WE Care Women Entering Care

WECare Depressed Subject Recruitment by Month-Year

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

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.

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

The First Interview: Facilitating Recruitment Selection of Interviewers --Interviewers who are committed --Have training in diagnosis and assessment Training and Supervision I --Intensive training for 2-3 weeks --Mandatory weekly supervision meeting Facilitating Collaboration with Interviewers and Site Staff --Regular visit to sites --Continuous problem-solving to increase efficiency in Recruitment

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

Key Characteristics of WECare Treatment Approach Persistence Flexibility Excellent Clinical Relationship Support for Treatment Success Cultural Sensitivity

Persistence Repeated calls to subjects Friendly upbeat approach Nonjudgmental Offer choices when possible Don’t short circuit - keep options open

Flexibility Work meetings around subject’s 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

Excellent Clinical Relationship Frequent scheduled follow up calls Actively problem solve to anticipate needs and concerns Be available for subject’s problems (crises, calls, worries) Maintain therapeutic boundaries

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

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

Phone Interviewing Flexible Scheduling Persistence and Boundaries Establishing Relationships with Subjects

Effects on Children 5-year NIMH-funded study, 1998 – mother and child dyads –Same distribution of race/ethnicity –Same 3 treatment groups –Same Non-Depressed Control group (N=50) Children 4 – 10 years old

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.

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

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

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)

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

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

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

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

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

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

Convergence of Studies -- The Outcome