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Description of MOMcare : Culturally Relevant Treatment Services for Perinatal Depression Nancy K. Grote, Ph.D. Research Associate Professor School of Social Work, University of Washington. Acknowledgement. NIMH R01 MH084897 Horizons Foundation, Seattle, WA

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Description of MOMcare:Culturally Relevant Treatment Services for Perinatal DepressionNancy K. Grote, Ph.D. Research Associate ProfessorSchool of Social Work, University of Washington

  • NIMH R01 MH084897
  • Horizons Foundation, Seattle, WA
  • Co-investigator (Wayne Katon, M.D.) and MOMCare team
  • Expectant moms in public health system of Seattle and King County, WA
  • MOMCare – What is it?
  • Depression during the perinatal period and underutilization of mental health services
  • Evidence on barriers to care and poverty, stress, and depression
  • Culturally relevant enhancements to Interpersonal Psychotherapy (IPT) -- e.g., case management
  • MOMCare design, outcomes, and sample description
momcare a 5 year randomized effectiveness trial
MOMCare: A 5-year Randomized Effectiveness Trial
  • 220 pregnant women on Medicaid
  • 3 depression care specialists (DCSs) cover 10 public health centers trained in engagement session, culturally relevant IPT-B, and pharmacotherapy (in collaboration with OB provider & team M.D.s)
  • MOMCare DCS screens for

inclusion criteria: > 18 years old; 12-32 weeks gestation; major depression or dysthymia; access to a phone; English speaking

exclusion criteria – schizophrenia, bipolar disorder, substance abuse/dependence during the past 3 months, acute suicidality, severe intimate partner violence

major or minor depression during pregnancy
Major or Minor Depression during Pregnancy
  • Prevalence rates:

1 out of 10 middle- or upper-income women (Gotlib et al., 1989)

1 out of 4-5 women living in poverty (Hobfall et al., 1995; Scholle et al., 2002)

  • Negatively affects development of fetus in utero(Field, 2000;Lundy et al., 1999)and may interfere with the attachment bond between mother and infant(Murray & Cooper, 1997)
  • Predicts postpartum depression(O’Hara & Swain, 1996) and subsequent maternal depression(Kumar & Robson, 1984)
underutilization of mental health services
Underutilization of Mental Health Services
  • National Comorbidity Survey Replication (Wang et al., 2005)

* nationally representative sample of 9282 adult respondents

* most people with depression and other mental illness

remain either untreated (60%) or poorly treated (66%)

* the unmet need for mental health services were highest for those with low incomes, racial/ethnic minorities, the elderly, and rural respondents

* minimally adequate treatment (APA guidelines):

8 sessions of psychotherapy (at least 30 minutes a session)

2 months of medication & at least 4 check-ups

practical barriers to care
Costs – 40% African Americans and 52% Hispanics lack health insurance in the US(US Census Bureau, 2003)


Inconvenient or inaccessible clinic locations

Limited clinic hours

Transportation problems

Competing Obligations

Child care and social network

Loss of pay for missing work

Time indealing with chronic stressors

Practical Barriers to Care
psychological barriers to care
Public Stigma and Internalized Stigma

Stigmatizing treatment settings

Previous negative experiences with treatment, including therapist characteristics

Childhood trauma (abuse and neglect)

Burden of depression

Psychological Barriers to Care
cultural barriers to care the culture of race
Cultural Barriers to Care: The Culture of Race
  • Clinicians may fail to appreciate the personal resources that minority women with low incomes have relied on to cope with stress.
  • Spirituality and religion are often important psychological coping mechanisms and sources of resilience in Latina and African American women.

(Mays, Caldwell, & Jackson, 1996; Miranda et al., 1996)

cultural barriers to care the culture of poverty
Cultural Barriers to Care: The Culture of Poverty
  • “No one can understand what my depression is like ‘til they have walked in my shoes and had no money.”
  • “My therapist seemed overwhelmed by all my practical problems, so how could she help me?”
  • “I don’t see how just talking about something can change it. How is me talking about losing my job going to get me another job?”

