Pediatric-Based Intervention to Motivate Mothers

to Seek Follow-up for Depression Screens: The

Motivating Our Mothers (MOM) TrialErik Fernandez y Garcia, MD, MPH; Jill Joseph, MD, PhD; Machelle D. Wilson, PhD;Ladson Hinton, MD; Gregory Simon, MD, MPH; Evette Ludman, PhD;Fiona Scott, MPH, MS, MHI; Richard L. Kravitz, MD, MSHS

From the Department of Pediatrics, School of Medicine (Dr Fernandez y Garcia), Betty Irene Moore School of Nursing (Dr Joseph), Clinicaland Translational Science Center, Department of Public Health Sciences (Dr Wilson), Department of Psychiatry and Behavioral Sciences,School of Medicine (Dr Hinton), School of Medicine (Ms Scott), Department of Internal Medicine, School of Medicine (Dr Kravitz), University ofCalifornia Davis, Sacramento, Calif; and Group Health Research Institute (Drs Simon and Ludman), Seattle, WashThe authors declare that they have no conflict of interest.Address correspondence to Erik Fernandez y Garcia, MD, MPH, Department of Pediatrics, School of Medicine, University of California Davis,2516 Stockton Blvd, Sacramento, CA 95819 (e-mail: erik.fernandez@ucdmc.ucdavis.edu).Received for publication January 4, 2014; accepted November 25, 2014.

ABSTRACT

AC

OBJECTIVE: To determine the initial effectiveness of a novel,pediatric office-based intervention in motivating mothers toseek further assessment of positive depression screens.METHODS: In this pilot randomized controlled trial, English-speaking mothers (n ¼ 104) with positive 2-question depres-sion screens and presenting with children 0 to 12 years oldfor well-child care to a general pediatric training clinicreceived interventions from a trained research assistant.The Motivating Our Mothers (MOM) intervention includedoffice-based written and verbal targeted depression educationand motivational messages encouraging further depressionassessment and a semistructured telephone booster delivered2 days later. The control intervention included nontargetedwritten and verbal messages and 2 days later, an attentioncontrol telephone survey. Both groups received a list ofdepression care resources. The primary outcome was theproportion of mothers in each group who reported trying tocontact any of 6 types of resources to discuss the positive

CADEMIC PEDIATRICSopyright ª 2015 by Academic Pediatric Association 311

screen at 2 weeks after intervention (ClinicalTrials.govNCT01453790).RESULTS: Despite 6 contact attempts, 10 MOM and 9 controlmothers were lost to follow-up. More mothers in the MOMintervention tried to contact a resource compared to control(73.8% vs 53.5%, difference 20.3%, 95% confidence intervalfor difference �0.1 to 38.5, P ¼ .052).CONCLUSIONS: Mothers receiving the MOM interventionmade more attempts to contact a resource for follow-up of pos-itive depression screens. If found effective in larger studies,MOM may prove a promising approach for motivating depres-sion screen–positive mothers identified in general pediatric set-tings within and beyond the postpartum period to seek furtherdepression assessment and support.

KEYWORDS: depression care seeking; maternal depression;motivational intervention; primary care; screening

ACADEMIC PEDIATRICS 2015;15:311–318

WHAT’S NEW

Treating maternal depression may improve maternaland child well-being. On the basis of results of this pilottrial, the Motivating Our Mothers (MOM) interventionmay be a promising method for pediatricians to screenmothers for depression and motivate them to seekfurther assessment and support.

DEPRESSION IS A leading cause of disability in theUnited States. It is common in mothers parenting youngchildren and negatively affects mothers’ well-being,parenting, and compliance with pediatric preventive ser-vices and practices.1–3 Children cared for by motherswith untreated or undertreated depression are at higherrisk of poor health, psychiatric disorders, abuse,utilization of higher acuity health care, behavioral-developmental problems, and medical morbidity.3–5

Mental health therapies targeted to mothers havedemonstrated beneficial effects on maternal functioningand depressive symptoms. Reduction of mothers’depressive symptoms is associated with the preventionand improvement of psychiatric, behavioral, anddevelopmental problems in their children.6 However,maternal depression therapy is underutilized.1,7 Althoughthe contributing factors are complex, there is evidencethat mothers in need of depression care face barriers indiagnosis, care seeking, referral, and treatment.8 Growingevidence, primarily in the postpartum period, suggeststhat interventions targeted to some of these barriers canimprove the utilization of maternal depression care.9–11

