Brief Interpersonal Psychotherapy for Perinatal Depression in Socio-Economically Disadvantaged Women: Effectiveness and Cost Effectiveness

Background: Effectiveness of collaborative care for perinatal depression has been demonstrated in the MOMCare intervention from pregnancy up to 15-months postpartum for pregnant women on Medicaid in the Seattle-King County Public Health System.  MOMCare, using Brief Interpersonal Psychotherapy and/or pharmacotherapy, had a greater impact on reducing depressive symptoms and improving functioning for women with comorbid post-traumatic stress disorder(PTSD) than for those without PTSD. Implementation of improved depression care by health insurers and public health systems for women with major depression(MDD) and PTSD will ultimately depend on estimating incremental benefit, incremental cost, and net benefit. To date, the incremental benefit of collaborative care for perinatal depression has not been evaluated.

The present study examines costs from a health system perspective,especially regarding poor and racially/ethnically diverse women who are at least twice as likely as middle-class women to meet diagnostic criteria for major depression during pregnancy and who are more likely to suffer from PTSD due to childhood abuse and neglect and intimate partner violence.   We predicted that MOMCare would lead to more depression-free days and a positive incremental net benefit for depressed women with comorbid PTSD, compared with enhanced Maternity Support Services(MSS-Plus) provided in 10 clinics in the Seattle-King County Public Health System.  MSS-Plus did not provide depression care, but offered supportive services for having a healthy pregnancy leading to healthy birth outcomes.

Methods: A randomized trial, conducted from September 2009-December 2014,compared the MOMCare collaborative care depression intervention (choice of brief Interpersonal Psychotherapy and/or pharmacotherapy) with intensive Maternity Support Services(MSS-Plus) in public health Seattle-King County.  Pregnant women were recruited who had a probable diagnosis of MDD and/or dysthymia (n=164). Two-thirds of the sample met criteria for probable PTSD(n=106). Independent blinded assessments at 3-,6-,12-,and 18-months post-baseline included the Symptom Checklist-20 depression scale and  the Cornell Services Index. Analyses of covariance estimated gain in depression free days by intervention and PTSD status.

Results: Over 18 months, for women with probable MDD and PTSD, MOMCare led to a gain of 68 depression-free days[F(1,92)=4.56,p<.05],controlling for baseline depression severity. Given the increased depression care cost of $1312 per MOMCare participant with comorbid PTSD, the incremental net benefit was positive if a day free of depression was valued at $20 or greater.

Implications: Compared with public health MSS-Plus, MOMCare for perinatal depression in women with probable MDD and PTSD had significant clinical benefit,with only a moderate increase in health services cost. Notably, MOMCare over 18 months was estimated to cost about $2.50 a day, less than a tall caffee latte. Because of these cost effectiveness findings, in the near future Seattle-King County Public Health System will be implementing MOMCare, funded by Washington State Medicaid. MSS-Plus social workers will be trained and supervised in providing evidence-based Brief Interpersonal Psychotherapy and/or pharmacotherapy to their depressed, pregnant clients who also have PTSD. These social workers will collaborate from pregnancy up to six-months postpartum with the MOMCare collaborative care team of UW professionals, including a psychiatrist, masters-level clinical social work supervisors, and the pregnant woman’s local obstetrician.