Self-Actualization Needs

The need to fulfill one’s unique potential

Esteem Needs: to achieve, be confident, gain approval and recognition

Psychological Needs

Belongingness and Love Needs: to affiliate with others; to be accepted and belong

Safety Needs: to feel secure, SAFE, and out of danger,


Basic Needs

Physiological Needs: to have enough FOOD, water,

and satisfy sex drives

Maslow’s Hierarchy of Needs, 1979

study of acute stress chronic stress and depressive symptoms grote bledsoe larkin brown 2007
Study of acute stress, chronic stress, and depressive symptoms (Grote, Bledsoe, Larkin, & Brown, 2007)
  • How can we better understand and engage in treatment women living in poverty who have multiple stressors, but few financial or social resources to deal with them?
    • Sample of 97 African American and 97 White Ob/Gyn patients with low incomes
  • Definition of acute stress -- a time-limited event requiring a certain degree of life change)
Chronic Stressors of Living in Poverty (many represent continuing demanding conditions that do not change)
  • trying to get landlord to make repairs
  • living in a neighborhood with high crime
  • living in a violent neighborhood
  • living in an excessively noisy neighborhood
  • trying to make ends meet/running out of money
  • unable to afford a car
  • being the only parent
  • being on welfare, being unemployed
  • being approached/spoken to disrespectfully by someone discriminating against you
Chronic Stress Amplifies the Effects of Acute Stress on Depressive Symptoms(Grote, Bledsoe, Larkin & Brown, 2007)

Depressive Symptoms

introduction what is interpersonal psychotherapy ipt
Introduction: What is Interpersonal Psychotherapy (IPT)?
  • Time-limited (12-16 weeks) individual psychotherapy for depression
  • Structured, manualized treatment that has been used in research protocols
  • Demonstrated efficacy in general and for antenatal depression (Grote et al., 2004; Spinelli, 1997) and postpartum depression (O’Hara et al., 2000)
  • Therapists and patients like it: “it makes sense”
introduction the bio psycho social formulation of depression
Introduction: The bio-psycho-social formulation of depression

Expansion of IPT focus on current interpersonal functioning to address the chronic stressors of living in or near poverty.

ipt cultural enhancements to promote treatment engagement and retention
IPT Cultural Enhancements to Promote Treatment Engagement and Retention
  • Engagement Session before rx to address barriers to care – practical, psychological, and cultural (manualized)
  • IPT-B -- Full course of IPT in 8 vs. 16 sessions (Swartz, Frank, & Shear, 2002) and maintenance IPT
  • Enhancement to IPT-B relevant to culture of poverty – personalized case management for chronic economic problems (i.e., FOOD, BED, housing, job training, baby supplies)
  • Enhancements to IPT-B relevant to culture of race/ethnicity (Bernal et al., 1995)
the pre treatment engagement session grote swartz zuckoff bledsoe et al 2007
The Pre-Treatment Engagement Session(Grote, Swartz, Zuckoff , Bledsoe et al., 2007)
  • First Part (45 minutes) -- We asked about:
    • HER STORY: her perception of her depression experience (stigma)

and the acute & chronic stressors of living in poverty linked with her depression

    • HER STRENGTHS and cultural coping mechanisms, e.g., spirituality, familialism
    • WHAT SHE DOES NOT WANT -- previous negative experiences with mental health care or social service agencies (self and sig. others)
    • WHAT SHE WANTS – from rx or a therapist – does race matter?
    • SUMMARY of practical, psychological, and cultural barriers – transportation, child care, scheduling, stigma, depression burden
  • Second Part (15 minutes) -- We provided:
    • Psychoeducation about depression and treatment options – inclusion

of a case management component to deal with chronic stressors

    • Problem-solving the barriers, affirmation of strengths, and hope
structure of brief ipt ipt b 8 vs 16 sessions
Structure of Brief IPT (IPT-B) (8 vs. 16 sessions)
  • Initial Phase (1-2 sessions)

