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Strengthening Systemic, Workforce, and Fiscal Policies to Promote Research-Informed Practices

SUMMARY

Systemic Challenges

  • A variety of systemic policies act as a barrier to implement research-informed practices to improve the quality care needed for depressed parents and their children. These challenges include, creating a two-generation response, meeting the need of vulnerable populations as well as those who experience depression with other comorbidities and family adversities, and developing complex interventions that can be adopted in a variety of settings.

Workforce Capacity and Competency

  • Evidence shows that a variety of workforce issues remain as a barrier to implement research-informed practices to care for depressed parents and their children. These issues include mental health and primary care provider shortages; a lack of comfort with clinical skills, capacity, and awareness for dealing with depression and its co-occurring conditions in families; and a lack of effective training models to help providers learn and take on multiple roles.

Fiscal Policies

  • A variety of financial challenges exist in implementing researchinformed practices to improve the quality of care for depressed



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9 Strengthening Systemic, Workforce, and Fiscal Policies to Promote Research-Informed Practices SUMMARY Systemic Challenges • A variety of systemic policies act as a barrier to implement re- search-informed practices to improve the quality care needed for depressed parents and their children. These challenges include, creating a two-generation response, meeting the need of vulnerable populations as well as those who experience depression with other comorbidities and family adversities, and developing complex in- terventions that can be adopted in a variety of settings. Workforce Capacity and Competency • Evidence shows that a variety of workforce issues remain as a bar- rier to implement research-informed practices to care for depressed parents and their children. These issues include mental health and primary care provider shortages; a lack of comfort with clinical skills, capacity, and awareness for dealing with depression and its co-occurring conditions in families; and a lack of effective training models to help providers learn and take on multiple roles. Fiscal Policies • A variety of financial challenges exist in implementing research- informed practices to improve the quality of care for depressed 

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN parents and their children. These challenges include a lack of or inadequate insurance coverage, reimbursement practices and policies that are inconsistent with the research base, and a lack of funding streams to pay for two-generation, research-informed pre- vention and parenting interventions as well as early interventions for children. ____________________ This chapter provides an overview of the policy environments that can resolve systemic, workforce, and fiscal policy challenges associated with implementing innovative and research-informed practices to improve out- comes for depressed parents and their children. It concludes by highlighting policy recommendations that support bolder federal and state responses to the problem of parental depression. Three broad issues must be addressed to create a more responsive pol- icy framework to increase access to research-based prevention, screening, and treatment through a family-focused lens for those coping with parental depression: (1) systemic barriers, (2) workforce capacity and competence, and (3) fiscal barriers. SYSTEMIC OPPORTUNITIES Building a comprehensive policy and service response to parental de- pression that includes attention to impacts on adults, on children (especially young children), and on parent-child relationships, as described in Chapter 8, requires refocusing program strategies through a family lens. Right now, few, if any, policy models exist for delivering family-focused mental health services. Systemic barriers across health, mental health, and other systems will have to be overcome to provide the range and intensity of research- informed prevention, treatment, and parenting support services discussed in this report. Below we highlight four of the most important systemic policy and services frameworks challenges to overcome to implement these strategies: 1. creating a two-generation response to parental depression; 2. responding to the needs of vulnerable populations, particularly low-income and culturally and ethnically diverse families; 3. responding to families experiencing depression along with other comorbidities and family adversities; and 4. developing complex interventions that build on collaborative, inte- grated, and comprehensive service models.

