Bobbie Posmontier PI, PhD, CNM, PMHNP-BC Assistant Professor Drexel University

1. Session # I5 October _29_, 20111:30 PM Multidisciplinary Model of Nurse Midwife Administered Psychotherapy for Postpartum Depression (5R21MH86610-2) Bobbie Posmontier PI, PhD, CNM, PMHNP-BC Assistant Professor Drexel University Richard Neugebauer, PhD, Columbia University, Co-I Scott Stuart, MD, University of Iowa, Co-I Collaborative Family Healthcare Association 13th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

2. Faculty Disclosure • We have not had any relevant financial relationships during the past 12 months. • Acknowledgement: Funding though the National Institute of Mental Health 5R21MH86610-2

3. Need/Practice Gap & Supporting Resources • Only 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)

4. Objectives • Describe 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

5. Problem • PPD affects 6.5% to 30% of all childbearing women • Only 20% to 25 % receive treatment. • Major barriers • Stigma • Retelling story to unknown provider • Competing childcare responsibilities • Financial/insurance • Transportation • Fragmentation services • Most studies focus on treatment by mental health professionals

6. Specific Aims • Evaluate 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 team • Efficacy of IPT administered by nurse midwives in • Improving the general level of maternal functioning • Specific improvement in marital adjustment • Increase in maternal infant bonding

7. Innovation • Using Nurse Midwives (NMC) in Primary Care to fill treatment gap • Multidisciplinary/Collaborative • Connection with mental health system • Build on established relationships to improve engagement/retention

8. Innovation • Utilize telephone to address maternal time and childcare constraints. • Reduce costs • Manualize intervention for other advanced practice nurses for full-scale RCT

9. Methods • RCT – pilot study • Experimental group receives NMC IPT intervention • Control group receives treatment as usual (TAU) or wait list • NMC recruits women with depressive symptoms at their six-week postpartum check-ups at nine national sites in US • Screen • EPDS ≥ 10 • Sociodemographic, health history • Structured interview for depression • Assessments/Diagnosis- baseline, 4 weeks, 8 weeks, 12 weeks by PMHNP

10. Treatment:Interpersonal Psychotherapy • Brief • Evidence based – 30 years experience with PPD • Effective • Can be taught to lay people • Helps to improve depression related to • Role • Interpersonal disputes • Interpersonal Deficits • Grief

11. Current Recruitment Population • OB practices from AZ, DC, MA, NJ, PA, TX, • ~9922 women • AZ-240 diverse low income 50% PPD • DC –2400 diverse low income 30% PPD • MA – 2400 middle income 12-18%PPD • NJ- 742 low income 8% PPD • PA - 1200 middle income 15% PPD • PA – 1440 middle income women 15% PPD • PA - 720 –diverse low income 40% PPD • TX -780 diverse low income 6% PPD • Power analysis – 130 women with 65 randomized to each group

12. Screening at 6 weeks postpartum (n = 9,922) EPDS ≥ 10 (n =644) Decline Assess (n = 399) Training subjects (n = 24) Assess for Eligibility (n =221) Excluded (refused) (n = 79) Randomization of enrolled participants (n = 130) IPT Intervention (n = 65) Treatment as Usual (n = 65) Treatment as Allocated (n = 65) Treatment as Allocated (n =65) 4-week post-randomization (n = 59) 4-week post-randomization (n =61) 8-week post-randomization end IPT (n = 56) 8-week post-randomization (n = 59) 12-week post-randomization (n = 55) Estimated Flow 12-week post-randomization (n = 52)

13. Instruments • MINI International Neuropsychiatric Interview • Hamilton 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

14. Inclusion • 6 to 24 weeks postpartum • 18 years and older • English-speaking • Access to a telephone • Consents to enter the trial • Diagnosis 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

15. Exclusion • Infant complications requiring medical care beyond 6 weeks postpartum • Infant birth defects • Infant being placed for adoption by 6 weeks postpartum • Maternal mental retardation • Active substance or alcohol abuse or dependence • Active suicidality, homicidality, or current psychosis • Disabling pain that interferes with ADLs • Concurrent serious medical co-morbidities

16. Procedure • NMC training • Two day IPT workshop • Human subjects • Recording software • DropBox • Administration EPDS • IPT certification • RA training • Instruments • Blinded

17. Procedure • Recruitment over 18 months • NMC screens all pts with EPDS at 6 week checkup • NMC refers interested patients with EPDS ≥ 10 • Time commitment NMCs 2 hours per week (one hour therapy, one hour supervision), plus 30 minute monthly team meetings • PI calls patients, explains study, consents • RA screen and diagnose PPD • Referral suicidal, homicidal, beyond scope NMC

18. Procedure • Randomize to treatment vs. TAU(treatment as usual) or wait list • Eight weekly 50 minute telephone sessions over 12 weeks • TAU referral to MH provider of NMC choice • Treatment- NMC sets up telephone appointments • Three training patients, 7-8 post-training patients • NMC weekly telephone supervision with IPT supervisor • $25 gift card for all patients

19. Progress • Study began June 2010 • Original five NJ sites • Problems • One CNM left her position • One CNM did not seek permission from medical director • Three CNMs trained August 2010 including PI • PI delivered intervention but disallowed by NIMH • One NMC dropped out due to personal problems • One NMC major practice change but still in study

20. Progress • 24 women expressed interest • Refusals • Confidentiality • Did 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

21. Just a peek ….

22. Progress • Needed to address provider problem • Sent mass email • 4,415 CNMs through ACNM • 31,897 WHNP through AANP • 555 positive responses • 460 midwives • 95 NPs • Women’s health • Psychiatric • Family

23. Locations of Respondents • Represented 45 states Washington DC, Japan • AK, 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, Japan

24. Qualitative Responses • 319 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 .

25. Qualitative Responses • I 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.

26. Qualitative Responses • After 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.

27. Qualitative Responses • Does 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.

28. Qualitative Responses • I 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.

29. Qualitative Responses • I 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)?

30. Qualitative Responses • I 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.

31. Qualitative Responses • We 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.

32. Qualitative Responses • I 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.

33. Progress • 10 CNMs chosen from national sites 7 still in study • One IRB not approved • One potential NMC became ill at training • One developed personal problem • Second training August 2011 • One NJ site still recruiting • Total 8 NMCs recruiting • Recruitment for new NMCs started September 1, 2011 • Spoke to program officer at NIMH about ITT group

34. Questions?

35. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!

36. Questions?