IPT Inventory includes assessment of chronic stressors and relationships with social service agencies

Case formulation of the interpersonal problem ares most linked with the onset or exacerbation of the depression

  • Middle Phase (5 sessions)

Choose only one interpersonal problem area:

Role transition, role dispute, complicated grief

Choose a “manageable” problem in 8 sessions

Build on existing cultural strengths and ways of coping

Behavioral activation (explicit weekly homework) with an interpersonal and culturally relevant focus  assessing needed social services (e.g., housing, food banks, job training, free baby supplies)

  • Termination (1-2 sessions) -- Support self-efficacy

Swartz et al., 2004, Psychiatric Services

Grote et al., 2009, J of Contemporary Psychotherapy

cultural enhancements to ipt b grote et al 2009 psychiatric services 60 313 321
Cultural Enhancements to IPT-B(Grote et al., 2009, Psychiatric Services, 60, 313-321)
  • Enhancements regarding culture of poverty:
  • facilitation of access to social services; convenient

public health setting, phone therapy; reminder phone calls

  • Enhancements related to culture of race/ethnicity

(based on Bernal et al., 1995)

  • culturally sensitive, experienced clinicians
  • incorporating cultural resources and strengths
  • treatment setting served others from same racial/ethnic group
  • using stories from patient culture to support treatment goals
  • providing psychoeducation and treatment information

congruent with patient’s cultural preferences and values

e.g. therapy= a class; depression could be re-labeled “stress”

use of case management cm services grote et al 2009 psychiatric services 60 313 321
Use of Case Management (CM) Services(Grote et al., 2009, Psychiatric Services, 60, 313-321)
  • previous small RCT of IPT-B showed that 50% of pregnant women on low-incomes received case management services
  • on average, they received 2 referrals to social service


  • 66% of those who received referrals reported successfully following through
  • clinical observations:

1) focusing on CM took little time away from an IPT focus

2) including CM made IPT more meaningful and relevant to

the women

momcare design
MOMcare Design
  • Eligible public health clients consent to be randomized to:
  • MOMcare intervention(engagement PLUS choice of evidence-based brief IPT and/or anti-depressant medication plus case management)

8 sessions acute rx BEFORE BIRTH and monthly maintenance sessions to 1 year postpartum

  • Care Plus(the care they receive as a public health client – psychoeducation, treatment referral, and depression monitoring)
  • MOMCare DCS delivers the intervention in the public health center or by phone
momcare outcomes
MomCare Outcomes
  • Effectiveness outcomes for MOMcare relative to Care Plus:

1) Reduction in depression, improvement in social functioning

2) Better maternal role functioning, e.g. maternal sensitivity and responsivity to infant cues at 6 and 12 months postpartum

e.g. home observations of mother-infant interaction in collaboration with Center for Infant Mental Health at UW

3) Infant – higher rates of secure attachment and better mental

health outcomes at 12 months postpartum

  • Cost effectivenss outcomes – depression free days, more well-baby visits and higher rates of immunizations
effectiveness study
Effectiveness Study

Brief Initial Screening by DCS n=246

Eligible Pregnant Women (n=82)

Age > 18, MDD or Dysthymia

Enhanced Usual care in community (n=41)

Engage & IPT-B and/or anti-

depressant medication (n=41)

Diagnostic Screening – AFTER engagement

Usual care (n=42)IPT-B (n=42)

3-, 6-, 12- and 18-month follow-up assessments

conclusions about culturally relevant ipt b
Conclusions about Culturally Relevant IPT-B
  • Preliminary findings on clinician-rated PHQ-9 depression measure suggest that culturally relevant IPT-B may ameliorate antenatal depression in MOMCare participants (did not look at usual care yet)
  • Observations:
    • Most women needed and have accepted CM services – increasing evictions, homelessness, job loss, food insecurity
    • Excerpt