Pediatric visits provide an opportunity to identifymothers with depression and motivate them to take upeffective treatments. Because pediatricians care for 80%of children up to 5 years of age12 and children are seen atregular intervals for well-child care, mothers are more

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312 FERNANDEZ Y GARCIA ET AL ACADEMIC PEDIATRICS

likely to see their child’s pediatrician than their own healthcare provider in a given year.13 Mothers understand thattheir emotional health affects their child’s well-beingand, if placed in that context, find it appropriate for pedia-tricians to inquire about depression and recommendfollow-up.14,15 Pediatric providers know that maternaldepression affects children’s well-being and healthpractices and are receptive to guidelines recommendingpediatric-based maternal depression screening.16,17

Pediatric-based maternal depression screening instrumentshave been validated,18,19 universal screening programs inpediatric settings have been successfully tested,9,11 and16% to 39%2,9 of mothers accompanying children topediatric visits have been found to have positivedepression screens. Although literature on the uptake ofmaternal depression care referrals in pediatric settings isencouraging,8–11,20,21 no standardized pediatric-basedapproach exists for encouraging depression screen–posi-tive mothers to seek further assessment followed by treat-ment if indicated. Pediatricians report that a lack oftraining and confidence in addressing positive maternaldepression screens are barriers to both screeningand referral.10,16,22 The best ways for pediatricians toprovide maternal depression education and advice havenot been determined. Developing effective approachescould ultimately improve both screening uptake bypediatricians and care uptake by these mothers.10,16

We report on a pilot randomized controlled trial of anovel intervention to motivate screen-positive mothers inpediatric offices to seek further depression assessmentand possible care. We hypothesized that an interventionemphasizing motivational and educational messages basedon the mother’s maternal role and their children’s well-being would be more effective than a control interventionlacking those aspects. Our objective was to assess theinitial effectiveness of a practical pediatric-based interven-tion in promoting seeking of further assessment andpossible care for positive maternal depression screens.

METHODS

DESIGN AND PARTICIPANTS

We conducted a randomized controlled trial comparing anovel intervention, Motivating Our Mothers (MOM), withan active control intervention in a general pediatric traineeand faculty practice from August to November 2011. Theclinic draws from a large urban, suburban, and rural catch-ment area in Northern California. Although the rate of apositive 2-item depression screen (Online Supplement;Box)18 in mothers during a previous quality assurance proj-ect was 20%, there was no depression screening in theclinic at the time of the trial. The local institutional reviewboard approved the study, and it was registered withClinicalTrials.gov (NCT01453790).

Our recruitment process occurred in 3 steps (Figure).First, we identified 2111 scheduled well-child appoint-ments for children 0 to 12 years old. Second, we identi-fied for eligibility screening those 1685 consecutivelypresenting adults accompanying the children who kept

the appointment. Of these, 171 adults declined eligibilityscreening, 210 were not approached because schedulingdata indicated that they were non-English speaking, and102 left the clinic before they could be approached.Third, the remaining 1202 adults were screened foreligibility. To be eligible, mothers were required to be18 to 65 years of age, to have a positive written 2-itemdepression screen (administered as part of eligibilityscreening and not clinical care), and to report notreceiving professional care for any mental health condi-tion during the previous 12 months.18,23 Of the 128mothers meeting study eligibility criteria, 24 (19%)declined participation, and 104 (81%) consented to thestudy (described as a test of a “long way” vs a “shortway” of providing information for parental emotionalhealth) and randomized. We chose the sample size of104 (with 52 randomized to each group) on the basisof power calculations and to account for dropouts. Astatistician not associated with the trial randomizedintervention allocation in blocks of 8.The research assistant (RA), who was blinded to the

intervention randomization, met mothers after the pediatricvisit in a private room adjacent to the clinic, administered abrief demographic survey, delivered the assigned interven-tion using materials enclosed in a previously sealed, opa-que envelope, and then left the mothers in the roomalone to complete a 3-question postvisit survey on theirintention to contact in the future any resource to discussthe symptoms in the screen. Two days later, the RA con-tacted mothers by telephone to complete the intervention(MOM) or administer a survey (control). Telephonefollow-up to assess outcomes was attempted at 2 weeksand 8 weeks by a second RA blinded to group allocation.We allowed up to 6 attempts to contact participants, pro-vided them with callback numbers to reach us at their con-venience for all calls, and provided a $10 thank-you gift foreach contact ($40 total possible). To assess fidelity, theprincipal investigator observed a 10% subset of RA inter-actions via a 2-way mirror for the clinical interventionsand face to face with the RA during telephone calls. Therewere no noted deviations from the scripts.

