WE Care

1. WE Care Women Entering Care

2. WECare Depressed Subject Recruitment by Month-Year

3. Randomized study MDD • SSRI given by nurse practitioner, supervised by CL Psychiatrist • CBT given by psychologist • TAU - referral to appropriate community care

4. Recruitment strategies • Involved in pilot interventions • Believed treatment could be done and would be useful. • Willing to be creative (loosen some boundaries) within reasonable bounds.

5. Establishing Trust • Selection of Sites for Recruitment • Establishing Relationship with Leaders of Sites • Informed Buy-in of Site Staff

6. The First Interview: Facilitating Recruitment • Selection of Interviewers --Interviewers who are committed --Have training in diagnosis and assessment • Training and Supervision --Intensive training for 2-3 weeks --Mandatory weekly supervision meeting I • Facilitating Collaboration with Interviewers and Site Staff --Regular visit to sites --Continuous problem-solving to increase efficiency in Recruitment

7. Clinical Treatment • Subjects’ first face to face meeting is a 2 hour clinical interview after which they are informed of their treatment assignment • Contacting, scheduling, rescheduling, identifying barriers, and completing this interview can take up to 2 months • We are fortified by the knowledge that we are offering treatment or referral to care

8. Key Characteristics of WECare Treatment Approach • Persistence • Flexibility • Excellent Clinical Relationship • Support for Treatment Success • Cultural Sensitivity

9. Persistence • Repeated calls to subjects • Friendly upbeat approach • Nonjudgmental • Offer choices when possible • Don’t short circuit - keep options open

10. Flexibility • Work meetings around subject’s schedule (weekends, evenings, early morning) • Convenient locations (homes, restaurants, local clinic, coordinate w/ appointments) • Provide transportation that is reliable and convenient • Initiate treatment when the subject is ready

11. Excellent Clinical Relationship • Frequent scheduled follow up calls • Actively problem solve to anticipate needs and concerns • Be available for subject’s problems (crises, calls, worries) • Maintain therapeutic boundaries

12. Support for Treatment Success • Strong team centered approach helps prevent burnout, generate ideas, set precedent for handling difficult situations • Excellent relationship w/ community sites and staff • “Blitz days” as outgrowth of team centered approach

13. Cultural Sensitivity • Appreciate unique issues for immigrant women • More relaxed conversational style of interviewing • Include family if desired by subject • Adapt language and pace of interview to educational level of subject

14. Phone Interviewing • Flexible Scheduling • Persistence and Boundaries • Establishing Relationships with Subjects

15. Effects on Children • 5-year NIMH-funded study, 1998 – 2003 • 200 mother and child dyads • Same distribution of race/ethnicity • Same 3 treatment groups • Same Non-Depressed Control group (N=50) • Children 4 – 10 years old

16. Effects on Children • Investigators: • Anne Riley, Ph.D. • Jeanne Miranda, Ph.D. • Marina Broitman [Coordinator] • Patricia Heiber, Ph.D. • Mary Jo Coiro, Ph.D. • Interviewer Supervisor • Kristen Hurley, M.S.

17. Primary Hypothesis Children of mothers whose depression remits will improve, compared to children whose mothers remain depressed, in • Mental health • Academic functioning • Social functioning

18. Child Component Challenges • Resistance to home visits • Resistance to involving their children and families • Resistance to the additional interviews, some up to 3 hours long

19. Child Component Challenges • 50% of eligible families did not enter child component up to December, 2000 • In 2001, only 35% not entering child component • High demand for contacts (average of 12 contacts to complete baseline interview)

20. How do we do it? • Persistence in phone contacts • Goals set for the number of phone calls per week • Weekly team meetings to review phone calls and difficulties • Calling at different times of day, from different phone numbers, to different phone numbers • Sending letters or going to the house for contact

21. How do we do it? • Reducing cancellations and no-shows • Incentives for completion • Rescheduling quickly and in-person if possible • Explain interviewers’ travel time • Offer to talk to partner and child, if appropriate • Offer to do interview in clinic, if needed • Offer transportation and babysitting, if needed

22. Other Important Factors • Build rapport and trust with mother and child • Checking in with family • Offering help with problems • Support and encourage staff • Help staff avoid feeling rejected by subjects • Only hire flexible interviewers • Interviewers need to be prepared for the population

23. Convergence of Studies • What was happening: • High percentage of refusals: • 20% of those who agreed to be contacted refused to participate. • Women were contacted by multiple people for interviews • Complaints of feeling overwhelmed, not understanding the flow of the studies

24. Convergence of Studies Need to identify the common mission: The two studies are really one, the goal of which is to identify the needs and outcomes of depressed, low-income women and their families

25. Convergence of Studies • Results of establishing a common mission: • Clinicians identified as the best suited to be the gatekeepers • Clinicians now fully introduce the “child component” • Clinicians can identify any hesitation by the subject and address the concern more quickly • Staff now sees the project in terms of a common goal rather than in terms of separate studies

26. Convergence of Studies -- The Outcome