The New Haven MOMS Partnership: Combatting Depression, Reducing Stress and Building Foundational Skills for Success - PDF

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The New Haven MOMS Partnership: Combatting Depression, Reducing Stress and Building Foundational Skills for Success Dr. Megan V. Smith Departments of Psychiatry & Child Study Center Yale University School
The New Haven MOMS Partnership: Combatting Depression, Reducing Stress and Building Foundational Skills for Success Dr. Megan V. Smith Departments of Psychiatry & Child Study Center Yale University School of Medicine Division of Social & Behavioral Sciences Yale School of Public Health S L I D E 0 Overview of Today s Webinar Addressing mental health Achieving high rates of participation Using technology to keep people engaged Building a partnership that works S L I D E 1 Addressing Mental Health Strategies for a community-based approach S L I D E 2 Ensuring the Emotional Health of Our City s Families S L I D E 3 Our Target Population Low-income, African American and Latina pregnant and parenting women in New Haven S L I D E 4 The New Haven Mental health Outreach for MotherS (MOMS) Partnership All Our Kin Clifford Beers Guidance Clinic Housing Authority of New Haven New Haven Health Department New Haven Healthy Start State of CT Department of Children & Families State of CT Department of Social Services The Diaper Bank Yale Child Study Center & Psychiatry Advisory Committee of 40+ local and state leaders S L I D E 5 Age-Specific Rates of depression in the USA ECA study 2.5 Female Male Rates/ Age at Onset Weissman et al. JAMA, 1998 S L I D E 6 Public Health Significance: Maternal Depression In the United States, depression is the leading cause of non-obstetric hospitalizations among women aged Specifically for parents, depression can Interfere with parenting quality Put children at risk for poor health and development At least 15.6 million children live with an adult who had major depression in the past year S L I D E 7 Maternal Mental Health: Public Health Impact Mitchell et al, American J of Obstetrics & Gynecology, 2011, Vol 205: 51, e1-e8 S L I D E 8 Impact on Children Less likely to engage in positive parenting practices and preventive child health practices Parental depression linked to lack of school readiness and early school success impairments in cognitive and motor function increased risk for mental illness Smith MV et al, 2009; AMJ Public Health 63(120); NICHD Early Child Care Research Network Developmental Psychology 35(5): Kavanaugh, Ambulatory Pediatrics 6(1): Surkan, 2012, Pediatrics 130 (4) S L I D E 9 Maternal Mental Health in New Haven 54% of children under age 3 live in poverty, in single, female-headed household. For low-income women with young children, 40%- 60% with depressive symptoms Early Head Start mothers: 20% report illicit drug use Kahn, RS 2006; Bassuk, Buckner, Perloff, & Bassuk, 1998; de Groot, Auslander, Williams, Sherraden, & Haire-Joshu, 2003; Hall, Williams, & Greenberg, 1985; Heneghan, Silver, Bauman, Westbrook, & Stein, 1998; Hobfoll, Ritter, Lavin, Hulsizer, & Cameron, 1995 de Groot et al., 2003; Galea, 2007 S L I D E 10 Mental Health and Employment People with mental health problems have the highest want to work rate [of out of work people] with up to 90% wanting to work. Employees with depression are more likely than others to lose their jobs and to change jobs frequently. Only about one in four employees with major depression received adequate treatment for the disorder. S L I D E 11 Cognitive Behavioral Therapy Bandura, 1977 embodies principles of behavior change that are universally relevant, i.e., potentially applicable across cultures. Social learning theory: reciprocal determinism, we both shape and are shaped by our environments. Flexible, to prevent, treat, and maintain after treatment. Most effective intervention for depression, trauma, addiction. S L I D E 12 Specifics of CBT Just as we have been taught to think and act in certain ways, we can also learn new, more adaptive ways to think and act when our old patterns are not helpful in dealing with our current situations. Pleasant activity scheduling, interpersonal skills training, and cognitive restructuring served as core elements