Session # I5
October _29_, 2011
1:30 PM
Bobbie Posmontier PI, PhD, CNM, PMHNP-BC
Assistant Professor Drexel University
Richard Neugebauer, PhD, Columbia University, Co-I
Scott Stuart, MD, University of Iowa, Co-I
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Faculty Disclosure
 We have not had any relevant financial relationships
during the past 12 months.
 Acknowledgement: Funding though the National Institute
of Mental Health 5R21MH86610-2
Need/Practice Gap & Supporting Resources
 Only 20-25% of childbearing women receive care for
postpartum depression due to barriers such as insurance
coverage, financial barriers, transportation, stigma, fears of
entering the mental health system, lack of qualified mental
health professionals, and competing childcare demands.
Holopainen (2002); Whitton, et al (1996); Huang, et al 2007; Dennis & ChungLee (2006); Anderson, et al (2006); Boyd et al (2006); Beck (2002)
Objectives
1.
Describe the current barriers to postpartum depression
treatment
2. Describe a novel interdisciplinary approach to decreasing
the access gap for postpartum depression treatment
3. Describe the current challenges experienced and progress
to date
Problem
 PPD affects 6.5% to 30% of all childbearing women
 Only 20% to 25 % receive treatment.
 Major barriers
 Stigma
 Retelling story to unknown provider
 Competing childcare responsibilities
 Financial/insurance
 Transportation
 Fragmentation services
 Most studies focus on treatment by mental health
professionals
Specific Aims
 Evaluate among women with PPD recruited
between 6 and 24 weeks postpartum:
 Feasibility, acceptability, and safety telephone IPT
provided by nurse midwives in collaboration with a
mental health team
 Efficacy of IPT administered by nurse midwives in
 Improving the general level of maternal functioning
 Specific improvement in marital adjustment
 Increase in maternal infant bonding
Innovation
 Using Nurse Midwives (NMC) in Primary
Care to fill treatment gap
 Multidisciplinary/Collaborative
 Connection with mental health system
 Build on established relationships to
improve engagement/retention
Innovation
 Utilize telephone to address maternal time
and childcare constraints.
 Reduce costs
 Manualize intervention for other advanced
practice nurses for full-scale RCT
Methods
 RCT – pilot study
 Experimental group receives NMC IPT intervention
 Control group receives treatment as usual (TAU) or wait list
 NMC recruits women with depressive symptoms at their
six-week postpartum check-ups at nine national sites in US
 Screen
 EPDS ≥ 10
 Sociodemographic, health history
 Structured interview for depression
 Assessments/Diagnosis- baseline, 4 weeks, 8 weeks, 12
weeks by PMHNP
Treatment:
Interpersonal Psychotherapy
 Brief
 Evidence based – 30 years experience with PPD
 Effective
 Can be taught to lay people
 Helps to improve depression related to
 Role
 Interpersonal disputes
 Interpersonal Deficits
 Grief
Current Recruitment Population
 OB practices from AZ, DC, MA, NJ, PA, TX,
 ~9922 women
 AZ-240 diverse low income 50% PPD
 DC –2400 diverse low income 30% PPD
 MA – 2400 middle income 12-18%PPD
 NJ- 742 low income 8% PPD
 PA - 1200 middle income 15% PPD
 PA – 1440 middle income women 15% PPD
 PA - 720 –diverse low income 40% PPD
 TX -780 diverse low income 6% PPD
 Power analysis – 130 women with 65 randomized to each
group
Estimated Flow
Screening at 6 weeks postpartum (n = 9,922)
EPDS ≥ 10 (n =644)
Decline Assess (n = 399)
Training subjects (n = 24)
Assess for Eligibility (n =221)
Excluded (refused) (n = 79)
Randomization of enrolled participants (n = 130)
IPT Intervention (n = 65)
Treatment as Allocated (n = 65)
4-week post-randomization (n = 59)
8-week post-randomization end IPT (n = 56)
12-week post-randomization (n = 55)
Treatment as Usual (n = 65)
Treatment as Allocated (n =65)
4-week post-randomization (n =61)
8-week post-randomization (n = 59)
12-week post-randomization (n = 52)
Instruments
 MINI International Neuropsychiatric Interview
 Hamilton Rating Scale for Depression (HRSD)
 Dyadic Adjustment Scale (DAS)
 Mother-to-Infant Bonding Scale (MIBS)
 Social Support Questionnaire (SSQ)
 Global Assessment of Functioning (GAF)
 Client Satisfaction Questionnaire (CSQ)
 Question on acceptability (patients, NMC)
 Dropout Survey
Inclusion
 6 to 24 weeks postpartum
 18 years and older
 English-speaking
 Access to a telephone
 Consents to enter the trial
 Diagnosis of Major Depression with the MINI
Neuropsychiatric Interview (MINI)
 Score of ≥ 10 on the Edinburgh Postnatal Depression Scale
 Current use of antidepressant medication is allowed
Exclusion
 Infant complications requiring medical care beyond 6







weeks postpartum
Infant birth defects
Infant being placed for adoption by 6 weeks
postpartum
Maternal mental retardation
Active substance or alcohol abuse or dependence
Active suicidality, homicidality, or current psychosis
Disabling pain that interferes with ADLs
Concurrent serious medical co-morbidities
Procedure
 NMC training
 Two day IPT workshop
 Human subjects
 Recording software
 DropBox
 Administration EPDS
 IPT certification
 RA training
 Instruments
 Blinded
Procedure
 Recruitment over 18 months
 NMC screens all pts with EPDS at 6 week checkup
 NMC refers interested patients with EPDS ≥ 10
 Time commitment NMCs 2 hours per week (one hour
therapy, one hour supervision), plus 30 minute
monthly team meetings
 PI calls patients, explains study, consents
 RA screen and diagnose PPD
 Referral suicidal, homicidal, beyond scope NMC
Procedure
 Randomize to treatment vs. TAU(treatment as usual)
or wait list
 Eight weekly 50 minute telephone sessions over 12 weeks
 TAU referral to MH provider of NMC choice
 Treatment- NMC sets up telephone appointments
 Three training patients, 7-8 post-training patients
 NMC weekly telephone supervision with IPT
supervisor
 $25 gift card for all patients
Progress
 Study began June 2010
 Original five NJ sites
 Problems
 One CNM left her position
 One CNM did not seek permission from medical
director
 Three CNMs trained August 2010 including PI
 PI delivered intervention but disallowed by NIMH
 One NMC dropped out due to personal problems
 One NMC major practice change but still in study
Progress
 24 women expressed interest
 Refusals
 Confidentiality
 Did not want to be in control group
 Collected complete data on two women in the treatment group and one
woman in the control group.
