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6 Treatment of Depression in Parents SUMMARY Treatment Rates â¢ Studies of community samples indicate that approximately 30 per- cent of depressed adults receive any treatment for their illness. Al- though limited, evidence suggests that treatment rates for mothers may be even lower than the general population. Treatment Tools â¢ Evidence shows that a variety of safe and effective tools exist for treating adults with depression, including pharmacotherapies, psy- chotherapies, behavioral therapies, and alternative medicines. â¢ Studies of depression treatment tools in adults rarely measure out- comes that specifically affect parents, including parenting quality and impact of therapeutic treatments on children. Quality studies documenting the safety and efficacy of therapeutic treatments for perinatal depression are limited as well, although preliminary evi- dence and observational data are generally favorable. Treatment Delivery Approaches â¢ A variety of approaches exist to deliver depression treatment in multiple settings, including primary and specialty care, web- and 205
206 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN community-based. Evidence from primary care settings suggests that models of care that integrate multiple interventions (e.g., edu- cation, care management, frequent telephone follow-up) are clini- cally effective in reducing depressive symptoms in adults. Existing studies are relatively short term, however, and the cost-effectiveness and exportability of these models are not usually considered. â¢ Studies of approaches to effectively deliver treatment and to pre- vent relapse in adults with depression rarely target parents, espe- cially in settings in which traditionally underserved populations of parents or their children are seen. â¢ Treatments that address individual patient preferences, concurrent conditions (such as medical comorbidities and substance abuse), overcoming depression-related stigma and mistrust, and health disparities tend to be better received and more effective than ap- proaches that rely on health provider experience alone. ____________________ Depression is a common and recurrent disorder that can have pro- found effects on medical, social, and financial well-being, and a large body of literature documents safe and effective therapeutic strategies. In this chapter, we have divided these strategies into treatments (i.e., tools) and interventions (i.e., approaches). Standard treatments for depression include pharmacotherapy, psychotherapy and alternative remedies. Successful in- terventions have generally been more structured and comprehensive, often featuring multidisciplinary approaches that emphasize several treatment modalities (e.g., collaborative care). Although the evidence base is rich for depression treatments and inter- ventions in the general adult population, far fewer studies have analyzed outcomes in parents or families. For this reason, we have chosen to pro- ceed in this chapter with a brief summary of treatment rates, therapeutic options, and interventions in the general adult population before focusing more intently on the body of literature specific to parents. Chapter 7 ad- dresses the approaches to prevent adverse outcomes in depressed parents and the children of depressed parents, including the impact of treatment on families. The committee reviewed the relevant literature in order to identify depression treatment rates, therapeutic options that are available to treat depression, and options for the delivery of depression treatment in the gen- eral adult population that address outcomes for depressed adults and then specifically in parents, as well as to identify areas in which relatively little research has been conducted. The committee did not seek to systematically
TREATMENT OF DEPRESSION IN PARENTS 207 identify every study on the evaluation of existing therapeutic tools or de- livery interventions for treating depression in adults (and parents); instead, whenever possible, the committee drew on existing meta-analyses and systematic reviews. Whenever possible, the committee limited its review to interventions that have been evaluated in at least one randomized trial and presents a summary of the methodological details, study population demo- graphics, and outcome measures (i.e., depressive symptoms or depression diagnosis) that were used for studies of treatment delivery interventions in a table that is described in the second part of this chapter. TREATMENT RATES General Population More recent nationally representative work has illustrated that those in racial or ethnic minority populations with past-year depressive order are significantly more likely to go without mental health treatment than non-Hispanic whites (64 percent Hispanics, 69 percent Asians, 60 percent of African Americans, compared to 40 percent of non-Hispanic whites) AlegrÃa et al., 2008). Disparities in the likelihood of both having access to and receiving adequate care for depression were significantly different for Asians and African Americans in contrast to non-Hispanic whites. Simply relying on present health care systems without consideration of the unique barriers to quality care that ethnic and racial minority populations face is unlikely to affect the pattern of disparities observed. Populations reluctant to visit a clinic for depression care may have correctly anticipated the lim- ited quality of usual care. The close association of depression with certain medical conditions (e.g., neurological, cardiovascular, and endocrine disorders) has inspired researchers to explore the feasibility of addressing this mental illness in spe- cialty medical clinics. For example, recent investigations document higher treatment rates and superior outcomes among depressed patients identified at diabetes clinics (Simon et al., 2007). Mothers with Depression At the present time, there are no epidemiological data documenting treatment rates among depressed parents, although indirect evidence sug- gests that these figures are even lower than in the general population. In the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial (a large national trial designed to identify depression treatment strategies), for example, only 22 percent of women seeking treatment had children living
208 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN with them, implying that depressed mothers were underrepresented in this sample, perhaps owing to the perception of stigma or domestic responsibili- ties discouraging travel (Pilowsky et al., 2006). It is also documented that depressed people in the general population are at higher risk of having com- plex comorbid illnesses, including substance abuse and domestic violence (Regier et al., 1990). Exposure to interpersonal violence, for example, has been associated with poorer outcomes in mothers with substance use and mental health disorders (Amaro et al., 2005). Mothers with Antepartum Depression Treatment rates for pregnant women are believed to be considerably lower than the rest of the adult population, despite the fact that the risks of untreated antepartum depression usually outweigh any risks posed by psychotherapy or commonly prescribed antidepressants (see the discussion of the safety and efficacy of pharmacotherapy below). For example, Marcus et al. conducted a prospective study examining the incidence of antepar- tum depression in obstetric settings (Marcus et al., 2003). They reported that 20 percent of the women met a conventional threshold for significant depressive illness (they scored higher than 16 on the Center for Epidemio- logic Studies Depression Scale, CESD), yet only 14 percent of these women ultimately received any treatment. Another study screened pregnant women and proceeded to conduct structured interviews to confirm the diagnosis and severity (Flynn, Blow, and Marcus, 2006). Among the pregnant women with a confirmed diagnosis of acute major depression, only 33 percent received any treatment. Another investigation was conducted using a large patient database in Canada (119,547 mothers; Oberlander et al., 2006). Approximately 15 percent of the population received a diagnostic code for depression within 4 months of delivery, yet less than 10 percent of this subset received a prescription for an antidepressant. Mothers with Postpartum Depression Data for the frequency of depression treatment during the postpartum period are scarce. One of the few investigations examined a secondary analysis of a mother-infant study that followed 117 mothers who were identified as depressed between 2 and 4 weeks postpartum. Three months after screening, only 14 women (12 percent) had received psychotherapy, and only 4 (3.4 percent) had received pharmacotherapy (Horowitz and Cousins, 2006). Even when depression is addressed, the initiation of medication or counseling does not guarantee success. Insurance data claims and health maintenance organization (HMO) refill records suggest that approximately
TREATMENT OF DEPRESSION IN PARENTS 209 half of patients will stop their antidepressants during the first 3 months, and a vast majority do not complete the minimum recommended duration of 6 months. These figures are slightly higher among privately insured ben- eficiaries and somewhat lower in the public sector (National Committee on Quality Assurance, 2005). Data describing the percentage of parents who receive adequate treatment are not currently available. There is a growing awareness of the undertreatment of depression, including govern- ment efforts to improve medication adherence and treatment follow-up through such measures as Healthcare Effectiveness Data and Information Set (HEDIS), a tool created by the National Committee for Quality Assur- ance, to collect data about the quality of care, including depression care, provided by health plans. However, data from health care organizations do not indicate that significant improvement has transpired during the past decade (National Committee on Quality Assurance, 2008). Although depression treatment rates are low, there remains available a variety of safe and effective therapeutic interventions. PHARMACOTHERAPY General Population Antidepressants are among the most commonly prescribed medica- tions in health care today. Much of this popularity can be traced to the development of newer medications such as selective serotonin reuptake inhibitors (SSRI: fluoxetine, sertraline, paroxetine, citalopram), serotonin norepinephrine reuptake inhibitors (SNRI: venlafaxine, duloxetine), and norepinephrine reuptake inhibitors (NRI: bupropion), which are perceived to be safer than older antidepressants (Barbui et al., 2007). The enhanced utility of newer antidepressants may also add to their popularity as sero- tonergic agents (SSRI and SNRI) as they have proven to be very effective for anxiety disorders. For the treatment of major depression, it is widely believed that roughly two-thirds of patients will respond to the first antidepressant that is initi- ated (Fava and Davidson, 1996). Data to support these response rates, however, have been gathered historically from randomized controlled trials conducted by pharmaceutical companies to demonstrate drug efficacy for regulatory bodies. Depressed subjects enrolled in such trials were usually young men with minimal medical and psychiatric comorbidity and do not necessarily represent the demographic characteristics of depressed parents. In the STAR*D trial, which attempted to examine antidepressant effects in a real-world setting, fewer than half of the subjects exhibited a clinical response after a full therapeutic trial of an SSRI (Trivedi et al., 2006). Another notable development in research and clinical antidepressant
210 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN trials has been a change in what is considered the ideal therapeutic endpoint. While a therapeutic response was the historic goalâdefined as a greater than 50 percent decline on a given depression severity scaleâexperts have realized that patients who satisfied this criterion often had significant re- sidual symptoms and fairly high relapse rates. Remission is now regarded as the desired therapeutic endpoint. In practical terms, remission is achieved when virtually all depressive symptoms are absent. Operationally, remis- sion is usually defined as a depression severity score below an established threshold (e.g., a score of less than 7 on the Hamilton Depression Rating Scale). From recent research trials, the remission rates for antidepressants range from 30 to 40 percent (Thase, Entsuah, and Rudolph, 2001). Higher remission rates may be achieved through the addition of other antidepres- sant medications (i.e., augmentation) or concurrent psychotherapy (Keller et al., 2000). Mothers with Antepartum Depression The safety and efficacy of antidepressants during the antepartum period are a major concern from maternal, scientific, and health policy perspec- tives. Mothers, fathers, and health care providers must weigh the substan- tial risks of untreated antepartum depression against the potential risks of antidepressant exposure. When faced with this dilemma, many women have historically discontinued medications as soon as their pregnancy was con- firmed, although a naturalistic investigation recently reported that women who stopped their antidepressants during the first trimester were much more likely to relapse before delivery than those who continued (68 versus 26 percent) (Cohen et al., 2006). And over half of these relapses actually occurred during the first trimester. Prospective randomized studies of medications are rarely conducted on pregnant women in part because of ethical concerns. As a result, we have only retrospective or naturalistic data to consider when evaluating the efficacy and safety of antidepressants in the antepartum period. Since the effectiveness of antidepressants can be accurately assessed only through blinded, controlled trials, the literature summarizing the efficacy of antide- pressants during pregnancy is nonexistent. The relative safety, however, can be inferred from a body of evidence that has grown remarkably in recent years. As the SSRIs are currently the most popular class of antidepressants, most of the recent investigations have examined their relative safety. For the most part, it appears that SSRIs do not carry a significant risk for ma- jor congenital malformations. The only potential exception can be found in data suggesting that paroxetine may be associated with cardiovascular defects. A recent analysis of the Swedish Medical Birth Registry confirmed
TREATMENT OF DEPRESSION IN PARENTS 211 previous reports of this risk, citing an odds ratio of 1.81 (95 percent con- fidence interval, CI = 0.96â3.09) for ventricular and atrial defects (Kallen and Olausson, 2007). This finding was based on 13 cases among 959 ex- posures. A subsequent analysis of data pertaining to over 3,000 exposures was performed by the Motherisk Program in Canada, which found that paroxetine was associated with a decreased risk of malformations (0.7 per- cent versus an established population risk of 1.0 percent) (Einarson et al., 2008). On the basis of previous reports, however, the U.S. Food and Drug Administration (FDA) chose to demote paroxetine to Category D status in pregnancy, discouraging its use unless absolutely necessary. Other adverse outcomes associated with SSRI in pregnancy are worth considering, including persistent pulmonary hypertension, preterm labor, and neonatal adaptation syndrome. Persistent pulmonary hypertension (PPHN) is a relatively rare complication occurring shortly after deliv- ery that has been associated with a 20 percent mortality rate (Hageman, Adams, and Gardner, 1984). Results of a case-control study identified 14 cases of SSRI-induced PPHN in the case group (n = 377) and 6 cases of PPHN among controls (n = 836) (Chambers et al., 2006). The risk appeared to be highest with exposure after 20 weeks gestation. While the SSRIs were associated with a sixfold increase in the relative risk of this serious phenom- enon, it should also be remembered that the absolute risk remains quite low (6â12 cases per 1,000 exposures) and is probably not as serious as the risks posed by untreated depression on the mother and the infant alike. Several studies have noted that SSRIs are associated with a decrease in gestational age, birth weight, or both. Although depression itself has been associated with these two effects, comparisons between SSRIs and other antidepressants and between SSRIs and matched controls appear to confirm these findings. For example, Suri et al. followed the outcomes of three dif- ferent cohorts (antidepressants, depressed without antidepressants, nonde- pressed controls; n = 90) and reported significant differences in gestational age (38.5, 39.4, and 39.7 weeks, respectively), rates of preterm birth (14, 0, and 5 percent, respectively) and special care nursery admissions (21, 9, and 0 percent, respectively) (Suri et al., 2007). Results of this investigation were confirmed in the large retrospective study by Oberlander cited above. In comparison to depressed mothers not receiving pharmacotherapy, moth- ers who were prescribed SSRIs were much more likely to give birth before 37 weeks gestation (6 percent versus 9 percent; 95 percent CI = â0.009 to â0.04), and their infants were more likely to suffer respiratory distress â For detailed description of U.S. Food and Drug Administration risk categories for drug use in pregnancy, see http://www.fda.gov/fdac/features/2001/301_preg.html#categories. Categories depend on the type of studies available and the risk of fetal abnormalities and include: A, B, C, D, and X.
