Depression treatment for impoverished mothers by point-of-care providers: A randomized controlled trial.

One in five women report clinically significant depressive symptoms, an estimate that is consistent among general community samples of women of childbearing age (Kessler, McGonagle, Swartz, Blazer, & Nelson, 1993) as well as specific samples of postpartum women (Gavin et al., 2005). Among impoverished women, depression is two to three times more prevalent in both community and postpartum convenience samples (Hobfoll, Ritter, Lavin, Hulsizer, & Cameron, 1995; Mayberry, Horowitz, & Declercq, 2007). An extensive body of research has documented that even in its milder forms, depression diminishes a woman’s capacity for sensitive parenting and places infants at risk for a broad range of developmental delays, e.g., behavioral problems and cognitive delays in the form of poor language and lower IQ (O'Hara & McCabe, 2013). Further, among impoverished women, depression is associated with loss of welfare support, household food insecurity, and less optimal child health (Casey et al., 2004). Over half of depressed adults never receive treatment of any sort (Kohn, Saxena, Levav, & Saraceno, 2004). Moreover, impoverished individuals, who are already at risk for depression, are actually the least likely to receive treatment; and for the few who do receive care, it is likely inadequate (Wang et al., 2005). Similarly, among perinatal women identified as depressed the percentage who access care is very low. Specifically in one study, only 13.8% of the 689 women identified with elevated depressive symptoms reported receiving some form of treatment (Marcus, Flynn, Blow, & Barry, 2003). Among perinatal women, there are numerous well- documented barriers to treatment (Dennis & Chung-Lee, 2006) that for impoverished women are compounded by additional obstacles (e.g., difficulties in finding a provider, transportation, and day care). Researchers in one treatment trial in an urban setting attempted to remedy logistical challenges of delivering Cognitive Behavioral Therapy (CBT) to depressed low-income ethnic minority women by providing services such as day care and transportation. Despite removing these perceived barriers to treatment, few women attended treatment sessions (Miranda et al., 2003). In that trial, the study psychologists typically made an average of ten phone calls before a woman would attend just one treatment session, a strategy unlikely to be adopted outside of the context of a funded trial. Even though the results of that trial supported the efficacy of CBT for impoverished women of childbearing age, the considerable difficulty of engaging these women suggests that this form of care will not be readily utilized. The study research team speculated that, to surmount engagement barriers, treatment should be provided by someone familiar to the women, thus leveraging an established trusted relationship (Miranda et al., 2003). Listening Visits (LV) provide depressed, postpartum women counseling by a trusted and familiar provider. A complete description of the core techniques of this two-part, non-directive counseling intervention is published (Segre, Stasik, O'Hara, & Arndt, 2010). Briefly, LV can be described as a reflective-listening exploration of a woman’s problems and, once genuine understanding is achieved, collaborative problem solving. In the United Kingdom (UK) where LV were developed, counseling is delivered by home-visiting nurses or health visitors (Holden, Sagovsky, & Cox, 1989) who have completed three years of university-level, generalist-nursing education and one year of specialist training. Because of the considerable evidence-base gathered in the UK and Sweden (Cooper, Murray, Wilson, & Romaniuk, 2003; Holden et al., 1989; Morrell et al., 2009; Wickberg & Hwang, 1996), LV are now recommended by Britain’s National Institute for Clinical Excellence as an evidence-based treatment for mild to moderate postnatal depression (National Collaborating Center for Mental Health, 2007). Borrowing from the medical point-of-care testing model, in which laboratory testing is performed at the patient’s bedside to expedite diagnosis, speed treatment, and lower expenses (Price, 2001), LV could leverage both the accessibility and trust of US home visitors and clinic nurses to provide depression treatment to an otherwise difficult-to-reach-and-engage, at-risk group. In the UK, implementing this approach is more straightforward because LV are embedded in a healthcare system that provides universal surveillance to all postpartum women in the form of a postpartum home visit within 10 days of an infant’s birth. In contrast, universal surveillance of postpartum women is not the US norm; however, numerous home-visiting programs serve families with young children, particularly economically disadvantaged families, with small to moderate effects on a broad range of child and maternal outcomes (Olds et al., 2004; Sweet & Applebaum, 2004). Home-visiting programs have considerable potential to reach vulnerable mothers because they typically serve at-risk, low-income pregnant and postpartum women (Leis, Mendelson, Tandon, & Perry, 2009). Moreover, two recent US-based randomized controlled clinical trials support the efficacy of maternal depression treatment delivered in the home by licensed mental health specialists, such as psychiatric nurses (Beeber, Holditch-Davis, Belyea, Funk, & Canuso, 2004) or licensed, masters-prepared social workers (Ammerman et al., 2013). Incorporating the provision of mental health services into the repertoire of US home visitors—similar to the model of care in the UK—has significant potential to address the gap in provision of mental health services to high risk population of women who otherwise will not receive treatment. In 2002, low-income and ethnic-minority women living in areas with high infant mortality rates were targeted by the Health Resources and Services Administration to receive standardized depression screening by the home-visiting program Healthy Start (Segre, O'Hara, & Fisher, 2012). Nevertheless, this directive did not produce the full intended benefit because over half of the women who screened positively for depression did not receive treatment. To address this problem, a subsequent open trial evaluated the efficacy of LV in the Des Moines Healthy Start program. Here, Healthy Start home visitors were trained to provide, when necessary, integrated depression treatment in the form of LV. This approach took advantage of the relationship between Healthy Start home visitors and their at-risk clients. Moreover, treatment demonstrated significant pre- to post-LV decreases in depression symptoms scores (Segre et al., 2010). Despite this early success, definitive conclusions regarding the effectiveness of LV in the US are limited by the open trial design, the small number of participants, and the limitation of the evaluation to a single site. To address the methodological limitations of the open trial, we conducted a multisite, randomized controlled trial to assess the effectiveness of LV for impoverished mothers. In addition, we recognized that in the US not all women who fit the target demographic profile have home-visiting services but may instead be seen in OB offices, so this alternative setting was also included as a venue for conveniently accessed care. The primary aim of this study was to assess the effectiveness of LV delivered at a woman’s usual point-of-care, either in a home-visiting program or in an OB clinic, by home visitors or an OB clinical staff member. LV were offered to economically disadvantaged women of childbearing age, most of whom were also ethnic minorities. We hypothesized that compared to a wait-list control group (WLC), those who received LV would show a significant reduction in severity of depressive symptoms and a significant improvement in psychosocial adjustment at the 8-week assessment point. Finally, we also assessed women’s satisfaction with this intervention.