An ob.gyn. practice in rural Washington state has successfully implemented a collaborative care model for depression management that relies on “depression care managers” and a consulting psychiatrist to aid ob.gyns. in providing effective depression care.
The initiative was a rural test run of the DAWN (Depression Attention for Women Now) intervention that was shown in a randomized controlled trial 2 years ago to improve depression outcomes for women in two urban ob.gyn. clinics affiliated with the University of Washington in Seattle. Both the trial and the pilot project were funded by the National Institute of Mental Health.
Nearly 75% of the 25 women enrolled in the rural pilot project had a significant improvement in their Patient Health Questionnaire-9 (PHQ-9) scores, and more than half improved their depression symptoms by at least 50%, Roger Rowles , MD, of the Generations practice in Yakima, Wash., and Susan D. Reed, MD , a coinvestigator of the original DAWN trial, reported at the annual meeting of the American College of Obstetricians and Gynecologists.
They urged others to consider taking a similar collaborative approach to depression care, especially now that the U.S. Preventive Services Task Force has recommended depression screening for all adults, including pregnant and postpartum women.
Previously, “when we identified someone with perinatal depression, we’d need a 30-minute initial consultation and then 15-20 minutes on a regular basis,” Dr. Rowles said. “We didn’t have the time to do that. … And I had no training. Most of us felt we weren’t capable [of providing quality depression care].”
In the DAWN model, a social worker, nurse, medical assistant, or other staff member is trained to provide collaborative depression care and takes charge of this care, regularly meeting in-person or by phone with the patient to promote engagement and to closely monitor treatment progress.
Patients choose their initial treatment, including medication and Problem-Solving Treatment in Primary Care (PST-PC) therapy, an evidence-based brief behavioral intervention that helps identify stressors and improve problem solving. The depression care manager delivers the PST-PC therapy, tracks treatment response and compliance, and participates in weekly structured case reviews with the ob.gyn. and a consulting psychiatrist.
Results then and now
The original DAWN trial randomized women at two urban clinics to either 12 months of collaborative depression care or to usual care. Usual care included educational material, access to the clinic social worker, and possible psychiatry referral and prescriptions from the ob.gyn.
At 6 months, the reduction in depression scores as measured by the 20-item Hopkins Symptom Checklist was similar between the two groups, but at 12 months and at 18 months follow-up, the intervention group had significantly lower scores. They were more likely to have at least a 50% decrease in depressive symptoms at 12 months and were significantly more satisfied with their depression care ( Obstet Gynecol. 2014 Jun;123:1237-46 ).
The pilot project in Yakima, a farming community of 80,000 people, was of shorter duration than the randomized trial and focused on women coming for periconception, pregnancy, and postpartum care.
The majority – 74% – had significant improvement in their PHQ scores (a final score of less than 10), and almost one-third had a final score of less than 5. A score of 10 or more indicates the likelihood of having major depression. More than half – 59% – had at least a 50% improvement in depressive symptoms.
Unlike in the original DAWN trial, depression care managers in the Yakima project used text messaging in addition to phone calls to stay engaged with patients and monitor treatment. Almost all of the 25 enrolled women received PST-PC, and approximately 56% received antidepressants, for a mean treatment time of 14 weeks.
“Given that short duration of follow-up, the improvement we saw was very good,” said Amritha Bhat, MD, MBBS , the University of Washington psychiatrist who served as the consulting psychiatrist for the project.
Without a placebo-controlled arm, the researchers don’t know how much of the improvement was due to the collaborative care, Dr. Bhat said in an interview. “But we know now that it’s feasible in a rural setting.”
Depression care needs
Women have two times the rate of major depression as men, with prevalence rates of 13% annually and 21% over a lifetime, and low-income and minority women are at highest risk of depression and are also more likely to seek routine care from ob.gyns., according to Dr. Reed, who is a professor of ob.gyn at the University of Washington, Seattle, and chief of ob.gyn. at Harborview Medical Center.
Dr. Rowles said he was “astounded” that 30% of the screened patients in his practice had positive results. Many “either didn’t want to participate in the project or had exclusions, but even so we enrolled [our cohort] quickly,” he said.
The DAWN model stipulates that depression care managers support women as much as possible with social service interventions, facilitating financial assistance for medications, and serving as a “point person” for assistance with housing, food, domestic abuse, and other issues.
The task of integrating a social service element into depression care is necessary but can be daunting, Dr. Rowles said. In Yakima, he said, the significant need for basic assistance was a “big frustration” to the depression care managers involved in the project. “They wanted to do more, because they’d identified these problems and had a rapport [with the women], but our resources in Yakima are not that great.”
To prepare the Yakima practice for the intervention, a University of Washington team visited the clinic to educate staff about collaborative care, and three depression care managers were trained to deliver PST-PC and manage care. The depression care managers – a nurse employed by the local hospital, a nurse employed by another clinic for farm workers, and a local psychologist – “were the glue for this program,” Dr. Rowles said.
In other settings, depression care managers might more likely be clinic social workers or other members of the practice.
A psychiatrist’s involvement is also crucial, particularly when it comes to prescribing antidepressant medications at their full effective doses, Dr. Reed stressed. “You won’t feel comfortable pushing those doses to the max without [a psychiatrist to consult with],” Dr. Reed said at the ACOG meeting.
In the DAWN trial, similar numbers of patients in the collaborative care group and the usual care group were prescribed antidepressants, but more patients in the intervention group had their doses increased to an effective therapeutic range, and more patients adhered to their medication regimens, she said.
The 12-month DAWN intervention was provided at a cost per patient of up to $1,000.
Dr. Reed’s clinic has sustained funding for the intervention since the National Institute of Mental Health grant expired, and Dr. Rowles said he was seeking funding to continue DAWN at his Yakima clinic. Funding sources for ob.gyn. practices interested in implementing the model may include state funding agencies and organizations such as the March of Dimes, Dr. Reed said, noting that some states offer maternal services support that could be helpful for integrating collaborative depression care.
While the pilot project focused on pregnancy care, Dr. Reed urged ob.gyns. to think broadly. “Do you know when you catch these women? When they come in for their Pap smears and their routine care, before they become pregnant,” she said. “If you help them with their mood disorder early, they’ll do so much better with pregnancy.”
Information about DAWN – including resources on PST-PC and antidepressant medication, and an intervention manual – can be found at www.dawncare.org.