212 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN (8 percent versus 14 percent; 95 percent CI = 0.042â0.079). These signifi- cant differences were upheld after propensity score matching as well. Neonatal adaptation syndrome is a constellation of symptoms that have been attributed to third-trimester exposure of the fetus to concurrent SSRI or SNRI use. Symptoms include high-pitched crying, decreased ap- petite, tremor, hypertonicity, and respiratory distress. A prospective study used a scale created by Finnegan (1990) to measure these symptoms and concluded that the SSRIs were much more likely to be associated with this syndrome (Levinson-Castiel et al., 2006). In general, the symptoms peaked by day 2 after delivery and had remitted by the end of day 4. As neonatal adaptation syndrome has been implicated in a potential increase in the risk of admissions, some experts have recommended tapering mothers off anti- depressants prior to delivery (U.S. Food and Drug Administration, 2004). This practice is somewhat controversial; however, opponents have pointed out that drug discontinuation would itself be associated with an increased risk for withdrawal symptoms in the mother, as well as an increased risk of relapse during the immediate postpartum period. Adverse effects of SSRI antidepressants are a major concern in the par- ent and should be factored into the decision-making process as well. For instance, SSRIs have been associated with a 30â50 percent incidence of sexual dysfunction, which can impart considerable strain on a relationship regardless of the parentâs reproductive status. Nausea is also common with SSRIs, which may diminish the motherâs appetite, and sleep disturbances are frequently reported as well. Data documenting the safety of other antidepressants in pregnancy is relatively limited. Bupropion was once considered the safest of the avail- able antidepressants in pregnancy, but the FDA recently demoted it from Category B to Category C. This was based on a review of reproduction studies in rabbits, which found a slight increase in fetal malformations and skeletal variations with relatively low-dose exposure. Mirtazapine and venlafaxine have not been associated with major fetal malformations. As duloxetine was approved for use only recently, data regarding its safety in pregnancy are inconclusive. One theoretical concern found with duloxetine (as well as venlafaxine and bupropion) involves preeclampsia. As all three antidepressants have been shown to cause a small but significant increase in blood pressure and heart rate in adults, they may also predispose expect- ant mothers to this complication (Eli Lilly, 2009; GlaxoSmithKline, 2008; Wyeth Pharmaceuticals, 2008). The long-term effects of in utero antidepressant exposure on the de- veloping child have not been rigorously explored. Early studies reporting abnormal psychomotor development lacked sufficient control groups to separate the effects of the antidepressant from depression itself (i.e., the control groups were not depressed) (Mortensen et al., 2003). As untreated
TREATMENT OF DEPRESSION IN PARENTS 213 antepartum depression has been associated with deficits in IQ, language development, social functioning, and acceptable behavior, well-designed studies with matched controls would be required to distinguish the etiology of any detrimental effects. Two relatively small studies were unable to find an association between SSRI exposure and developmental abnormalities (Misri et al., 2006; Nulman et al., 2002). Another study concluded that externalizing behaviors in children were much more likely to be a reflection of the motherâs current mood than exposure to antidepressants (Oberlander et al., 2007). Mothers with Postpartum Depression Untreated postpartum depression has been associated with serious consequences, most notably impaired mother-infant bonding and long-term effects on emotional behavior and cognitive skills. Although the risks of antidepressant transmission through breast milk are a common concern, it should be remembered that the risks of untreated depression are also readily transmitted to infants. Studies examining the concentrations of antidepressants in breast milk have generally shown that the cumulative exposure of infants to antidepres- sants through lactation is low and the behavioral risks are minimal (Gentile, 2005). Until recently, the methodology employed in these investigations was quite diverse (or unknown), precluding any meaningful comparisons about the relative risk of various agents. In 2005, however, two comparative stud- ies were published, both of which appeared to confirm that infant exposure was considerably lower than maternal exposure. In one study, the investiga- tors compared the ratio of breast milk concentrations to maternal plasma concentrations among seven antidepressants, reporting values ranging from 0.021 (sertraline) to 0.33 (desipramine) (Whitby and Smith, 2005). In the other investigation, authors estimated the relative infant dose via breast milk for five antidepressants, with values ranging from 0.5 percent (sertra- line) to 8.9 percent (fluoxetine) (Gentile, 2005), all of which were safely below the 10 percent threshold advocated by the American Academy of Pediatrics (Figure 6-1). Prospective studies of adverse effects in infants receiving antidepres- sants through breast milk have not been numerous but generally support the relative safety of this exposure (Burt et al., 2001; Eberhard-Gran, Eskild, and Opjordsmoen, 2006). A total of eight studies have been published, examining the impact of antidepressants on the treatment or prevention of postpartum depression. Only three of these investigations featured a randomized, double-blind de- sign, but all reported positive findings. Appleby found that both fluoxetine and cognitive-behavioral therapy were significantly more effective than
214 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN 10 8 6 Percentage 4 2 0 Ac Pa Fl Se C Ve ita uo ce ro rtr nl lo xe af xe al pt pr ax in tin ab tin am e in e le e e Th re sh ol d FIGURE 6-1â The safety of newer antidepressants in pregnancy and breast- feeding. SOURCE: Adapted, with permission from data in Table II and Table III from Gen- tile (2005). Copyright (2005) by Wolters Kluwer. placebo and that the combined treatment did not confer any additional benefits (Appleby et al., 1997). Similarly, Misri et al. (2004) found that paroxetine was associated with a highly significant treatment effect and that the combination of paroxetine plus cognitive-behavioral therapy was equally efficacious (versus monotherapy). Figure 6-1In the only head-to-head comparison of antidepressants, 95 women with postpartum depression were randomized to sertraline or nortriptyline (Wisner et al., 2006). Both medications improved psychosocial function, the only difference being an earlier separation of sertraline from baseline among responders (versus nortriptyline). Three small open-label trials with fluvoxamine, venlafaxine, and bupropion provide additional evidence for the effectiveness of antidepressants in relieving postpartum symptoms. The data supporting the prevention of relapse of depression in women postpartum is limited. Two small randomized trials on prevention of relapse have also been published (Wisner et al., 2001, 2004). Patients given ser- traline were much less likely to relapse than those randomized to placebo among nondepressed women with a history of perinatal depression (a re-
TREATMENT OF DEPRESSION IN PARENTS 215 lapse rate of 1 in 14 with active medication versus 4 in 8 with placebo). A similar investigation failed to find any difference between nortriptyline and placebo (a relapse rate of 6 in 26 versus 6 in 25 with placebo). INTERPERSONAL PSYCHOTHERAPY AND COGNITIVE-BEHAVIORAL THERAPY General Population Multiple studies and meta-analyses provide evidence that cognitive-be- havioral therapy (CBT) and interpersonal psychotherapy (IPT) are effica- cious treatments for general depression (de Mello et al., 2005; Deckersbach, Gershuny, and Otto, 2000; Dobson, 1989). Cognitive-behavioral therapy is based on the idea that the way a person perceives an event determines how they will respond both affectively and behaviorally (Dennis and Hod- nett, 2007). CBT helps patients identify and correct self-critical beliefs and distortions in thinking to reduce distress and enhance coping efforts. Interpersonal psychotherapy is a brief, highly structured, manual-based psy- chotherapy that addresses interpersonal issues in depression, such as role disputes, social isolation, or prolonged grief (Whooley and Simon, 2000). In summary, cognitive-behavioral therapy addresses distorted, negative think- ing associated with depression, and interpersonal psychotherapy addresses stressful social and interpersonal relationships associated with the onset of depressive symptoms (Weissman, 2007). Interpersonal psychotherapy is an accepted treatment for depression and has been found to be effective in multiple studies. A recent meta- analysis concluded that it was superior to placebo, similar to medication, and, when combined with medication, did not show an adjunctive effect compared with medication alone for acute treatment, maintenance treat- ment, or prophylactic treatment (de Mello et al., 2005). Although the meta- analysis found that IPT was more efficacious than CBT, other studies suggest that IPT is comparable to CBT in terms of outcomes. A recent review by Parker stated that IPT is unlikely to be the universal therapy for depression, given the heterogeneity of depressive disorders, but it may be appropriate therapy under specific circumstances (Parker et al., 2006). Cognitive-behavioral therapy is widely used for the treatment of de- pression. Although earlier studies suggested that its use was less efficacious than medications for patients with severe depression (Elkin et al., 1995), more recent studies have found that CBT is as efficacious as medications for even severely depressed patients (DeRubeis et al., 2005). There is also evidence that the effects of CBT last beyond the end of treatment (Hollon, Stewart, and Strunk, 2006), and studies have shown that patients treated with CBT are less likely to relapse after treatment termination than are
216 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN patients treated to remission with medications (Blackburn, Eunson, and Bishop, 1986; Gotlib and Hammen, 2008; Kovacs et al., 1981). In addi- tion, studies suggest that CBT is effective for the prevention of depression in patients who are at risk but are not currently depressed (Seligman et al., 1999). Recent studies have suggested that, among the components of CBT, behavioral activation (i.e., getting patients to pleasurable and meaningful activities) may be even more effective than the cognitive restructuring com- ponent of CBT (Dimidjian et al., 2006). Because it is easy to teach patients and requires less therapist training than cognitive interventions, behavioral activation might extend the availability and effectiveness of psychotherapy for depression. However, strong empirical evidence is absent with regard to the efficacy of CBTs and other behavioral interventions among diverse racial and ethnic minority populations. Larger studies, including those examining adaptations of evidence-based treatments for diverse popula- tions are needed. The use of race and/or ethnicity should be considered an integral part of the study methodology, data collection, and analyses, along with the utilization of culturally and linguistically appropriate instruments and measures (de Arellano et al., 2005). Studies examining disparities in depression treatment highlight the unique barriers that racial and ethnic minorities experience when seeking mental health care and quality of care remains a critical issue. Actually, having access to any mental health treat- ment remains a central point of concern for racial and ethnic minority groups (AlegrÃa et al., 2008). A new therapy, mindfulness-based cognitive therapy (MBCT), combines meditation with more conventional CBT (Segal, Williams, and Teasdale, 2002). MBCT is based on the Mindfulness-Based Stress Reduction Program developed by Jon Kabat-Zinn at the University of Massachusetts Medical Center. It integrates elements of CBT with components of Kabat-Zinnâs mindfulness stress reduction program and âteaches patients to recognize and disengage from modes of mind characterized by negative and rumina- tive thinking and to access and use a new mode of mind characterized by acceptance and âbeingââ (Coelho, Canter, and Ernst, 2007). Studies have demonstrated that MBCT is an effective therapy to prevent relapse or recurrence in recovered depressed patients with three or more previous episodes (Ma and Teasdale, 2004). It has also been shown to be an ad- junct to the treatment of other psychological problems, including substance abuse, as well as changing behavior (Margolin et al., 2006; Witkiewitz and Marlatt, 2004). Multiple studies are currently investigating the effectiveness of MBCT for the treatment of current depression and prevention of relapse or recurrence. Furthermore, MBCT therapies have been effectively used in African American and Hispanic women to prevent relapse or recurrence of co-occurring disorders (i.e., substance use and trauma) (personal commu-
TREATMENT OF DEPRESSION IN PARENTS 217 nication, H. Amaro, Northeastern University, February 13, 2009; Vallejo and Amaro, in press). Mothers with Antepartum Depression Given concerns over the safety of antidepressants during pregnancy and the postpartum period, psychological and psychosocial treatments for de- pression are an important alternative therapy for depression during this pe- riod. However, few studies have investigated whether cognitive-behavioral therapy or interpersonal psychotherapy are efficacious in the setting of antenatal depression. In fact, a recent Cochrane review (which are sys- tematic reviews of health care interventions, see http://www.cochrane.org) found only one U.S. trial that met inclusion criteria to investigate the topic (Dennis, Ross, and Grigoriadis, 2007). One trial of 38 outpatient antenatal women who met criteria for major depression found that interpersonal psy- chotherapy compared with a parenting education program was associated with a reduction in the risk of depressive symptoms immediately following treatment. It also found that women who received 16 weeks of modified IPT were more likely to recover than controls (Spinelli and Endicott, 2003). Given the small size of the trial and the nongeneralizable sample, the Co- chrane review concluded that the evidence was inconclusive regarding the effects of IPT for the treatment of antenatal depression. Mothers with Postpartum Depression Although the evidence is inconclusive in the setting of antepartum depression, a number of randomized trials have shown the benefit of psy- chological and psychosocial interventions to reduce postpartum depression diagnoses and symptoms. A recent review included nine trials of CBT, IPT, and psychodynamic therapy, as well as psychosocial interventions, such as peer support and nondirective counseling. The authors found that any psy- chosocial or psychological intervention, compared with usual postpartum care (variously defined), was associated with a reduction in the likelihood of depressive symptomatology at the final postpartum assessment (nine tri- als; n = 956, relative risk, RR = 0.70, 95 percent CI = 0.60â0.81) (Dennis and Hodnett, 2007). ALTERNATIVE MEDICINE Given the reluctance of many mothers to consume prescription antide- pressants during pregnancy or breastfeeding, researchers have conducted several small studies examining alternative treatments. Results are very preliminary but encouraging.
