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 rate10% (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 l 40.8% of depressed get any care POOR YOUNG WOMEN l 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 §Many are uninsured. §Few use general medical care. §Obstetrics - be a difficult time to treat. §Population is seen in: l Title X county family planning clinics l Women Infant & Children food entitlements l 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: l 53% are never reached l 39% schedule but no show repeatedly l 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 l multiple telephone contacts l willingness to meet on own turf l transportation/babysitting §Latinas l personal contact in clinic l home visits/engaging friends or family

WE Care Sample §267 women randomly assigned l 117 Black women l 16 White women l 134 Latina women §Randomly assigned l 88 Medications by nurse practitioner l 90 CBT by psychologist l 89 Referred to community mental health

Ethnic-Specific Treatment §African American women l De-emphasize “treatment” l De-emphasize professional role l Emphasize group support l Provide treatment within their structure l Flexible

Ethnic-specific Treatment - Latinas §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 l 44.4% in medication arm l 32.2% in psychotherapy arm l 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 co- morbid PTSD.

Case example §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.