Rapid Access to Perinatal Psychiatric Care in Depression (RAPPID): A Master’s Thesis
Faculty Advisor
Lori Pbert, PhDAcademic Program
Master of Science in Clinical InvestigationUMass Chan Affiliations
MedicineDocument Type
Master's ThesisPublication Date
2015-04-14Keywords
Theses, UMMSPerinatal Care
Depression
Depressive Disorder
Mental Health Services
Postpartum Period
Perinatal Care
Depression
Depressive Disorder
Mental Health ServicesPostpartum PeriodHealth Services ResearchMaternal and Child HealthMental and Social HealthObstetrics and GynecologyPsychiatric and Mental HealthWomen's Health
Metadata
Show full item recordAbstract
Depression is the leading cause of disability among women of reproductive age worldwide. Upwards of 1 in 5 women suffer from perinatal depression. This condition has deleterious effects on several birth outcomes, infant attachment, and children’s behavior/development. Maternal suicide causes 20% of postpartum deaths in depressed women. Although the vast majority of perinatal women are amenable to being screened for depression, screening alone does not improve treatment rates or patient outcomes. Obstetrics/Gynecology (Ob/Gyn) clinics need supports in place to adequately address depression in their patient populations. The primary goal of this thesis is to develop, refine, and pilot test a new low-cost and sustainable stepped care program for Ob/Gyn clinics that will improve perinatal women’s depression treatment rates and outcomes. We developed and beta tested the Rapid Access to Perinatal Psychiatric Care in Depression (RAPPID) Program, to create a comprehensive intervention that is proactive, multifaceted, and practical. RAPPID aims to improve perinatal depression treatment and treatment response rates through: (1) access to immediate resource provision/referrals and psychiatric telephone consultation for Ob/Gyn providers; (2) clinic-specific implementation of depression care, including training support and toolkits; and (3) proactive depression screening, assessment, and treatment in OB/Gyn clinics. RAPPID builds on a low-cost and widely disseminated population-based model for delivering psychiatric care in primary care settings. Formative data and feedback from key stakeholders also informed the development of RAPPID. Our formative and pilot work in real-world settings suggests RAPPID is feasible and has the potential to improve depression detection and treatment in Ob/Gyn settings. The next step will be to compare two active interventions, RAPPID vs. enhanced usual care (access to resource provision/referrals and psychiatric telephone consultation) in a cluster-randomized trial in which we will randomize 12 Ob/Gyn clinics to either RAPPID or enhanced usual care.DOI
10.13028/M2XG6MPermanent Link to this Item
http://hdl.handle.net/20.500.14038/32092Rights
Copyright is held by the author, with all rights reserved.Scopus Count
Collections
Related items
Showing items related by title, author, creator and subject.
-
Latent Variable Approaches for Understanding Heterogeneity in Depression: A DissertationBackground: Major depression is one of the most prevalent, disabling, and costly illnesses worldwide. Despite a 400% increase in antidepressant medication use since 1988, fewer than half of treated depression patients experience a clinically meaningful reduction in symptoms and uncertainty exists regarding how to successfully obtain symptom remission. Identifying homogenous subgroups based on clinically observable characteristics could improve the ability to efficiently predict who will benefit from which treatments. Methods: Latent class analysis and latent transition analysis (LTA) were applied to data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study to explore how to efficiently identify subgroups comprised of the multiple dimensions of depression and examine changes in subgroup membership during treatment. The specific aims of this dissertation were to: 1) evaluate latent depression subgroups for men and women prior to antidepressant treatment; 2) examine transitions in these subgroups over 12 weeks of citalopram treatment; and 3) examine differences in functional impairment between women’s depression subgroups throughout treatment. Results: Four subgroups of depression were identified for men and women throughout this work. Men’s subgroups were distinguished by depression severity and psychomotor agitation and retardation. Severity, appetite changes, insomnia, and psychomotor disturbances characterized women’s subgroups. Psychiatric comorbidities, especially anxiety disorders, were related to increased odds of membership in baseline moderate and severe depression subgroups for men and women. After 12 weeks of citalopram treatment, depression severity and psychomotor agitation were related to men’s chances of improving. Severity and appetite changes were related to women’s likelihood of improving during treatment. When functional impairment was incorporated in LTA models for women, baseline functional impairment levels were related to both depression subgroups at baseline and chances of moving to a different depression subgroup after treatment. Conclusion: Depression severity, psychomotor disturbances, appetite changes, and insomnia distinguished depression subgroups in STAR*D. Gender, functional impairment, comorbid psychiatric disorders, and likelihood of transitioning to subgroups characterized by symptom improvement differed between these subgroups. The results of this work highlight how relying solely on summary symptom rating scale scores during treatment obscures changes in depression that might be informative for improving treatment response.
-
New Measure to Screen Deaf Women for Perinatal Depression [English, Spanish and Portuguese versions]Approximately 1 million women in the U.S. have profound hearing loss and use American Sign Language (ASL) as their primary language. Many providers are unfamiliar with the unique linguistic and cultural needs of the Deaf community, therefore Deaf women experience major obstacles to receiving effective physical and mental healthcare. For example, failure to provide ASL interpreters or translations from written English is a common communication barrier that prevents Deaf women from receiving health-related treatment and information. In 2017, Drs. Melissa Anderson, Kelly Wolf Craig, and Nancy Byatt were awarded a 1-year pilot project grant for their Creating the Capacity to Screen Deaf Women for Perinatal Depression project. The primary goal of this project was to translate the Edinburgh Postnatal Depression Scale (EPDS) from written English to American Sign Language (ASL). Using the new ASL EPDS, the team aimed to recruit 50 Deaf perinatal women from across the United States to conduct depression screening interviews. This brief describes the study, its results and future plans.
-
Combinatorial Pharmacogenomic Testing Improves Outcomes for Older Adults With DepressionOBJECTIVE: Evaluate the clinical utility of combinatorial pharmacogenomic testing for informing medication selection among older adults who have experienced antidepressant medication failure for major depressive disorder (MDD). DESIGN: Post hoc analysis of data from a blinded, randomized controlled trial comparing two active treatment arms. SETTING: Psychiatry specialty and primary care clinics across 60 U.S. community and academic sites. PARTICIPANTS: Adults age 65 years or older at baseline (n=206), diagnosed with MDD and inadequate response to at least one medication on the combinatorial pharmacogenomic test report during the current depressive episode. INTERVENTION: Combinatorial pharmacogenomic testing to inform medication selection (guided-care), compared with treatment as usual (TAU). OUTCOMES: Mean percent symptom improvement, response rate, and remission rat eat week 8, measured using the 17-item Hamilton Depression Rating Scale; medication switching; and comorbidity moderator analysis. RESULTS: At week 8, symptom improvement was not significantly different for guided-care than for TAU (=8.1%, t=1.64, df=187; p=0.102); however, guided-care showed significantly improved response (=13.6%, t=2.16, df=187; p=0.032) and remission (=12.7%, t=2.49, df=189; p=0.014) relative to TAU. By week 8, more than twice as many patients in guided-care than in TAU were on medications predicted to have no gene-drug interactions (chi(2)=19.3, df=2; p < 0.001). Outcomes in the guided-care arm showed consistent improvement through the end of the open-design 24-week trial, indicating durability of the effect. Differences in outcomes between arms were not significantly impacted by comorbidities. CONCLUSIONS: Combinatorial pharmacogenomic test-informed medication selection improved outcomes over TAU among older adults with depression.
