Pennsylvania

Pennsylvania Strategies

Treatment for Maternal Depression in Home Visiting: Moving Beyond Depression

Moving Beyond Depression (MBD) is an evidence-based program that partners with home visiting programs and primary care providers to deliver in-home cognitive behavior therapy (IH-CBT) to mothers experiencing depression. MBD was designed at Cincinnati Children’s Hospital Medical Center as a supplement to Every Child Succeeds, a home visiting program serving first-time, at-risk mothers in southwest Ohio and northern Kentucky. The initial development of MBD was guided by two considerations: 1) the need to reduce barriers to engaging mothers, especially those in poverty, in treatment for depression, and 2) the intention to disseminate the model to other home visiting programs and healthcare settings. MBD is currently delivered in home visiting programs in nine states (California, Florida, Illinois, Kansas, Kentucky, Missouri, Ohio, Pennsylvania, and Texas) including Adolescent Family Life Program, Early Head Start, Healthy Families, Healthy Start, Nurse-Family Partnership, and Parents as Teachers. This profile provides an overview of MBD and examines how it is implemented in Healthy Start home visiting in Pittsburgh, Pennsylvania.

Home visitors identify mothers for referral to MBD through regular maternal depression screening. When a mother scores above a designated threshold on a validated screening tool, the home visitor describes MBD to the mother and, if the mother expresses interest, provides a warm handoff to a master’s-level licensed mental health clinician trained in this model. The clinician conducts a diagnostic assessment with the mother to ensure she meets eligibility criteria for major depressive disorder and does not have other certain conditions that would require a different intervention. MBD is then delivered in the mother’s home over the course of 15 weekly hour-long sessions, with a follow-up booster session a month later.

The delivery of MBD in the mother’s home is key to addressing barriers to mental health treatment such as a lack of transportation or discomfort with visiting a mental health setting. In MBD, the clinician uses CBT (cognitive behavior therapy) which many clinicians already use, augmented with additional clinical tools tailored to the needs of young, low-income mothers. While MBD is designed to treat depression, many of the mothers experience symptoms of other mental health disorders such as anxiety and post-traumatic stress disorder (PTSD). The skills mothers learn during MBD, such as mood management, can help with these other symptoms. MBD developers are considering the addition of a brief PTSD treatment to the model.

The MBD clinician and home visitor establish a close relationship, with the home visitor attending the final MBD session. This relationship ensures that when a home visitor makes a referral to MBD, the mother experiences a warm handoff to a trusted partner. During the course of MBD, the clinician is able to share with the home visitor any concerns the mother brings up that the home visiting program is better suited to address, such as housing, food, or transportation problems. Home visitors also have more time to work with mothers on meeting these needs and on promoting positive, responsive mother-child interactions and a healthy mother-child relationship. while the MBD clinician focuses on supporting the mother’s mental health.

In most cases, an organization with a home visiting program reaches out to MBD to initiate implementation, typically because the home visiting program does not have reliable access to mental health treatment for its clients otherwise. Home visiting programs will often partner with a community mental health center or other nonprofit partner to provide MBD clinicians, though they may hire a clinician to serve in their agency or already have mental health clinicians on staff. Having a champion within the home visiting program is critical for successful implementation and ongoing sustainability. MBD will work with the home visiting program to develop an implementation plan and provide initial training and support for two years.

Workforce Development

MBD offers two trainings. The first, virtual sessions over two days, is for the clinician and their team leader/supervisor, as well as home visiting agency leads. The second is five hours of training, typically virtual, for home visitors and covers an introduction to perinatal depression and trauma; research findings on MBD and video testimonials from mothers who have participated in MBD; and the methods for integrating MBD into home visiting and presenting it to mothers.

During the two-year implementation period, clinicians have monthly calls with MBD to discuss challenging cases. They also provide audio recordings of sessions to MBD for feedback on building their clinical skills. Home visiting program leaders have calls with MBD at least every quarter to address difficulties incorporating MBD into home visiting, such as variation in referral rates to MBD among home visitors. Following the initial two-year implementation period, MBD offers support on an ad hoc basis.

If a home visiting program hires additional clinicians, MBD will train them. Sites in Florida and Pittsburgh participated in train-the-trainer trainings, and are able to train new clinicians in-house, but MBD only offers this capability to experienced sites. MBD training of newly hired home visitors is handled by the MDB clinician or an experienced home visitor within the agency.