Cultural relevance S L I D E 13 Features of CBT: Help to organize thinking Mothers are encouraged to shape aspects of their reality so as to reduce risk and severity of depressive episodes. and (1) identification of specific thoughts (e.g., I m worthless ) and behaviors that worsen or improve mood, (2) provision of skills to make conscious choices that minimize the impact of harmful thoughts and behaviors, such as engaging in pleasant activities, (3) acquisition of skills for disputing harmful thoughts, using cognitive restructuring techniques, and (4) development of a personal sense of meaning fulfillment in life. S L I D E 14 Achieving high rates of participation S L I D E 15 Patient Health Questionairre-2 More thannearly Not Several half the every at all days days day a. Little interest or pleasure in doing things b. Feeling down, depressed, or hopeless Scores range from 0-6; score of to 3 indicates a high likelihood of depression S L I D E 16 Treatment Attendance (N=315) Child Care In Treatment % 18% 19% 35% Drop In Hours % month 3 month 6 month Any Tx 205 Payment # In Treatment Not in Treatme Transportation Treatment = attended 1 appointment Bilingual Clinicians Smith MV et al. Success of mental health referral among pregnant and postpartum women with psychiatric distress. General Hospital Psychiatry, 31(2): , S L I D E 17 Barriers to Mental Health Care Reported by Pregnant and Parenting Women (N=609) 12% Time 10% 27% 24% 13% 18% Transportation Fear of losing custody of children Embarrassed/Pride Will be judged by others/stigma Not sure where to go for help Smith et al, 2009; Gen Hosp Psych 31(2): , S L I D E 18 Mothers (N=1,207) Needed Support With. 73% 70% 70% 70% 69% 67% 64% 44% 44% 30% Exercise Neighborhood safety Basic needs Eating well Skills to control stress Coping with traumatic Managing sadness Quitting alcohol, Safe, affordable Violent relationship S L I D E 19 Community Mental Health Ambassadors Unique understanding of the experience, language and/or culture of mothers Interviewed over 1,300 mothers Conduct two-generation outreach in mental health, child development, alleviation of stress S L I D E 20 Engagement S L I D E 21 96% Adherence (n=97) S L I D E 22 Innovation in Location Locate services in locations where families live, learn, work, play and network 2012 IOM report: integrate health in non health is essential to addressing chronic health needs 1 1 IOM. Living Well with Chronic Illness: A Call for Public Action S L I D E 23 Public Housing Adapt an evidence-based CBT intervention for delivery in 1) groups of low-income, pregnant and parenting women; 2) public housing complexes 3) teams (CMHAs & clinician) 3) partnership with City of New Haven Randomized cluster design, 8 sessions and homework help (weekly), graduation Initially diminish stress and depression Increase self control, planning, monitoring S L I D E 24 Key Outcomes Maternal Mental Health (depression, trauma, substance abuse) (primary) Parental Functioning (primary) Executive Function (primary) Child welfare services referrals Employment Food Housing stability Healthcare utilization S L I D E 25 Using technology to keep people engaged S L I D E 26 Enhance Social Networks Social relationships, or the relative lack thereof, constitute a major risk factor for health rivaling the effect of well established health risk factors such as cigarette smoking, blood pressure, blood lipids, obesity and physical activity. House, Landis, and Umberson; Science 1988 S L I D E 27 MoMba s Theoretical Constructs 1. Models of behavior change 2. Social epidemiology Social support Social network Social capital 3. Attachment theory 4. Behavioral economics Fishbein, M., & Ajzen, I. (1975). Belief, Attitude, Intention, and Behavior: Berkman LF, & Kawachi I. (2000) Social Epidemiology Bowlby J (1958). International Journal of Psychoanalysis Volpp, L, Troxel (2008) JAMA Tversky & Kahneman (1974) Science S L I D E 28 . MoMba s Goals Connect new mothers to each other (social support and networks) Connect new mothers to infants (attachment theory) Connect new mothers to local resources (community connectedness) Connect new mothers to information about their health and the health of their children (health behavior) Incentivize pro-social, health promoting