Rapid Access to Perinatal Psychiatric Care in Depression Program (RAPPID): An Innovative Stepped-Care Approach for Obstetrics and Gynecology Clinics

 描述（由申请人提供）：本U 01提案的主要目标是完善、评估和传播一种新的低成本和可持续的妇产科（Ob/Gyn）诊所阶梯式护理计划，该计划将提高围产期妇女的治疗率和结局。这项研究具有巨大的公共卫生需求，因为抑郁症是全球育龄妇女残疾的主要原因。五分之一以上的妇女患有围产期抑郁症。它对出生结果、婴儿依恋和儿童的行为/发育有有害影响。产妇自杀导致20%的抑郁症妇女产后死亡。虽然绝大多数围产期妇女都愿意接受抑郁症筛查，但单独筛查并不能提高治疗率或患者预后。妇产科诊所需要适当的支持，以充分解决其患者人群中的抑郁症。因此，我们开发并试点测试了抑郁症围产期精神病护理快速访问（RAPPID）计划，以创建一个积极主动，多方面和实用的综合干预措施。RAPPID旨在通过以下方式提高围产期抑郁症治疗和治疗反应率：（1）为妇产科提供者提供即时资源提供/转介和精神科电话咨询;（2）针对具体诊所实施阶梯式护理，包括培训支持和工具包;以及（3）积极主动的治疗参与，患者监测和对抑郁症筛查/评估的阶梯式治疗反应。RAPPID建立在我们团队开发的低成本和广泛传播的基于人群的模型基础上，用于在初级保健环境中提供精神病护理。关键利益攸关方的形成性数据和反馈也为快速发展方案的制定提供了信息。我们在现实世界环境中的试点工作表明RAPPID是可行的，并改善了Ob/Gyn环境中的抑郁症检测和治疗。由于该方案利用现有的基础设施和资源，因此具有可行性、可持续性和可推广到其他实践环境的潜力。我们建议在一项随机分组试验中比较两种积极干预措施，RAPPID与加强常规护理（获得资源提供/转诊和精神科电话咨询），在该试验中，我们将12家妇产科诊所随机分配至RAPPID或加强常规护理。我们将在300例患者（n=150/组，25/诊所）中比较RAPPID与加强常规护理在改善妊娠期至产后12个月的抑郁严重程度和治疗参与方面的有效性。然后，我们将通过多层面传播战略传播调查结果和建议，以促进国家的吸收。我们与利益攸关方建立的关系增强了广泛传播和实施快速行动方案的潜力。我们在产科和抑郁症护理，集群随机试验和Ob/Gyn整合的综合专业知识使我们非常适合实施，测试和广泛传播RAPPID。如果证明是有效的，将准备在全国推广该方案。

 DESCRIPTION (provided by applicant): The primary goal of this U01 proposal is to refine, evaluate, and disseminate a new low-cost and sustainable stepped care program for Obstetrics/Gynecology (Ob/Gyn) clinics that will improve perinatal women's treatment rates and outcomes. There is a tremendous public health need for this research as depression is the leading cause of disability among women of reproductive age worldwide. Upwards of 1 in 5 women suffer from perinatal depression. It has deleterious effects on birth outcomes, infant attachment, and children's behavior/development. Maternal suicide causes 20% of postpartum deaths in depressed women. Although the vast majority of perinatal women are amenable to being screened for depression, screening alone does not improve treatment rates or patient outcomes. Ob/Gyn clinics need supports in place to adequately address depression in their patient populations. Thus, we developed and pilot tested the Rapid Access to Perinatal Psychiatric Care in Depression (RAPPID) Program, to create a comprehensive intervention that is proactive, multifaceted, and practical. RAPPID aims to improve perinatal depression treatment and treatment response rates through: (1) access to immediate resource provision/referrals and psychiatric telephone consultation for Ob/Gyn providers; (2) clinic-specific implementation of stepped care, including training support and toolkits; and, (3) proactive treatment engagement, patient monitoring, and stepped treatment response to depression screening/assessment. RAPPID builds on a low-cost and widely disseminated population-based model for delivering psychiatric care in primary care settings developed by our team. Formative data and feedback from key stakeholders also informed the development of RAPPID. Our pilot work in real-world settings suggests RAPPID is feasible and improves depression detection and treatment in Ob/Gyn settings. Because it uses existing infrastructure and resources, RAPPID, has the potential to be feasible, sustainable and transportable to other practice settings. We propose to compare two active interventions, RAPPID vs. enhanced usual care (access to resource provision/referrals and psychiatric telephone consultation) in a cluster-randomized trial in which we will randomize 12 Ob/Gyn clinics to either RAPPID or enhanced usual care. We will compare the effectiveness of RAPPID vs. enhanced usual care to improve depression severity and treatment participation in pregnancy through 12 months postpartum among 300 patients (n=150/group, 25/clinic). We will then disseminate findings and recommendations via a multi-dimensional dissemination strategy to facilitate national uptake. Our established relationships with stakeholders boosts the potential for widespread dissemination and implementation of RAPPID. Our combined expertise in the integration of obstetric and depression care, cluster-randomized trials and Ob/Gyn make us ideally suited to implement, test and widely disseminate RAPPID. If proven effective, RAPPID will be poised for national dissemination.