INTERVENTIONS

MOTIVATING OUR MOTHERS INTERVENTION

We created the MOM intervention protocol on the basisof prior literature in pediatric-based maternal depressionstudies11,14,15,20,24; motivational interviewing techniquesin programs for alcohol cessation25; maternal depressiontreatment adherence interventions26,27; obstetric-basedmaternal depression screening10,15; and our clinicalexperience. The first component was office based andconsisted of a pamphlet and an accompanying structuredverbal motivational interaction lasting 5 minutes.The pamphlet contained depression education, includingdifferentiating between screening and diagnosis, andmessages meant to motivate mothers to seek furtherassessment for depression and possible care. Alleducation and motivational messages (both written

Figure. CONSORT flow diagram showing progress of participants in MOM pilot trial.

ACADEMIC PEDIATRICS MOTIVATING MOTHERS TO SEEK FOLLOW-UP 313

statements and images) were targeted to mothers andinterspersed among listings of free, accessible parentingand depression care resources. The targeting focused ondestigmatizing depression and included the following: 1)relating care for depressive symptoms to maintainingchild health; 2) using terms such as “low mood” and“maternal depression” rather than “depression” alone; 3)stating that symptoms are common in mothers; and 4)including parenting resources along with mental healthresources. The interaction included repeating the samemessages in a discussion style while going over thepamphlet. The second component was a 15-minute semi-structured telephone interaction delivered 2 days later asa motivational booster.

CONTROL INTERVENTION

We designed the control as an active control, stillproviding depression education and advice, including dis-

tinguishing between positive screens and a diagnosis ofclinically significant depression. However, we did notinclude in the control those aspects of the MOM that weconsider novel and which would not be delivered routinelyin adult primary care settings. The control consisted of apamphlet and accompanying script. One side of thepamphlet was the JAMA Depression Patient Page(2010).28 The other side contained the same care resourcesprovided in the MOM, presented as a list with explanatoryheadings rather than being interspersed among motiva-tional messages. The control script replaced any termsrelated to the participants’ role as a mother (eg, “clinicaldepression” for “maternal depression”), removed any ref-erences to child health (eg, “your well-being” for “thewell-being of yourself and your child”), and was presentedwithout questions meant to stimulate discussion. Controlmothers received a telephone survey without additionalmotivational component at 2 days.

314 FERNANDEZ Y GARCIA ET AL ACADEMIC PEDIATRICS

OUTCOMES AND MEASURES

OUTCOMES

We designed the MOM to motivate depression screen–positive mothers in pediatric settings to seek further assess-ment and possible care for depression and hypothesizedthat its greatest impact would occur within days to weeksof the initial contact. Therefore, our primary outcomewas the proportion of mothers in each group who reportedtrying to contact any resource to discuss “feeling down,depressed, hopeless, or having little interest or pleasurein doing things” (the symptoms in the 2-question screen)at 2 weeks after enrollment. Secondary outcomes included:1) intention to contact any resource measured immediatelyafter the office-based intervention; 2) the types of depres-sion care resources mothers tried to contact (as reportedat 2 weeks); 3) intention to contact any resource in thefuture (amongmothers who had not made an actual attemptto contact any resource to discuss the symptoms in thescreen at 2 weeks); and 4) the proportion of mothers ineach group who reported trying to contact any resourceto discuss the symptoms in the screen by 8 weeks. We as-sessed outcomes at 8 weeks to capture any participants whoneeded more time to attempt to seek further assessment fordepression and possible care.