218 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Omega-3 Fatty Acids Omega-3 fatty acid supplementation has been studied for the treat- ment and prevention of unipolar and bipolar depression in the general population with success reported for daily regimens of approximately 2â3g daily of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) (Freeman et al., 2008; Su et al., 2008). As these two fatty acids are typi- cally found in cold-water fish and many women avoid fish perinatally due to concerns over mercury exposure, supplementation would appear to be a prudent approach. Additional benefits of DHA in pregnant women would include decreasing the risks of preeclampsia and promoting healthy child development. Following a small, open-label study documenting benefits among 15 women with antepartum depression, Freeman examined the benefit of omega-3 fatty acids among 59 women with perinatal depression (i.e., ante- partum and postpartum subjects combined) (Freeman et al., 2006a, 2008). Subjects were randomized to 1.9g of omega-3 fatty acids daily (DHA + EPA) or placebo. At the end of the 8-week trial, both groups experienced substantial benefit, but the application of manualized CBT to both study groups may have prevented the authors from detecting a statistically sig- nificant difference. Su et al. also conducted a small, randomized controlled trial of omega-3 fatty acids for antepartum depression, enrolling 33 subjects in their 8-week trial (Su et al., 2008). A total of 24 subjects completed the trial, with the group assigned to omega-3 fatty acids (3.4g daily) demonstrating superior response rates (62 versus 27 percent; p = 0.03) and remission rates (38 versus 18 percent; p = 0.28) in comparison to placebo controls. While the favorable findings from these antepartum and other post- partum studies are encouraging, the investigations have been quite small, and little is known about the effective dosing range (Freeman et al., 2006b; Llorente et al., 2003). Omega-3 fatty acids have been very well tolerated, however. And given the fact that these naturally occurring compounds may impart additional benefits to adults (e.g., anti-inflammatory effects) and pregnant women in particular (decreased risks of complications), further studies are clearly warranted. St. Johnâs Wort St. Johnâs wort, an herbal remedy from the Hypericum perforatum plant, has been used to treat major depression for many years (Maurer and Colt, 2006). An initial Cochrane review investigated 37 randomized trials and concluded that the evidence for the use of St. Johnâs wort for depres- sion was confusing and inconsistent (Linde et al., 2005). However, a more
TREATMENT OF DEPRESSION IN PARENTS 219 recent review of 29 studies concluded that St. Johnâs wort was more effec- tive than placebo, comparable in effectiveness to standard antidepressants, and appeared to cause fewer side effects than prescription remedies (Linde, Berner, and Kriston, 2008). Authors did note that St. Johnâs wort appeared to be more effective in studies conducted in German-speaking countries, owing perhaps due to the greater potency of preparations administered. An additional review of 13 studies comparing St. Johnâs wort to SSRIs reported that the two treatments were equivalent in efficacy and adverse effects but that St. Johnâs wort was associated with lower dropout rates (Rahimi, Nikfar, and Abdollahi, 2009). An additional systematic review investigated whether St. Johnâs wort was safe during pregnancy and breast-feeding. It reported that there is very weak evidence that St. Johnâs wort is safe dur- ing pregnancy and lactation and concluded that more research is needed (Dugoua et al., 2006). In addition, it should be noted that St. Johnâs wort is a potent inducer of several liver enzymes, potentially interacting with many prescription and nonprescription drugs (e.g., birth control pills, antibiotics) (Weier and Beal, 2004). Phototherapy Bright light therapy or phototherapy has been used with some success for seasonal affective disorder, but there is less evidence supporting its use in major depression. A Cochrane review analyzed 20 studies and found the results of its use for the treatment of nonseasonal depression to be modest but promising (Tuunainen, Kripke, and Endo, 2004). Light therapy has also been proposed as a safe and effective intervention for perinatal depression, which can be safely and conveniently administered in oneâs home. The rationale for this approach to perinatal depression may stem from the fact that pregnant and postpartum women are often deficient in exposure to natural sunlight. Small open-label trials have featured 7,000â10,000 lux of bright light for up to 1 hour daily with generally favorable results; these should serve as a stimulus for more rigorous investigations (Corral, Kuan, and Kostaras, 2000; Epperson et al., 2004; Oren et al., 2002). Exercise Exercise has long been promoted as an alternative to prescription an- tidepressants in the postpartum period as well. For the general population of depressed adults, a wide variety of studies have reported therapeutic benefits with exercise regimens, although the number of large, randomized investigations with appropriate controls is very limited (Stathopoulou et al., 2006). Frequent modest cardiovascular workouts impart a wide variety of benefits to depressed people, including appetite regulation, sleep and energy
220 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN improvements, an enhanced sense of well-being, and observed increases in plasma serotonin concentrations. A 2007 review of the literature identified a total of two small, random- ized controlled trials of pram (baby carriage) walking in postnatal mothers, both of which reported significant benefit (Armstrong and Edwards, 2003, 2004; Daley, Macarthur, and Winter, 2007). However, the authors were not able to control for the confounding influence of concurrent medications. A variety of other uncontrolled or observational studies for postpartum depression have reported similar positive preliminary findings. Yoga Yoga consists of a complex system of spiritual, moral, and physi- cal practices aimed at raising self-awareness (Pilkington, Rampes, and Richardson, 2006). It has been studied for the treatment of depression. Five randomized controlled trials evaluating the efficacy of yoga in the treatment of depression were identified in a systematic review (Pilkington et al., 2005). Different forms of yoga were used. All trials reported positive findings, but poor study quality limited the usefulness of their results. Yoga is a particularly interesting therapy during pregnancy and the postpartum period, given the other physical and emotional symptoms women experi- ence (such as back pain, anxiety) at this time. Yoga programs for perinatal women are widely available throughout the country, and further research of this intervention appears warranted. Acupuncture Acupuncture has been used in China and other Asian countries for thousands of years. Acupuncture is generally safe, and studies suggest that it may be an effective treatment for psychological problems, includ- ing depression (Weier and Beal, 2004). A Cochrane review that examined the efficacy of acupuncture for depression included seven trials: five trials compared acupuncture with medication, and two trials compared acupunc- ture with a wait-list control of sham acupuncture (Smith and Hay, 2005). There was no evidence that medication was better than acupuncture in reducing the severity of depression or in improving depression. Given the small sample sizes and poor quality of the studies, the authors concluded that there was insufficient evidence to determine the efficacy of acupuncture compared with medication for depression. There are no randomized trials evaluating the use of acupuncture for depression during pregnancy or for postpartum depression. Other therapies, such as aromatherapy, massage therapy, and reflexol-
TREATMENT OF DEPRESSION IN PARENTS 221 ogy, have also been investigated as adjunctive therapies for depression. The evidence is inconclusive, and further research is needed. IMPACT OF TREATMENT OF DEPRESSED PARENTS AND THEIR CHILDREN While the benefits and risks of antidepressants for adult depression have been widely studied, very few investigations have examined the use of antidepressants, interpersonal psychotherapy, or cognitive-behavioral therapy by parents and its role in the prevention of adverse outcomes in their children. The treatment of parentsâ depression to remission and to prevent relapse reduces or removes exposure to this risk factor for their children. Chapter 7 reviews preventive interventions and programs that investigate the role of treatment of a parentâs depression in the prevention of adverse outcomes for children as well as approaches that target inter- mediate mechanisms (i.e., parenting, social support). In general, successful treatment of a parentâs depression has been associated with improvement in childrenâs symptoms of emotional and behavioral problems, academic and global functioning, and parent-children interactions, but it may not be sufficient for improving some other aspects of their cognitive development and functioning (Gunlicks and Weissman, 2008). The systematic review by Gunlicks and Weissman (2008) found no studies of the effects on children of treating depressed fathers. INTERVENTIONS Depression is best viewed as a chronic illness, with most patients suffer- ing multiple episodes over the course of a lifetime. Thus, the treatments used acutely to relieve depressive symptoms are best viewed as tools, whereas interventions may be analogous to comprehensive approaches to delivering treatments and preventing relapse. In response, researchers have answered this challenge by applying structured and comprehensive treatment strate- gies inspired by Wagnerâs chronic illness model. Most of these interventions are consistent with this model to the extent that they feature (1) frequent, scheduled follow-up, (2) efficient information systems, (3) decision support trees, and (4) emphasis on self-management. By individualizing the manage- ment of a patientâs depression in this stepped care approach, researchers have been able to demonstrate very positive outcomes, but the preponder- ance of these studies have been conducted in primary care settings. As with the previous section on treatments, the body of literature on interventions for parents, specifically, is quite thin. It is also site specific. Thus, we have provided a brief summary of interventions in the general depressed population (which has been studied almost exclusively in primary
222 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN care) to take a closer look at interventions for parental depression (which have occurred in a variety of clinical and community settings). Within these sites, we have summarized the specific interventions, beginning with monotherapeutic approaches (e.g., emphasizing education, providing tele- phone support) and progressing to programs that incorporate several of these elements (e.g., collaborative care). These studies are summarized in Table 6-1. Primary Care Practices For adults, the medical management of depressive illness has ordinar- ily fallen under the purview of primary care providers, as over 70 percent of patients receive treatment in this setting (Katon and Schulberg, 1992). Under the influence of managed care, this trend has been further accentu- ated in the United States, placing greater emphasis on the diagnostic and therapeutic skills of the primary care provider to facilitate recovery from mental illness. A significant body of evidence has accumulated in the past decade strongly suggesting that outcomes for depressed patients in this health service model are suboptimal (Kessler et al., 2003). Inefficiencies with health care delivery for depressed individuals have inspired a wide variety of interventions targeting the primary care set- ting. They have ranged from didactic educational programs to web-based monitoring and counseling to a complete restructuring of health service delivery, mandating the integration of mental health professionalsâthat is, collaborative care. Health policy experts and researchers have come to a general consensus that collaborative care models are the most efficacious approach to managing depression, incorporating several specific interven- tions within respective protocols. The relative merits of these interventions, as well as a review of evidence supporting the collaborative care approach, are found below. Education Many efforts have been made to improve the basic understanding of patients and providers toward depression and the effectiveness of treat- ments. Two pivotal trials strongly suggest that these training programs are effective only in the context of systemic changes to care delivery and follow-up (Lin et al., 2001; Thompson et al., 2000). In the first study, known as the Hampshire Project, 59 primary care practices in England were randomized to two conditions: enhanced educa- tion focused on practice guidelines (in the form of a 4-hour seminar for physicians) and the control group (Lin et al., 1997). At endpoint, there were no apparent improvements in detection (39 percent sensitivity to diagnos-
TREATMENT OF DEPRESSION IN PARENTS 223 ing depression in the intervention group versus 36 percent in the control group) or in rates of recovery at 6 weeks or 6 months. In the second study, researchers examined the impact of enhanced education of provider per- formance in two staff model HMOs. Physicians in the intervention group received a 2-hour training session from psychiatrists (didactic presentations as well as role playing) and then met with them on several other occasions to discuss patient welfare for the first 3 months of the study. One year later, there were no statistically significant differences between groups in regard to detection rates, new prescriptions for antidepressants, or adherence to medication guidelines. This investigation confirmed the results of a previ- ous study by this same research group, which failed to find any persistent benefits to provider training. Although these studies demonstrate that education alone is not a suf- ficient and enduring approach to improving outcomes, there is still a widely held belief that education should be an important ingredient in any system- atic intervention. Several meta-analyses of collaborative care interventions have been published recently (see collaborative care section below) that have attempted to determine which aspect of this approach was most influ- ential in improving medication adherence or depressive symptoms (Bower et al., 2006; Craven and Bland, 2006; Gilbody et al., 2006). Bower et al. (2006) were unable to show that physician training improved outcomes significantly for either of these outcome measures (p = 0.194 and 0.237, respectively). Craven and Bland (2006) did not conduct this type of statisti- cal analysis but did note that the most successful interventions contained an educational component. An interesting body of literature has also emerged that takes the analysis a step further, attempting to identify the most im- portant aspects of efficient patient-provider communication (Nolan and Badger, 2005). Guideline-Based Treatment Many of the educational efforts targeting primary care providers have used guideline-based treatments to improve outcomes. Some have ana- lyzed the impact of guidelines specifically as the primary intervention, and results have not been favorable (Linden and Schotte, 2007; Thompson et al., 2000). One investigation compared the impact of guideline-based treatment, enhanced physician communication skills, and the combination of the two; it concluded that both components are required to witness significant change in depressive symptoms (van Os et al., 2005). As the content and recommendations in guidelines may vary widely, Hepner et al. (2007) looked at 20 different indicators found in guidelines and examined their impact on clinical outcomes. Overall, they reported that adherence to treatment guidelines was associated with a significant decrease in depressive
224 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 6-1â Detailed Summary of the Approaches to Delivering Treatment and Preventing Relapse in Adults and Parents with Depression Populations and Primary Demographics Intervention Citation Studied Settings Education Bower et al. (2006) Adults with major Primary care (of health Lin et al. (1997) depression professional) Thompson et al. and depressive (2000) symptoms Rost, Smith, and Mothers with Dickinson (2004) depression Education (of the Christensen, Adults with Pregnancy/ patient) Griffiths, and depression postpartum Jorm (2004) and depressive Primary care Craven and Bland symptoms Community (2006) Mothers with Web-based Hayes and Muller depression (2004) Jorm et al. (2003) Lumley et al. (2006) Tam et al., (2003) Guideline-Based Flynn et al. (2006) Adults Community Treatment Hepner et al. Adults with ICD-9 Mental health (2007) clinical depression Primary care Linden and Schotte Mothers (some Pregnancy/ (2007) minority and postpartum Miranda et al. low-income) (2003, 2006) Adults with major Revicki et al. depressive disorder (2005) (some with alcohol Thompson et al. or drug problems) (2000) Trivedi et al. (2004) Van Os et al. (2005) Self-Help (written Clarke et al. (2002) Adults (some at risk Primary care and computer- Gellatly et al. for and some with Mental health assisted) (2007) clinical depression) Web-based Wright et al. (2005)
TREATMENT OF DEPRESSION IN PARENTS 225 Outcomes/Follow-up Research Method No significant improvements in depression detection or treatment Randomized outcomes in adults, except in one study in adults beginning new experimental treatment As a component of collaborative care, the physician training component was not most influential in improving depressive symptoms and medication adherence in adults No difference in depressive outcomes in adults and mothers Randomized Enhanced patient education along with provider education in experimental addition to usual care in existing community and primary care services did not significantly improve identification of depression in women postpartum As a component of collaborative care, most successful interventions contained an enhanced patient education component Useful in changing attitudes about treatment Literacy website effective in reducing symptoms of depression in adults Greater clinician adherence of guidelines is associated with Observational significant decrease in depressive symptoms Randomized Combined with enhanced communication skills found significant experimental improvements in depressive symptoms In pregnancy/postpartum settings, screening combined with clinician notification and follow-up showed only modest short-term impact on depressive symptoms in mothers In community settings, guideline-based care with case management and referral was more effective in reducing depressive symptoms at 6 months and 1 year than those only referred to community care among minority and low-income mothers In mental health setting, combined with clinical support and patient and family education, algorithm-based approach significantly reduced depressive symptoms and overall mental functioning at 1 year Cognitive-based therapy reduced depressive symptoms for adults Randomized with major depressive disorder in mental health specialty settings experimental and at 6 month follow-up, reduced therapist time Meta-analysis revealed reduction of depressive symptoms were associated with self-help models that recruit participants from nonclinical settings, included participants who had an existing mood disorder (not prevention), featured some sort of expert guidance, and used CBT principles with adults In addition to usual care, Internet-based self-help program was effective in reducing depressive symptoms in adults only with follow-up reminders continued
226 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 6-1â Continued Populations and Primary Demographics Intervention Citation Studied Settings Telecare Bullock et al. Adults with Primary care (1995) depression Workplace Dennis and Antenatal women Pregnancy/ Kingston (2008) Postpartum women postpartum Hunkeler et al. (2000) Wang et al. (2007) Collaborative Care Bower et al. (2006) Adults with Primary care Craven and Bland depression Pregnancy/ (2006) postpartum Dietrich et al. Workplace (2004b) Gilbody et al. (2006) Rojas et al. (2007) Wang et al. (2007) Problem Solving Dowrick et al. Adults with Community (home) (2000) depression Group Brown et al. (2004) Adults with Community sites Psychoeducation Christensen, depression Pregnancy/ Griffiths, and Mothers with postpartum Jorm (2004) postpartum Web-based Dowrick et al. depression (2000) (low-income) Rojas et al. (2007) Spek et al. (2007) Home Visitation Ammerman et al. Mothers with Home (2005) postpartum Barnet et al. (2007) depression (some Lagerberg (2000) defined as at Navaie-Waliser et higher risk, first al. (2000) time mothers) Pregnant adolescents Culturally Grote et al. (2009) Low-income Pregnancy/ Enhanced pregnant/ postpartum postpartum women NOTES: The committee did not seek to systematically identify every study on the evaluation of delivery interventions for treating depression in adults (and parents); instead, whenever possible, the committee drew on existing meta-analyses and systematic reviews and lim-
TREATMENT OF DEPRESSION IN PARENTS 227 Outcomes/Follow-up Research Method Compared with usual pharmacotherapy care, telecare in addition to Randomized usual care significantly improved depressive symptoms at 6 weeks experimental and 6 months for adults in primary care and at 4â8 weeks for mothers considered at high risk for postpartum depression Telephone outreach and care management significantly improved self-reported depressive symptoms and some indicators of work performance in adults Telephone support for women throughout pregnancy was associated with lower depressed mood, stress, and anxiety scores compared with controls Compared with usual care, multidisciplinary models of care Randomized significantly improved depressive symptoms in adults experimental Increased antidepressant use and adherence in adults Use of mental health specialists as care managers is associated with improved depressive symptoms in adults Structured follow-up improves depressive symptoms in adults Care management and referral using telephone outreach significantly improved self-reported depressive symptoms and some indicators of work performance in adults Compared with usual care, delivering problem-solving techniques at Randomized home significantly improved depressive symptoms at 6 months experimental Compared with usual care, group psychoeducation significantly Randomized decreased depressive episodes and symptoms at 3 and 6 months experimental (not at 1 year) for adults Interventions that included psychoeducational groups, treatment adherence support, and pharmacotherapy if needed significantly lowered depressive scores at 3 months (not at 6 months) for low- income mothers postpartum Web-based psychoeducational and CBT with therapist support significantly reduced symptoms of depression in adults Compared with controls, treatment through a support and Randomized counseling program or CBT improved postpartum depression experimental symptoms at 1 year after treatment but not for pregnant adolescents Culturally enhanced psychotherapy reduced depression diagnosis Randomized and symptoms experimental ited its review to interventions that have been evaluated in at least one randomized trial. CBT = cognitive-behavioral therapy; ICD-9 = International Classification of Diseases, ninth revision.