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 STRENGTHENING SYSTEMIC, WORKFORCE, AND FISCAL POLICIES Family-Focused Two-Generation Issues A central gap across the relevant systems is the difficulty of implement- ing screening and services responsive not just to adults or to children, but to both, taking into account the family context. Barriers to a responsive fam- ily-focused perspective from the adult mental health system, for example, include the failure to require in protocols or administrative regulations that adults in treatment for any mental health issues are asked whether they are parents and what the impact of the illness is on the children. A recent study found that only 12 states report that they systematically inquire as to whether adults with any mental illness under their care are parents and provide some parenting services (Biebel et al., 2006). Similarly, the child mental health system lacks the capacity to provide either treatment or par- enting interventions to parents with depression. Furthermore, despite evidence about the importance of addressing the risks that parental depression poses to children, particularly young children, most children’s mental health agencies lack the resources (or the legal man- date) to serve children at risk of developing mental health problems and instead focus all resources on those with diagnosed problems (Cooper et al., 2008). Financing for services and supports for children without a diagnosis remains limited. Nor are we aware of states that explicitly set forth referral priorities for children. This is further compounded for the youngest chil- dren because only a handful of states permit an early childhood diagnostic classification system, known as DC-03, as a basis for reimbursement for Medicaid (Stebbins and Knitzer, 2007), although it is widely recognized that there is a lack of fit with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) for this age group. Similarly, there are still some states that do not permit family therapy for children under age 3 years, although according to a Kaiser Permanente study, 1 in 10 children from birth to age 3 has a parent with diagnosed depression or depressive symptoms (Dietz et al., 2007). Taking the family context into account requires policy and administra- tive remedies to resolve several challenges. Introducing a responsive family- focused perspective from the adult mental health system, for example, will require changes in protocols or administrative regulations so that adults in treatment for any mental health issues are asked about their parental status and are invited to describe the impact of their illness on their children. Responding to the Needs of Low-Income and Minority Families A responsive policy framework for parental depression has to be flex- ible enough to support different approaches focused on different popu- lations. For example, given that depression disproportionately impacts

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN low-income populations, a supportive parental depression policy agenda must be able to provide incentives to implement effective outreach and engagement strategies known to enhance treatment, as well as efforts to adapt research-informed practices to diverse families. It is also important in crafting a policy framework responsive to low-income parents, particularly single parents, to take into account their need for other supportive benefits to reduce the stresses and hardship related to poverty that can in fact trigger or exacerbate depression. One study shows that depressed mothers on welfare were more likely to report food insecurity, to have food stamps sanctioned or reduced, or to lose their welfare benefit than mothers who were not depressed (Casey et al., 2004), compounding the hardship to their families. Particularly for low-income and culturally diverse populations, interventions are often best delivered in nonclinical, community-based settings that children, youth, and families frequent and trust. Prevention, screening, treatment, and parenting support services therefore need to be available in a range of community- based settings that include not only obstetrics-gynecology, pediatric offices, and community health care settings, but also early childhood programs such as Head Start and Early Head Start and public assistance programs (e.g., Temporary Assistance to Needy Families, the Special Supplemental Nutrition Program for Women, Infants, and Children, or WIC). This means that clinicians must acquire experience in delivering services in these set- tings, as well as in homes, particularly for infants and toddlers, where the family and service providers can be linked to home visiting programs. State policies that prohibit services in nonclinical settings represent an important area for change to support these new collaborative approaches. Co-Occurring Conditions Depression rarely occurs in isolation. Chapter 3 on etiology of depres- sion, for example, notes that adult depression typically occurs in a context of chronic and acute stress and includes multiple co-occurring hardships, such as social disadvantage, exposure to violence, low social support, and comorbid psychiatric, substance, and medical problems. This constellation of risk factors may be essential to understanding the problems in children of depressed parents. The associated features also may be essential in identifying approaches to treating parents’ depression and also improving the quality of parenting and children’s outcomes. Such recognition might involve, at a minimum, assessing the constellation of risk factors and also evaluating the relative contribution of the multiple disor- ders to the problems with parenting and with child functioning. These risk factors may also affect how and where services can best be provided. Multiple initiatives to promote integrated care approaches have emerged

