There is a pressing need to expand the reach of perinatal depression care to low income women from race/ethnic minority populations. Large disparities in depression care delivery between women receiving Medicaid and those with private insurance are documented. Strategies to reduce these disparities must address economic, social, and cultural barriers on the patient side as well as limited resources in the safety net system serving these patients. Patient Centered Outcomes Research (PCOR) methods have not been applied to the problem of how to reduce these disparities. This K18 career enhancement award in PCOR proposes, through a program of mentoring, formal coursework, and a linked research project, to build skills in PCOR methods targeting the delivery of evidence based care to low income women with perinatal depression. In the research component a participatory design and rapid prototyping approach will be employed to develop and pilot a mHealth intervention to support sustained implementation of the evidence based collaborative care approach to depression services in non specialty mental health settings. This project will address work needed to prepare for a pragmatic comparative effectiveness trial to be carried out after the development of a beta version of the mHealth system. While over 40 high quality studies now show collaborative care models improve the quality of depression treatment and outcomes in general medical settings, this approach has not been widely implemented or sustained. Central to the collaborative care model is a care manager who monitors patient adherence, response to treatments, and side effects, while providing effective clinical feedback to other members of the depression care team regarding the status of the patient. The resources required for care management are high;however, particularly for relatively under-resourced sites caring for low income women~ this high resource cost reduces the sustained implementation of collaborative care. mHealth approaches, which capitalize on the widespread patient use of mobile phones, hold promise as effective strategies to assist and even enhance the work of care managers. These systems can potentially carry out substantial portions of the monitoring, adherence assessment/support, and clinical feedback functions of care managers. To improve the end user acceptability of the proposed system it will be developed in a participatory manner with patients and care team members from three diverse prenatal clinics serving low income women with established care managers.
The burden of untreated perinatal depression on public health is very large with direct effects on maternal child health outcomes and long lasting effects on health and health care utilization for both mothers and their children. Improving the sustained implementation of the evidence based collaborative care approach to perinatal depression is expected to have large returns on the mental health of the public while reducing the costs of delivering this care.