228 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN symptoms. They also reported that adherence to guideline treatment was fairly high for certain factorsâsuch as patient education, disease detec- tion, and acute care treatmentâbut low for many othersâsuch as inquiry into suicide assessment, alcohol abuse, previous history of depression, as well as subsequent medication adjustment. In summary, guidelines for the management of depressed patients in primary care may be very influential in facilitating recovery. Adherence to accepted guidelines should be widely encouraged. The ultimate impact of guideline-based treatment cannot be observed, however, unless this approach is embedded in protocols featuring multiple interventions, as guideline adherence alone has not been demon- strated to improve depression outcomes. Self-Help As many clients have difficulty accessing the services of therapists or care managers, investigators have begun to look at methods to improve treatment of depressive illness through remote technology or self-guided protocols (e.g., bibliotherapy, computer programs). Theoretically, these approaches may be more cost-effective and promote a broader dissemina- tion of interventions, but clients must also be sufficiently motivated and educated to persist with treatment. Previous investigations of various self-help models for depression have met with varying degrees of success. A recent meta-analysis was conducted in an attempt to determine which moderators were associated with posi- tive outcomes. The authors found that there were considerable differences in study methodology (i.e., heterogeneity) among the 34 investigations that were identified (Gellatly et al., 2007). The analysis featured 29 inter- ventions with written materials of which 10 were computer-assisted (e.g., web-based). The researchers concluded that the following moderators were associated with superior outcomes: (1) recruitment of participants from nonclinical settings, (2) inclusion of participants who had an existing mood disorder at baseline (as opposed to prevention), and (3) some sort of expert âguidance.â CBT principles appeared to be more effective than education alone. No significant associations were demonstrated based on the duration of the intervention, the delivery mode, or the therapistsâ background. Telecare Telecare involves extensive telephone follow-up, often delivered by trained care managers (e.g., nurses or pharmacists) who relay treatment outcomes and recommendations to referring providers. This type of inter- vention is relatively inexpensive and can be implemented fairly easily. Theo- retically, it may be performed by adequately trained paraprofessionals at
TREATMENT OF DEPRESSION IN PARENTS 229 remote sites (e.g., administrative assistants), rendering the model even more cost-effective. Most of the investigations employing telecare have done so in combination with other systematic improvements, and systematic reviews examining the impact of telecare alone have not been published. Two investigations emphasized telecare as the primary intervention for depressed patients. In the first study, Hunkeler et al. (2000) demon- strated an improvement in depression scores among primary care patients at an HMO, despite the fact that the model had no significant impact on medication adherence. As a result, the authors theorized that the protocol may have effectively delivered more of a psychosocial intervention. More recently, Wang et al. (2007) examined the impact of telephone outreach and associated care management on clinical parameters and work performance. After 6 and 12 months of treatment, employees demonstrated significantly more clinical improvement, as well as higher job retention and measured work productivity. The popularity of telecare can be traced to the relative simplicity of this approach, but the inclusion of this component in highly successful models suggests that regularly scheduled telephone follow-up is conducive to therapeutic success. As many experts have emphasized the importance of a therapeutic alliance in optimizing depression outcomes (developed, pre- sumably, through face-to-face contact with case managers), it would appear that telecare would be most effective after a relationship with individual clients has been forged. Given the fact that meta-analyses of collaborative care models have consistently demonstrated superior outcomes with case managers from the mental health sector, it also remains to be seen how ef- fective telecare can be when delivered by paraprofessionals who lack this training. Mailed Reminders Insurance companies and health care organizations have relied on mailed reminders as a means for improving medication adherence for many years. This would appear to be an inexpensive approach to improving adherence to depression measures from the Healthcare Effectiveness Data and Information Set, although the lack of individualized follow-up is less than ideal, particularly when one considers that most patients started on antidepressants may eventually require medication adjustment to achieve remission (Trivedi et al., 2006). As with the other interventions discussed, there is little evidence suggesting that this approach alone would suffice in optimizing outcomes. And mailed reminders have generally been just one component of a system-wide intervention. Although the authors are aware of several pilot projects or programs that have emphasized mailed
230 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN reminders, there are no randomized controlled trials of this intervention for depression in the medical literature. Collaborative Care Collaborative care is the most comprehensive of primary care interven- tions and often incorporates several of the other interventions discussed above. The development of collaborative care models is consistent with the principles laid out by Wagner in his seminal papers on the management of chronic illness, emphasizing close follow-up, efficient information systems, self-management, and decision support (Wagner, Austin, and VonKorff, 1996). For the management of depression in primary care, investigators have applied these concepts, with three essential components noted: a prepared practice (i.e., with providers and support staff suitably trained), care management, and a mental health interface (Oxman et al., 2002; Wells et al., 2000). Although no consensus exists as to what constitutes collabora- tive care, the most common components include the following: â¢ Advanced training provided to the primary care provider regarding guideline-based care â¢ Enhanced patient education â¢ Skilled medication management and/or brief psychotherapy â¢ Increased duration and/or number of clinic visits â¢ Routine surveillance of progress (featuring validated instruments) â¢ Integration of the mental health specialist into the primary care setting for care management, clinical consultation, or supervision â¢ Feedback/recommendations provided to the primary care provider by care managers Collaborative care is probably the most extensively studied of primary care interventions, and a reasonably strong body of evidence to encourage integrated care, at least for depression, have been published. Numerous systematic reviews are currently available in the literature, most recently by Bower et al. (2006), Butler et al. (2008), Craven and Bland (2006), and Gilbody et al. (2006). Results of these reviews are fairly consistent in regard to (1) collaborative care results in superior clinical outcomes (e.g., 0.25 standardized mean difference in outcomes with 95 percent CI = 0.18â0.32 in the Gilbody analysis), (2) collaborative care results in greater antidepres- sant medication use or adherence, (3) the use of mental health specialists as care managesr/supervisors is associated with better outcomes, and (4) structured follow-up improves outcomes. Racial and ethnic minority populations appear to utilize the primary care setting more often for mental health interventions. Simultaneously,
TREATMENT OF DEPRESSION IN PARENTS 231 research indicates that dramatic differences in the utilization of mental health services for minority groups are not due to differences in rates of mental illnesses (AlegrÃa et al., 2007, 2008; Takeuchi et al., 2007). There- fore, employing treatments for depression in primary care settings may be more advantageous for minority populations and a more viable approach to reducing and ultimately eliminating mental health disparities (Chapa, 2009). Exemplar studies in these systematic reviews and others are further detailed in Table 6-2. The therapeutic modalities employed in the collaborative care studies ordinarily feature pharmacotherapy (either prescribed independently by the provider or based on the recommendations of care managers) or psy- chotherapy (most often manualized cognitive-behavioral therapy) or both. The informed choice of preferred treatments by participants appears to be a common feature of successful models and has been widely advocated in both adolescents and adults with depression (Asarnow et al., 2005; Rost et al., 2001). As mentioned above, meta-analyses of collaborative care models have demonstrated a positive impact on clinical outcomes and on medication adherence. Interestingly, medication adherence has not always been associated with superior clinical responses in individual studies or quantitative reviews (Bower et al., 2006; Craven and Bland, 2006). Meta- analyses have also examined the influence of counseling or CBT alone on depression outcomes and failed to demonstrate clinical benefit with brief psychotherapy in multicomponent models (Gilbody et al., 2006). Further- more, attempts to demonstrate an association between the number and duration of psychotherapy sessions with clinical response have met with equivocal results in collaborative care models (Bower et al., 2006). Although randomized controlled trials of collaborative care interven- tions have consistently reported positive findings, the cost-effectiveness of these relatively intensive multidisciplinary models is not clear. Most col- laborative care studies for depression have been conducted in the primary care settings of academic centers or HMOs, and the generalizability of these results to real-world settings has been questioned (Gilbody, Bower, and Whitty, 2006). From these investigations, collaborative care interven- tions appear to be most cost-effective for new episodes of depression, severe depression, or high users of health care resources, but the relative cost- effectiveness of systematic interventions for mild to moderate depression or subsyndromal depression have been either inconclusive or not adequately studied. Critical issues persist in regard to the exportability and sustainability of the various collaborative care models. Consequently, recent efforts have been made to examine the impact of collaborative care on populations rather than individuals, the implication being that most health care systems and settings have limited resources, and financial incentives are not always
232 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 6-2â Detailed Summary of Exemplar Collaborative Care Studies Delivering Treatments and Preventing Relapse in Adults with Depression Patient Study Setting Population Study Design Study Duration Asarnow et al. Primary care Adolescents Randomized 6 months (2005) clinics between ages after Practices 13 and 21 screening affiliated Average age: 17 Intervention (n with 5 years = 211) different 78% female Usual care (n = health care 56% Hispanic 207) organizations (includes managed care, public- sector, and academia) managed care settings Dietrich et al. Primary care 81% female Randomized 60 6 months (2004b) practices Average age: 42 practices Practices years Intervention (n affiliated 57% married = 177) with 5 34% ethnic Usual care (n = different minority 146) health care organizations Nonacademic Rojas et al. Primary care 100% female Randomized 6 months (2007) practices Average age = 27 years 65% married or cohabitating All treatment- naÃ¯ve at baseline
TREATMENT OF DEPRESSION IN PARENTS 233 Intervention Outcomes Comments Care managers were Statistically significant Greater emphasis placed on psychotherapists difference of intervention psychotherapy, particularly Subjects and clinicians compared to control at 6 in intervention group had treatment choice months for the following Unclear as to what interface of medications (QI- outcomes: was between primary meds), psychotherapy â¢ depressive symptoms care physicians and care (QI-therapy), or both (CESD = 19.0 vs 21.4; managers (QI-both) p = 0.02) Degree of improvement For QI-meds, care managers â¢ quality of life scores (SF- consistent with previous followed guideline-based 12-MCS = 44.6 versus studies among adults and algorithms 42.8; p = 0.03) elderly conducted by same For QI-therapy, care Nonsignificant research group (Partners in managers provided improvements seen Care) weekly sessions of in greater decrease of manualized CBT (group suicide attempts among or individual) intervention subjects versus controls (14.2% to 6.4% versus 11.6% to 9.5%) Centrally located care Statistically significant Subsequent analysis managers contacted difference of intervention demonstrated that high subjects after 1 week and compared to control in fidelity with chronic care monthly thereafter to depressive symptoms, model associated with better assess response, promote remission rates, and at outcomes (e.g., education adherence, and endorse least one follow-up visit of subjects, regular contact self-help practices at 3 and 6 months with care managers, Providers were contacted Not significantly different interface with mental with treatment updates on antidepressant health) and recommendations adherence and specialty Psychiatrists supervised care counseling managers on weekly basis via telephone Intervention group received Statistically significant Psychoeducation attendance psychoeducation (hour- difference of intervention very low (2.7 visits of 8 long session weekly Ã compared to control in possible) 8 weeks), adherence depressive symptoms Authors attribute failure monitoring and advice (EPDS), social function, to sustain response due from ânonprofessionalâ and vitality (SF-36) at to decrease medication care managers 3 months adherence over time (68% Providers for intervention Increase in antidepressant relapse rate if medication subjects received training adherence discontinued during first 3 in pharmacotherapy months versus 26% relapse (5 hours) plus weekly if medication continued) supervision by research psychiatrist continued
234 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 6-2â Continued Patient Study Setting Population Study Design Study Duration Rost et al. Primary care 84% female 12 clinics 24 months (2001) practices Average age: randomized Recruited from 43 years Intervention (n practice 47% married = 221) networks 83% had health Usual care (n = Nonacademic insurance 240) Practices not 16% minority permitted to have mental health specialist on site Miranda et al. Women 100% female Randomized 6 months (2003) screened at Average age: Medications (subsequent food subsidy 29 years (n = 88) 12-month programs 46% married Psychotherapy follow-up) and family or living with (n = 90) planning partner Usual care clinics âVast majorityâ (referral to Nonacademic living with community children mental health (average = services 2.3) (n = 89)
TREATMENT OF DEPRESSION IN PARENTS 235 Intervention Outcomes Comments Two physicians and one Statistically significant Effects most pronounced in nurse at each intervention difference of intervention subjects willing to accept site received training compared to control in pharmacotherapy or if consistent with AHCPR the following: newly diagnosed episode treatment guidelines â¢ antidepressant adherence Intervention also noted Subjects encouraged by â¢ percentage receiving to improve physical clinicians to seek their specialty counseling functioning (61 points treatment of choice â¢ remission rates at 24 versus 44 points), and Nurses called subjects months (74% versus 35% of improvement over weekly Ã first 5â8 weeks, 41%) baseline attributable to assessing symptoms and â¢ physical functioning (61 intervention promoting medication points versus 44 points adherence on SF-36) If suboptimal response, subjects encouraged by nurse to contact provider Otherwise, providers contacted subjects on monthly basis to adjust treatment Subjects assigned to Statistically significant Subjects randomized to medication were treated difference of psychotherapy much less by nurse practitioners intervention compared likely to complete protocol supervised by a to control in depressive in spite of extensive psychiatrist symptoms (HRSD), outreach (e.g., childcare, They received an empiric social functioning, transportation) paroxetine trial and were and instrumental role switched to bupropion if (medication therapy only) unsuccessful all at 6 months Psychotherapy group received 8 weekly sessions of manualized CBT (group or individual) delivered by psychotherapist supervised by clinical psychologist continued
236 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 6-2â Continued Patient Study Setting Population Study Design Study Duration Wang et al. Employees 74% female Eligible subjects 12 months (2007) identified Average age: had to have through 42 years at least health 41% college moderate screening and educated depression referred to (QIDS-SR behavioral > 7) health Randomized management Intervention (n company = 304) Employees Usual care (n = from 16 large 300) companies Wells et al. Primary care, 71% female Group level 12 months (2000) managed care Average age = randomized settings 44 years of 30 clinics Nonacademic 55% married Randomized 57% White 14 to 30% Hispanic intervention (n = 913) 16 to usual care (n = 44) NOTES: AHCPR = Agency for Health Care Policy and Research; CBT = cognitive behav- ioral therapy; CESD = Center for Epidemiologic Studies Depression Scale; EPDS = Edinburg Postnatal Scale; HRSD = Hamilton Rating Scale for Depression; QI = quality improvement; QIDS-SR = Quick Inventory of Depressive Symptomatology-Self-report; SF-12-MCS = Short- Form Survey-12-Mental Component Score; SF-36 = Short-Form Survey-36.