 Another woman in treatment group did not complete treatment.
 Two in progress
 Premature to draw any conclusions with few subjects
Just a peek ….
Subj
T EPDS
vs. 0-30
C
Ham-D GAF
0-50
0-100
DAS
0-150
1
T
99 to 99
2
C
3
T
18 to
14
30 to
16
18 to 3
18 to
10.5
24 to
20
15 to 3
78 to
80
67 to
77
72 to
83
SS
27-162
MIBS
0-24
CSQ
8-32
100 to
125
116 to 104 116 to
140
87 to 89
162 to
162
23 to
19
22 to
20
24 to
24
32
18
32
Progress
 Needed to address provider problem
 Sent mass email
 4,415 CNMs through ACNM
 31,897 WHNP through AANP
 555 positive responses
 460 midwives
 95 NPs



Women’s health
Psychiatric
Family
Locations of Respondents
 Represented 45 states Washington DC, Japan
 AK, AL, AZ, CA, CO, CT, DE, DC, FL, GA, HI, IA, ID, IL,
IN, KY, KS, LA, MA, ME, MD, MI, MO, MN, MT, NC,
NE, NH, NM, NY, NV, NJ, OH, OK, OR, PA, RI, SC, SD,
TN, TX, UT, VA, WA, WI, WV, Japan
Qualitative Responses
 319 commented
 This is a particular area of interest of mine. We
provided a 2 week post partum visit in attempt to
capture woman at risk, until billing was a problem , Yet
this visit was usually the most important of the entire
pregnancy. Problem was also no referral available for
people in need .
Qualitative Responses
 I am curious if I am doing everything possible to help
my patients.
 This is outstanding. New moms with PPD have very
limited resources. In my 10 year practice as a midwife, I
have called one patient every three hours every day /
day and night for 5 days until I could get a psychologist
to see her.
 These nurse midwives would serve their patients
better by encouraging them to seek a fully-trained
mental health professional.
Qualitative Responses
 After participation in the study, will the APN have
sufficient skills to continue to provide postpartum
depression counseling within their own practice
setting?
 I know this is primarily aimed toward nurse midwifes
but I would love to participate if able.
 Military who has almost double the rates of the civilian
population. I am starting my own practice because of
the lack of response of the military to women's
[mental] health care needs.
Qualitative Responses
 Does the psychotherapy training involve travel? What
kind of time commitment does the training involve?
Sounds like a wonderful study!
 Have been very interested in PPD for years - would
love to participate. Live and work in rural area (for a
health center) where transportation and availability of
mental health providers are very real barriers for my
patients.
Qualitative Responses
 I am a new CNM and military wife living overseas in
Okinawa, Japan. I am currently in the process of
obtaining a job or volunteering with the Red Cross in
order to provide patient care. I believe military families
endure unique circumstances i which I have great
empathy for. I hope to be able to serve these women in
the near future, and welcome the opportunity to
participate in your study if you desire.
Qualitative Responses
 I am a CNS, certified by ANNC for the practice of adult
psychiatric and mental health services. I have
licensure to practice independent psychotherapy and
collaborative-agreement prescribing in the state of
Minnesota. I am writing with concern about midwives
being "trained" for licensure in interpersonal
psychotherapy. (Would you be concerned if I could
get a "licensure" to deliever babies)?
Qualitative Responses
 I have no official training in counseling and would like
to extend my help beyond supportive listening. So,
this training opportunity would be beneficial to both
myself and my clients and their families.
 I AM so EXCITED that you are creating such a
dynamic program. I happen to be a mother of four
children who experienced PPD; I know first hand how
PPD robs a family of their dreams.
Qualitative Responses
 We recognize that a CNM/PMHNP dual certified
provider would be immensely helpful but that is a
strategic goal not to be realized in our short term
planning for this coming year due to budget and other
pressing issues.
 I am very interested in this project both as a clinician
and as a future researcher.
 I have felt inadequate in helping my pts with PP
depression.
Qualitative Responses
 I work mainly with Spanish speaking patients via
interpreters and do not know if this setting is conducive to
your study.
 This is something that is tremendously needed in our
profession.
 Native Alaska women are not often outspoken, rather they
are shy. We realize it takes awhile to build trust. Many
providers come and go in Native healthcare, so when they
connect, that person has deep meaning to the patient. We
have no good program to handle postpartum depression,
we are down now to one psychiatrist for 13,000 people.
Progress
 10 CNMs chosen from national sites 7 still in study
 One IRB not approved
 One potential NMC became ill at training
 One developed personal problem
 Second training August 2011
 One NJ site still recruiting
 Total 8 NMCs recruiting
 Recruitment for new NMCs started September 1, 2011
 Spoke to program officer at NIMH about ITT group
Questions?
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