Care Managers for Perinatal Depression (CMPD)
The purpose of the intervention is to measure the effect of adding depression care managers to the team of prenatal providers in a range of clinical settings serving low income and racial/ethnic minority women. Mothers from low-income and vulnerable populations have limited access to high-quality mental health services and often stop established treatment during pregnancy. The goal of CMPD is to increase the capacity to provide services for perinatal depression within the medical home, and make sure attention is paid to this disorder through the transition to postpartum care.
A randomized trial will evaluate the care manager’s impact on the timely diagnosis and treatment of major depression, and the continuity of depression care from pregnancy to postpartum. Though the evaluation of the intervention is not complete, there are already several lessons learned. The first is the need to identify project champions from each of the specialties involved with the intervention. A single champion (such as a physician) is not adequate if nurses, social workers, and other staff members are needed for the work. There are also benefits in drawing depression care managers from existing staff. While finding a way to add to ongoing responsibilities can be challenging, the advantage is that a current staff member already knows the clinic and its patient population, and this model avoids the need to hire additional staff. The CMPD project has also seen great benefit in using videoconferencing to keep their network of care managers engaged, using face-to-face contact for training and discussions. The videoconference approach also allows researchers to record all sessions and use them for future training needs.
Lancaster General Health, Lancaster PA, and University of Pennsylvania Health System, Philadelphia, PA
Three Federally Qualified Community Health Care Centers in Philadelphia and Lancaster, PA; one hospital-based outpatient clinic in Lancaster, PA
Ian Bennett, MD, PhD
Assistant Professor, Department of Family Medicine and Community Health, University of Pennsylvania
The CMPD intervention was developed in order to promote the growth and use of collaborative models of depression care in safety-net clinical sites providing perinatal care for low-income, ethnic minority women.
More than 70 randomized clinical trials have shown the significant benefits of a collaborative care approach to depression in primary care. “Collaborative care” includes the use of a multidisciplinary care team to provide proactive patient-centered care, typically coordinated by a designated depression care manager. However, there have been virtually no studies of this approach for perinatal depression in low-income populations, for whom the delivery of depression care in pregnancy and postpartum is particularly lacking.
Care providers at CMPD sites have been trained to screen pregnant women for depression risk using an efficient two-stage approach which rapidly rules out the risk of current major depression in the majority of women in prenatal care. Those identified as at risk then see a clinician identified as a “perinatal depression champion” for a formal diagnostic evaluation and, if needed, are treated for depression by their prenatal provider, a mental health specialist, or both. This study, funded by Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation, is adding the use of a depression care manager, drawn from among existing staff, at two sites in Lancaster and two in Philadelphia. The care manager’s role is to advocate for patients, support self-management of depression, assist with care navigation, monitor symptoms, provide feedback to maternal care providers, and maintain contact with mental health specialists. On-site and ongoing training for care managers is supplemented by monthly training and discussion sessions via videoconference that allows the care managers at all locations to interact. In Lancaster, researchers have also created a community partnered advisory board to actively engage in the evaluation of the project and help us interpret results. Members of the board include women who have experienced perinatal depression.
Pregnant women at risk for major depression are randomized either to a control group, which receives usual care, or to the intervention, which features usual care plus the care manager. Researchers will use the sites’ electronic medical records to evaluate the effects of introducing a care manager on: (1) patient receipt of diagnosis within 2 weeks of screening, and treatment within 1 month of diagnosis; and (2) continuity of care into the postpartum period. In addition, researchers will observe each site’s perinatal depression care processes and survey clinical staff to identify factors affecting the success of the care manager model. They also will quantify the cost of implementing and maintaining the intervention.