MEASURES

We used standard or adapted instruments to assess out-comes. To facilitate clinic work flow and minimize refusalsdue to excessive time requirements, we decided to use theavailable time with participants to deliver the interventionsand minimally collect data. At enrollment, participantswere asked only to provide their age, children’s ages, andif they were currently taking any medications for mood ordepression (all of which were part of eligibility screening).Immediately after the intervention, mothers completed awritten 3-item measure of intention to contact any resourceto discuss the symptoms in the depression screen (Box),adapted from Azjen29 and other depression studies.30 Anoverall mean score across the 3 items was determined,with higher scores indicating stronger intention (Cronbach’sa ¼ 0.9815). At 2 days via telephone, all mothers providedinformation on self-identified race/ethnicity, level of educa-tion, employment status, household income, access to theInternet, health insurance status, medical and mental healthprovider access, depression treatment history, and the Pa-tient Health Questionnaire Depression Scale (PHQ) 8. ThePHQ-8 omits the question on self-harm contained in thePHQ-9; it has equal validity to the PHQ-9 and is commonlyused in telephone studies where adequate follow-up for self-harm disclosure cannot be ensured.11,31,32 At 2 and 8 weeks,mothers reported whether or not they had tried to contacteach of 6 types of resources (Box, available at http://www.academicpedsjnl.net/) to discuss “feeling down, depressed,hopeless or having little interest or pleasure in doing things”since receiving the intervention. The listed resources (med-ical provider, mental health provider, obstetrician-gynecologist, pediatrician, Internet resource, or clergy)have been identified in the literature as those mothers may

seek24 and were included in the pamphlets both groupsreceived. If they reported no attempts to contact care re-sources, they were again asked the intention measure. Allmothers were administered the PHQ-8 at 2 and 8 weeks.

STATISTICAL ANALYSIS

We used a c2 test to compare by group the proportion ofmothers who had tried to contact care resources (from anyof the 6 resources). Intention scale mean scores werecompared between groups via Kruskal-Wallis test and ttest. We used Fischer’s exact test to compare the differ-ences in the proportion of participants who tried to contactspecific types of resources by group.We used c2 or Fisher’sexact test to compare participant characteristics by group.

RESULTS

PARTICIPANTS

Differences in baseline characteristics between groupswere not statistically significant, and equal numbers of par-ticipants had missing data in each group (Table 1). Overall,the sample was diverse racially/ethnically and socioeco-nomically. Most mothers were beyond the postpartumperiod and had access to health care. About 10% ofmothers reported taking medications for mood; however,none reported seeing a general or mental health care pro-fessional for a psychiatric condition in the last 12 months.

OUTCOMES

PRIMARY OUTCOME

Ten MOM and 9 control mothers were not reached bytelephone at 2 weeks after intervention, despite up to 6 at-tempts to contact them. Of the 42 MOM and 43 controlmothers whom we were able to reach, the proportion ofMOM mothers who reported that they tried to contact anyof 6 resources to discuss the symptoms in the depressionscreen was greater than control mothers (difference20.3%, 95% confidence interval [CI], �0.1 to �38.5,Table 2). The number needed to treat to avert a single caseof “not trying to contact a resource for follow-up” was 4.9(95% CI, 2.4 to 290). We performed a sensitivity analysisrestricted to mothers with baseline PHQ-8 scores of 10 orgreater, as these mothers would be more likely to receivea diagnosis of depression and have a symptom burden whichmay hinder motivation. We found that within this moresymptomatic subgroup, MOM mothers were more likelyto attempt to contact any resource than controls, but the dif-ference was not significant (75% vs 54.6%, P ¼ .17). Thiscompares to a more robust difference among mothers withPHQ-8 scores of 9 or less (80% vs 43.8%, P ¼ .066).

SECONDARY OUTCOMES

In the postvisit surveys administered in the office (n ¼104), intention to contact any resource to discuss the symp-toms in the depression screen was significantly higher inMOM mothers (mean score 5.22; 95% CI, 4.76 to 5.68)than control mothers (mean score 4.00; 95% CI, 3.46 to4.55) (P ¼ .009). At 2 weeks after intervention (n ¼ 85),