Financing

MBD treatment is reimbursable through Medicaid. However, home visiting programs need additional sources of funding, such as philanthropic funds or internal funds, for unreimbursed time such as clinician travel (which can be significant because of the in-home delivery of MBD) and no-show appointments. Home visiting programs also have used time-limited sources of funding, such as philanthropic, for the initial training and implementation costs.

Evaluation and Monitoring

In a clinical trial of MBD, 93 mothers who had received a diagnosis of major depressive disorder were randomly assigned to a control group or MBD. Compared to the control group, mothers who received MBD showed significantly greater improvements in depression, psychological distress, and social functioning post-treatment and three months later.[i] A cost-effectiveness analysis using the clinical trial data found MBD is more cost-effective than a current standard of practice defined as home visiting combined with antidepressant medication.[ii]

Home visiting programs upload data to MBD on a regular basis. In addition to pre- and post-intervention depression screening scores, these data include depression screenings conducted at each session by the clinician. MBD has developed a standardized report for programs that shows trends in these scores over time and compares results to those from the original clinical trial. These reports help home visiting programs make the case for the value of MBD as part their sustainability efforts.

Healthy Start in Allegheny County, Pennsylvania

Healthy Start, Inc. (HS) in Allegheny County, Pennsylvania, has been delivering MBD as part of its home visiting program since 2019. HS, which has served families in Pittsburgh and Allegheny County since 1991, aims to improve maternal and child health and reduce poor birth outcomes and infant mortality. The program focuses on improving racial health equity in Pittsburgh, particularly for Black families. It also serves families in neighboring Westmoreland County. HS offers perinatal home visiting, birth doulas, lactation support, fatherhood coordinators, community education, assistance from community nurses and social workers, and other supports provided through a multidisciplinary team approach. Through its home visiting program, community health workers offer health assessment, case coordination, education, and advocacy support. There are two primary referral pathways for enrollment into home visiting with HS: 1) prenatally, through a federally funded initiative to eliminate racial disparities in perinatal health outcomes, HS recruits families from zip codes with higher percentages of Black households, through healthcare providers, community outreach, and relationships with Medicaid managed care organizations; and 2) after giving birth, by referral from the Allegheny County Department of Human Services through its universal Hello Baby family support program, for families having complex needs, such as a mental health diagnosis, substance use disorder, or involvement with the child welfare system. Each year 300 families receive HS home visiting services and approximately 90 percent of families served by HS are Black.

HS originally aimed to incorporate MBD into its home visiting program because of long waiting lists for outpatient mental health treatment, especially for families seeking to work with a Black therapist. At the time of this new implementation process, rates of formal maternal depression screening conducted by the home visitor (called community health workers) were low. To increase MBD referrals, HS encouraged home visitors to conduct maternal depression screening on a quarterly basis with families and held meetings with home visitors to learn about their experience administering it. At these meetings, HS also emphasized that maternal depression screening is not about diagnosis or treatment and that the home visitor’s only next step is to ask the mother if she would like to talk with a mental health clinician. The home visitor leaves the offer open-ended and does not put any pressure on the family, but can invite the clinician to join the next visit or arrange a warm handoff.

As home visitors grew more comfortable with maternal depression screening and began to see the benefits of MBD with their clients, rates, and frequency of screening increased to one hundred percent. Now home visitors screen for depression monthly. Between 30 and 40 percent of mothers screened score an 11 or higher on the Edinburgh Postnatal Depression Scale (EPDS), which makes them eligible for MBD. About 60 percent of mothers begin MBD sessions with a therapist. While occasionally there is a short waitlist for MBD, the treatment is free and has shorter waitlists than outpatient mental health treatment, and in the interim families continue to receive support from the home visitor.

When families begin MBD, the clinician conducts a preassessment, which covers mental health history, family history, trauma, ACEs (Adverse Childhood Experiences), social supports, and a psychological assessment. If the preassessment identifies the need for a higher level of care or a different potential diagnosis (e.g., substance use disorder, bipolar disorder), then the mother and clinician may not proceed with MBD. For those who do proceed, having treatment delivered at home, via telehealth or in-person, is a significant benefit. HS has tailored some MBD materials to better serve the families it works with, including adding visual representations of content and reducing the wordiness of content. HS is also developing video content.

