Collaborative Care Model for Perinatal Depression Support Services -- Population-Level Equity-Centered Systems Change (COMPASS-PLUS): A Hybrid Type 2 Cluster Randomized Trial

项目摘要/摘要 在美国，超过15%的女性在怀孕期间或怀孕后受到抑郁症的影响。未经治疗 围产期抑郁极大地损害了母亲的生活质量，在最极端的情况下，可能会导致自杀 这仍然是孕产妇死亡率的主要贡献者。尽管它的重要性得到了承认，但多重障碍 存在于抑郁症的护理瀑布中。这些障碍之一是现有的卫生系统结构，其中 产科和精神科护理存在于孤岛中，而精神健康的社会决定因素(SDoMH)不存在 系统地纳入护理计划。如果没有一个协同的方法来对待整个女人，无论是身体上的 在精神上，抑郁症状的筛查并不一致。即使在进行筛查和 抑郁症被诊断出来，治疗通常没有开始，抑郁症状没有被跟踪，护理也没有被跟踪 随着症状缓解的目标逐步升级。这种缺乏协调和个性化护理的情况导致数千人 美国每年都有很多易受伤害的女性。此外，围产期存在显著的不平等。 抑郁症护理，导致种族和民族生活质量差距扩大，孕产妇发病率， 和产妇死亡率。当务之急是，我们必须确定替代机制，以充分识别和治疗 以公平的方式治疗围产期抑郁，并将心理保健作为干预的一个组成部分 旨在降低孕产妇死亡率和严重孕产妇发病率。 协作护理模式(CCM)在初级保健环境中实施时，可改善 心理健康结果。然而，围产期情况在患者、临床医生和系统水平上是独一无二的。 因此，围产期CCM(PCCM)需要自己的验证。一项小规模(n=168)的随机试验表明 PCCM对减轻抑郁症状有效。尽管有这些数据，pCCM仍然很少被利用，因为 从研究到实践的连续体中存在的两个差距。首先，现有的疗效数据缺乏概括性 广泛传播所需的信息。其次，还没有发表任何研究报告，以提供关于尊重 关于母婴疾病综合管理的一揽子实施战略，并注意围产期环境的独特方面。 此外，虽然pCCM是一种以公平为中心的干预措施，但在怀孕期间观察到的持续差异 结局和围产期心理健康需要有目的的、创新的、包容的、反种族主义的方法，以建立 在传统的以股权为中心的CCM基础和中心基础上，对SDoMH进行识别和缓解。 我们将利用为建立和成功的pCCM而开发的现有临床算法和数据库 进行严格的阶梯楔形整群随机试验以评估公平增强型pCCM的效果 [COMPASS-PLUS(围产期抑郁症支持服务的协作护理模式-人口级别 以健康公平为中心的结构性改革)]对产妇心理健康结果和心理健康差距的影响。 我们将通过混合类型2优化针对围产期护理量身定做的实施战略包 执行

PROJECT SUMMARY/ABSTRACT Over 15% of women in the United States are impacted by depression during or after pregnancy. Untreated perinatal depression dramatically impairs maternal quality of life and, in its most extreme form, can lead to suicide which remains a leading contributor to maternal mortality. Despite recognition of its importance, multiple barriers exist in the depression care cascade. One of these barriers is the existing health system structure, wherein obstetric and psychiatric care exists in silos and social determinants of mental health (SDoMH) are not systematically integrated into care plans. Without a synergistic approach to the whole woman, both physically and mentally, screening for depressive symptoms occurs inconsistently. Even when screening occurs and depression is diagnosed, treatment is often not initiated, depressive symptoms are not tracked, and care is not escalated with the goal of symptom remission. This lack in coordinated and personalized care has left thousands of women vulnerable each year in the United States. Moreover, there are significant inequities in perinatal depression care which contribute to the widening racial and ethnic disparities in quality of life, maternal morbidity, and maternal mortality. It is imperative that we identify alternative mechanisms to adequately identify and treat perinatal depression in an equitable manner and incorporate mental healthcare as a component of interventions designed to reduce maternal mortality and severe maternal morbidity. The collaborative care model (CCM), when implemented in the primary care context, leads to improvements in mental health outcomes. However, the perinatal context is unique on the patient, clinician, and systems levels. Thus the perinatal CCM (pCCM) requires its own validation. One small (n=168), randomized trial suggests the pCCM is efficacious in reducing depressive symptoms. Despite these data, pCCM remains rarely utilized due to two existing gaps in the research-to-practice continuum. First, the existing efficacy data lack generalizability needed for broad dissemination. Second, no studies have been published to inform best practices with respect to an implementation strategies package for pCCM, with attention to the unique aspects of the perinatal context. Moreover, while the pCCM is an equity-centered intervention, the persistent disparities observed in pregnancy outcomes and perinatal mental health require an intentional, innovative, inclusive, anti-racist approach that builds upon the traditional equity-centered CCM foundations and centers identification and mitigation of SDoMH. We will leverage existing clinical algorithms and databases developed for an established and successful pCCM to perform a rigorous stepped-wedge cluster-randomized trial to evaluate the effect of an equity-enhanced pCCM [COMPASS-PLUS (Collaborative Care Model for Perinatal Depression Support Services – Population-Level Health Equity-Centered Structural Changes)] on maternal mental health outcomes and mental health disparities. We will optimize an implementation strategy package tailored to perinatal care via a hybrid type 2 implementation-effectiveness design with the goal of broad dissemination of the pCCM.