Culturally relevant treatment services for perinatal depression in socio-economically disadvantaged women: The design of the MOMCare study

Abstract

Background

Depression during pregnancy has been demonstrated to be predictive of low birthweight, prematurity, and postpartum depression. These adverse outcomes potentially have lasting effects on maternal and child well-being. Socio-economically disadvantaged women are twice as likely as middle-class women to meet diagnostic criteria for antenatal major depression (MDD), but have proven difficult to engage and retain in treatment. Collaborative care treatment models for depression have not been evaluated for racially/ethnically diverse, pregnant women on Medicaid receiving care in a public health system. This paper describes the design, methodology, culturally relevant enhancements, and implementation of a randomized controlled trial of depression care management compared to public health Maternity Support Services (MSS).

Methods

Pregnant, public health patients, > 18 years with a likely diagnosis of MDD or dysthymia, measured respectively by the Patient Health Questionnaire-9 (PHQ-9) or the Mini-International Neuropsychiatric Interview (MINI), were randomized to the intervention or to public health MSS. The primary outcome was reduction in depression severity from baseline during pregnancy to 18-months post-baseline (one-year postpartum).

Baseline results

168 women with likely MDD (96.4%) and/or dysthymia (24.4%) were randomized. Average age was 27.6 years and gestational age was 22.4 weeks; 58.3% racial/ethnic minority; 71.4% unmarried; 22% no high school degree/GED; 65.3% unemployed; 42.1% making <$10,000 annually; 80.4% having recurrent depression; 64.6% PTSD, and 72% unplanned pregnancy.

Conclusions

A collaborative care team, including a psychiatrist, psychologist, project manager, and 3 social workers, met weekly, collaborated with the patients' obstetrics providers, and monitored depression severity using an electronic tracking system. Potential sustainability of the intervention within a public health system requires further study.

Introduction

A report from the Agency for Healthcare Research and Quality concluded that despite the fact that perinatal depression is a significant mental health and public health problem, there is a paucity of high-quality research on the identification and management of perinatal depression in “real world” systems of care [1]. Depression during pregnancy has been demonstrated to be the most potent predictor of postpartum depression [2] and has been linked to low birthweight and prematurity, especially for socio-economically disadvantaged women in the United States [3]. Maternal postpartum depression, in turn, has potential lasting, adverse effects on maternal, infant and child well-being [4], [5], [6]. Prevalence rates show that poor, urban women are at least twice as likely as middle-class women to meet diagnostic criteria for major depression during pregnancy [7], [8], [9]. Critical gaps also exist in screening for perinatal depression in medical and non-medical settings and racially/ethnically diverse depressed women on low incomes have proven difficult to engage and retain in a minimally adequate course of mental health treatment [10], [11], [12], [13].

Socio-economically disadvantaged women face numerous barriers to care at the system, provider, and patient levels [14]. System barriers (medical and mental health settings) may include: a culturally insensitive and/or stigmatizing environment, lack of minority health care providers and consumers; [15] few strategies for maintaining evidence-based practices; lack of electronic technology; failure to align system and financial incentives for quality of care improvements; [16], [17], [18] high staffing ratios and long waiting times [19]. Provider barriers may involve the lack of: 1) culturally sensitive or minority health providers; 2) systematic depression screening; 3) time to educate patient about depression; 4) monitoring adherence and outcomes; and 5) exploration of patient's preferences about treatment (i.e., medication or psychotherapy) [16], [17], [18].

Potential patient barriers include: 1) practical barriers (e.g., economic problems; lack of medical insurance, transportation, or childcare; competing priorities and limited time; inaccessible clinic locations); [20], [21], [22] 2) cultural barriers (e.g., clinician insensitivity to cultural values, preferred ways of coping, and beliefs about depression); [15], [23], [24] and 3) psychological barriers (e.g., previous negative experiences with service use; [25] stigma of depression [26]). Another barrier appears to be an avoidant or fearful attachment style, often resulting from exposure to childhood or domestic trauma [27], [28] and characterized by strong self-reliance and/or distrust of others, potentially making it difficult to engage in treatment [29].

Collaborative care (CC) models for treating depression in primary care have received over a decade of substantial empirical support [30], [31], [32], [33] and hold promise for improving access to evidence-based care for antenatal depression and for maintaining postpartum recovery. In brief, collaborative care is a systematic approach that includes: 1) a negotiated definition of the clinical problem in terms that both the patient and health care provider understand; 2) joint development of a care plan; 3) provision of support for self-management training and affective, cognitive, and behavioral change; and 4) active, sustained follow-up [14]. CC models typically involve two stepped care principles: [32] 1) treatment should always have the best chance of delivering positive outcomes while burdening the patient as little as possible and 2) scheduled reviews, to detect and act on non-improvement, must be in place to enable stepping up to more intensive treatments, stepping down where a less intensive treatment becomes appropriate, and stepping out when an alternative treatment or no treatment becomes appropriate.

The CC approach has been adapted to patients with chronic medical illness [34], [35] and socio-economically disadvantaged populations [10]. Studies have shown that CC interventions that activate and educate patients to become active partners and that extend a masters-level social worker or nurse (depression care specialist), supervised by a mental health team, into the primary care setting are highly effective in improving outcomes [14]. CC models address patient-level barriers by providing education about depression and by offering patients a choice of evidence-based brief psychotherapy and/or pharmacotherapy, and if the patient does not respond to the initial line of treatment, augmenting care with the alternative treatment [14]. These models also address provider-level barriers by using a collaborative approach to integrate mental health specialty knowledge into primary care, closely monitoring patient symptoms and adherence [14], and using the telephone as well as in-person visits.

Pregnancy is known to be an opportune time for suggesting health interventions [36] because pregnant women may be unusually open to making changes to improve their mental health and health risk behaviors, such as smoking and/or substance use, before their baby is born [37]. This paper reports on the design and methods of a National Institute of Mental Health-funded randomized controlled trial, MOMCare, which provided a multi-component, collaborative care model for engaging and retaining depressed, pregnant women in treatment to ameliorate antenatal depression and reduce the risk of postpartum depression. The MOMCare study built upon a previous randomized pilot study of a pre-treatment engagement session and brief interpersonal psychotherapy, enhanced to be culturally relevant to a diverse population of low-income women during the perinatal period [12], [38]. By “culturally relevant”, we mean an intervention adapted to be relevant both to the culture of poverty and the culture of race/ethnicity. This paper also describes the process whereby the MOMCare study was implemented in a unique, progressive service environment — the 10 public health centers of Public Health Seattle-King County (PHSKC) of Western Washington.