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9 STRENGTHENING SYSTEMIC, WORKFORCE, AND FISCAL POLICIES in diverse settings (as discussed in Chapter 8) but they are often stymied by policy, institutional, and practice barriers (Dausey et al., 2007). Rather than providing incentives for treatment strategies that recognize comorbidi- ties, the policy environment often sets up barriers. Thus, for the most part, even the limited empirical knowledge about how best to treat adults with comorbid conditions remains largely unexploited (Drake et al., 1998). One striking example involves the absence of strategies that can re- spond effectively to depressed parents who are also substance abusers. While it is known that 24 percent of adults with depression have a co- occurring substance use disorder (Kessler et al., 2003), less than 19 percent of individuals with co-occurring depression and substance use disorders receive treatment (Mark, 2003). This is fewer than the 30 percent of indi- viduals with either disorder alone. For those individuals with co-occurring disorders (depression and alcohol addiction) that are treated, treatment is more costly, 68–80 percent higher than treatment for either disorder alone (Mark, 2003). Many parents, particularly low-income parents, experience not just depression, but depression and trauma, substance abuse, domestic violence, and other conditions that impair effective parenting (Cooper et al., 2007; Flynn and Chermack, 2008). Furthermore, evidence suggests that when parents experience multiple risk factors, this is reflected in negative cognitive and behavioral outcomes for children, particularly very young children (Whitaker, Orzol, and Kahn, 2006). Complexity of Interventions Many model programs tested in controlled trials and found to be effec- tive for parental depression prevention and care involve complex strategies such as integrated services, coordinated programs, and comprehensive care, and strive to align the complexity of an intervention or organization with the complexity of the environment in which it functions (Dietrich et al., 2004; Katon et al., 2004; Wells et al., 2000). This approach, an example of the concept of requisite variety in systems theory, involves more of the vari- ables that can affect a problem, but at the cost of increased difficulties in replicating complex solutions in new settings (Ashby, 1958; Bodenheimer, Wagner, and Grumbach, 2002; Pfeffer and Sutton, 2006). The limited evidence available on the implementation of depression care interventions, either after clinical trials or in nontrial settings, has shown increased varia- tion in performance (Fisher, Goodman, and Chandra, 2008; Pearson et al., 2005; Pincus et al., 2005), which could be owing to many factors. But certainly the multiple working parts of these interventions—that is, their complexity—may be among the relevant influences. The limited available evidence casts collaboration in depression care in a promising light (Bluthenthal et al., 2006; Wells et al., 2006). But the

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90 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN evidence is not yet sufficient to support confident interpretation that success can be attributed to generalizable factors rather than idiosyncrasies (e.g., a particular leader or a particular agency). In studies of the chronic care model, community collaboration has been found to be the least successful of the model’s components, suggesting the inherent challenges of forging reliable and effective operational linkages across organizational boundar- ies and multiple providers (Pearson et al., 2005). For the most part, people and organizations will not adopt a practice or program if they cannot see it as an appropriate response to problems they care about. The intervention needs to have enough resonance with their existing beliefs and values to seem at least a little bit familiar (Hargadon and Douglas, 2001). Prevention models may fail to spread because they differ markedly from the usual prac- tices carried out in communities (Gottfredson and Gottfredson, 2002). In most diffusion research, the complexity of an intervention has been found to be a deterrent to adoption (Damanpour and Schneider, 2006; Rogers, 1995; Rye and Kimberly, 2007). However, the likelihood of imple- menting a complex intervention may be enhanced if the intervention is clearly perceived by its audience as a better solution than its rivals to a salient problem, if the audience has relatively high levels of absorptive capacity, or if an intervention is supported by an ample funding source (Knudsen and Roman, 2004). The health care and human services literature often refers to making the business case for innovations (Green et al., 2006; Unützer et al., 2006). In an environment in which insurers and policy makers wish to control costs, the uptake of improvements in depression care may depend on whether such improvements can be shown over time to save more than they cost, will be cost-neutral, or will achieve major gains in quality and health outcomes for patients for a modest net increase in costs. At this point, cost-benefit and cost-effectiveness studies on some parental depression interventions show mixed results (Gilbody, Bower, and Whitty, 2006; Neumeyer-Gromen et al., 2004; Ofman et al., 2004). Moreover, costs are frequently more certain than the expected effects or benefits, especially when the latter are based on the carefully controlled and somewhat unreal conditions of clinical trial investigations. Many of the benefits to the children of depressed parents are only realized far into the future and may be difficult to account for in the usual cost-benefit analysis. In addition to these aggregate cost issues, the question of incentives that would facilitate the adoption of evidence-based depression care procedures by clinicians deserves attention. Here, again, the evidence is mixed (Armour et al., 2001; Chaix-Couturier et al., 2000). By and large, bonus payments to induce behavior change have not been successful among physicians, per- haps because the bonuses are not large enough to be meaningful (Armour et al., 2001; Epstein, Lee, and Hamel, 2004; Town et al., 2005). Other,