TREATMENT OF DEPRESSION IN PARENTS 237 Intervention Outcomes Comments Intervention group received Statistically significant Very modest clinical in-person treatment via difference of intervention improvements care manager referral compared to control in Intervention patients 70% (psychotherapy or depressive symptoms more likely to receive pharmacotherapy) or (QIDS-SR) at 12 months; mental health specialty care manualized CBT over remission rates at 6 (OR = 1.6; CI = 1.1â2.3). phone and 12 months; work Authors also reported decrease If suboptimal response after productivity and job in presenteeism and stated 2 months, weekly CBT retention at 6 and 12 that cost savings were much program Ã 8 weeks months greater than investment All received self-help in outreach and care manuals management Care managers assessed response and adherence, and delivered treatment recommendations to provider Patients and providers Statistically significant Rates of subjects receiving had choice of either difference of intervention appropriate care higher in medications (QI-meds) compared to control at 6 QI-med group than QI- or psychotherapy months and 12 months therapy (14% higher than (QI-therapy) for the following: control versus 8% higher For QI-meds, subjects â¢ depressive symptoms than control) contacted by nurses (CESD), QI-therapy group less likely to monthly to assess clinical â¢ antidepressant adherence be diagnosed as depressed outcomes and promote â¢ use of specialty counseling upon follow-up (vs. QI- adherence Also, job retention rates med; p = 0.05) Subjects had access to usual higher in intervention Benefits of intervention not care counseling but not to than control after 12 sustained after conclusion study CBT months of study For QI-therapy, Relative cost-effectiveness of psychotherapists provided intervention unknown 12â16 sessions of manualized CBT (group or individual)
238 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN aligned in a manner consistent with HMO practices (Katon and Seelig, 2008). As with earlier collaborative care models, the population-based interventions are multidisciplinary and multimodal, but the emphasis is on more of a stepped approach (i.e., intensity of treatment based on the sever- ity and complexity of the depressive illness). These models emphasize flex- ibility and sustainability, as care managers and behavioral health specialists are often centrally located away from the primary care setting. For example, Dietrich and colleagues designed an intervention whereby care managers contacted patients over the phone, monitoring their progress on a monthly basis and relaying their outcomes and treatment recommen- dations to primary care providers (Dietrich et al., 2004b). Psychiatrists supervised these care managers and were available for consultation with the primary care provider as well. Clearly, the emphasis in this intervention was on creating a practical and exportable model, but, given issues surrounding the reimbursement of mental health specialists, the relative cost-effective- ness of this approach can vary with the treatment setting (Dietrich et al., 2004a). Wang et al. conducted a collaborative care study of depression from a slightly different perspective, analyzing the impact of successful treatment on productivity (as well as clinical outcomes) (Wang et al., 2007). De- pressed employees were identified through a behavioral health management company, which used care managers to discuss treatment options. Care managers authorized psychotherapy referrals or pharmacological manage- ment services or both for participants willing to pursue in-person treatment. Others received manualized CBT over the telephone from the care manag- ers, and all employees were encouraged to incorporate self-help practices to promote recovery. Those given the intervention had significantly different (lower) depressive scores and significantly higher job retention and more hours worked. While benefits of this trial may not be generalizable to un- employed or marginally employed individuals, it is certainly applicable to many real-world settings in which employers experience much of the eco- nomic impact of decreased productivity among depressed employees. Pregnancy and Postpartum Settings Fewer data are available on interventions targeting depression during and after pregnancy. Although collaborative care for depression has been extensively studied in the primary care setting, there are few data examin- ing the effectiveness of large-scale, systems-based approaches to antepartum or postpartum depression care (Gjerdingen, Katon, and Rich, 2008). The majority of depression cases during and after pregnancy are not recog- nized, and even more are not treated or are inadequately treated (Evins, Theofrastous, and Galvin, 2000; Georgiopoulos et al., 2001).
TREATMENT OF DEPRESSION IN PARENTS 239 The vast majority of studies on the treatment of antepartum and postpartum depression investigate single-treatment modalities rather than multicomponent interventions or systems-based approaches. Strategies to improve antepartum and postpartum depression care range from screening and education to support. Few studies have rigorously evaluated these strat- egies. There have been a few multidisciplinary interventions, and a number of promising interventions to treat maternal depression in the setting of antepartum and postpartum care are now under evaluation. The merits and limitations of each of these strategies are described below. Patient Education As in the primary care setting, evidence for the use of education to prevent or treat perinatal depression suggests that education is effective only in the context of multicomponent care. A few studies have evaluated interventions aimed at educating pregnant or postpartum mothers about postpartum depression. Hayes and Muller (2004) conducted a randomized controlled trial to evaluate an education intervention to reduce antenatal depression. They distributed an educational package and assessed women once antenatally (at 12â28 weeks) and twice postnatally (at 8â12 and 16â24 weeks). They found that the women in both the study and the con- trol groups were more depressed antenatally than postnatally. There was no difference detected when comparing the intervention group with the control group. Another randomized controlled trial of educational coun- seling on the management of women who suffered suboptimal outcomes in pregnancy found that educational counseling, given on top of routine clinical care, did not impart any additional beneficial effects on the womenâs psychological well-being or quality of life (Tam et al., 2003). Although nonrandomized studies that utilize community health worker models, such as Promotoras de Salud, appear to be highly effective educational models for minority, monolingual or non-English proficient, and rural populations (Getrich, 2007; Ro, Treadwell, and Northridge, 2003). Guideline-Based Treatment Guidelines of the American College of Obstetricians and Gynecolo- gists for perinatal depression address the safety of pharmacological agents during pregnancy and the postpartum period (American College of Ob- stetricians and Gynecologists, 2007). They recommend multidisciplinary care and individualization of a patientâs treatment. Few, if any, studies have investigated whether guideline-based care improves outcomes in the perinatal setting. One study investigated the impact of prenatal depression screening and obstetrical clinician notification procedures with depres-
240 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN sion treatment (Flynn et al., 2006). The researchers found that depression screening combined with systematic clinician follow-up showed a modest short-term impact on depression treatment rates for perinatal depression, but it did not affect depression treatment rates postpartum. The majority of women with major depression were not engaged in treatment throughout the follow-up period despite the interventions. Telephone Support Telecare as the primary intervention for perinatal depression has not been investigated. However, telephone support has been evaluated in a few studies. Bullock et al. (1995) conducted a randomized controlled trial of antenatal women at less than 20 weeks gestation. The women in the inter- vention group received weekly telephone calls throughout their pregnancy. Women were interviewed initially and at 34 weeks gestation. The interven- tion group at 34 weeks had lower depressed mood, lower stress scores, and lower trait anxiety compared with the control group. A recent systematic review found only one study aimed at investigat- ing the effect of telephone peer support on postpartum depression. It was a small study to evaluate the effect of peer support (mother-to-mother) on depressive symptoms among mothers identified as at high risk for postpar- tum depression (Dennis and Kingston, 2008). A total of 42 mothers were randomly assigned to either a control group or an experimental group. The experimental group received standard care plus telephone-based peer sup- port, initiated within 48â72 hours of randomization, from a mother who previously experienced postpartum depression and attended a 4-hour train- ing session. Follow-up assessments were conducted at 4 and 8 weeks after randomization. At the 4-week assessment, 41 percent (n = 9) of the moth- ers in the control group scored higher than 12 on the Edinburgh Postnatal Depression Scale (EPDS), compared with only 10 percent (n = 2) in the experimental group. Similar findings were found at the 8-week assessment. Of the 16 mothers in the experimental group who evaluated the interven- tion, 87.5 percent were satisfied with their peer-support experience. Multidisciplinary Models of Care The American College of Obstetricians and Gynecologists recommends multidisciplinary care for the treatment of antepartum and postpartum depression. Few if any studies have evaluated multidisciplinary care for depression treatment in the obstetrics and gynecology (ob-gyn) setting. A few studies of maternal depression have been instituted in other primary care settings. In Australia, Lumley et al. (2006) conducted a community-randomized
TREATMENT OF DEPRESSION IN PARENTS 241 trial to reduce depression and improve womenâs physical health 6 months after birth. Primary care and community-based strategies embedded in ex- isting services were implemented in a cluster-randomized trial involving 16 rural and metropolitan communities, pair matched, in the state of Victoria. Intervention areas were also provided with a community development of- ficer for 2 years. The intervention strategy was to develop multifaceted edu- cational training programs for general practitioners, including workshops, simulated patients, clinical practice audits, and evidence-based guidelines. Patient education was given in the form of a listing of local services for mothers and babies, two booklets outlining common physical and emo- tional health issues for mothers, a booklet for fathers, a package of free or discounted service vouchers, and a range of mother-to-mother support strategies. Primary outcomes were obtained by postal questionnaires and intent-to-treat analysis (i.e., based on initial treatment intent, not what was administered) was performed. Womenâs mental health scores or probable diagnosis for depression were not significantly different in the intervention and the comparison components. They did not investigate the impact of the intervention on child outcomes. A multicomponent intervention for postpartum depression treatment was evaluated in 230 low-income mothers with major depression attend- ing postnatal clinics in Chile to improve the recognition and treatment of postnatal depression (Rojas et al., 2007). Mothers were randomized to either a multicomponent intervention (n = 114) or usual care (n = 116). The multicomponent intervention included a psychoeducational group, treatment adherence support, and pharmacotherapy if needed. Usual care included all services normally available in the clinics (i.e., therapeutic and psychotherapeutic interventions, medical consultations, and external re- ferral). Using intent-to-treat analysis, the crude mean EPDS score was significantly lower for the multicomponent intervention group than for the usual care group at 3 months (â4.5 on this 10-item scale, 95 percent CI = â6.3 to â2.7, p < 0.0001) and 6 months, although the differences between groups decreased by 6 months. Box 6-1 describes other multicomponent treatment models that are currently being evaluated for treatment of peri- natal depression. As multidisciplinary care and new models of care are evaluated for the treatment of antepartum and postpartum depression, respect for patient preferences should be an integral component of any intervention. Studies have shown that pregnant women have preferences for type of treatment (Sleath et al., 2005). Delivering mental health care treatment in a nonstig- matizing environment, respecting patient choice, and using a multidisci- plinary framework for the delivery of depression care are all likely to be essential components for effective depression treatment in the perinatal period.
242 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN BOX 6-1 Examples of Existing Multicomponent Treatment Models in Perinatal Care A number of other multicomponent interventions and models of care are currently being evaluated for treatment of perinatal depression. â¢ he UIC Perinatal Mental Health Project is a program at the University of Illi- T nois at Chicago (Miller, 2008). The program includes provider training and con- sultation, stepped-care models for perinatal clinics, and MotherCare (guided self-care) as part of the perinatal care. The provider training includes basic education, screening assessment, perinatal psychopharmacology, and detec- tion/intervention for mother-infant relationship problems. The program also provides consultation services via a telephone line with experts in postpartum depression. This comprehensive programâs preliminary findings are promising, but there are no published data yet (Miller, 2008). â¢ he Olmstead Medical Center in Minnesota is currently conducting a random- T ized controlled trial (Yawn, 2008) to test the impact of translation of a universal screening and follow-up program for postpartum depression versus usual care in family physician's offices. The study, which includes 28 family practices in the United States, uses the EPDS for screening and evidence-based tools developed for primary care follow-up of major depression that have been modified for management of postpartum depression (Yawn, 2008). â¢ ollaborative care in the primary care setting has been extensively studied C for the treatment of depression and has consistently been associated with improved outcomes. The collaborative care model has not been studied in the perinatal setting. However, recently Gjerdingen, Katon, and Rich (2008) describe a type of collaborative care model, Stepped Care Treatment of Post- partum Depression, which is being evaluated at seven sites and is sponsored by the National Institute of Mental Health. Mothers from seven family medicine and pediatric clinics are screened for depression during their infantsâ 0â9 month well-child visits, and depressed women are randomized to usual care or stepped care. Stepped-care patients receive patient education and team- based management, involving a primary care provider, a case manager, and a mental health specialist as needed. Both treatment arms are advised to see their primary care providers for initial depression care (medications and/or psychotherapy). Specialty Mental Health Settings Although treatments have been found effective for those in specialty mental health care settings, little has been done to understand the most ef- fective ways to deliver these treatments. Such settings include mental health clinics, psychiatric hospitals, rehabilitation and reintegration, and mental healthârelated departments in institutions. Recently one study investigated
TREATMENT OF DEPRESSION IN PARENTS 243 the effectiveness of using cognitive therapy to treat depression in adults in a clinical settingâin this case a community mental health setting (Merrill, Tolbert, and Wade, 2003). Compared with two benchmark randomized controlled trials of cognitive therapy, delivering the cognitive-behavioral therapy in a community mental health setting found similar results in ef- fectively reducing depressive symptoms. Individual characteristics that led to more favorable outcomes included having less severe depression, having more therapy sessions and more years of education, and having an absence of a comorbid personality disorder. The delivery mechanisms that have been studied to increase the effec- tiveness of treatment in these settings include an algorithm-based disease management program, computer-assisted therapies, and more accessible settings for follow-on treatment. One study used an algorithm-based disease management approach, which involves a sequence of treatment steps to increase the likelihood of response or remission of persistently and severely mentally ill patients (i.e., major depressive disorder) in the public mental health system (Trivedi et al., 2004). This type of delivery holds the promise of consistency of treatment and more efficient use of health care resources. Combined with clinical support and a patient and family educational package, the algorithm ap- proach was found to significantly reduce clinician-rated and self-reported symptoms and overall mental functioning at 1 year compared with usual treatment. The participants included a mix of racial and ethnic groups and were mostly women. Of importance to note is that one-third of the partici- pants had a current alcohol or drug problem, and the treatment-as-usual group had a significantly higher percentage receiving financial assistance. The only exclusion criteria were other mental healthârelated disorders or being hospitalized for detoxification. Another study used a computer-assisted cognitive therapy approach in delivering treatment of major depressive disorder in a psychiatric center (Wright et al., 2005). This approach could decrease costs and improve ac- cess to cognitive therapy for depression. In the computer-assisted therapy, therapist time was reduced after the first visit from 50-minute to 25-minute sessions. Both computer-assisted and standard therapy reduced depres- sion in the medication-free patients and maintained this result in 6-month follow-up evaluations. Exclusion criteria included those with other mental health disorders, including substance abuse and chronic major depression, and those with a history of past treatment using cognitive therapy. Another small, pilot study looked to provide follow-up psychotherapy of women diagnosed with depression in rural, community, mental health clinics in a supermarket rather than in the clinic (Swartz et al., 2002). This approach, in a novel setting, aimed to reduce barriers and the stigma of receiving treatment for low-income women and mothers. This study found
244 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN significant improvement on standardized depression and anxiety scores. Although this study was small, it shows that alternative follow-up sessions may hold promise for specific vulnerable populations that have barriers to care. Community-Based Settings There is little information available on effective interventions targeting depressed parents in community-based settings as alternatives to traditional primary care settings. However, such interventions hold promise to reach individuals who would not generally seek treatment because of a variety of individual, community, and system barriers. These settings include family planning clinics, child care programs, food subsidy programs, schools, and community centers. The majority of studies found during a literature search on the treatment of depression in alternative community settings target adults rather than multiple generations. Strategies to improve the effec- tiveness of the treatment of depression in these settings have incorporated additional approaches to usual care (e.g., CBT, pharmacotherapy), includ- ing social support, problem solving, and referral. A number of promising interventions to treat depressed parents in alternative community-based settings are just beginning to be evaluated. The merits and limitations of each of these strategies are described below. Problem Solving Problem solving has been found to be as effective as pharmacotherapy for major depression in primary care (Mynors-Wallis et al., 1995, 2000). Researchers have investigated the acceptability and effectiveness of prob- lem solving to treat depression in community settings, since it is easily taught to a range of health professionals. Problem solving links depressive symptoms to problems, the problems are clearly defined, and a structured attempt is made to solve the problems. One randomized controlled study in an international multicenter found that using problem-solving techniques delivered at home to treat adults with depression was acceptable and effec- tive in treating depression in comparison to a group that was not given the intervention at 6 month follow-up (Dowrick et al., 2000). Such differences were not seen at 1-year follow-up. Concurrent treatment using antidepres- sants and diagnosis category (i.e., single episode, recurrent episode) did not affect the results.
