Depression in Parents, Parenting, and Children Opportunities to Improve Identification, Treatment, and Prevention (2009) / Chapter Skim
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6 Treatment of Depression in Parents
6 Treatment of Depression in Parents
Pages 205-280
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From page 205... ...
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 • A variety of approaches exist to deliver depression treatment in multiple settings, including primary and specialty care, web- and 205
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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 general 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
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From page 207... ...
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) Alegría et al., 2008)
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From page 208... ...
. 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)
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. 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.
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Since the effectiveness of antidepressants can be accurately assessed only through blinded, controlled trials, the literature summarizing the efficacy of antidepressants during pregnancy is nonexistent. The relative safety, however, can be inferred from a body of evidence that has grown remarkably in recent years.
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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)
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. 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.
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. A total of eight studies have been published, examining the impact of antidepressants on the treatment or prevention of postpartum depression.
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. 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)
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. INTERPERSONAL PSYCHOTHERAPY AND COGNITIVE-BEHAVIORAL THERAPY General Population Multiple studies and meta-analyses provide evidence that cognitive-behavioral therapy (CBT)
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. 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.
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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 psychological 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.
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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)
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. 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.
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Five randomized controlled trials evaluating the efficacy of yoga in the treatment of depression were identified in a systematic review (Pilkington et al., 2005)
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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 parents' depression to remission and to prevent relapse reduces or removes exposure to this risk factor for their children.
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From page 222... ...
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 professionals -- that 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 interventions within respective protocols.
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From page 223... ...
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 influential in improving medication adherence or depressive symptoms (Bower et al., 2006; Craven and Bland, 2006; Gilbody et al., 2006)
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depressive disorder (2005) (some with alcohol Thompson et al.
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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
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(2007) Collaborative Care Bower et al.
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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.
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From page 228... ...
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 demonstrated 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)
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From page 229... ...
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 effective 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.
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From page 230... ...
• Integration of the mental health specialist into the primary care setting for care management, clinical consultation, or supervision • 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.
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. Although randomized controlled trials of collaborative care interventions have consistently reported positive findings, the cost-effectiveness of these relatively intensive multidisciplinary models is not clear.
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with 5 34% ethnic Usual care (n = different minority 146) health care organizations Nonacademic Rojas et al.
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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)
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practices Average age: randomized Recruited from 43 years Intervention (n practice 47% married = 221) networks 83% had health Usual care (n = Nonacademic insurance 240)
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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
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16 to usual care (n = 44) NOTES: AHCPR = Agency for Health Care Policy and Research; CBT = cognitive behavioral 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 = ShortForm Survey-12-Mental Component Score; SF-36 = Short-Form Survey-36.
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From page 237... ...
. 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 × 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)
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From page 238... ...
Although collaborative care for depression has been extensively studied in the primary care setting, there are few data examining the effectiveness of large-scale, systems-based approaches to antepartum or postpartum depression care (Gjerdingen, Katon, and Rich, 2008)
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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 12–28 weeks)
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. 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.
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From page 241... ...
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 attending postnatal clinics in Chile to improve the recognition and treatment of postnatal depression (Rojas et al., 2007)
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From page 242... ...
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)
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. 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 effectively reducing depressive symptoms.
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From page 244... ...
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 effective in treating depression in comparison to a group that was not given the intervention at 6 month follow-up (Dowrick et al., 2000)
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. Australian researchers developed an evidence-based consumer guide about effective depression treatment options to change attitudes and take actions to reduce depression in adults.
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. Internet-based interventions are particularly attractive in the setting of depression treatment.
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. Web-based perinatal and postpartum depression treatment and intervention programs are well suited for the everyday lives of expectant and new mothers.
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randomized 12 primary care practices to enhanced or usual care. Enhanced care clinicians and care managers received brief training on high-quality depression care (i.e., guideline-based pharmacotherapy or psychotherapy during the acute phase of treatment)
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. 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)
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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 employer's 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 societal perspective.
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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
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From page 252... ...
However, studies are under way to investigate the effectiveness of the latter two strategies, which embed depression treatment 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)
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From page 253... ...
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.
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. Box 6-2 describes other integrated treatment models of care that have been used in substance abuse disorder settings.
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. evidence that integrated treatment for mental illness, trauma, and addiction produced better outcomes than did standard substance abuse treatment.
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. VULNERABLE POPULATIONS Low-Income and Minority Mothers The impact of treatment interventions and, more specifically, collaborative care models on parental depression has not been rigorously studied
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They conducted a randomized controlled trial with 53 pregnant patients and found significant reductions in depression diagnoses 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
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From page 258... ...
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 populations' 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)
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. Differential access to insurance and providers does not account for all the disparities in rates of depression treatment, however.
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From page 260... ...
. 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 exacerbates mistrust, perpetuates marginalization, and impedes depression treatment (Center for Reducing Health Disparities, 2007)
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From page 261... ...
This patient-focused strategy may be particularly beneficial for ethnic minorities because it assists patients unfamiliar with and at the margins of the traditional 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.
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From page 262... ...
. 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 appropriate use of mental health services that will simultaneously act to overcome stigma and build trust from the perspective of the targeted communities (Bernal and Sáez-Santiago, 2006; Center for Reducing Health Disparities, 2007; Miranda, 2008; Shin, 2002)
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From page 263... ...
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.
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From page 264... ...
; 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.
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From page 265... ...
Despite the lack of research documenting the effectiveness of interventions 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 participants in a wide variety of community and clinical settings.
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From page 266... ...
. The effects of exercise and social support on moth ers reporting depressive symptoms: A pilot randomized controlled trial.
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From page 267... ...
. Collaborative care for depression in primary care -- making sense of a complex intervention: Systematic review and meta-regression.
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From page 268... ...
. Delivering interventions for depres sion by using the Internet: Randomized controlled trial.
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From page 269... ...
. Re-engineering systems for the treatment of depression in primary care: Cluster randomized controlled trial.
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From page 270... ...
. Randomized dose-ranging pilot trial of omega-3 fatty acids for postpartum depression.
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From page 271... ...
. A randomized controlled trial of culturally relevant, brief interpersonal psychotherapy for perinatal depression.
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From page 272... ...
. Postpartum depression treatment rates for at-risk women.
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From page 273... ...
. A randomized controlled trial comparing guideline exposed and guideline-naïve physicians in respect to dosage selection and treatment outcome with doxpein with depressive disorders.
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From page 274... ...
. Treating depression in predominantly low-income young minority women: A randomized controlled trial.
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From page 275... ...
. Randomized controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care.
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From page 276... ...
. Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: A randomized controlled trial.
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From page 277... ...
. Omega-3 fatty acids for major depression during pregnancy: Results from a randomized, double-blind, placebo-controlled trial.
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. A randomized controlled trial of educational counselling on the management of women who have suffered suboptimal outcomes in pregnancy.
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. Telephone screening, outreach, and care management for de pressed workers and impact on clinical and work productivity outcomes: A randomized controlled trial.
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American Journal of Psychiatry, 162, 1158–1164. Wyeth Pharmaceuticals.
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