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9 STRENGTHENING SYSTEMIC, WORKFORCE, AND FISCAL POLICIES nonpecuniary inducements, such as public recognition and more attractive health care quality contracts with health plans, have seemed to have better success, although, in at least one study, less so for depression than other chronic diseases (Casalino et al., 2003). WORKFORCE CAPACITY AND COMPETENCY Workforce challenges—both provider shortages to meet the demand of those who need treatment and a poor fit between provider capacity and the skills that are needed to deliver effective, research-informed services, including those related to parental depression—are at the root of many mental health policy challenges (Annapolis Coalition, 2007; Institute of Medicine, 2006). Although this report does not focus on these workforce issues, they are a part of the context for the committee’s depression-specific recommendations. One study reported that more than half of all counties in the United States lack a practicing mental health clinician (Pion et al., 1997). In primary care settings, pediatricians and other practitioners have indicated that the lack of community-based mental health capacity severely undermines their ability and confidence to appropriately identify and refer for mental health treatment, including family depression (Leaf et al., 2004; Nicholson et al., 2004). In addition, a lack of training in cultural compe- tence is frequently cited. Among mental health professionals, providers from underrepresented minority communities are less than 25 percent of psychiatrists, 20 percent of social workers and psychiatric nurses, and 10 percent of psychologists (Duffy et al., 2004). Furthermore, among providers from the majority community, many lack the cultural and linguistic compe- tence to adequately serve diverse communities (New Freedom Commission on Mental Health, 2003). As the U.S. population becomes more diverse—1 in 3 Americans are now from one of the four major racial/ethnic minority groups (U.S. Census Bureau, 2008)—the implications of these disparities widen. Specific to maternal depression, a recent survey by the state of Iowa found that, among nursing programs in the state, on average, fewer than 3 hours of curriculum-based instruction were devoted to perinatal depres- sion and to infant mental health (Montgomery and Trusty, n.d.). Research also shows that many practitioners and clinicians lack the skills to screen or treat parental depression, resulting in inappropriate responses (Horowitz et al., 2007; Leaf et al., 2004). These include not knowing how to respond to fears on the part of mothers that they may lose custody of their children as well as an inability or unwillingness to discuss depression with their patients (Busch and Redlich, 2007; Nicholson et al., 2004; Park, Solomon, and Mandell, 2006). Thus, the lack of clinician skills or understanding can contribute to stigma and discourage parents with depression from

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92 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN seeking care. Among clinicians and staff that attend to individuals with co-occurring disorders, there is a similar disconnect between the body of knowledge about effective practices and their implementation in everyday settings (Flynn and Brown, 2008). Cross-system training is limited or in- adequate and undermines efforts to improve the quality of integrated care. One study of mental health professionals revealed that less than 40 percent had any formal training in substance use disorders or addiction services (Harwood, Kowalski, and Ameen, 2004). Only half had any exposure to substance abuse issues during their training, and only 7 percent were dually certified in substance abuse and mental health (Harwood, Kowalski, and Ameen, 2004). The problem of lack of training is exacerbated by uneven preparation and entry standards (Gallon, Gabriel, and Knudsen, 2003). The research does not even address the clinicians’ lack of knowledge of the impact of parental comorbidities on children. Onsite training requirements are dictated by multiple factors, includ- ing training resources, availability of staff time, model complexity, levels of differentiation of provider roles, data collection, and model fidelity requirements. Models of moderate to greater complexity cannot be effec- tively learned through on-the-job experience alone (Feltovich, Prietula, and Ericsson, 2006; Taatgen, Huss, and Anderson, 2006; Velmahos et al., 2004) or by reading manuals or information received through the mail (Ellis et al., 2005). Indeed, even the simplest models (e.g., brief depression screens) may be difficult to execute properly just by reading up on them. Their implementers are likely to need to be trained to minimize the probability of biased interpretations (Chi and Ohlsson, 2005). Although formal training or education appears to be fairly common in research-informed practices and programs, including some of the more mature and sophisticated depression care models (e.g., Cole et al., 2000; Kilbourne et al., 2004; Wells et al., 2000), the adequacy of these training systems remains largely unknown. Specific descriptions of training are rare in the literature. In the field of training research, advances have been made in identifying factors that may contribute to training effectiveness (e.g., Burke and Hutchins, 2007; Clark and Elen, 2006; Merrill, 2002; Paas et al., 2005; Van Merrienboer and Kirschner, 2007). However, there is little indi- cation that this knowledge has been or is being applied to the training as- sociated with research-informed interventions (but see Cole et al., 2000). While training may be necessary in learning how to operate a new prac- tice or program, it is often not sufficient, given the context-dependence of learning (Anderson, Reder, and Simon, 1996; Ellis et al., 2005; Fixsen et al., 2005; Joyce and Showers, 2002). When clinicians learn in a formal training program, they are learning in that context, which will differ to a greater or lesser degree from the work context in which they will need to apply what they have learned. Evidence suggests that the knowledge acquired through