TREATMENT OF DEPRESSION IN PARENTS 245 Group Psychoeducation Group psychoeducation emphasizes instruction and promotes relax- ation, positive thinking, and general coping and social skills. It has been used in primary care settings and seems effective in preventing depression and improving quality of life. Researchers have investigated the role of adapting cognitive-behavioral techniques to a group educational approach in treating adults with depression in alternative settings. Using community centers or other local places, researchers have found that this approach significantly reduced depressive episodes and increased other social func- tioning in adults diagnosed with a depressive episode at 6 months follow- up, but not significantly so at 1 year (Brown et al., 2004; Dowrick et al., 2000). Researchers have also investigated the role of social support and cop- ing skills in the mental health of those taking care of chronically ill family members in community-based family support interventions. Using a variety of approaches, (e.g., linking the parents of children with similar chronic ill- nesses with family-led educational approaches involving problem solving, communication skills training, and family support) researchers demon- strated improvements in the parentâs or caretakerâs psychological well-being (i.e., anxiety, depressive symptoms) that were sustained for 6 months after the intervention phase (Ireys et al., 2001; Pickett-Schenk et al., 2006). Although the evaluation literature is limited, group psychoeducation holds promise in alternative community settings. Researchers note the ease of training diverse health professionals and the limited infrastructural needs in implementing this approach. In addition, psychoeducation in these alter- native community settings may reach out to individuals who never sought treatment before. One researcher noted that 40 percent of the experimental group (i.e., those diagnosed with a depressive episode) had never seen a health practitioner for their depression (Brown et al., 2004). Health Communication Health communication is one tool for promoting or improving health. It can increase knowledge, influence or reinforce perception, beliefs, and attitudes, and increase demand or support for health services. Combined with other strategies, it can overcome barriers or system issues. However, health communication alone cannot compensate for inadequate health care or access to health care (Loughery et al., 2001). Australian researchers developed an evidence-based consumer guide about effective depression treatment options to change attitudes and take actions to reduce depres- sion in adults. In a randomized controlled study, this evidence-based guide was found to be useful in changing attitudes about treatment, but it did
246 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN not significantly change depressive symptoms compared with a general informational brochure (Jorm et al., 2003). This study illustrates a promis- ing opportunity to increase the knowledge and attitudes of individuals with depressive symptoms. Web-Based Interventions The rapid expansion of the Internet into the homes of a large segment of the population offers new treatment opportunities. Women, minorities, and the elderly are increasingly using the Internet, and its use continues to rise, particularly among ethnic minority individuals. In 2005, the Pew Internet and American Life Project reported that 79 percent of web users reported using the Internet to obtain health information, with 23 percent searching for specific information related to depression, anxiety, and other mental health issues (Fox, 2005). Internet-based interventions are particu- larly attractive in the setting of depression treatment. The Internet offers anonymity, avoids the stigma of seeing a therapist, offers the maximum flexibility in terms of access to treatment (access in oneâs home, in the office, in the middle of the night, etc.), allows for monitoring and feedback, and has the potential to provide treatment to patients who do not seek help for depression (Christensen, Griffiths, and Jorm, 2004; Spek et al., 2007). One treatment, cognitive-behavioral therapy, is a structured treatment approach that has been adapted to a computer format. Previous studies have demonstrated that computerized cognitive-behavioral therapy is effec- tive for the treatment of depression (Kaltenthaler et al., 2002). CBT has also been found to be effective when provided over the Internet (Christensen, Griffiths, and Jorm, 2004; Clarke et al., 2005). Christensen, Griffiths, and Jorm (2004) tested the efficacy of a psychoeducational website offering information about depression and an interactive website offering CBT to reduce symptoms of depression. They recruited by survey 525 community residents with increased depressive symptoms and randomized them into three groups: psychoeducation, CBT, and attention placebo. For the first two intervention groups, lay interviewers contacted participants weekly by phone to direct their use of the websites. Participants were given guides out- lining the weekly assignments and details about the websites. The placebo participants were phoned weekly by the interviewers to discuss lifestyle and environmental factors. Both interventions delivered via the Internet were more effective in reducing symptoms of depression than the control intervention. CBT reduced dysfunctional thinking, and the psychoeduca- tion group had an improved understanding of effective evidence-based treatments for depression (Christensen, Griffiths, and Jorm, 2004). There is also evidence that these benefits were sustained at 6 and 12 months (MacKinnon, Griffiths, and Christensen, 2008).
TREATMENT OF DEPRESSION IN PARENTS 247 Successful programs that use Internet-based treatment approaches (in- cluding CBT) incorporate some telephone or e-mail contact, and adherence to Internet treatment programs is better when an interviewer or counselor provides tracking, contact, or support (Christensen et al., 2006). A meta- analysis on the use of Internet-based CBT for depression and anxiety found that the study with the highest effect size in depression treatment was an Internet-based intervention with therapist support (Spek et al., 2007). It was not the type of problem (anxiety or depression) that explained the ef- fect size but rather whether support was added or not. Clarke et al. (2002) conducted two randomized trials to test whether an Internet-based cognitive therapy, self-help program was effective in reducing depression. In the first trial, they randomized 299 adults with highly elevated depressive symptoms to either access or no access to the Overcoming Depression on the Internet (ODIN) website. Subjects were free to receive treatment as part of usual care. Participants in the intervention group infrequently used the website, and they found no effect of the Inter- net program on the reduction of depressive symptoms. In their second trial, they randomized 255 persons to either usual control group without access to the Internet site, ODIN program group with postcard reminders, or ODIN program group with telephone reminders. Intervention participants had a significantly greater reduction in depression compared with the con- trol group. There was no difference in the reduction in depression between the intervention group with telephone reminders and the intervention group with postcard reminders (Clarke et al., 2005). Studies have shown that online, brief, CBT-based interventions are not as effective as extended CBT (Christensen et al., 2006). Other studies con- firm that web-based interventions with support or contact (e.g., minimal therapist contact, e-mail contact, e-mail feedback) are effective for reduc- ing depressive symptoms (Andersson et al., 2005; van Straten, Cuijpers, and Smits, 2008). Interestingly, while the majority of Internet-based pro- grams use CBT or problem-solving strategies, a trial that tested a depres- sion literacy website (offering evidence-based information on depression and its treatment) was also effective in reducing symptoms of depression (Christensen, Griffiths, and Jorm, 2004). Web-based perinatal and postpartum depression treatment and inter- vention programs are well suited for the everyday lives of expectant and new mothers. Internet-based programs are accessible to individuals who are less inclined to seek psychological services (Bai et al., 2001; Christensen and Griffiths, 2002), such as women suffering from perinatal and postpartum depression. Pregnant women screening positive for depression can be en- couraged to seek medical and psychological consultation for this condition so it can be treated prior to delivery, which will have an immediate and long-term desired impact on both the mother and her newborn baby. Thus,
248 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN health-related websites have the potential of functioning as viable resources to eliminate disparities in service availability or access to care. There are a number of examples of educational or support websites or community programs that have not been evaluated but may be helpful to parents and families experiencing depression. A few examples of such programs are Postpartum Support International, Postpartum Dads, Bootcamp for New Dads, Heartstrings (postpartum depression), Families First, and Postpar- tum Education for Parents. Workplace Interventions Depression significantly impacts an employeeâs ability to work (Rost, Smith, and Dickinson, 2004). Multiple studies have demonstrated that depression is associated with increased absenteeism and reduced productiv- ity during days at work (Rost, Smith, and Dickinson, 2004). Depression has been found to be the most common âsevereâ mental health diagnosis encountered in employee assistance programs (Conti and Burton, 1994) and is one of the most costly of all health problems for employers (Stewart et al., 2003). Stewart et al. (2003) estimated the impact of depression on labor costs (work absence and reduced performance while at work) in the U.S. workforce to be $44 billion per year, not including costs for short-term and long-term disability (Stewart et al., 2003). In their study, workers with depression reported significantly more total health-related lost productive time than those without depression (mean, 5.6 hours per week versus an expected 1.5 hour per week), and 81 percent of the lost productive time costs were explained by reduced performance while at work. Given the large economic burden of depressive illness, it is important to evaluate the impact of depression treatment programs on work out- comes. Studies in the primary care setting have evaluated the impact of enhanced depression treatment programs on work outcomes. Rost, Smith, and Dickinson (2004) randomized 12 primary care practices to enhanced or usual care. Enhanced care clinicians and care managers received brief train- ing on high-quality depression care (i.e., guideline-based pharmacotherapy or psychotherapy during the acute phase of treatment) for depressed pa- â See http://postpartum.net/. â See http://postpartumdads.wordpress.com/. â See http://www.bootcampfornewdads.org/. â See http://postpartum.net/resources/women-mothers/heartstrings/. â See http://www.familiesfirstri.org/index.html. â See http://www.sbpep.org/. â Axis I Level: According to the definitions and criteria of the International Statistical Clas- sification of Diseases and Related Health Problems, 10th revision, and the Diagnostic and Statistical Manual of Mental Disorders, 4th edition.
TREATMENT OF DEPRESSION IN PARENTS 249 tients during treatment. Care managers followed patients and encouraged treatment adherence. Employed patients in the enhanced care condition reported 6.1 percent greater productivity and 22.8 percent less absenteeism over 2 years. Despite the large cost to employers, studies evaluating employer-based programs for screening, outreach, and disease management efforts are scarce (Stewart et al., 2003). A recent study evaluated the impact of an employer-based depression care management system (Wang et al., 2007). A randomized controlled trial of 604 employees with depression covered by a behavioral health plan tested whether telephone screening, outreach, and care management for depressed workers had any impact on clinical outcomes and work productivity (Wang et al., 2007). The program en- couraged workers to enter outpatient treatment psychotherapy and/or use antidepressant medications, monitored treatment quality continuity, and attempted to improve treatment by giving recommendations to providers. The outcomes of interest were depression severity and work performance at 6 and 12 months. The intervention group had significantly lower Quick Inventory of Depressive scores (RR of recovery = 1.4, 95 percent CI = 1.1â2.0, p = 0.009) and significantly higher job retention (RR = 1.7, 95 percent CI = 1.1â3.3, p = 0.02). Workplace initiatives to screen and treat depression are increasing, although evaluations of these programs have not been published. For ex- ample, the MidAmerica Coalition on Health Care collaborated with the city of Kansas City, Missouri, and 15 large area employers to develop the Com- munity Initiative on Depression (CID) in 2000 (Mid-America Coalition on Health Care, 2009). The project was designed to reduce community and workplace depression by raising awareness, reducing stigma, and improv- ing depression care quality for depressed employees and their dependents. It is a multiphase project with a projected timeline of 3 to 5 years. Phase I included a multilevel needs assessment among employees and employers regarding knowledge, attitudes, health care use, and the costs of depression and depression care among 13 of the 15 CID-partnered work sites. It also included extensive educational programs for employers, employees, provid- ers, and health plans. These educational efforts were continued in Phase II, along with a series of work site and clinical research projects, including a study of employer benefit design practices, and a health planâmedical office manager collaboration to reduce outpatient coding barriers for depression care. Phase III will include a community public relations campaign to in- crease depression awareness and reduce stigma, a postintervention reassess- ment of depression help-seeking behavior among employees, and depression care quality profiling of onsite occupational health care providers. Given the enormous costs of depression in the workplace, investment in enhanced depression care is essential. Enhanced depression care improves
250 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN absenteeism and productivity among employees. Accumulating evidence suggests that improvements in depression management in employed work- forces offset the costs of such programs. Wang et al. (2006) estimated the costs and benefits of enhanced depression care for workers from the societal and employer-purchaser perspectives in a recent study. They found that screening and depression care management for workers result in an incremental cost-effectiveness ratio of $19,976 per quality-adjusted life year relative to usual care, and, from the employerâs perspective, enhanced depression care yielded a net cumulative benefit of $2,895 after 5 years. The case for the cost-effectiveness of enhanced depression care for workers would probably be even stronger if the costs of parental depression on children and families were fully captured in these analyses from the so- cietal perspective. A human capital development and household production economic model of the impact of parental depression on children highlights the costs of depression on parents individually and on their children and families, as well as the longer term economic consequences of parental de- pression on children. The evidence demonstrates that parental depression is associated with reduced family resources; increased child health risks; nega- tive human capital outcomes in children, such as poorer cognitive and be- havioral outcomes (Farahati, Marcotte, and Wilcox-GÃ¶k, 2003; Meara and Frank, 2008); poorer academic performance; and poor social outcomes in children such as impairment in marital and work relationships (Weissman et al., 2006). The costs of such negative outcomes are rarely included in cost-effectiveness models evaluating the impact of depression treatment. Furthermore, the longer-term costs of parental depression are not in- cluded in cost-effectiveness models. Exposure to parental depression in childhood leads to increased rates of work difficulty, health problems, and health service use. Additional studies have linked negative school and so- cial outcomes with negative outcomes in adulthood, such as reduced levels of employment, greater contact with the justice system, and increased use of public services (Fronstin, 2005; Haveman and Wolfe, 1995; Trostel, Walker, and Woolley, 2002). The economic costs of parental depression on parents, children, families, and society are enormous, and the case for cost-effectiveness of depression treatment may be much stronger when cost models include a comprehensive assessment of the costs of depression on parents, children, and families. Home Visitation A wide range of exclusively home visiting programs and programs that included home visiting among their interventions have been fielded, although only a few were rigorously evaluated. The number of home visitingâbased programs in the United States has been estimated in the
TREATMENT OF DEPRESSION IN PARENTS 251 thousands (Gomby, Culross, and Behrman, 1999). The Parents as Teachers model has over 3,000 sites alone. At any given time, an estimated half- million families are receiving some form of home visitation services, ranging from a single postpartum âwelcome homeâ visit by a public health nurse to multiyear intensive services (Gomby, Culross, and Behrman, 1999). Initially formulated to prevent child maltreatment, home visiting programs also seek to promote optimal child development and improve maternal well-being. Home visits can begin prenatally and may continue until the child is 2 to 5 years of age, depending on the model. Programs typically target parent- ing skills, the mother-child relationship, home safety, maternal health and educational/occupational attainment, and infant health, especially immu- nization and nutrition. Many of the correlates and predictors of maternal depression, such as low self-esteem, stress related to child care, low social support, and poor marital relationships (Goodman and Gotlib, 1999), are at least partly addressed by the major home visiting models, such as the Nurse-Family Partnership and Healthy Families America. Observational studies suggest that, for some mothers, participation in a home visitation program reduces scores on standard depression measures, but they may not be clinically significant. A review of a diverse set of European home visitation programs for new mothers identified the reduction of maternal depression as the most robust outcome common for many of them (Lagerberg, 2000). Investigating the impact of a paraprofessional home visitation model on maternal depres- sion, Navaie-Waliser et al. (2000) found that, after 1 year, home-visited mothers reported a decrease in depression compared with a demographi- cally similar control group. A community-based, paraprofessional home visitation program did not, however, have any effect relative to a matched comparison group on CESD scores for pregnant adolescents (Barnet et al., 2007). Over 30 percent of both the intervention and control groups scored 22 or higher on the CESD. The Ammerman et al. (2009) study of over 800 mothers found only a minimal average decrease of about two points (12.29 Â± 8.9 to 10.12 Â± 8.9, statistically significantly different [p < .001], but not clinically significant) on the Beck Depression Inventory (BDI-II) over a 9- month period for the sample as a whole. The evaluation of Healthy Families Massachusetts (Jacobs et al., 2005) concluded that approximately half of the mothers scoring in the depressed range were chronically depressed. In the aggregate, the extant data suggest that home visiting alone has a rela- tively minimal, nonclinical impact on maternal depressive symptoms. Home visitation programs potentially provide an important context in which to identify and intervene in parental depression and associated parenting difficulties. The high rate of depressed mothers encountered by home visitation programs, together with the negative impacts that maternal depression has on the effectiveness of home visitation, has led to a number
252 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN of home visitationâbased interventions. These can be categorized into three basic strategies: (1) screening by the home visitor with referral to com- munity mental health services (discussed in Chapter 5); (2) mental health consultation provided to home visitors, who in turn are expected to deliver an intervention to depressed mothers; and (3) in-home treatment provided by mental health specialists in addition to the standard home visitation services. Examples of strategies 2 and 3 are described below. No randomized clinical trial outcomes have yet been published for any of these strategies. Thus, at this time, these strategies should be regarded as promising but unproven. However, studies are under way to investigate the effectiveness of the latter two strategies, which embed depression treat- ment services in home visiting programs instead of depending on referrals to the community for treatment. This approach is warranted on the basis of several studies that indicate that home visitors as a group are not good at connecting families with community-based services for depression, domestic violence, or substance abuse (Hebbeler and Gerlach-Downie, 2002; Tandon et al., 2005). These integrated treatment models, however, face the daunt- ing task not only of providing effective depression treatments but also of addressing the often considerable psychiatric and social comorbidity found in the families served by home visitation programs. Mental Health Consultants to Home Visitors Boris et al. (2006) provided a qualitative description of the incorpo- ration of mental health consultants into nurse home visitation teams in Louisiana. The mental health consultants first received 4 months of training in infant mental health and then provided consultation and support to the home visiting nurses. They conducted ongoing case conferences with the nursing team and provided additional one-on-one consultation for nurses with difficult cases. Telephone consultations proved to be the most effective. Initially some of the nurses expressed concern or skepticism about the role of the mental health consultant, and it took approximately a year for them to be integrated into the team. Some nurses reported feeling overwhelmed by the recommendations of the mental health consultant in addition to ful- filling their own duties. The mental health consultants, who were primarily experienced with adults, reported feeling like novices with some of the in- fant mental health issues. Boris et al. (2006) concluded that adding a mental health consultant to a team of nurse home visitors is complex but offers promise in reaching a large number of families with mental health needs.
