Reducing Disparities and Improving Care for Depression in OB-GYN Clinics

描述（由申请人提供）：背景：重度抑郁发作发生在女性的整个生命周期中，在生殖和绝经过渡期发生率最高。在此期间，OB-GYN是许多女性经常看到的唯一提供者。低收入和少数民族妇女特别有可能在妇产科诊所寻求常规护理。在妇产科诊所的诊断准确性和抑郁症护理质量方面存在明显差距，抑郁症护理质量的差异超过了初级保健诊所。将抑郁症护理纳入临床环境的模型可能适用于OB-GYN环境，但尚未在围产期外进行测试。大多数妇产科医生看到的妇女没有怀孕;因此，仅关注围产期抑郁症的研究排除了大量可以从护理中受益的妇女。到目前为止，还没有完成将抑郁症护理模式适应于整个OB-GYN诊所的研究。研究目的：我们提出了一个由三部分组成的干预措施，与OB-GYN护理相结合，包括（i）加强教育;（ii）参与;（iii）抑郁症护理管理（抗抑郁药监测和/或提供简短的心理治疗）。我们假设，三部分抑郁症干预，整合到OB-GYN临床环境，将改善抑郁症的治疗结果，功能结果和抑郁症护理的满意度。研究设计：在拟议的随机对照试验中，260例患有重度抑郁症和/或心境恶劣的OB-GYN门诊患者将被分配到：1）综合抑郁干预或2）常规护理（UC）。我们将在两个城市妇产科诊所对约8，300名预约门诊的患者进行为期18个月的重度抑郁症/心境恶劣的筛查。这些患者中有许多是低收入和少数民族妇女。潜在合格的患者也可以由诊所提供者转介或回复诊所张贴的信息传单。综合抑郁症干预将持续12个月。将由设盲研究人员在基线和6、12和18个月时通过电话访谈评估结局。目的：我们的主要目标是：1）与UC相比，评价综合OB-GYN抑郁干预对抑郁治疗结局的影响，包括抑郁症状和抑郁治疗反应的变化; 2）与UC相比，评价综合OB-GYN抑郁干预对功能结局的影响。我们的次要目标是：3）与UC相比，评估综合OB-GYN抑郁干预对抑郁症护理指标质量的影响，包括治疗访视次数，剂量，持续时间和抗抑郁药物的依从性;以及对抑郁症护理的满意度，包括患者和提供者满意度，以及提供者对OB-GYN诊所抑郁症护理的态度;和4）[为了确定潜在的促进者和障碍，以可持续性的综合OB-GYN干预。] 公共卫生相关性：我们提出的随机对照试验的结果将极大地影响公共卫生，通过满足未满足的需求，有效的抑郁症服务的所有妇女看到在OB-GYN临床设置。在这种情况下接受治疗的大部分妇女的抑郁症治疗结果和生活质量的潜在改善将是巨大的。

DESCRIPTION (provided by applicant): Background: Major depressive episodes occur throughout a woman's lifespan, with the highest rates during the reproductive and menopausal transition years. During this time, OB-GYNs are the only providers whom many women regularly see. Low income and minority women are particularly likely to seek their routine care in OB-GYN clinics. There are marked gaps in accuracy of diagnosis and quality of depression care in OB-GYN clinics, with disparities in quality of depression care which exceed those seen in primary care clinics. Models incorporating depression care into clinical settings may be adaptable to OB-GYN settings but have not been tested outside of the perinatal period. Most women seen by OB-GYNs are not pregnant; thus, studies focusing solely on perinatal depression excludes a large number of women who could benefit from care. No studies to date have been completed that have adapted depression care models to OB-GYN clinics as a whole. Research Goal: We propose a three-part intervention, integrated with OB-GYN care, consisting of (i) enhanced education; (ii) engagement; and (iii) depression care management (with antidepressant monitoring and/or provision of brief psychotherapy). We hypothesize that a three-part depression intervention, integrated into the OB-GYN clinical setting, will improve treatment outcomes for depression, functional outcomes, and satisfaction with depression care. Study Design: In the proposed randomized controlled trial, 260 OB-GYN clinic patients with major depression and/or dysthymia will be assigned to either: 1) an integrated depression intervention or 2) usual care (UC). We will screen approximately 8,300 patients presenting for scheduled clinic appointments at two urban OB-GYN clinics over 18-months for major depression/dysthymia. A large number of these patients are low-income and minority women. Potentially eligible patients may also be referred by a clinic provider or reply to informational flyers posted in the clinics. The integrated depression intervention will last 12 months. Outcomes will be assessed at baseline and at 6, 12, and 18 months by telephone interviews by blinded research staff. Aims: Our Primary Aims are: 1) To evaluate, compared to UC, the impact of an integrated OB-GYN depression intervention on depression treatment outcomes, including change in depressive symptoms and depression treatment response; and 2) To evaluate, compared to UC, the impact of an integrated OB-GYN depression intervention on functional outcomes. Our Secondary Aims are: 3) To evaluate, compared to UC, the impact of an integrated OB-GYN depression intervention on quality of depression care indicators, including number of therapy visits, and dose, duration, and adherence to antidepressant medications; and on satisfaction with depression care, including patient and provider satisfaction, and provider attitudes toward depression care in OB-GYN clinics; and 4) [To identify potential facilitators and barriers to sustainability of the integrated OB-GYN intervention.] PUBLIC HEALTH RELEVANCE: The results of our proposed randomized controlled trial will greatly impact public health by satisfying an unmet need for effective depression services for all women seen in the OB-GYN clinical setting. The potential improvements in depression treatment outcomes and quality of life for the large proportion of women who receive their care in this setting will be substantial.