Enhancing Parenting for Depressed Caregivers Research Coordinator Brooke Rothman, MSSP October 20, 2011

Addressing Barriers to Mental Health Treatment Few depressed parents seek MH treatment (20-57%) Barriers to accessing mental health treatment Stigma associated with mental health agencies Denial of depression Lack of payment or insurance for services Need for childcare Lack of time or transportation Lack of social support Other issues perceived as priorities (e.g. housing issues, pregnancy, marital, etc.) Confusing to navigate options of treatment Personalized MH referrals needed to address barriers

Identification of Depressed Caregivers: Depression Screening in the Primary Care Setting Screening Tool: Patient Health Questionnaire-2 (PHQ-2) Caregivers screened at 1 and 2 year old well child visits at 7 participating primary care pediatric practices in Philadelphia Healthcare providers trained on screening procedure Language provided on how to address positive screens Mental health resource packet Lists emergency phone numbers, crisis centers, and community mental health centers in Philadelphia Explanation of study and consent for contact PHQ-2 – validated depression screening tool Addresses mood and anhedonia (lack of interest or pleasure in doing things) Uses a response scale of 0, 1, 2, 3 (none, some of the time, most of the time, all the time)

Study Design If caregiver (CG) interested/eligible, set up first study visit (3 total) Study visits conducted at home and in primary care center Both groups provided individualized enhanced mental health referrals for 6 to 7 months Role as an “Access Navigator” – facilitating mental health service utilization

Access Navigator: In-Person Contact Review of mental health resource list at study visits Highlight crisis centers and emergency numbers Indicate mental health centers near residency Identify agencies that are convenient for caregiver’s needs Assure follow-up with caregiver about outcome of referrals

Access Navigator: Problem-Solving To problem-solve, motivate to make appointments, and navigate the mental health system in Philadelphia Find caregiver the best place to seek treatment based on health insurance status, location, schedule, and situational needs Make appointment with caregiver through three-way calling or Make appointment for caregiver with appropriate information (Social Security number, type of health insurance, phone number, address, DOB) Partnership with Philadelphia’s Office of Mental Health- Community Behavioral Health Member Services Department to identify referrals Member Services Department is point of contact for people seeking assistance in overcoming addiction and/or mental health issues. Direct people to available behavioral health resources, emergency services and treatment programs. Toll-free line available 24 hours a day. Community Behavioral Health (CBH) is a not-for-profit 501c (3) corporation contracted by the City of Philadelphia to provide mental health and substance abuse services for Philadelphia County Medicaid recipients.

Follow-Up Phone Calls Questions asked: Stress status Acknowledge difficulty of seeking appointments as a busy parent Whether sought help for stress Social support Professional support Reiterate ability to assist CG If did seek help: Encourage to make appointment during phone call if interested Gather details (agency, frequency of appointments, satisfaction with services) If appointment made, reminder phone calls/text messages before appointment If did not seek help:

Access Navigator: Build Relationships Home visits and frequent phone calls gains trust and allows assistance to be more personalized for effective problem-solving Frequent contact by phone or text messaging to follow-up Call caregivers AT LEAST once per month Call an average 2-3 times per month Each phone call takes 5 – 30 min. Caregivers often difficult to reach (phone numbers changed frequently, phones out of service, voicemails not returned) To reestablish contact, send reminder postcards, do drive-bys to homes, text message “It’s okay that you call me so much, I’ve come to think of you as a friend.” – Caregiver over the phone

Accessing Services - 31 (53%) caregivers took action towards mental health treatment A majority of those who went to their appointments have continued to go regularly, while others only went to the intake appointment.

Implications Enhanced mental health referrals do not guarantee caregiver will utilize services, however, it may be the guidance and support needed to access services in the future. To effectively refer caregivers with depression, access navigators must cultivate relationships with the often fragmented mental health resources and services in the area to gather a comprehensive, customized, and centralized list of services available. Access navigators can feasibly assist caregivers with depression to access services, however it requires a lot of time and attention and relationship building with caregivers and mental health service providers.

Feedback “I couldn’t have done this without you. I’ve been trying to do this for so long, but I usually can’t focus and I needed someone like you to help me figure this out.” “I was skeptical at first, but now I like going each week. [My therapist] really makes me think.” – Study Participant – Study Participant “My visits [to the therapist] are lifesavers. She really understands what I’m going through. Ever since I started going, it feels less stressful to be with my [four] children. - Study Participant

Acknowledgements Principal Investigator: Jim Guevara, MD, MPH Study Team: Marsha Gerdes, PhD Russell Localio, JD, MA, MPH, MS, PhD Rhonda Boyd, PhD Susan Dougherty, PhD Denise Actie, MSW