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9 STRENGTHENING SYSTEMIC, WORKFORCE, AND FISCAL POLICIES training decays fairly rapidly unless it is used (Salas and Cannon-Bowers, 2001; Tunney, 2003; Wexley and Latham, 2002), and use depends on a context that will encourage and support it socially (Burke and Hutchins, 2007) as well as financially (Bachman et al., 2006). People in supervisory roles and external sources of technical aid or coaching may need to be readily available to provide guidance and to help troubleshoot problems (Burke and Hutchins, 2007; Fixsen et al., 2005; Smith-Jentsch, Salas, and Brannick, 2001). Systems may need to be in place that provide regular, objective feedback on performance (Dunning, 2005; Ericsson, Krampe, and Tesch-Romer, 1993; Kluger and DeNisi, 1998; Webb and Sheeran, 2006). For especially complex interventions, developing pro- ficiency may take a considerable period of time (Ericsson, 2003; Norman, 2005), during which the supportiveness of the context may be as important as individual ability in determining success. Early training to prepare new entrants into the health care workforce is an important way to integrate parental depression care competencies, but it is even more important for general learning and collaboration skills. Doctors, nurses, pharmacists, and other health professionals are not being adequately prepared to provide the highest quality and safest medical care possible, and there is insufficient assessment of their ongoing proficiency (Institute of Medicine, 2003). In 2003, the Institute of Medicine made 10 recommendations designed to move training toward five interdisciplinary core competencies that support the goals of enhancing the quality and safety of care. Most of these recommendations have never been enacted, and training has not moved toward this aspiration. Promising parental depression program models often involve multiple tasks, such as screening, referral, counseling or treatment, and ancillary social services. These different roles must either be performed by program staff with the appropriate skills or provided through referrals to a network of specialists and services partnering with the parental depression program. The necessity of covering multiple roles, either in the parental depression program or through collaboration with other providers, poses significant training, communication, funding, and sustainability challenges for paren- tal depression programs. For parental depression models in which all services are provided by staff that are primarily charged with delivering another service (e.g., home visitation, pediatric well-child visits, child care, etc.), training represents an additional burden of time and effort in addition to the paperwork and supervision required by the model. Staff tasked with multiple roles often face conflicting priorities in terms of which services take precedent over other roles. In such cases, good supervision informed by clear priorities is essential. For parental depression models involving coordination among multiple

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9 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN providers (e.g., a risk screening program with facilitated referrals for mental health, a prevention program that addresses associated comorbidities), it may be necessary to cotrain all parties in the overall model and process to reduce misunderstandings about roles and responsibilities, identify program interfaces and potential problems, and to develop working relationships. It can be difficult to schedule staff from multiple systems for common training unless times have been preestablished. Significant workforce challenges—including provider shortages, lack of skills and competencies, and lack of comprehensive training programs— remain a barrier to and offer opportunities for implementing research- informed strategies and improving the quality of care for parents who are depressed as well as support services for their children. In addition, opportunities for improving the quality of care exist in the fiscal policy environment. FISCAL CHALLENGES The foundation of a strong policy framework to address parental depression is largely based on who does and does not have insurance and what can and cannot be funded through the insurance. The problems fall into three large categories: (1) lack of insurance, (2) reimbursement prac- tices and policies that are inconsistent with the evidence base of how best to respond to parental depression, and (3) funding gaps. For lower income families, under the current system, this is largely (although not exclusively) shaped at the federal level, particularly through Medicaid and the State Children’s Health Insurance Program (CHIP), although states also have of- ten unrecognized degrees of freedom (Rosenthal and Kaye, 2005; Stebbins and Knitzer, 2007). Furthermore, the majority of the payments made for mental health care are made by public sources (Institute of Medicine, 2006). However, it is also important to note the role that private-sector payers and purchasers play on the purchasing of services that are covered, includ- ing carve-out arrangements, that can be deleterious to insurance coverage for and the quality of mental health services. In general, there is a lack of publically accessible information on any specific barriers in implementing a family-focused, research-informed model of depression, but when such information is available we highlighted it in this section. The fiscal chal- lenges identified below compound and exacerbate the workforce challenges just discussed. Lack of or Adequate Insurance Having health insurance is associated with better health outcomes for adults. Further population groups that most often lack stable health insur-

