Systems of Care for New Moms: Integrating Depression Treatment

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DESCRIPTION (provided by applicant): Maternal depression in the postpartum period is a significant public health matter, particularly among poor urban minority women with limited access to mental health services. Through research we know how to treat depression. What we do not know is how to translate effective depression treatments into community non- specialty mental health settings beyond office-based primary care. Nurse home visitation programs provide an opportunity to efficiently increase access to depression treatment for low income disadvantaged mothers. This study explores the co-location of depression treatment (Problem Solving Therapy) within nurse home visitation and the organizational changes needed to maintain access to evidence-based treatment. Problem Solving Therapy (PST) is suited to use by non-specialists and for in-home use. The brevity of the intervention (4-8 sessions) and its non-pathologizing approach should be acceptable to low income minority women. Through multiple methodologies, this study will gather information from women and their providers to determine what system and treatment modifications are needed to effectively deliver acceptable depression treatment in home visitation programs as they strive to implement policy directives to identify and treat mothers with depression. An expert panel, which blends local and global knowledge will provide advice on decisions regarding the intervention adaptation. Once these adaptation decisions are made a small group of experts will adapt a PST manual for use in home visitation. We will then carry out a small three-arm randomized trial comparing the effectiveness, acceptability, and practicality of PST provided by home visitation RNs, by a psychiatric advance practice RN usual care (referral to mental health specialty care). Forty two women will be matched and randomized into the three study conditions. Outcomes will be measured using both quantitative and qualitative methods. Depression outcomes will be measured using the Beck depression Inventory and PHQ-9 at 6 and 12 months post intervention. The Parenting Stress Index will be used to measure parental functioning. Women in the usual care condition will be tracked to assess barriers to their accessing depression treatment once referred. A sub-set of mothers and will be interviewed regarding the acceptability and practicality of receiving PST at home either from their regular nurse or a psychiatric advanced practice nurse. Nurse home visitors will be interviewed to assess the acceptability and practicality of their delivery of PST to mothers on their caseloads. Effect sizes and information on the acceptability and practicality of the intervention to both mothers and nurses will be used to prepare a full scale R01. PST delivered through home visitation holds promise for providing access to effective and acceptability depression treatment for poor urban minority mothers. Significantly, our study has the potential to provide home visitation agencies with a viable means of access to effective and acceptable depression treatment for mothers in the face of policy mandates for depression screening. 7. * Project Narrative Depression in the postpartum is a major public health problem, not only because of lost productivity and social functioning for the mother, but because of devastating health, mental health, and developmental consequences for the child, its effects on family functioning, and overall costs to society. Even mild depression in new mothers has been shown to impact on the establishment of mother-child bonding, while effective depression treatment for mothers can significantly improve outcomes for both mother and child. The postpartum period is a window of opportunity in which to address depression in women because they are more likely to come into contact with the health care system.