MDD in Women
Treatment of Depression in
Disadvantaged, Young Women
Jeanne Miranda, Bonnie Green,
Janice Krupnick, Dennis Revicki, and
Joyce Chung
Focus on Young Women
vMost first episodes before 30
vDepression is associated with poor
parenting
vLifetime rate 17% (NCS)
v12-month rate 10% (NCS)
v2:1 female-male ratio
Depression, Poverty and Minority
women
vDepression rates higher among those who
are poor than among others.
vNearly half of all African American and
Latinas live at or near the poverty level
vPoor child outcomes in offspring of
depressed mothers
Rates of Mental Health Care
Need address:
GENERAL POPULATION
vTreatment of depression in poor, young
women, most of whom are single mothers.
vTreatment of depression in ethnic
minorities.
vImpact of treatment of depression among
women with comorbid PTSD.
O
40.8% of depressed get any care
POOR YOUNG WOMEN
O
10% of depressed get any care
1
Context for treating poor young
women
Screening of Low-income
Women not Seeking Care
vMany are uninsured.
vFew use general medical care.
vObstetrics - be a difficult time to treat.
vPopulation is seen in:
v10% screen positive
O
O
O
v6.1% screen eligible
Title X county family planning clinics
Women Infant & Children food entitlements
Pediatrics
Recruiting low-income women
Diagnostic Completers
vContacted 4.1 times on average prior to
diagnostic interview.
v68% of those who screen positive complete
diagnostic interview
vOf the 35% who do not:
v63% of those who complete diagnostic
interview are eligible (27% no MDD,
6% SA, 4% psychotic)
O
O
O
53% are never reached
39% schedule but no show repeatedly
8% refuse
Contacts for recruitment
v72% of those eligible get treatment
Ethnic-specific recruitment
vAfrican American
vClinicians contacted women an average of
7.8 times to encourage attendance at initial
clinical session.
O
O
O
multiple telephone contacts
willingness to meet on own turf
transportation/babysitting
vLatinas
vWomen attended an average of 2
educational sessions before entering care.
O
O
personal contact in clinic
home visits/engaging friends or family
2
WE Care Sample
Ethnic-Specific Treatment
v267 women randomly assigned
vAfrican American women
O
O
O
117 Black women
16 White women
134 Latina women
vRandomly assigned
O
O
O
88 Medications by nurse practitioner
90 CBT by psychologist
89 Referred to community mental health
Ethnic-specific Treatment Latinas
vEmphasize importance of care to family
vTherapists clear role – Dra.
vStructure of care clear
vWork to gain support of the family
vTimes around work schedules
O
O
O
O
O
De-emphasize “treatment”
De-emphasize professional role
Emphasize group support
Provide treatment within their structure
Flexible
Attendance at Care
v76% of those assigned to medications got
guideline care for 9 weeks.
v36% received at least 6 weeks of CBT
v17% attended at least 1 session of
community care
Outcomes of Care
vMonth 6 HAM less than 7
O
44.4% in medication arm
O
32.2% in psychotherapy arm
O
28.1% in community referral
3
Treatment works across groups
Case example
vNo ethnic differences were found in
response to care.
vThose with co-morbid PTSD responded to
treatment equally to those without comorbid PTSD.
vEngagement
vReal life circumstances
vDysfunctional thinking
vAbility to garner important support as
treatment progressed
vOne year follow-up – maintained gains
What have we learned
Where do we go from here?
vCare for depression works in this highly
stressed, disadvantaged population.
vCare for depression works across cultural
boundaries.
vThe nurse practitioner model is effective for
providing care.
vIdentification in County facilities is not
efficient.
vCommunity education is needed.
vIntegrate mental health care within daily
routine – child pick up from day care,
churches, schools, work settings, welfare.
vDevelop a stepped-care model, with
continued monitoring and availability of
care.
4