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9 STRENGTHENING SYSTEMIC, WORKFORCE, AND FISCAL POLICIES ance coverage, including racial and ethnic minorities and lower income adults, would be likely to benefit most from increased health insurance coverage, and such coverage would probably reduce some of the disparities in health among these groups (Institute of Medicine, 2002). For both chil- dren and adults, the lack of insurance, including underinsurance (in which benefit packages lack comprehensive mental health coverage), is a major problem that limits access to treatment and supportive strategies related to parental depression. Overall, it is estimated that 11.1 million parents and 9 million children are uninsured (Henry J. Kaiser Family Foundation, 2009; Holahan, Cook, and Dubay, 2007). Most of those who are insured are covered through private insurance. For example, 18 percent of women in the general population are uninsured (16.7 million), another 10 percent are covered by Medicaid, and 64 percent are covered through their (or their spouse’s) job (Henry J. Kaiser Family Foundation, 2008). A total of 29 million children are enrolled in Medicaid and 7 million in CHIP (Henry J. Kaiser Family Foundation, 2009). One major concern is the parents whose income is too high for Med- icaid but who lack private insurance, particularly parents with incomes between 100 and 300 percent of the official poverty level: for example, 11 states permit eligibility at or above 200 percent of the federal poverty level for working families, and 20 states permit eligibility at or above this level for pregnant women. But half of the states have an income eligibil- ity requirement that is at or below the official poverty level (Stebbins and Knitzer, 2007). It is estimated that 6.2 million parents have incomes that fall below 300 percent of the official poverty level (Holahan, Cook, and Dubay, 2007). Recent parity legislation was adopted after completion of the com- mittee’s deliberations, and therefore this report includes no analysis of its potential impact on access to appropriate services for parental depression. Although the new parity law could potentially improve treatment for adults and children with mental health and substance abuse problems, it does not tackle the fundamental problem that the committee is addressing—that children of parents with depression as well as parenting supports are not addressed by the payment system. Funding Restrictions Inconsistent with Research-Informed Practice Below we cite examples of how funding restrictions work to create barriers to implementing family-focused, research-informed prevention and treatment strategies related to parental depression. One major problem is that, when clinicians are trained and want to implement research-informed practices, in most states the appropriate reim- bursement mechanisms do not exist. Current billing mechanisms that facili-

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9 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN that together pose risks to children, paying for integrated services is very challenging. Paying for treatment in a manner that recognizes the com- plexity of treating co-occurring disorders requires flexibility to incorporate different approaches that address both conditions either sequentially or simultaneously and with different levels of intensity. Current fiscal policy is generally unresponsive to this type of integrated treatment model. For ex- ample, programs with dual diagnosis capacity, or enhanced dual diagnosis services, cost more than programs that provide addiction or mental health services only. Yet neither Medicaid nor private insurance (which has even more limited benefits for substance use disorders) provides fiscal incentives to increase the capacity to address dual diagnosis. Indeed, there are fiscal policies that undermine an integrated approach to addressing co-occurring disorders. Even in Medicaid, mental health and addiction services are not covered evenly. For example, while all Medicaid programs cover assess- ment and treatment for mental health, many will not do so if they are done by primary care providers, and a handful of states do not cover substance abuse–related assessment and treatment (Robinson et al., 2003). Only half of states cover extensive outpatient services, and only a quarter of states cover case management for individuals with substance use conditions, both vital components of the service array of an integrated treatment approach (Robinson et al., 2003). Reimbursement rates for mental health services are generally higher than addiction services and credentialing and certification requirements also differ (O’Brien and Wilford, 2003). Finally, the chronic nature of depression and substance use disorders necessitates financing that is responsive to monitoring and support to prevent or manage relapse (Flynn and Brown, 2008). Again, across the board, both Medicaid and private insurance remain restricted. Funding Gaps There are three related and major funding gaps in supporting research- informed practices for depressed parents and their children. One is the absence of an ongoing federal funding stream to pay for two-generation, research-informed prevention and parental support activities to improve outcomes for children and their parents who are at risk of depression and its consequences. Addressing parental depression often requires parent- focused or parent and child–focused strategies. Some of these are directly linked to treatment, but others are linked to a range of other parenting supports, including prevention efforts to reduce risk factors (e.g., isolation, high stress levels linked to poverty); parent support groups; and even par- ent training interventions that take into account parental depression. And yet there is no dedicated federal funding stream that allows mental health providers to meet the needs of parents whose children are at high risk of

