Treatment of Depression in Disadvantaged, Young Women

Jeanne Miranda, Bonnie Green, Janice Krupnick, Dennis Revicki, and

Joyce Chung

MDD in Women

Lifetime rate 17% (NCS)

12-month rate 10% (NCS)

2:1 female-male ratio

Focus on Young Women

Most first episodes before 30

Depression is associated with poor parenting

Poor child outcomes in offspring of depressed mothers

Depression, Poverty and Minority women

Depression rates higher among those who are poor than among others.

Nearly half of all African American and Latinas live at or near the poverty level

Rates of Mental Health Care

GENERAL POPULATION

40.8% of depressed get any care

POOR YOUNG WOMEN

10% of depressed get any care

Need address:

Treatment of depression in poor, young women, most of whom are single mothers.

Treatment of depression in ethnic minorities.

Impact of treatment of depression among women with comorbid PTSD.

Context for treating poor young women

Many are uninsured.Few use general medical care.Obstetrics - be a difficult time to treat.Population is seen in:

Title X county family planning clinics Women Infant & Children food entitlements Pediatrics

Screening of Low-income Women not Seeking Care

10% screen positive

6.1% screen eligible

Recruiting low-income women

Contacted 4.1 times on average prior to diagnostic interview.

68% of those who screen positive complete diagnostic interview

Of the 35% who do not: 53% are never reached 39% schedule but no show repeatedly 8% refuse

Diagnostic Completers

63% of those who complete diagnostic interview are eligible (27% no

MDD, 6% SA, 4% psychotic)

72% of those eligible get treatment

Contacts for recruitment

Clinicians contacted women an average of 7.8 times to encourage attendance at initial clinical session.

Women attended an average of 2 educational sessions before entering care.

Ethnic-specific recruitment

African American multiple telephone contacts willingness to meet on own turf transportation/babysitting

Latinas personal contact in clinic home visits/engaging friends or family

WE Care Sample

267 women randomly assigned 117 Black women 16 White women 134 Latina women

Randomly assigned 88 Medications by nurse practitioner 90 CBT by psychologist 89 Referred to community mental health

Ethnic-Specific Treatment

African American women De-emphasize “treatment” De-emphasize professional role Emphasize group support Provide treatment within their structure Flexible

Ethnic-specific Treatment - Latinas

Emphasize importance of care to familyTherapists clear role – Dra.Structure of care clear Work to gain support of the familyTimes around work schedules

Attendance at Care

76% of those assigned to medications got guideline care for 9 weeks.

36% received at least 6 weeks of CBT

17% attended at least 1 session of community care

Outcomes of Care

Month 6 HAM less than 7

44.4% in medication arm

32.2% in psychotherapy arm

28.1% in community referral

Treatment works across groups

No ethnic differences were found in response to care.

Those with co-morbid PTSD responded to treatment equally to those without co-morbid PTSD.

Case example

EngagementReal life circumstancesDysfunctional thinkingAbility to garner important support as

treatment progressedOne year follow-up – maintained gains

What have we learned

Care for depression works in this highly stressed, disadvantaged population.

Care for depression works across cultural boundaries.

The nurse practitioner model is effective for providing care.

Identification in County facilities is not efficient.

Where do we go from here?

Community education is needed.Integrate mental health care within daily

routine – child pick up from day care, churches, schools, work settings, welfare.

Develop a stepped-care model, with continued monitoring and availability of care.