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
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Many are uninsured.
Few use general medical care.
Obstetrics - be a difficult time to treat.
Population is seen in:
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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:
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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
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multiple telephone contacts
willingness to meet on own turf
transportation/babysitting
 Latinas
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personal contact in clinic
home visits/engaging friends or family
WE Care Sample
 267 women randomly assigned
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117 Black women
16 White women
134 Latina women
 Randomly assigned
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88 Medications by nurse practitioner
90 CBT by psychologist
89 Referred to community mental health
Ethnic-Specific Treatment
 African American women
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De-emphasize “treatment”
De-emphasize professional role
Emphasize group support
Provide treatment within their structure
Flexible
Ethnic-specific Treatment Latinas
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Emphasize importance of care to family
Therapists clear role – Dra.
Structure of care clear
Work to gain support of the family
Times 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 comorbid PTSD.
Case example
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Engagement
Real life circumstances
Dysfunctional thinking
Ability to garner important support as
treatment progressed
 One 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.