Table 1. Characteristics of Participating Mothers by Randomized Group

Characteristic

Group*

P†MOM Control Total

Available data collected at enrollment n ¼ 52 n ¼ 52 n ¼ 104

Mothers endorsing both depression screening questions 28 (54%) 25 (48%) 53 (51%) .47Mothers endorsing 1 (either) depression screening question 24 (46%) 27 (52%) 51 (49%)Mothers in the early postpartum (any child <6 mo) period 14 (27%) 15 (29%) 29 (28%) .73Mothers in the late postpartum (any child 6–12 mo) period 10 (19%) 7 (13%) 17 (16%)Mothers not in the postpartum (all children >12 mo) period 28 (54%) 30 (58%) 58 (56%)Age of mothers, y 30.4 (8.1) 31 (6.4) 30.7 (7.3) .68Age of child receiving care, y 3.6 (3.4) 4.1 (3.9) 3.8 (3.7) .52Total no. of children parented by mothers 2.3 (1.3) 2.1 (1.2) 2.2 (1.2) .48

Available data collected at day 2 call n ¼ 43 n ¼ 43 n ¼ 86

First time mother met pediatrician 13 (30%) 20 (47%) 33 (38%) .12Scale of child care availability‡ 2.6 (1.2) 2.7 (2.4) 2.6 (1.3) .71Mother living with a partner 34 (79%) 26 (60%) 60 (70%) .06Has Internet access 39 (91%) 34 (79%) 73 (85%) .23Has any kind of health insurance 38 (88%) 39 (91%) 77 (89%) 1.00Has a primary care or mental health professional 30 (70%) 34 (79%) 64 (74%) .46Race/ethnicity of mothers

Non-Hispanic, white 13 (30%) 10 (23%) 23 (27%) .75Non-Hispanic, black 9 (21%) 8 (19%) 17 (20%)Non-Hispanic, other 9 (21%) 9 (21%) 18 (21%)Hispanic, any race 12 (28%) 16 (37%) 28 (32%)

Level of education of mothersPartial and completed high school 20 (47%) 14 (32%) 34 (39%) .69Partial college and above 23 (53%) 29 (68%) 52 (60%)

Employment of mothersEmployed outside of home 17 (39%) 13 (30%) 30 (35%) .84Out of work, homemaker, or student 26 (61%) 30 (70%) 56 (65%)

Yearly household income, US$ n ¼ 41 n ¼ 42 n ¼ 83

<10,000 14 (34%) 15 (35%) 29 (35%) .3110,000 to 34,999 17 (42%) 18 (43%) 25 (42%)$35,000 10 (24%) 9 (22%) 19 (23%)

Mothers’ history of depression n ¼ 43 n ¼ 43 n ¼ 86

Has ever been told they have depression by a professional 21 (49%) 24 (56%) 45 (52%) .52Were mothers when told they had depression 16 (37%) 17 (40%) 33 (38%) .75

Mothers’ depression symptoms n ¼ 42 n ¼ 43 n ¼ 85

Mean PHQ-8 scores§ 10.4 (5.5) 11.1 (5.7) 10.8 (5.5) .54PHQ-8 Score Categories

0–4 6 (14%) 7 (16%) 13 (15%) .825–9 12 (29%) 11 (26%) 23 (27%)10–14 15 (35%) 12 (28%) 27 (32%)15–19 5 (12%) 9 (21%) 14 (17%)20–24 4 (10%) 4 (9%) 8 (9%)

MOM indicates Motivating Our Mothers trial; PHQ-8, Patient Health Questionnaire Depression Scale 8.

*All percentages are rounded up to the nearest whole integer. Data are presented as n (%) or mean (SD).

†Tests were c2 or Fisher’s exact tests, depending on cell size and 2-tailed t test for means.

‡Scale: 1 all of the time, 2 most of the time, 3 some of the time, 4 a little of the time, 5 none of the time.

§Scale: summative score with range 0–24.

ACADEMIC PEDIATRICS MOTIVATING MOTHERS TO SEEK FOLLOW-UP 315

many mothers reported attempts to contact more than onetype of resource to discuss the symptoms in the depressionscreen. No mothers indicated pursuing any resource otherthan those included in the survey. In general, MOMmothers were more likely to try to contact mental healthproviders and were less likely to try to contact medical pro-fessionals or clergy than control mothers (P¼ .05; Table 2).In those mothers who did not report attempts to contact anyresource by 2 weeks (n ¼ 31), MOM mothers reportedhigher intention to do so in the future (mean score, 4.39;

