions)
IPT Inventory includes assessment of chronic stressors and
relationships with social service agencies
Case formulation of the interpersonal problem ares most linked with
the onset or exacerbation of the depression

Middle Phase (5 sessions)
Choose only one interpersonal problem area:
Role transition, role dispute, complicated grief
Choose a “manageable” problem in 8 sessions
Build on existing cultural strengths and ways of coping
Behavioral activation (explicit weekly homework) with an
interpersonal and culturally relevant focus  assessing needed
social services (e.g., housing, food banks, job training, free baby
supplies)

Termination (1-2 sessions) -- Support self-efficacy
Swartz et al., 2004, Psychiatric Services
Grote et al., 2009, J of Contemporary Psychotherapy
Cultural Enhancements to IPT-B
(Grote et al., 2009, Psychiatric Services, 60, 313-321)

Enhancements regarding culture of poverty:


facilitation of access to social services; convenient
public health setting, phone therapy; reminder phone calls
Enhancements related to culture of race/ethnicity
(based on Bernal et al., 1995)





culturally sensitive, experienced clinicians
incorporating cultural resources and strengths
treatment setting served others from same racial/ethnic group
using stories from patient culture to support treatment goals
providing psychoeducation and treatment information
congruent with patient’s cultural preferences and values
e.g. therapy= a class; depression could be re-labeled “stress”
Use of Case Management (CM) Services
(Grote et al., 2009, Psychiatric Services, 60, 313-321)

previous small RCT of IPT-B showed that 50% of pregnant
women on low-incomes received case management services

on average, they received 2 referrals to social service
agencies

66% of those who received referrals reported successfully
following through

clinical observations:
1) focusing on CM took little time away from an IPT focus
2) including CM made IPT more meaningful and relevant to
the women
MOMcare Design

Eligible public health clients consent to be randomized to:
MOMcare intervention (engagement PLUS choice of
evidence-based brief IPT and/or anti-depressant medication
plus case management)
8 sessions acute rx BEFORE BIRTH and monthly
maintenance sessions to 1 year postpartum

Care Plus (the care they receive as a public health client –
psychoeducation, treatment referral, and depression
monitoring)


MOMCare DCS delivers the intervention in the public health
center or by phone
MomCare Outcomes

Effectiveness outcomes for MOMcare relative to Care Plus:
1) Reduction in depression, improvement in social functioning
2) Better maternal role functioning, e.g. maternal sensitivity
and responsivity to infant cues at 6 and 12 months postpartum
e.g. home observations of mother-infant interaction in
collaboration with Center for Infant Mental Health at UW
3) Infant – higher rates of secure attachment and better mental
health outcomes at 12 months postpartum

Cost effectivenss outcomes – depression free days, more wellbaby visits and higher rates of immunizations
Effectiveness Study
Brief 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 antidepressant 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
* p<.05 MOMcare participants more
likely to be married that Usual Care
61%
15.9%
19.5%
7.3%
2.4%
13.4%
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-B

Preliminary findings on clinician-rated PHQ-9 depression
measure suggest that culturally relevant IPT-B may
ameliorate antenatal depression in MOMCare participants
(did not look at usual care yet)

Observations:


Most women needed and have accepted CM services – increasing
evictions, homelessness, job loss, food insecurity
Excerpt