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