95% CI, 3.52 to 5.27) than control mothers (mean score,2.35; 95% CI, 1.47 to 3.23) (P ¼ .001). At 8 weeks afterintervention, we were able to reach 28 MOM and 29 con-trol mothers. Few mothers (3 MOM and 2 control) whohad not tried to contact any resource to discuss the symp-toms in the depression screen at 2 weeks reported doingso by 8 weeks. The proportion of MOM mothers who re-ported that they tried to contact any resource by 8 weeks(89%) was greater than control mothers (59%) (P ¼.015). The number needed to treat to avert a single case

Table 2. Mothers Reporting Attempts to Contact Resources for

Follow-up of Positive Depression Screens by Group and Measured

at 2 Weeks After Intervention*

Resources of Care for

Depressive Symptoms†

MOM (n ¼ 42) Control (n ¼ 43)

n (%) 95% CI n (%) 95% CI

Any resource 31 (74) 61 to 87 23 (53) 39 to 68Mental health professional

(with or without otherresources)

14 (33) 19 to 48 5 (11) 2 to 21

Medical provider (with orwithout other resources)

6 (14) 4 to 25 9 (21) 9 to 33

Clergy (with or withoutother resources)

4 (10) 1 to 18 6 (14) 4 to 24

Internet site only 7 (17) 5 to 28 3 (7) 0 to 15

CI indicates confidence interval; MOM, Motivating Our Mothers

trial.

*Numbers are thosewith available data. Percentages are rounded

to nearest whole number. P ¼ .052 for c2 test comparing any at-

tempts vs no attempts to seek resources for care between interven-

tion and control (the primary outcome); and P ¼ .05 for Fisher’s

exact test comparing distribution of attempts to seek care between

intervention and control.

†A mental health professional is a therapist, counselor, psycholo-

gist, psychiatrist, or social worker. A medical provider is a doctor,

nurse practitioner, physician assistant, or obstetrician/gynecologist.

Clergy is pastor, priest, rabbi, imam, or spiritual counselor.

316 FERNANDEZ Y GARCIA ET AL ACADEMIC PEDIATRICS

of “not trying to contact a resource for follow-up” was 3.26(95% CI, 1.95 to 10.65).

DISCUSSION

In this pilot randomized control trial, we found thatmothers receiving the targeted MOM intervention weremore likely to try to contact a resource to discuss symp-toms in the depression screens than controls. In addition,as ancillary evidence of intervention effect, MOMmothershad greater intention to contact a resource for screenfollow-up, whether they actually tried to contact a resourceor not, and tended to try to contact traditional mental healthsources of care more than controls. Our primary and ancil-lary findings together suggest that pediatric-specific mes-sages demonstrate promise in motivating mothers withdepressive symptoms to seek care for those symptoms.These messages may also reduce stigma associated withseeking care frommental health providers. Our pilot resultsprovide a critical first step in eventually linking maternaldepression screening in pediatrics9,11,20,24 to effective butunderused maternal depression treatment programs,10

thereby maximizing the opportunity presented in pediatricsettings to improve care of maternal depression. Given ad-vances in epigenetic science demonstrating the long lastingeffects of environmental stress on child health,33 the goal ofeventually improving maternal depression is of utmostimportance in ensuring the health of generations of pediat-ric patients.

We identified 4 related studies investigating pediatric-based referrals for depression care in samples of depressionscreen–positive mothers not exclusively in the postpartumperiod. In 2 studies, the method of referral was not speci-fied and the proportion of mothers who intended or re-ported seeking care was 59%21 and 46%.34 In 2 studies,

both using the “5 As” approach to referral, one did notreport uptake of referrals10 and the other found that 90%of parents who agreed to be proactively contacted by cen-tral referral telephone line were assisted, while only 5% ofparents who were asked to call the line themselves chose todo so.11 Most other studies investigating uptake of referralfor maternal depression care from pediatric practices areexclusive to the postpartum period, and have found uptaketo be varied and highest for on-site services.9,20 Mothers’uptake of referral to maternal depression care from peri-and postpartum care providers is similarly varieddepending on the resource to which they were referred.7,35

