Project Name: 
Feasibility of Behavioral Activation for Perinatal Depression

Principal Investigator:
Arne Beck, PhD

Principal Investigator Contact Information:
arne.beck@kp.org

Principal Investigator institution:
Kaiser Permanente Colorado, Denver, CO

Funder:
NIMH

Funding Period:
07/2010 – 07/2014

Abstract:
At four MHRN sites (Group Health, HealthPartners, KP Colorado, and KP Georgia) women with moderate or greater symptoms of depression were identified either by visit-based screening (by OB clinic staff at first prenatal visits) or mailed screening (of all pregnant women during the first and/or second trimester).  Those identified were offered participation in a randomized trial comparing continued care as usual to Behavioral Activation (BA) Psychotherapy added to care as usual.  The BA program was adapted for the specific needs of mothers (including delivery by telephone) and for delivery by a range of clinicians (including OB clinical staff).  The project also took advantage of the MHRN’s centralized online survey platform for administration of standard assessments at baseline and follow-up.

Grant Number:
U19MH092201

Participating Sites:                                       
Kaiser Permanente Colorado, Denver, CO (Lead Site)
Group Health Cooperative, Seattle, WA
HealthPartners, Minneapolis, MN
Kaiser Permanente Georgia, Atlanta, GA

Investigators:
Arne Beck, PhD - KPCO
Sona Dimidjian, PhD – University of Colorado Boulder
Greg Simon, MD – GH
Nancy Sherwood, PhD – HP
Sherryl Goodman, PhD – KPGA
Evette Ludman, PhD - GH

Major Goals:
Demonstrate the feasibility of innovative and efficient methods for multi-site comparative effectiveness trials in mental health, using perinatal depression as an example, including:

  1. Screening for depression at the point of care and via low-cost mail and web surveys
  2. Training real-world clinicians to deliver a structured behavioral activation intervention
  3. Delivering a structured psychotherapy intervention via telephone contacts and in-person visits
  4. Assessing outcomes via low-cost web-based interactive voice response surveys

In a population-based sample of pregnant women with current depression, conduct a randomized comparison of a structured Behavioral Activation intervention to care as usual in order to evaluate feasibility and acceptability – and make a preliminary comparison of effectiveness.

Description of study sample:
Women with moderate or greater symptoms of depression were identified either by visit-based screening (by OB clinic staff at first prenatal visits) or mailed screening (of all pregnant women during the first and/or second trimester).  Using various methods of recruitment, women were randomized into this study to usual care or to the intervention.  For all participating sites, 163 women participated in the randomized trial. 

Follow-up surveys were completed for all participating sites with the completion of the last 3-month post-partum surveys.  Only 9 participants out of the 163 women who were enrolled at all the sites were lost to follow-up (filled out the baseline but did not complete any follow-ups), 6 in the intervention group and 3 in the usual care group. 

Current Status:
Nurse practitioners, nurse midwives, and mental health therapists were trained to deliver 10 telephonic sessions of behavioral activation (BA) therapy to women screening positive for depression at prenatal visits who are randomized to the BA arm of the trial.

An efficient web-based survey using the DatStat platform was developed and used to collect data on several measures from participants at enrollment, 5 and 10 weeks, and 3 months post-partum. 

Study Registration:
NCT01401231

Publications:
Dimidjian, S, Goodman, SH, Sherwood, NE, Simon, G, Ludman, S, Gallop, R, Welch, SS, Boggs, JM, Metcalf, CM, Hubley, S, Beck, A. (2016) A Pragmatic Randomized Clinical Trial of Behavioral Activation for Depressed Pregnant Women.  Journal of Consulting and Clinical Psychology. In Press.

Resources:
N/A

Lessons Learned:

  • The most efficient recruitment procedure was developed and implemented at HP, involving large mailings of PHQ9 surveys to women scheduled for prenatal visits. Recruitment is also being done at the point of care at KPCO, GHC, and KPGA, when women are given the PHQ9 or EPDS to assess their level of depression symptoms.
  • Nurse practitioners and midwives can be trained to deliver BA with an acceptable level of fidelity.
  • Telephonic BA is feasible and acceptable to participants.
  • Compared to treatment as usual, patient randomized to the behavioral activation group, had significantly lower depressive symptoms and higher remission rates.
  • Behavioral activation also showed significant reductions in symptoms of anxiety and perceived stress. 

What’s next?
Following this trials demonstration of the acceptability and effectiveness of behavioral activation delivered by allied health providers, the study teams approached the OB-GYN departments at each institution regarding implementation of a BA intervention in the OB-GYN setting.  While there was recognition of the effectiveness of the BA model for perinatal depression, implementation of an operation program was met with hesitancy regarding financial and logistical hurdles.  Specific barriers included a lack of continued funding for the BA clinicians employed during the study and coordination hurdles surrounding nurses or other allied health professionals taking time away from their current job roles to provide BA for women with depression.  Therefore, the study team took this feedback and Sona Dimidjian proposed a new study using peer specialists who would be trained in BA combined with research to practice engagement methods.  This R34 was funded in September, 2016 for 3 years.  The goals of this study are to engage all stakeholders in the design of a Peer BA intervention for perinatal and post-partum depression using research to practice frameworks to better facilitate successful adoption following the trial.   Stakeholders include patients, OB-GYN, Behavioral Health, and other relevant departments at KPCO.