TREATMENT OF DEPRESSION IN PARENTS 253 Depression Treatment Delivered in Home Visitation Efforts have been made to adapt cognitive-behavioral therapy, a well- established office-based treatment for depression, for delivery in the context of a home visitation program. Ammerman et al. (2005) conducted an open trial of in-home cognitive-behavioral therapy with 26 first-time mothers in a home visitation program. Subjects scored 20 or higher on the screening BDI-II and were diagnosed with major depression on the Primary Care Evaluation of Mental Disorders (PRIME-MD), a semistructured diagnostic interview designed for clinical settings using DSM-IV criteria for common mental disorders. A total of 24 mothers received the full course of 15 in- home CBT sessions, and 2 received partial treatments of 11 and 8 sessions, respectively. An intent-to-treat analysis found that 84 percent of the moth- ers had either fully (69 percent) or partially (15 percent) remitted major depressive disorder on the PRIME-MD. There was a significant reduction (p < 0.001) in BDI-II scores from a pretreatment mean of 30.4 (Â± 8.2) to a posttreatment mean of 13.7 (Â± 9.4). Maternal function as measured by the Brief Patient Health Questionnaire was significantly improved, as was self-reported maternal parenting satisfaction as measured by the Maternal Attitudes Questionnaire. In-home CBT is currently undergoing a random- ized clinical trial funded by the National Institute of Mental Health. Substance Use Disorder Treatment Setting Evidence has repeatedly supported the link between substance use dis- orders (SUDs) and depression and the finding that the combination of these disorders can negatively impact the course of each illness, its treatment, and long-term outcomes (Dodge, Sindelar, and Sinha, 2005; Quello, Brady, and Sonne, 2005). Adequate treatment for depression reduces substance use disorders, and treatment of substance use disorders has been found to reduce depression (Davis et al., 2008). Among individuals seeking treatment for illicit substance use disorders, 30.5 percent met criteria for at least one major depressive episode in their lifetime (Rounsaville et al., 1991) and 60 percent had a comorbid mood disorder (Grant et al., 2004). Among alcohol treatment seekers, 40 percent had a co-occurring mood disorder (Grant et al., 2004). One of the most serious consequences of the combination of a substance use disorder and depression was found in a study showing that among patients with major depressive disorder, those with a substance use disorder were at greatest risk for suicide (Young et al., 1994), and over 66 percent of those who committed suicide had a substance use disorder (Rounsaville et al., 1991). The diagnosis of a mood disorder in the presence of an active SUD is challenging owing to the fact that recent cessation of drug use can produce
254 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN depressive mood states. The presence of a mood disorder may be mistakenly concluded if the patient is evaluated under the influence of or during active withdrawal from certain substances (Quello, Brady, and Sonne, 2005). For example, a patient under the influence of alcohol can manifest symptoms of mania or hypomania. In contrast, symptoms of alcohol (and/or cocaine) withdrawal may appear as dysphoria and depression (DSM-IV). While screening for depression typically occurs at SUD treatment intake, assess- ment and diagnosis are most accurately determined after withdrawal is complete and abstinence has been achieved (Brown and Schuckit, 1988). However, it is recognized that the severity of depressive symptoms must be carefully assessed, and immediate treatment may be required for severe depression and in order to initiate treatment (Quello, Brady, and Sonne, 2005). Behavioral Treatments Recent efforts to treat depression and substance use disorders have fo- cused on integrated treatments (Brown et al., 1997; Weiss et al., 2000). As described above, CBT is among the most powerful behavioral treatments for depression and also has proven efficacy for substance use disorders. A manual for CBT with substance use disorders is available from the Na- tional Institute on Drug Abuse (Carroll, 1998). Only one study has com- pared CBT for depression with a relaxation training control, i.e., condition plus treatment as usual for alcohol in patients who are currently alcohol dependent and with elevated depressive symptoms (BDI score > 9). CBT participants showed, on average, significant improvements in depressive symptoms relative to participants in the control condition. The average ef- fect size was 0.85. CBT participants showed, on average, more abstinence and reduced drinking at 3- and 6-month follow-up. Changes in depressive symptoms were reported to mediate the number of drinks ingested daily (Brown et al., 1997). More recently, a comparison of LETS Act!, a manual-based interven- tion modification of the Behavioral Activation Treatment for Depression for the SUD inpatient population, was compared with a control group of usual treatment. The results showed that, on average, LETS Act! partici- pants had greater reductions in depressive symptoms compared with the usual treatment group. This potentially promising treatment is unique in that it provides initial data in the development of a specialized depression- centered treatment for SUD patients with depressive symptoms (Daughters et al., 2008). Box 6-2 describes other integrated treatment models of care that have been used in substance abuse disorder settings. Both of these models were sites for the Substance Abuse and Mental Health Services Administrationâs Women, Co-Occurring Disorders Study. Results from this study provided
TREATMENT OF DEPRESSION IN PARENTS 255 BOX 6-2 Example Treatment Models in Substance Abuse Disorder Settings Specific to parenting women and families, two integrated models of care are promising programs with strong clinical services and initial evidence to support their use. â¢ he Boston Consortium of Services for Families in Recovery Model, un- T der the Boston Public Health Commission, has an active collaborative system of services for women with SUDs as well as mental health and trauma issues (Amaro et al., 2005). The system includes not only outpatient treatment but also residential treatment programs that serve women and their children, fo- cusing on culturally specific approaches to provide trauma-informed substance abuse treatment, parenting training, case management, and coordination of mental health services through partner providers. â¢ ROTOYPES: The Centers for Innovation in Health, Mental Health, and Social P Services is a nonprofit corporation in California that provides substance abuse and mental health treatment through a variety of programs, as well as addi- tional services, such as housing and domestic violence programs (Brown et al., 2004). The PROTOTYPES Womenâs Center is a residential treatment program for women and their children with a special focus on women with co-occurring disorders, such as mental illness, trauma, and HIV/AIDS. The residential pro- gram provides onsite comprehensive services that include substance abuse treatment, mental health services for women and their children, medical care, educational programs and vocational training, case management, parenting training, and programs for children, including child care and Head Start. Both of these programs participated in the Co-Occurring Disorders and Violence study funded by the Substance Abuse and Mental Health Services Administra- tion. This quasi-experimental treatment outcome study showed that, on average, compared with usual care, more integrated treatment for substance use disorders, mental health, and interpersonal trauma was associated with modest yet greater improvements in womenâs interpersonal violence and mental health symptoms when examined at 12 months (Morrissey et al., 2005). These programs have also shown that treatment retention is greater for the integrated model of care com- pared with treatment as usual (Amaro et al., 2007a). evidence that integrated treatment for mental illness, trauma, and addiction produced better outcomes than did standard substance abuse treatment. Together these findings show that integrated treatment produced better outcomes with respect to drug use and mental health symptomsâincluding depressionâand trauma symptoms (Amaro et al., 2007b; Morrissey et al., 2005); treatment retention (Amaro et al., 2007a) and HIV risk behaviors (Amaro et al., 2007c).
256 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Medications Compared with behavioral treatments, a somewhat larger body of work exists that examines medications to treat depression in SUD patients, including a meta-analysis (Nunes and Levin, 2004) and a recent review (Tiet and Mausbach, 2007). Nunes and Levin (2004) identified 14 studies from 300 studies examining the issue of treating depression with medi- cation in SUD patients. Tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) were the most common agents examined. Of the 14 studies, 57 percent (n = 8) reported a modest effect of medications to treat depression in this population. The pooled effect size from the random- effects model was 0.38 (95 percent CI = 0.18â0.58). The results appeared to be more robust in alcohol-dependent patients than drug-dependent pa- tients. It should be noted that the heterogeneity of effects on the measure of depression (HRSD) was significant (p < 0.02) and related to the placebo response. Overall, the results suggested that when medication effectively treats depression, it also appears to help reduce the use of substances (Nunes and Levin, 2004). The SSRIs were concluded to be first-line medications based on their tolerability and low toxicity relative to tricyclic antidepressants. The review concluded that existing treatments for reducing depressive symptoms also work in depressed SUD patients, and efficacious treatments of SUDs also reduce substance use in depressed SUD patients. However, the efficacy of integrated treatments remains uncertain given the limited data in this area and the methodological challenges that limit confidence in strong conclusions from the existing data (Tiet and Mausbach, 2007). Knowledge is clearly lacking in the interaction that depression medications and substance use may have on patients. While recent research is focused on developing and examining behavioral and pharmacotherapies in depressed SUD patients, to the best of our knowledge no studies have examined these interventions specifically in parents with depression and SUDs or examined the parenting outcomes that these treatments may help improve. Further- more, while effective treatments exist for depressed patients with SUD comorbidities, the current systems of SUD treatment and mental health treatment often operate in parallel rather than in integration, making opti- mal care a continuing challenge (Quello, Brady, and Sonne, 2005). VULNERABLE POPULATIONS Low-Income and Minority Mothers The impact of treatment interventions and, more specifically, collab- orative care models on parental depression has not been rigorously studied
TREATMENT OF DEPRESSION IN PARENTS 257 in vulnerable populations. Previous investigations of collaborative care models in the general depressed population have featured a preponderance of female subjects, most of whom were of childbearing age and many, pre- sumably, were mothers. Few if any of these studies conducted a subgroup analysis of parents or looked explicitly at the impact of interventions on the functioning and well-being of the family unit. Interest in increasing the engagement and treatment of depression in minority or low-income individuals has led researchers to study effective strategies to deliver treatment to these specific groups (see Ward, 2007). One randomized controlled study compared guideline-based treatments with case management and referral to community care (i.e., education about treatment in the community) in minority and low-income mothers with major depression recruited from public clinics (Special Supplemen- tal Nutrition Program for Women, Infants, and Children, Title X family planning). Overall, this study found that guideline-based treatment with case management was more effective for reducing depressive symptoms at 6 months than was referral to community care (Miranda et al., 2003). Results also suggest that pharmacotherapy interventions may be more effec- tive than psychotherapy. Although those with current substance or alcohol abuse were excluded, more than one-third reported trauma, including rape or child abuse victimization, and half reported domestic violence and post- traumatic stress disorder. Long-term follow-up revealed similar results after 1 year and have similar cost-effectiveness ratios compared with those in advantaged populations (Miranda et al., 2006; Revicki et al., 2005). Although the research is limited, this study found that evidence-based interventions appear effective for poor and minority women if the treat- ment scenario was culturally and linguistically appropriate, and if sup- ports to overcome barriers to care (i.e., transportation and child care) were provided. Interventions were appropriately tailored within a cultural context and provided in the patientâs preferred language (i.e., providing care in Spanish). Finally, professionals keenly sensitive to low-income and minority populations were employed in this study (Miranda et al., 2003). A small study by Grote et al. (2009) tested whether culturally enhanced brief interpersonal psychotherapy (enhanced IPT-B) was effective in reducing de- pression among low-income women attending a large, urban ob-gyn clinic. Enhanced IPT-B consisted of an engagement session, eight acute IPT-B ses- sions before the birth, and maintenance IPT up to 6 months postpartum and was specifically enhanced to make it culturally relevant to low-income and minority women. They conducted a randomized controlled trial with 53 pregnant patients and found significant reductions in depression diagno- ses and symptoms and significant improvements in social functioning before childbirth and at 6 months postpartum in the IPT-B participants compared with the enhanced usual care group. This study lends support to the notion
258 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN that evidence-based therapies for depression can be effective when appro- priately tailored for ethnic and disadvantaged populations. BARRIERS TO TREATMENT Despite the efficacy of depression treatments, this disorder is under- treated. Adults experiencing major depression are often not inclined to seek treatment for their illness. Barriers for pregnant and postpartum mothers with depression are similar to those in the general population, as described in Chapter 1, but they also include the tendency to normalize depressive symptoms and to dismiss them as self-limiting and the fear of losing oneâs baby (Dennis and Chung-Lee, 2006). The diagnosis of postpartum depres- sion is also complicated by the overlap of common postpartum symptoms with symptoms of depression (e.g., lack of sleep, change in eating). And, racial, ethnic, and non-English speakers are also less likely to seek or receive quality interventions (see AlegrÃa et al., 2008). Furthermore, the lack of insurance or underinsurance, in which the benefit package lacks comprehensive insurance, limits the access and use of mental health services for those seeking depression care. Often those with coverage are limited because of high cost-sharing methods (i.e., copay- ments, premiums) and benefit restrictions (i.e., annual or lifetime limits) (U.S. Surgeon General, 1999). However, recent efforts regarding mental health parity have picked up momentum at the federal level, with coopera- tion by state agencies. For example, the passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (P.L. 110-343) requires employers with 50 or more employees to offer health plans with mental health and substance abuse disorders coverage equal to all other medical and surgical benefits covered by the plan. Barriers to treatment operate at both institutional level and sociocul- tural levels. This categorization is not mutually exclusive, however, and there exists substantial mutual influence and interaction between the two realms. At the institutional level, lack of health insurance overall and lack of insurance coverage (and the associated high cost of care) for mental health services, referral system fragmentation, and the limited availability of mental health specialists are the primary factors limiting vulnerable populationsâ access to depression treatment (Das et al., 2006; Kung, 2004; Lazear et al., 2008; Thompson, Bazile, and Akbar, 2004; Van Voorhees et al., 2007; Wong et al., 2006). When they do receive depression treatment, racial and ethnic minority groups are more likely to seek and receive mental health care from the primary care setting. However, primary care physi- cians are not typically trained in the intricacies of diagnosing depression or any other mental illnesses, resulting in the underrecognition, diagnosis, and treatment of depression (Van Voorhees et al., 2007). The lack of ap-
TREATMENT OF DEPRESSION IN PARENTS 259 propriate language services further limits access and quality treatment to the already limited number of mental health services for those with limited English proficiency (Center for Reducing Health Disparities, 2007; Kung, 2004; Lazear et al., 2008; Scuglik et al., 2007; Wong et al., 2006). Differential access to insurance and providers does not account for all the disparities in rates of depression treatment, however. A study by Padgett and colleagues found that even in an insured population of federal em- ployees, whites were 1.7 times more likely to visit outpatient mental health providers and make 2.6 more mental health visits per year compared with their African American and Hispanic counterparts (Padgett et al., 1994). Moreover, after accounting for differences at the institutional level, there remain differences in treatment-seeking behaviors between non-Hispanic whites and minority populations. Disparities are likely to be attributable to sociocultural barriers and social determinants of health (World Health Organization, 2008), which operate at the level of both the community and the individual patient. According to the Surgeon Generalâs assessment, stigma plays a key role in shaping barriers to treatment that operate at the sociocultural level (U.S. Department of Health and Human Services, 2001), which manifest themselves in underutilization of mental health services, particularly among racial and ethnic minorities. Communities have different norms and beliefs surrounding depression, which include differential definitions of the illness and varying views on appropriateness of treatment options (Cooper et al., 2003; Givens et al., 2007; Scuglik et al., 2007; U.S. Department of Health and Human Services, 2001). These beliefs can be associated with stigma- tizing attitudes toward and privacy concerns among those manifesting symptoms of or seeking treatment for depression, thus acting as sources of denial in recognizing symptoms and as barriers to seeking and adhering to treatment (Ayalon and Alvidrez, 2007; Das et al., 2006; Grandbois, 2005; Interian et al., 2007; Nadeem et al., 2007; Sanchez and Gaw, 2007; Scuglik et al., 2007; Van Voorhees et al., 2007). Moreover, in some close-knit communities, where âboundary maintenanceâ is perceived as a necessity for maintaining community cohesion, those who âleave the communityâ to seek mental health services may be subjected to severe negativity (Van Voorhees et al., 2007). This problem is further compounded by low levels of mental health literacy found in many communities, especially as it relates to mainstream definitions, availability, and effectiveness of treatments for depression (Ayalon and Alvidrez, 2007; Corrigan et al., 2004; Jorm et al., 2003; Kung, 2004; Thompson, Bazile, and Akbar, 2004). The mental health encounter is unique, requiring a higher level of understanding, empathy, and sensitivity. Racial and ethnic minorities experience issues of trust and linguistic barriers and emphasize a greater need for provider cultural and linguistic sensitivity (Chapa, 2009).