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99 STRENGTHENING SYSTEMIC, WORKFORCE, AND FISCAL POLICIES developing problems related to parental depression. Specifically, neither Medicaid nor the only targeted funds for children’s mental health, through the Mental Health Services for Children and Families Community Program, allow for family-focused prevention or early intervention services. The second funding gap results from the fact that it is very difficult to pay for early intervention services for children, particularly young children, who show signs of problematic behavior that falls below the clinical thresh- old of diagnosable disorders. In some states, Medicaid does pay for children at risk of problems, but there is no accurate count of how many. More typically, even for infants and toddlers, children whose developmental and social and emotional behavior is problematic, cannot, in most states, access services. The federal Part C Early Intervention program of the Individuals with Disabilities Education Act, which provides services to infants and tod- dlers with identified developmental delays and, in theory, allows states to cover babies and toddlers at risk of such delays, does not work as it should, largely because it is inadequately funded. Today, only six states currently allow for the youngest children who are at risk to be served. The third major funding gap is the lack of training resources available at all levels of the system. As described earlier, workforce capacity and competence are major barriers to implementing research-informed practices to care for depressed parents and their children. As described in Chapter 8, there are a limited number of funding sources available through federal initiatives—namely the Maternal and Child Health Bureau and the Center for Mental Health Services—that target training and workforce develop- ment for those who provide mental health services. CONCLUSION Adoption of the core recommendations of this report will involve sig- nificant changes in the current policy framework to develop systemic strate- gies as well as the workforce and fiscal resources necessary to implement research-informed prevention, screening, treatment, and parent support services for parents experiencing or at risk of experiencing depression and their children. RECOMMENDATIONS This chapter examines the systemic, workforce, and fiscal challenges associated with implementing innovative and research-informed practices to improve outcomes for parents who are depressed and their children. The committee recognizes that some of these challenges are problems faced by the general health care system; however, the care of depressed parents has a number of distinctive characteristics, including identifying, treating, and

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00 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN preventing the effects on parenting practices and their children’s health and development, providing resources and referrals for comorbidities associated with depression, and supporting parent-child relationships. None of the recommendations below will fully address the systemic, workforce, and fiscal-related policy challenges in the health care system, and each involves a unique set of costs, benefits, and practical considerations. The commit- tee nonetheless makes three recommendations intended to support bolder federal, state, and private-sector responses to improve the outreach and delivery of services in different settings for diverse populations of families with a depressed parent. They are meant to complement current local, state, and federal efforts to improve education, awareness, and development of innovative strategies. Develop and Implement Systemic, Workforce, and Fiscal Policies Recommendation 4: State governors, in collaboration with the U.S. Department of Health and Human Services, should support an inter- agency task force within each state focused on depression in parents. The task force should develop local and regional strategies to support collaboration and capacity building to prepare for the implementation of evidence-based practices, new service strategies, and promising pro- grams for the identification, treatment, and prevention of depression in parents and its effects in children. The wide variation in state resources and structures for providing mental health services and family support resources suggests that broad experimentation with different service strategies may be necessary to imple- ment two-generation interventions for the treatment and prevention of de- pression in parents, to support parenting practices, and to prevent physical, behavioral, and mental health and problems in youth. First, state governors should designate a joint task force of state and local agencies to coordinate local efforts (e.g., counties) and to build linkages and the infrastructure that can support a strategic planning process; refine service models and delivery systems through collaboration among diverse agencies; prepare to incorporate an array of programs for different sites, settings, and target populations; prepare model plans that include multiple entry points in a variety of service sectors; and prepare for a stepwise rollout with ongoing or interim evaluation. Second, the state strategies should include policy protocols and fiscal strategies that offer incentives across multiple systems (including health and education) to expand the state’s capacity to respond to parental depression through a family-focused lens. These protocols and strategies could be supported by the efforts funded and coordinated by the U.S. Department