Midway through MBD treatment, the home visitor and clinician will meet to discuss the goals identified by the mother and how the home visitor can support her. They also talk about needs that are not related to mental health treatment, which the home visitor can address. The home visitor attends the final MBD session, and at this time, the clinician can help with any referrals to longer-term mental health therapy if the mother wants to continue treatment. HS is also introducing an aftercare group as a source of peer support for those who have completed MBD.

Workforce Development

Healthy Start, Inc. aims to strengthen access to culturally-responsive care by strengthening the Black maternal and child health workforce in Pittsburgh and Allegheny County. It is important that therapists represent the target population that they serve. The MBD program at HS currently has three clinicians, two of whom are Black women and the third clinician, who is white, serves families in the home visiting program recruited as part of the focus on reducing disparities in perinatal health outcomes.

HS has train-the-trainer status and has access to MBD training materials whenever a new clinician is hired. For instance, the PsyD student intern who will lead the new aftercare group will be trained on MBD and have a small caseload. Having train-the-trainer capacity has been key to sustainability. The clinician team also convenes regularly for internal case consultation discussions. The MBD program at HS holds quarterly lunch and learn sessions for agency staff, including doulas, social workers, and fatherhood coordinators, to help them become familiar with MBD.

Financing

The initial two-year implementation funding for MBD came from a local behavior and mental health foundation. Currently, funding for MBD is incorporated into any HS grant proposal to ensure it is as much a part of the program as its home visitors, doulas, fatherhood coordinators, and other roles. The primary sources of funding for HS that include coverage of MBD are a federal Health Resources and Services Administration Healthy Start grant, the Allegheny County Department of Human Services, and contracts with Medicaid managed care organizations.

Evaluation and Monitoring

HS has a contract with MBD to collect data on their behalf. These include the scores from the weekly maternal depression screeners administered during MBD. HS also has data collected by its home visitors, including monthly depression screening scores. The data show that HS has assessed 202 eligible mothers to take part in the MBD program. HS participants have a 68 percent program completion rate. This completion rate is higher than the clinical trial (48.9 percent). There was a change in the diagnosis of Major Depressive Disorder from pre-treatment to post-treatment for mothers who completed treatment; 73.3 percent of mothers had recovered by post-treatment and did not meet the criteria for MDD. Reviewing EPDS screenings from beginning to end of treatment, the current average of change in score is 8 points, which is double the clinical significance of improvement for an EPDS result.

Nurse-Family Partnership of Lancaster County, Pennsylvania

Nurse-Family Partnership (NFP) in Lancaster County, Pennsylvania, has delivered Moving Beyond Depression as part of its home visiting program since 2015. NFP, which has served families in Lancaster County since 2001, aims to improve pregnancy outcomes, child health and development, and family economic self-sufficiency. NFP offers income-eligible, first-time mothers weekly or biweekly visits from a nurse starting from between the 16th and 28th weeks of pregnancy through the child’s second birthday. Visits include health checks, preparation for childbirth and breastfeeding, mental health screening, safe sleep, child developmental screening, activities to support child development and parent-child interactions, and referrals to services such as WIC. Lancaster County consists of the city of Lancaster, as well as rural areas. The population NFP serves consists of high-risk, low-income, first-time mothers, and mothers are typically recruited through referrals. NFP serves 290 families each year.

Both NFP and Penn Medicine Lancaster General Health, the health system NFP is affiliated with, have a strong focus on maternal mental health. The hospital already routinely screens for depression and anxiety in its women and babies hospital, and NFP emphasizes mental health in its training and services. NFP screens for depression regularly using the Patient Health Questionnaire (PHQ-9) and GAD-7 (General Anxiety Disorder-7) and uses the results of these screens to refer to MBD. Nurses are educated on the symptoms of depression and can refer to MBD if they observe these symptoms even without a positive screen.

Following the referral, the MBD therapist can conduct an assessment or diagnostic visit. The nurse can help to reduce obstacles to engaging with the therapist, including addressing stigma around seeking mental health treatment, any previous negative experiences with therapy, and logistical challenges around child care, work, or schooling. The nurse can show the mother video testimonials from previous MBD clients and join a co-visit with the MBD therapist and mother. Nurses appreciate that parents’, participation in MBD not only supports maternal mental health but can increase participation and engagement in NFP visits with the nurse.