260 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN In many minority communities, there is an additional layer of mistrust of government agencies. This can be traced to historical and ongoing ex- perience of oppression and marginalization (Center for Reducing Health Disparities, 2007; Grandbois, 2005). Such âmistrust may include stories of how governmental agencies have determined âneedsâ of a community without consulting with the community being served, promised particular services that were never delivered, or come into a community with a service or program that was not sustainedâ (Center for Reducing Health Dispari- ties, 2007, p. 10). For example, American Indian communities have been found to avoid accessing mental health treatment because traditional healing practices are often not equally afforded the attention or respect given to mental health treatments implemented by Western psychology theory, which further ex- acerbates mistrust, perpetuates marginalization, and impedes depression treatment (Center for Reducing Health Disparities, 2007). Additionally, the sense of mistrust extends beyond government agencies to include a mistrust of Western models of care or mainstream mental health services altogether (Jesse, Dolbier, and Blanchard, 2008; Whaley, 2004; Wong et al., 2006). The limited number of racial and ethnic minority providers has resulted in a large proportion of race-discordant patient-provider relationships, often leading to adverse mental health treatment experiences, like miscommu- nication and diagnostic bias, thus creating adverse treatment experiences, further eroding trust, reinforcing stigma, and perpetuating treatment and service underutilization (Ayalon and Alvidrez, 2007; Das et al., 2006; Lazear et al., 2008; Thompson, Bazile, and Akbar, 2004; Van Voorhees et al., 2007). Simple variation in treatment preferences among different populations and between individualsâwhich may be, at least partially, the result of experiences with stigma and mistrustâfurther affect their utilization of mental health services and the appropriateness of the care they receive (Jesse, Dolbier, and Blanchard, 2008; Van Voorhees et al., 2007). Studies have found that community-based resources (such as ethnicity-specific com- munity agencies and churches) may be the preferred sources of depression- related support and care for minority communities, even though many such institutions may not be adequately equipped to provide psychiatric services (Brown, 2004; Sadavoy, Meier, and Ong, 2004; Sleath and Rubin, 2002). Yet others may seek primarily alternative sources of treatment, such as informal systems of care (Lazear et al., 2008) or non-Western approaches (Sanchez and Gaw, 2007; Wong et al., 2006), because of either cultural or personal preferences, stigma, negative experiences with the mental health care system, or alternative explanatory models of healing precluding their contact with the formal health care system (Shin, 2002; Van Voorhees et al., 2007).
TREATMENT OF DEPRESSION IN PARENTS 261 Studies have shown that cultural factors may be protective of men- tal health status. When comparing Mexican immigrants with U.S. born Mexican Americans, researchers found that Mexican Americans and non- Hispanic whites born in the United States have a higher risk (a ratio of 2â3 to 1) for developing psychiatric disorders including major depressive episode than their foreign-born counterparts who have emigrated to the United States (Grant et al., 2004; Vega et al., 1998). ENGAGING VULNERABLE POPULATIONS The relationship between mental health disparities, access to care, and quality of care is complex. Behavioral health care in the United States is fragmented and fraught with barriers, regardless of the point of entry. For racial and ethnic minority populations it includes poor quality, limited ac- cess to care, and a lack of utilization and little care coordinationâoften leading to more chronic and disabling mental health conditions (Chapa, 2009; U.S. Department of Health and Human Services, 2003). Furthermore, the existing knowledge on the interrelationship of these three areas has not been translated into specific programs (Aguilar-Gaxiola et al., 2002). When seeking to eliminate mental health disparities, treatment inter- ventions and single-component interventions, such as physician education, depression screening (Gilbody et al., 2003), and facilitated access to care (Brown et al., 1999), alone are not effective at reducing disparity gaps. Poor treatment rates and outcomes may be due to a lack of minority rep- resentation in the mental health provider workforce. Research suggests that enhancing quality in mental health care could potentially lead to the elimination of mental health disparities (Miranda et al., 2008). A culturally respectful environment coupled with culturally and linguistically competent providers may be a key to disparities elimination, along with numerous, systemic, multicomponent, chronic disease management interventions. Targeting the health care system was found to be effective at reducing disparities. One highly effective approach is clinical case management. This patient-focused strategy may be particularly beneficial for ethnic minorities because it assists patients unfamiliar with and at the margins of the tradi- tional mental health care system to navigate the already fragmented health care system. Moreover, case managers contribute to mental health literacy, helping to assuage adverse attitudes toward depression treatment protocols and stigma, alternative explanatory models, and variations in symptom descriptions. Case managers assists marginalized groups, such as racial and ethnic minorities, throughout their involvement in depression treatment, maintenance, and completion. The case managersâ specialized work involves serial conversations to address incremental barriers and provide ongoing guidance that is outside
262 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN the scope of time-short physician encounters. This may be critical to aid mi- norities and/or persons with limited English proficiency in circumnavigating the interrelated web of barriers. In addition, the relationship-building as- pect of case management may enhance trust and address negative attitudes toward treatment and alternative, culturally based explanatory models, thus acting to incrementally break down stigma-related barriers. Culturally focused and culturally appropriate community-based inter- ventions are additionally important approaches not evaluated by Van Voor- hees and colleagues, but highlighted by them and others (Aguilar-Gaxiola et al., 2008; Gilmer et al., 2007; Grandbois, 2005; Miranda, 2008; Park and Bernstein, 2008; Scuglik et al., 2007; Shin, 2002) as critical in improv- ing depression interventions for racial and ethnic minorities. Succinctly summarizing the extensive literature on this topic, Van Voorhees and col- leagues state that âethnic minorities have unique vulnerabilities (e.g., im- migration, racism), protective factors (social support), and adverse events (stressors such as âdaily hasslesâ) that must be simultaneously considered in treatment and prevention programsâ (2007, p. 162S). Further work by the Hogg Foundation for Mental Health through the University of Texas at Austin has been devoted to collect and highlight approaches to help assess, develop, and implement research-informed practices to racial and ethnic minorities, termed cultural adaptation (Hogg Foundation of Mental Health, 2006). Pescosolido (1996) formalized this insightâthat the social structure that systematically influences individualsâ health behavior and outcomes is the influence of personal, organizational, and community network tiesâ into a network-episode model of care use. This model acknowledges the importance of community factors in influencing care utilization and posits that it is necessary to adopt a network-focused approach to understanding treatment entry and outcome at the individual, organizational, and system levels (Miranda, 2008). As Miranda states, âcombining information from clients, their families and support networks, treatment providers, and bu- reaucratic officers is necessary to understand client episodes of treatment and outcomes of careâ (2008, p. 229). More generally, the importance of adapting a community-based approach has been emphasized as a key factor in developing culturally sensitive interventions aimed at encouraging appro- priate use of mental health services that will simultaneously act to overcome stigma and build trust from the perspective of the targeted communities (Bernal and SÃ¡ez-Santiago, 2006; Center for Reducing Health Disparities, 2007; Miranda, 2008; Shin, 2002). A report by the Center for Reducing Health Disparities at the Uni- versity of California, Davis, Building Partnerships: Key Considerations When Engaging Underserved Communities Under the MHSA, states the key principles and strategies for community engagement to facilitate mental
TREATMENT OF DEPRESSION IN PARENTS 263 health system transformation in underserved communities: paying attention to histories of discrimination and marginalization; engaging in transparent discussions of power dynamics; documenting community strengths and lo- cal knowledge; cooperating with key informants in communities; creating forums for communities to teach county providers about social networks, traditions, concepts of prevention, and community assets and needs; build- ing capacity; focusing on systems development and sustainability; and upholding ethics of engagement (Center for Reducing Health Disparities, 2007). In summary, the concept of vulnerability has important research and policy implications for two main reasons. First, risks may accumulate ad- ditively or multiplicatively, depending on the number of high-risk groups to which an individual or family belongs. Second, compared with their norma- tive counterparts, vulnerable populations may require additional medical and social services to meet their multiple coinciding physical and mental health needs, as well as their childrenâs developmental needs. Depression has been shown to adversely impact factors critical to establishing and maintaining social inclusion and functioning, such as educational attain- ment, productivity, and employment, and it may therefore be particularly damaging to socioeconomically disadvantaged ethnic minorities and other marginalized populations (Van Voorhees et al., 2007). Bearing in mind such vulnerability-related considerations is of particu- lar importance in the context of depression, because it is precisely those social environments and characteristics in which depression most com- monly occursâsuch as poverty, unmarried status, or disadvantage because of gender, race, or ethnicity, immigrant and/or refugee statusâthat are themselves factors likely to exacerbate or prolong depression. Because of their typically stressful and enduring nature, these conditions may create a constellation of vulnerabilities that overwhelm the personâs coping capabili- ties and diminish the effectiveness of treatments that have proven successful under less challenging circumstances. Moreover, given the disproportionate prevalence of depression among women in their prime childbearing and child rearing years, particularly those who are young, poor, and single, depression poses a concern because of its potential for impairing affected mothersâ parenting effectiveness. Community-based approaches to depression screening and treatment among vulnerable populations are highlighted in the literature as critical for overcoming depression-related stigma and mistrust and reducing health disparities. One key conclusion from our review is that stigma, which is often mentioned as one of many barriers to depression care and treatment among vulnerable populations, appears to have a far more pervasive role. In fact, the Surgeon General links stigma-related considerations to many, if not most, of the barriers enumerated in the research literature (U.S. Depart-
264 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN ment of Health and Human Services, 2001). Accordingly, stigma should be integrated into culturally and linguistically appropriate depression interven- tions; it may even lend itself to being addressed as a factor in its own right (Givens et al., 2007; Link et al., 1997). RESEARCH GAPS Although there is evidence available on the safety and efficacy of thera- peutic and delivery approaches to treating depression and preventing re- lapse in adults, little is known about the impact of the successful treatment of depression for (1) adults who are parents and its effects on the function- ing and well-being of their children (e.g., prevention of adverse outcomes), (2) racial and ethnic minority populations, and (3) non-English or limited English speakers. In order to maintain a variety of therapeutic treatments to choose from to satisfy patient preference, further research is needed on the safety and efficacy of therapeutic treatments specifically for depressed parents (e.g., anti-depressants, therapy, alternative medicine). Specifically, research is needed on culturally and linguistically competent evidenced-based models; the appropriate duration of perinatal depression interventions, including indications for prophylactic treatment; the long-term effects of antidepres- sants on the growth and development of children exposed in utero; and fur- ther studies on the safety and efficacy of alternative treatments for perinatal depression (e.g., herbal medications or supplements, ultraviolet light). With regard to delivery approaches for parents with depression, more research is needed to understand the effectiveness of certain settings in which parents and their children are regularly seen (i.e., pediatric, obstetric, gynecological settings, community-based centers, home); the effectiveness of alternative delivery mechanisms that can reduce barriers in receiving needed treatment (e.g., web-based therapy and follow-up for depressed parents, especially during pregnancy and postpartum periods); as well as the effectiveness of integrating treatment for depression and substance abuse disorders. CONCLUSION Although data specific to parents with depression are scarce, available evidence suggests that detection and treatment rates are even lower among mothers and fathers than rates reported for the general adult population. A variety of effective tools and approaches to delivery of treatment for depressed adults exist; however, studies rarely measure the effects of these tools that are important in depressed adults who are parents, including parenting quality and prevention of adverse child outcomes, nor do they ac-
TREATMENT OF DEPRESSION IN PARENTS 265 count for delivery approaches in settings in which traditionally underserved populations of parents are seen. Regarding the therapeutic interventions provided to depressed parents, it appears to be vital that individuals have an informed choice in treatment modalities (e.g., antidepressant medications, counseling, other alternatives). They should also be provided with the necessary resources and encourage- ment to pursue self-help options, and efforts should be made to tailor these interventions to accommodate the entire family. Despite the lack of research documenting the effectiveness of interven- tions for depression specifically in parents, collaborative care models, (i.e., those that incorporate multiple interventions) appear to be a reasonable approach to delivering care for depression, providing that treatment models are flexible, efficient, inexpensive, and, above all, acceptable to the partici- pants in a wide variety of community and clinical settings. At a minimum, the pivotal ingredients of collaborative care models have historically been (1) frequent client contact and follow-up, (2) stepped care tailored to the stage and severity of illness, (3) an active role for care managers and/or mental health specialists in orchestrating recovery or being accessible for questions and concerns, (4) the involvement of mental health specialists for treatment or consultation, and (5) community-based. Providers should consider taking advantage of technology-based (e.g., Internet) resources to assist and explore with depressed patients alternative and adjunct tools to traditional treatment modalities. For example, health providers servicing traditionally underserved populations (e.g., immigrant, limited or non- English proficient, rural) can help eliminate health disparities by accessing online health information for patients or using printed materials as adjunct tools in the treatment of depression and other psychological problems. Fur- ther, community-based approaches to depression screening and treatment among vulnerable populations are highlighted in the literature as critical for overcoming depression-related stigma and mistrust and in reducing health disparities. REFERENCES Aguilar-Gaxiola, S., Elliott, K., Debb-Sossa, N., King, R.T., MagaÃ±a, C.G., Miller, E., Sala, M., Sribney, W.M., and Breslau, J. (2008). Engaging the Underserved: Personal Accounts of Communities on Mental Health Needs for Prevention and Early Intervention Strategies. Center for Reducing Health Disparities, Monograph No. 1. Sacramento: University of California, Davis. Aguilar-Gaxiola, S.A., Zelezny, L., Garcia, B., Edmonson, C., Alejo-Garcia, C., and Vega, W.A. (2002). Translating research into action: Reducing disparities in mental health care for Mexican Americans. Psychiatric Services, 53, 1563â1568.
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