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0 STRENGTHENING SYSTEMIC, WORKFORCE, AND FISCAL POLICIES of Health and Human Services (HHS) through its agencies that include the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration. Third, the state strategies should offer flexible responses that can be adapted to the needs of urban and rural communities. Finally, states should be required to provide a bian- nual report to a designated office in HHS that describes their strategic plans as well as the challenges and barriers that affect their capacity to address depression in a family context for children of all ages. These reports should be shared to encourage states to learn from each other’s initiatives. Recommendation 5: The Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration, in collaboration with relevant professional organizations and accredit- ing bodies, should develop a national collaborative training program for primary, mental health care, and substance abuse treatment pro- viders to improve their capacity and competence to identify, treat, and prevent depression in parents and mitigate its effects on children of all ages. For this recommendation to be realized, the national collaborative training program should strengthen a workforce that is informed about and prepared to address parenting issues associated with depression and the effects of adult disorder on children in a diverse society. This program should explore opportunities to enhance attention to interactions between depression and parenting in ongoing mental health and primary care train- ing and continuing education programs, such as activities funded by Title VII and Title VIII of section 747 of the Public Health Service Act. Training efforts should include an emphasis on developmental issues, exploring the impact of depression and the combination of depression and its commonly co-occurring disorders (e.g., anxiety disorders, parental substance use dis- orders) on children of different ages, from pregnancy through adolescent development. Options for such training programs could include cross- disciplinary training with an emphasis on parental depression, parent - ing, and developmentally based, family-focused concerns that arise in the treatment of depression. Such training programs should call attention to identifying children at risk to adverse health and psychological outcomes. Training programs should also include efforts to build a more diverse and culturally competent workforce. Recommendation 6: Public and private payers—such as the Centers for Medicare and Medicaid Services, managed care plans, health mainte- nance organizations, health insurers, and employers—should improve current service coverage and reimbursement strategies to support the

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02 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN implementation of research-informed practices, structures, and settings that improve the quality of care for parents who are depressed and their children. Public and private payers should consider the following options for implementing this recommendation: • The Centers for Medicare and Medicaid Services (CMS) could ex- tend services and coverage of mothers to 24 months postpartum, which includes a critical period of early child development when interaction with parental care is especially important. Long-term coverage for parents would be optimal. CMS could remove re- strictions on Medicaid’s rehabilitation option and other payment options (including targeted case management and home visitation programs) that could reimburse services and supports in nonclini- cal settings and enhance access to quality care; allow same-day visit reimbursement for mental health and primary care services; reimburse primary care providers for mental health services; and remove prohibitions on serving children without medical diagno- ses, thereby covering health promotion services for children at risk before diagnosis. • States could work with CMS to implement financing mechanisms to support access to treatment and supportive services for de- pressed parents, through clarifying existing coverage, billing codes, or encouraging the use of research-informed practices. This would complement local and regional strategies developed by the states. Similarly, private health plans and self-insured employers could cover parental depression screening and treatment and support the implementation of effective models. REFERENCES Ammerman, R.T., Bodley, A.L., Putnam, F.W., Lopez, W.L., Holleb, L.J., Stevens, J., and Van Ginkel, J.B. (2007). In-home cognitive behavior therapy for a depressed mother in a home visitation program. Clinical Case Studies, , 161–180. Anderson, J.R., Reder, L.M., and Simon, H.A. (1996). Situated learning and education. Edu- cational Researcher, 2, 5–11. Annapolis Coalition. (2007). An Action Plan for Behavioral Health Workforce Development: A Framework for Discussion. (SAMHSA/DHHS Pub. No. 280-02-0302.) Rockville, MD: Substance Abuse and Mental Health Services Administration, Department of Health and Human Services. Armour, B.S., Pitts, M.M., MacLean, R., Cangialose, C., Kishel, M., Imai, H., and Etchason, J. (2001). The effective of explicit financial incentives on physician behavior. Archives of Internal Medicine, , 1261–1266.

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