Acknowledgement

1. Description of MOMcare:Culturally Relevant Treatment Services for Perinatal DepressionNancy K. Grote, Ph.D. Research Associate ProfessorSchool of Social Work, University of Washington

2. 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

3. 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

4. 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 IPT-B, 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

7. 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)

8. 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

9. 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 indealing with chronic stressors Practical Barriers to Care

10. Public Stigma and Internalized Stigma Stigmatizing treatment settings Previous negative experiences with treatment, including therapist characteristics Childhood trauma (abuse and neglect) Burden of depression Psychological Barriers to Care

11. 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)

12. 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?”

13. Self-Actualization Needs The need to fulfill one’s unique potential Esteem Needs: to achieve, be confident, gain approval and recognition Psychological Needs Belongingness and Love Needs: to affiliate with others; to be accepted and belong Safety Needs: to feel secure, SAFE, and out of danger, to have A PLACE TO LIVE and SLEEP (BED) Basic Needs Physiological Needs: to have enough FOOD, water, and satisfy sex drives Maslow’s Hierarchy of Needs, 1979

14. 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)

15. 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

16. Chronic Stress Amplifies the Effects of Acute Stress on Depressive Symptoms(Grote, Bledsoe, Larkin & Brown, 2007) Depressive Symptoms

17. 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”

18. Introduction: The bio-psycho-social formulation of depression Expansion of IPT focus on current interpersonal functioning to address the chronic stressors of living in or near poverty.

19. 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)

20. 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

21. 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

22. 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”

23. 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

24. 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

25. 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 well-baby visits and higher rates of immunizations

26. 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 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

27. Demographic Variables for Pregnant Study Participants (N=82)

28. Demographic Variables for Study Participants (N=82)

29. 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