2. The Boston Healthy Start Initiative Depression Among Black Women in the Boston Healthy Start Project Area Urmi Bhaumik, MBBS, MS, DSc. Local Evaluator, Boston Healthy Start Initiative Boston Public Health Commission Maia BrodyField, MPH Senior Manager Boston Public Health Commission

3. Objectives of Presentation  To describe the development and implementation of a depression screening initiative among Healthy Start women.  To report on the preliminary findings of the Boston Healthy Start women’s experience of depression during pregnancy and up to 2 years after delivery.

4. Boston Healthy Start Initiative A program designed to reduce perinatal disparities in health in Boston areas with the highest infant mortality rates.

5. BHSI MODEL  BHSI has a holistic case management model that includes services for mental health and interconceptional care  BHSI relies heavily on its Consortium--a partnership of community residents and agencies, and local government health organizations

6. Target Population  BHSI targets Black women in Boston neighborhoods experiencing racial disparities in perinatal health  Black women are defined as: African American Haitian Cape Verdean African Black Latinas

7. Needs Assessment  Focus groups with providers and consumers were conducted prior to the latest phase of the Boston Healthy Start Initiative  Depression was identified to be a major problem among women of color

8. Mental Health Task Force  Convened to address depression  Recruitment done through the BHSI Consortium  Members included: case managers mental health providers other frontline staff

9. Depression Screening Tools  BHSI consumers reviewed a number of depression screening tools like the Edinburgh PP and the self- rating Anxiety Scale  The Mental Health Task force decided to use the Beck tool based on consumer recommendation  Women are screened three times: At the point of entry into the program At the end of 8 weeks post-partum At the end of the first year after delivery

10. Women's Health Questionnaire (WHQ)  In addition women are offered an in-depth health assessment using the WHQ  A self administered tool  Assesses health and social problems along with depression  It is offered: At the point of entry At the end of the 1 st year after delivery At the end of the 2 nd year after delivery

11. Depression Prevalence: WHQ  506 women have responded to the Women’s Health Questionnaire at the point of entry  13.4% responded as being depressed at present  24.1% reported they suffered from depression either at present or in the past. Source: Women’s Health Questionnaire

12. Depression Prevalence: BDI During Pregnancy One in three (33.7%) women scored positive for depression using the BDI Source: Beck Depression Inventory Tool

13. Depression Prevalence: BDI At Postpartum Period Almost two out of ten (19%) women scored positive for depression. Source: Beck Depression Inventory Tool

14. Depression Prevalence: BDI At 1-year Interconception Eighteen percent of BHSI clients scored positive for depression. Source: Beck Depression Inventory Tool

15. Depression Prevalence WHQ vs. BDI-II: During Pregnancy

16. Depression Prevalence WHQ vs. BDI-II: During Pregnancy  A notable difference between depression prevalence obtained from WHQ responses compared to BDI-II scoring  Likely reason is that BDI-II is designed to capture depression if present and WHQ is the women’s perception of being depressed or not.

17. Depression Symptoms During Pregnancy:  Changes in Sleeping Pattern  Loss of Interest in Sex  Changes in Appetite  Crying  Punishment Feelings Source: Beck Depression Inventory During Postpartum:  Crying  Changes in Sleeping Pattern  Loss of Interest in Sex  Loss of Interest  Agitation Top 5 symptoms reported as severe:

18. Depression and Ethnicity  Depression differs across ethnic groups with the lowest prevalence among Haitians  Compared to Haitians: African Americans are eight times more likely to be depressed Latinos are almost six times more likely to be depressed All others are three times more likely to be depressed Source: Women’s Health Questionnaire

19. Depression and Birthplace The odds of being depressed are 3.1 times (p-value < 0.001) higher in those born in USA compared to those born abroad. Source: Women’s Health Questionnaire

20. Depression and Other Factors Adjusting for demographic and socio-economic factors, depression is also associated with:  Family Problem: OR 5.4*  Substance Use: OR 4.5*  Smoking: OR 2.1, p-value**  Health Care Access Problem: OR 1.7*** Source: Women’s Health Questionnaire * p-value <0.001; ** p-value <0.05 *** p-value <0.1

21. Attitude Towards Depression  Surveys on attitudes towards depression were administered to providers and clients  Findings show that depression is not perceived as a problem by many women scoring high in the BDI

22.  The BHSI population has a high threshold for depression, being consistently exposed to stress  Denial is a factor for many clients  Don’t want to be labeled as depressed due to fear of the mental health system  Not familiar with variations in mental health issues: “ you are crazy or you are not” Attitude Towards Depression

23. Interventions  Case managers provide education and support about depression  Referrals are made to community based resources  Women are consistently encouraged and reminded to keep their appointments  Distribution of educational materials on mental health/well-being

24. BHSI Interventions Creative approaches for clients to address emotional and physical needs of women:  “Sister’s Circle” – addresses the emotional and spiritual needs of women through monthly meetings and bimonthly individual coaching  “Slim Down Sisters” - focuses on the physical well being of the women

25. Conclusions  A significant proportion of Black women experience depression; in addition to those who experience postpartum depression, many begin their pregnancies depressed  Holistic case management and creative approaches are needed to address this need among inner city Healthy Start women

26. Conclusions  suggest a positive effect of screening and subsequent case referral and management.  Decreasing depression prevalence rates across different time points of care

27. Next Steps….  Continued case management for Healthy Start women, utilizing holistic and creative approaches.  Further evaluation and refinement of BHSI interventions for depression.