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

描述（由申请人提供）：母亲抑郁症对低收入和少数民族妇女的影响尤为严重，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精神卫生服务，导致她们在获得护理方面存在差异。2009年，医学研究所（IOM）发表了一份具有里程碑意义的报告《父母、养育和儿童中的抑郁症》（Depression In Parents, Parenting, and Children），在报告中，它认识到参与护理是取得更好结果的一个重大障碍，并呼吁将筛查工作与治疗计划联系起来的干预措施，这些干预措施应在以社区为基础、以家庭为中心的场所进行。与该报告一致，我们的研究小组在2010年获得了R01奖（R01MH091871），进行了一项随机试验，以预防母亲抑郁症的干预，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，根据母亲发展为重度抑郁发作（MDE）的风险，招募了“领先计划”的母亲；那些MDE患者被故意排除在外，并转介到更明确的治疗。本R21建议将那些被排除在预防试验之外的妇女纳入一项辅助试点研究，其主要目标是发展患者导航，作为促进抑郁症治疗的模式。患者导航是一种现场交付的病例管理方法，侧重于克服医疗的后勤障碍，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达到这一目的。因此，我们将对导航员进行“参与访谈”培训，这是一种有经验支持的技术，在这种技术中，采访者促进以客户为中心的生活经历探索、共同决策和目标设定，以此建立寻求治疗的动力。我们建议进行一项两组60名受试者的试点研究，在该研究中，我们将：实地测试研究机制，包括在MDE的先进性母亲中随机化的可接受性；采用质量改进方法优化干预措施的实施；并获得研究参数的经验性估计，以告知计划适当的功率RCT。尽管在成年癌症患者中出现了促进及时使用诊断服务的新证据，但它作为一种促进参与精神卫生保健的机制还有待研究。研究在以儿童为中心的“学前教育”环境中的参与情况，可以进一步了解如何利用这种以社区为基础的环境（强调儿童和家庭）来帮助MDE的母亲寻求护理。这些知识将为干预模式的后续试验的发展提供信息。我们的最终目标是通过“先发计划”在国家一级推广模式，并缩小在获得精神保健方面的差距。

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.