The MBD therapist conducts mid-treatment and end-of-treatment reviews. The MBD therapist works with the mother to develop a binder identifying successful strategies for addressing symptoms, which the nurse and mother can continue referring to after the end of MBD. Additionally, MBD offers an eight-week follow-up program if the mother experiences a relapse six months or more after the end of MBD and is still enrolled in NFP. Of the 151 clients MBD has treated, only five have needed the follow-up treatment. In cases where MBD is not appropriate for a mother, NFP has a social worker to help with referrals for treatment elsewhere and referrals to other community resources. However, MBD is typically the best option because referrals to other outpatient mental health services are less likely to lead to sustained engagement with treatment.

The strong relationship NFP nurses and MBD therapists have established leads to more effective collaboration and better outcomes. MBD is administratively part of the NFP program, rather than part of the behavioral health unit at Penn Medicine Lancaster General Health hospital, and is located in the same building as NFP, leading to better communication between nurses and therapists. MBD meets all new NFP nurses to begin developing a relationship, joins NFP staff meetings periodically, and can offer additional trainings on mental health topics.

MBD has incorporated trauma-informed care into its work with clients, many of whom have experienced abuse or trauma. The approach gives clients education and coping skills and helps them better understand their depression and symptoms. While not trauma-focused therapy (e.g., exposure therapy, narrative therapy), it can help with the transition to follow-up counselling to address trauma.

A Spanish-speaking therapist has allowed delivery of MBD in Spanish, helping support the large number Spanish-speaking families in NFP. This support is especially important because there are few outpatient mental health services in the community that can treat Spanish-speaking clients.

MBD has learned over time that flexibility with clients is key to success and aims to be as flexible as possible to maximize treatment outcomes. For example, MBD can be extended for up to three additional sessions for special circumstances (e.g., a client was doing well but then experienced a traumatic loss).

Workforce Development

MBD has a full-time master’s-level social worker who is Spanish-speaking. The MBD team lead offers weekly supervision to the clinician.

Financing

MBD is funded by Penn Medicine Lancaster General Health and the Children’s Trust Fund, which funds community-based programs to prevent child abuse and neglect through a surcharge on all applications for marriage licenses and divorce complaints in the state. MBD has not been able to use Medicaid funding because Medicaid in Pennsylvania will not reimburse for in-home psychotherapy or in-home cognitive behavioral therapy.

Monitoring and Evaluation

MBD continues to use the Redcap data system it initially used to collect data for the MBD national office. Its results are similar to those from the randomized controlled trials of MBD. Over the past eight years, MBD has served 151 clients. MBD clients average 11 sessions, compared to just over 4 for typical outpatient mental health treatment. More than 75 percent of clients attend eight or more sessions. The average Edinburgh Postnatal Depression Scale (EPDS) score is 13.49 at the start, which indicates a fairly high probability of depression, and 7.49 at 15 weeks, which is below clinical significance. At the final session, more than 85 percent of clients no longer meet criteria for major depressive disorder.

Special thanks to the following individuals for providing information for and reviewing this profile: Robert Ammerman and Olivia Cleary, Cincinnati Children’s Hospital Medical Center; Chaunda Cunningham and Jada Shirriel, Healthy Start Pittsburgh; and Janine Castle, Nurse-Family Partnership of Lancaster County.

Last updated October 2023

[i] Ammerman, R. T., Putnam, F. W., Altaye, M., Teeters, A. R., Stevens, J., & Van Ginkel, J. B. (2013). Treatment of depressed mothers in home visiting: Impact on psychological distress and social functioning. Child Abuse & Neglect, 37(8), 544-554.

Ammerman, R. T., Putnam, F. W., Altaye, M., Stevens, J., Teeters, A. R., & Van Ginkel, J. B. (2013). A clinical trial of in-home CBT for depressed mothers in home visitation. Behavior Therapy, 44(3), 359-372.

[ii] Ammerman, R. T., Mallow, P. J., Rizzo, J. A., Putnam, F. W., & Van Ginkel, J. B. (2017). Cost-effectiveness of In-Home Cognitive Behavioral Therapy for low-income depressed mothers participating in early childhood prevention programs. Journal of Affective Disorders, 208, 475-482.