This month’s column by Drs. Wayne Katon and Susan Reed reports on a recently completed study that shows us how psychiatrists can effectively collaborate with OB-GYN physicians and other women’s health providers to improve depression care for the millions of women who seek care in women’s health clinics. —Jürgen Unützer, M.D., M.P.H.
Major depression affects women twice as often as it does men over the course of a lifetime, with the highest rate occurring during reproductive and menopausal transition years. Many women seek care during these peak years of depression incidence in obstetrics and gynecology (OB-GYN) settings for birth control, pregnancy, and gynecological problems. In fact, one-third of visits for women aged 18 to 45 and the majority of non-illness-related visits for women younger than age 65 are to OB-GYN physicians.
Furthermore, it is estimated that over one-third of gynecology patients rely on OB-GYN physicians for primary care. This is especially true for socially disadvantaged and minority female populations who are often likely to seek care in university and county hospital women’s clinic settings.
Despite the fact that depression is one of the most common problems women face and that many women seek care in women’s clinic settings, OB-GYN physicians often have less training in diagnosis and management of depression than do other primary care physicians. Researchers have shown lower rates of diagnosis and quality of treatment in OB-GYN settings compared with other primary care specialties. OB-GYN physicians also perceive significant barriers to screening and treating depression, including inadequate training and lack of resources for follow-up mental health care.
Collaborative depression care has been found to significantly improve quality of depression care and depression outcomes in family medicine and internal medicine settings, but has not been tested in OB-GYN or women’s health care clinic settings.
The Depression Attention for Women Now (DAWN) collaborative model of care was recently tested in a randomized trial in two large OB-GYN clinics—a county-hospital-based clinic treating a largely minority and socially disadvantaged population with either no insurance or public insurance and a university-based OB-GYN clinic treating a mixed socioeconomic population, with about half having commercial insurance.
A total of 205 women with major depression and/or dysthymia was randomized to the DAWN intervention versus usual OB-GYN care. We adapted our collaborative care intervention to help engage women from socially disadvantaged backgrounds by hiring one social worker as a care manager in each clinic to assist with overcoming barriers to care, such as transportation, obtaining charity care for medications for uninsured patients, and housing issues.
The social workers were also trained to provide an initial engagement session that has been shown to improve rates of mental health follow-up care for socially disadvantaged women. The engagement session includes a unique combination of ethnographical and motivational interviewing to help understand the patient’s explanatory model of illness and potential barriers to care and to educate patients regarding depression and understanding which treatments might be especially acceptable and effective.
Care managers initially worked with the patients on behavioral activation goals, building in activities they enjoyed previously but had stopped doing due to depression. In addition, care managers provided a choice of starting with Problem-Solving Treatment in Primary Care (PST-PC) or antidepressant medication, as well as a choice of whether their contacts with patients would be in person, by phone, or a combination of these. Care managers completed a Patient Health Questionnaire (PHQ-9) depression scale at every contact and entered the dates of contacts and PHQ-9 results in an Excel registry that was reviewed to assess patient progress during weekly case-review meetings with a psychiatrist and a senior OB-GYN physician.
Recommendations about medication changes were then brought to the patient’s OB-GYN physician who wrote all prescriptions.
Women in the usual-care arm had their OB-GYN physicians notified about their depression, had access to a clinic social worker, and could be referred to psychiatry by their OB-GYN physician.
The DAWN program was a one-year intervention, and objective research follow-ups were completed at six, 12, and 18 months.
Intervention patients, compared with usual-care controls, were shown to have significant improvements in quality of depression treatment (number of mental health contacts and antidepressant adherence), as well as significant improvements in depressive symptoms and functioning over the 18-month follow-up period. Intervention patients were also more satisfied with the quality of depression care. A postintervention survey of OB-GYN providers showed a high level of satisfaction with the quality of care provided in the DAWN intervention.
Another important finding was that the results were similar in the two OB-GYN clinics despite differences in the socioeconomic strata of patients. The county hospital clinic population, which is predominantly a socially disadvantaged population, had almost two-fold higher rates of depression than the university-based clinic, and due to either lack of insurance or Medicaid insurance, clinic staff had limited ability to refer patients to mental health specialists for psychotherapy.
Women living in poverty have the highest incidence and persistence of depression. Because of the excellent outcomes associated with the DAWN intervention and the limited ability to find mental health referrals for this vulnerable population, the county-hospital clinic has continued to fund the DAWN intervention model (that is, the care manager and psychiatrist) after the grant funding ended. Our DAWN team hopes to be involved over the next five years in disseminating this model of care to other OB-GYN and women’s clinics. ■
More information about the DAWN program is posted at www.dawncare.org.