Patient Navigation for Depressed Mothers in Head Start - An Engagement Strategy

母亲抑郁症不成比例地影响低收入和少数民族妇女，并对其子女产生重大负面影响。在这些妇女中，无数的文化、心理和后勤障碍阻碍了她们接受心理健康服务，导致在获得护理方面存在差距。2009年，美国医学研究所（IOM）发表了一份具有里程碑意义的报告《父母、养育和儿童的抑郁症》，其中认识到参与护理是改善结果的一个重大障碍，并呼吁采取干预措施，将筛查工作与治疗计划联系起来，并在以社区为基础、以家庭为中心的场所进行。与此报告一致，我们的研究小组在2010年获得了R 01奖（R 01 MH 091871），在Head Start中进行了一项孕产妇抑郁预防干预的随机试验-这是一项联邦资助的学前教育计划，为全美约100万低收入家庭的儿童提供服务。在这项正在进行的研究中，根据他们患重度抑郁发作（MDE）的风险招募了Head Start母亲;故意排除MDE中的母亲，并将其转诊至更明确的护理。这项R21建议将那些被排除在预防试验之外的女性纳入一项辅助试点研究-其主要目标是将患者导航开发为促进抑郁症护理参与的模型。患者导航是一种现场交付的病例管理方法，其重点是在定义的事件期间克服护理的后勤障碍，例如交通，语言障碍或保险复杂性。然而，由于从事精神卫生保健需要解决额外的文化和心理障碍，我们认为传统的导航模型将不足以实现这一目的。因此，我们将在“参与面试”中培训我们的导航员，这是一种辅助技术，在这种技术中，面试官促进以客户为中心的生活体验探索，共同决策和目标设定，作为建立寻求治疗的动力的一种方式。我们提出了一项两组、60例受试者的试点研究，在该研究中，我们将：现场测试研究机制，包括MDE中的Head Start母亲中随机化的可接受性;使用质量改进方法优化干预措施;并获得研究参数的经验估计值，以告知适当把握度的RCT计划。虽然患者导航在成年癌症患者中有促进及时使用诊断服务的新证据，但尚未将其作为促进与精神卫生保健接触的机制进行研究。研究参与以儿童为中心的开端设置提供了进一步的可能性，学习如何以社区为基础的设置-其重点是儿童和家庭-可以利用帮助母亲在MDE寻求照顾。这些知识将为后续干预模型试验的开发提供信息。我们的最终目标是通过“先声夺人”在国家一级传播模式，并减少获得精神卫生保健方面的差距。

DESCRIPTION (provided by applicant): Maternal depression disproportionately affects low-income and minority women and has substantial negative impacts on their children. Among these women, myriad cultural, psychological and logistic barriers impede engagement with mental health services, resulting in disparities in access to care. In 2009, the Institute of Medicine (IOM) published a landmark report, Depression in Parents, Parenting, and Children, in which it recognized engagement with care to be a substantial hurdle to better outcomes, and called for interventions that link screening efforts to treatment plans, and that take place in community-based, family-focused venues. Consistent with this report, our research group obtained an R01 award (R01MH091871) in 2010 to conduct a randomized trial of a maternal depression prevention intervention in Head Start - a federally funded preschool program that provides services for ~1 million children of low-income families across the US. In this ongoing study, Head Start mothers are enrolled based on their risk for developing major depressive episode (MDE); those in MDE are deliberately excluded and referred to more definitive care. This R21 proposes to enroll those women excluded from the prevention trial in an adjunct pilot study - the principal goal of which is to develop Patient Navigation as a model to promote engagement with depression care. Patient Navigation is a lay-delivered case management approach that focuses on overcoming logistical hurdles to care, such as transportation, language barriers or insurance complexities, during a defined episode. However, because engaging with mental health care requires addressing additional cultural and psychological barriers, we believe that traditional Navigation models will be insufficient for this purpose. We will thus train our navigators in the 'Engagement Interview,' an empirically-supported technique, in which interviewers facilitate client-focused exploration of life experiences, shared decision making, and goal setting as a way to build motivation to seek treatment. We propose a two-arm, 60-subject pilot study, within which we will: field test study mechanics, including the acceptabiliy of randomization among Head Start mothers in MDE; use quality improvement methods to optimize intervention delivery; and obtain empiric estimates of study parameters to inform the planning of an appropriately powered RCT. Although Patient Navigation has emerging evidence among adult cancer patients for promoting timely use of diagnostic services, it has yet to be studied as a mechanism to promote engagement with mental health care. Studying engagement in the child-focused Head Start setting offers the further possibility of learning how such a community-based setting - with its emphasis on children and family - can be leveraged to help mothers in MDE seek care. Such knowledge will inform the development of a subsequent trial of the intervention model. Our ultimate goal is model dissemination at the national level through Head Start and a reduction in disparities in access to mental health care.