WE Care

1
WE Care
Women Entering Care
2
WECare Depressed Subject Recruitment by Month-Year
3
Randomized study MDD

• SSRI given by nurse practitioner, supervised by
  CL Psychiatrist
• CBT given by psychologist
• TAU - referral to appropriate community care

4
Recruitment strategies

• Involved in pilot interventions
• Believed treatment could be done and would be
  useful.
• Willing to be creative (loosen some boundaries)
  within reasonable bounds.

5
Establishing Trust

• Selection of Sites for Recruitment
• Establishing Relationship with Leaders of
  Sites
• Informed Buy-in of Site Staff

6
The First Interview Facilitating Recruitment

• Selection of Interviewers

--Interviewers who are committed --Have training
in diagnosis and assessment

• Training and Supervision

--Intensive training for 2-3 weeks --Mandatory
weekly supervision meeting
I

• Facilitating Collaboration with Interviewers
  and Site Staff

--Regular visit to sites --Continuous
problem-solving to increase efficiency in
Recruitment
7
Clinical Treatment

• Subjects first face to face meeting is a 2 hour
  clinical interview after which they are informed
  of their treatment assignment
• Contacting, scheduling, rescheduling, identifying
  barriers, and completing this interview can take
  up to 2 months
• We are fortified by the knowledge that we are
  offering treatment or referral to care

8
Key Characteristics of WECare Treatment Approach

• Persistence
• Flexibility
• Excellent Clinical Relationship
• Support for Treatment Success
• Cultural Sensitivity

9
Persistence

• Repeated calls to subjects
• Friendly upbeat approach
• Nonjudgmental
• Offer choices when possible
• Dont short circuit - keep options open

10
Flexibility

• Work meetings around subjects schedule
  (weekends, evenings, early morning)
• Convenient locations (homes, restaurants, local
  clinic, coordinate w/ appointments)
• Provide transportation that is reliable and
  convenient
• Initiate treatment when the subject is ready

11
Excellent Clinical Relationship

• Frequent scheduled follow up calls
• Actively problem solve to anticipate needs and
  concerns
• Be available for subjects problems (crises,
  calls, worries)
• Maintain therapeutic boundaries

12
Support for Treatment Success

• Strong team centered approach helps prevent
  burnout, generate ideas, set precedent for
  handling difficult situations
• Excellent relationship w/ community sites and
  staff
• Blitz days as outgrowth of team centered
  approach

13
Cultural Sensitivity

• Appreciate unique issues for immigrant women
• More relaxed conversational style of interviewing
• Include family if desired by subject
• Adapt language and pace of interview to
  educational level of subject

14
Phone Interviewing

• Flexible Scheduling
• Persistence and Boundaries
• Establishing Relationships with Subjects

15
Effects on Children

• 5-year NIMH-funded study, 1998 2003
• 200 mother and child dyads
• Same distribution of race/ethnicity
• Same 3 treatment groups
• Same Non-Depressed Control group (N50)
• Children 4 10 years old

16
Effects on Children

• Investigators
• Anne Riley, Ph.D.
• Jeanne Miranda, Ph.D.
• Marina Broitman Coordinator
• Patricia Heiber, Ph.D.
• Mary Jo Coiro, Ph.D.
• Interviewer Supervisor
• Kristen Hurley, M.S.

17
Primary Hypothesis

• Children of mothers whose depression remits will
  improve, compared to children whose mothers
  remain depressed, in
• Mental health
• Academic functioning
• Social functioning

18
Child Component Challenges

• Resistance to home visits
• Resistance to involving their children and
  families
• Resistance to the additional interviews, some up
  to 3 hours long

19
Child Component Challenges

• 50 of eligible families did not enter child
  component up to December, 2000
• In 2001, only 35 not entering child component
• High demand for contacts (average of 12 contacts
  to complete baseline interview)

20
How do we do it?

• Persistence in phone contacts
• Goals set for the number of phone calls per week
• Weekly team meetings to review phone calls and
  difficulties
• Calling at different times of day, from different
  phone numbers, to different phone numbers
• Sending letters or going to the house for contact

21
How do we do it?

• Reducing cancellations and no-shows
• Incentives for completion
• Rescheduling quickly and in-person if possible
• Explain interviewers travel time
• Offer to talk to partner and child, if
  appropriate
• Offer to do interview in clinic, if needed
• Offer transportation and babysitting, if needed

22
Other Important Factors

• Build rapport and trust with mother and child
• Checking in with family
• Offering help with problems
• Support and encourage staff
• Help staff avoid feeling rejected by subjects
• Only hire flexible interviewers
• Interviewers need to be prepared for the
  population

23
Convergence of Studies

• What was happening
• High percentage of refusals
• 20 of those who agreed to be contacted refused
  to participate.
• Women were contacted by multiple people for
  interviews
• Complaints of feeling overwhelmed, not
  understanding the flow of the studies

24
Convergence of Studies
Need to identify the common mission The two
studies are really one, the goal of which is to
identify the needs and outcomes of depressed,
low-income women and their families
25
Convergence of Studies

• Results of establishing a common mission
• Clinicians identified as the best suited to be
  the gatekeepers
• Clinicians now fully introduce the child
  component
• Clinicians can identify any hesitation by the
  subject and address the concern more quickly
• Staff now sees the project in terms of a common
  goal rather than in terms of separate studies

26
Convergence of Studies -- The Outcome