behaviors (behavioral economics) S L I D E 29 Token-based Economy & Challenge System Build and test trust Users challenge other users to do babyfocused, social capitalpromoting activities by wagering their personal tokens. If the other user completes a challenge, the challenger is rewarded. S L I D E 30 Challenges Walk in the park Reading to your baby S L I D E 31 Behavioral Economics Mothers earn tokens to invest in their baby, themselves, their friends, and their larger community S L I D E 32 MoMba: Pilot RCT Pilot randomized controlled trial 18 months 27 pilots initial feasibility 20 intervention (phone, Momba, data plan) 20 control (phone, data plan) Outcomes Depressive symptoms Perceived social support Perceived social capital Maternal-infant bonding S L I D E 33 Percent Percent of MoMba Challenges Completed by Category Social Promotion Attachment Info Baby Questionnaire Challenge Category S L I D E 34 PHQ-9 Score Median PHQ-9 score for MoMba participants 7 6 N= N=24 N=23 N=22 N=24 N=22 N= Date S L I D E 35 Cohen Score N=24 Median Cohen Perceived Stress Scores for MoMba participants N=24 N=23 N= N= Intake 10/10/ /7/ /5/2013 1/2/2014 S L I D E 36 Building a partnership that works Examples from the MOMS Partnership S L I D E 37 Core Tenets of Community Based Participatory Research Shared ownership and decisionmaking about research Shared resources and funds Long term benefit to the community Innovation occurs as decision making shifts from experts/academia to average citizen/family S L I D E 38 CBPR is Not A method or set of methods Specifically qualitative In communities, is research with communities S L I D E 39 The Promise of a Community-Partnered Approach Particularly relevant for situations where service need service use 1, 2,3,4 Can help to create consumer demand 5 1 Institute of Medicine (2000) 2 Freimuth, VS. Soc Sci Med (2001) 3 Tunis, SR. JAMA (2003) 4 Zerhouni, EA. N Engl J Med (2005) 5 AHRQ (2004) S L I D E 40 Does a community-partnered approach improve outcomes? Depression 1 df Physical Activity 1 Homelessness 1 Birth outcomes 2, 3 Utilization and adherence 4 Increased capacity of alternative sectors to engage depressed clients 1, 5 1 Wells KB. JGIM Tripathy P. Lancet, Coppcock DL. Science O Brien, RA Prev Sci Miranda J. JGIM 2013; 28 (10) S L I D E 41 (1) Identify 2-Generation Needs and Partners Identify non-traditional partners Banks, grocery stores, laundromats Formalize relationships MOUs Conduct Needs Assessment Goals as well as needed support Develop two generation strategic planning Health Mental Health Workforce Early care and education S L I D E 42 Goals of Mothers 1.) Securing stable employment 2.) Making my child proud (Stress impedes this) - I am the voice for my child - I am my child s inspiration - When you don t take care of yourself you don t take care of your child S L I D E 43 (2) Identify & Train Community Ambassadors Consider Community Ambassadors Across Sectors and Levels: Supermarket cashiers Existing staff: health department outreach workers, home visitors, TANF case workers Specialized staff: clinics, social service agencies, housing authorities, churches Two-generation connectors S L I D E 44 (3) Universal Implementation of Interventions to Build Capacity MOMS Stress Management Course Early childhood settings, public housing, mental health clinics, parent classes, child protective services, workforce TANF credit, community service credit incentivize S L I D E 45 Acknowledgements People: MOMS Partnership mothers, Cerella Craig, Heather Howell, Kimberly Yonkers, Anna Kruse, Kia Levey, Linda Mayes, Natasha Rivera-LaButhie, Kimberly Streater Fred Shic, Kathryn Cochran, Michael Perlmutter, MOMS Partnership Guide Team, Elizabeth Claydon, Janice Gruendel, John Padilla, Commissioner Bremby Funders: Annie E. Casey Foundation NIDA K12DA (PI:Smith) NIMH R34MH & R21MH (PI: Smith) U.S. Office of Women s Health CCEWH10100 (PI: Smith) Center on the Developing Child Charitable Gift from Thorne Family Trust Yale-New Haven Hospital Yale Center for Clinical and Translational Research Child Health & Development Institute S L I D E 46 Needs Assessment Community Mental Health Ambassadors MOMS Stress Management Course MoMba S L I D E 47
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