We propose to conduct a randomized controlled (RCT) trial of nurse midwife telephone-administered Interpersonal Psychotherapy (IPT) for women with postpartum depression (PPD). PPD is a major depressive disorder affecting 6.5% to 12.9% of all childbearing women and up to 50% of low-income childbearing women. Several studies demonstrate that PPD is persistent and is accompanied by substantial social disability. PPD is of special concern because of the established link between maternal depression and children's mental health. Women with PPD may be reluctant to enter the mental health system because of a variety of cultural and logistic factors including mental illness stigma, poor healthcare coverage, financial burdens, and childcare responsibilities. They may, however, be more willing to receive mental health care from an advanced practice nurse such as a nurse midwife (who has specialized training in psychotherapy). Current mental health care is complex with patients often being triaged to a variety of health care providers, which may result in duplication of services, increased cost, poor communication between health care providers, poor patient outcomes, and poor access to and timeliness of care. A number of studies have emphasized that a multidisciplinary healthcare team approach, especially between advanced practice nurses and specialty care providers, can result in better quality of care, better behavioral and psychiatric outcomes, and increased patient satisfaction. No studies, however, have examined a brief telephone-based counseling intervention such as IPT that could be delivered by a nurse midwife in consultation with a mental health team consisting of a psychiatrist team leader and a licensed social worker. We propose to evaluate feasibility, acceptability, safety and preliminary efficacy of nurse-midwife telephone-administered IPT in a two armed RCT. Women with PPD will be recruited from from a major healthcare system in New Jersey serving socially and ethnically diverse populations. We will enroll 96 women with scores >10 on the EPDS and who meet DSM-IV criteria for major depression. Subjects will be assigned with equal likelihood to 8 sessions of IPT plus and engagement session or treatment as usual (TAU). A structured interview for depression (MINI), the HRSD, GAF, Dyadic Adjustment Scale, and the Maternal Infant Bonding Scale will be administered to both groups at baseline, at 4 weeks, 8 weeks and 12 weeks post-randomization. The hypotheses for the study are that compared to women with PPD receiving TAU, women receiving IPT will experience a significant 1) decrease in depressive symptoms 2) increase in functional status 3) increase in marital adjustment levels and 4) increase in maternal infant bonding levels. We also hypothesize that women in the IPT group will express significantly greater satisfaction with the nurse midwife administered intervention than women in the TAU group. We will also examine whether participants'sociodemographic, clinical, social functioning and obstetric characteristics modify IPT's efficacy. Finally, among the patients in the experimental arm, we will examine whether these same characteristics influence drop out rate, number of accepted sessions and satisfaction with counseling. If found feasible, acceptable, safe, and efficacious, nurse midwife administered IPT offers a brief, comparatively simple, cost-effective method of reducing depressive symptoms, increasing engagement in treatment, and improving access to care among women with PPD.

Public Health Relevance

The goal of this project is to improve access to care for women with postpartum depression (PPD) who might not otherwise receive mental health treatment. Using nurse midwives to administer brief psychotherapy (Interpersonal Psychotherapy) by telephone to treat PPD may lessen fears about the stigma of having PPD and entering the mental health system, reduce long waits for appointments, alleviate interference with work and home responsibilities, and transcend the difficulties of inadequate healthcare insurance, inadequate childcare, lack of transportation and financial burdens. In a healthcare system where there are few mental health providers with expertise in pregnancy and postpartum care, nurse midwife counselors could easily fill this gap and engage more women with PPD in treatment to reduce depressive symptoms and improve interpersonal functioning.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Exploratory/Developmental Grants (R21)
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Mental Health Services in Non-Specialty Settings (SRNS)
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Azrin, Susan
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Drexel University
Schools of Nursing
United States
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