In this context, our study has 3 novel aspects. First, it wasdesigned specifically to assess the effect of a pediatric-based intervention on mother’s motivation to contactresources for follow-up of a positive depression screen.Second, the MOM was designed, and our study settingselected, so that our results would strongly encouragefurther testing and implantation of the MOM in general pe-diatric practices and for the diverse groups of mothers theyserve. Third, wewere able to describemothers’ preferencesfor depression assessment and care resources after theyreceived a menu of accessible services.Our study extends prior work9–11,20,21,34 by identifying

high rates of attempting to contact generally availablecommunity-based resources for follow-up of positivedepression screens in mothers referred from a general pe-diatric clinic. Furthermore, MOM mothers’ greater at-tempts at contact compared to control mothers maydemonstrate that mothers respond preferentially to depres-sion education and advice targeted specifically to them.Whether the MOM can be delivered by clinic staff (ratherthan trained RAs) needs to be explored in future studies.However, our results bolster current evidence for success-fully motivating depression screen-positive mothers in pe-diatric settings to seek further evaluation for theirsymptoms, and add a way to do so that is practical in thecontext of general pediatric clinic resources.In contrast to other studies,34,35 we found that mothers

with depressive symptoms tended to try to contact morethan 1 resource, including combinations of formal services,such as mental and medical providers, and informalservices like clergy and the Internet. Only one motherreported attempting to contact a pediatrician. We can onlyspeculate about the explanation, but many mothers hadbeen diagnosed with depression in the past and had accessto care. Therefore, they may have been aware of resourcesoutside of those that a pediatrician could direct themtoward. Last, mothers in the MOM group preferred mentalhealth professionals more than would have been expectedfrom preferences reported in previous studies, and morethan control mothers. We suspect that our targeting ofmessages, with a focus on destigmatization of depressivesymptoms and presenting further assessment and possibletreatment of depression as a means to improve child health,could have led MOM mothers to be more accepting ofdepression as a cause of their symptoms. Therefore, theywere more likely to consider mental health providers asappropriate sources of help.

ACADEMIC PEDIATRICS MOTIVATING MOTHERS TO SEEK FOLLOW-UP 317

Our results should be interpreted in light of various studylimitations. The sample size was small. However, this pilottrial was designed as an initial test of the concept of moti-vating mothers to seek follow-up for depression screens inpediatric settings and of feasibility and initial effectivenessof the MOM in doing so, and not as a means of estimating adefinitive effect size for the dichotomized outcome overallor within subgroups. Furthermore, taken as a whole, our re-sults indicate an effect of theMOMonmother’s attempts tocontact resources to discuss the symptoms expressed in thedepression screen despite the small sample size. The indi-viduals who were eligible but refused to participate or whoreceived the interventions but were lost to follow-updespite retention efforts could be less likely to attempt con-tact. Generalizability is further limited by the single sitedesign. In addition, because the same team of RAs wasused to deliver both the MOM and control interventions,there were opportunities for cross-contamination, particu-larly inadvertent delivery of MOM elements to control pa-tients. However, investigator observation of a 10% sampleof RA interactions revealed no deviations from protocol,and in any case, such cross-contamination would tend tobias the observed intervention effect toward the null. Themotivational interviewing components of the MOM madeinteractions between the RA and MOM mothers neces-sarily longer than those in the control. Differences in lengthof interaction alone may account for some of the differencein outcome.

In summary, we have demonstrated that mothers withinand beyond the postpartum period can be screened fordepression in a general pediatric clinic and those with pos-itive screens can be motivated to seek follow-up for thosescreens. We have also demonstrated the initial effective-ness of the MOM in increasing these mothers’ attemptsto contact resources to discuss the symptoms evaluated inthe screens. There are significant systematic barriers tomaternal depression care utilization.1,7,8,14,15 Thepediatric setting is not currently the place to addressthose barriers,36 even though it may become so as thenation turns toward organizing family-centered medicalhomes. Instead, our goal is to realize the potential of pedi-atric settings in identifying mothers with depression whowould otherwise not be identified or treated, includingmothers with ongoing symptoms who have lost contactwith treating providers, and motivating them to engage,to the extent possible, with effective but underutilizedmaternal depression evaluation and care programs. Thisstudy provides valuable information for others consideringpediatric-based interventions with similar aims. Our resultsencourage larger effectiveness trials, both to generate moreprecise estimates of the intervention’s impact and toexplore potential areas for intervention improvement andimplementation.

ACKNOWLEDGMENTS

The study was supported by the National Center for Advancing Trans-

lational Sciences (NCATS), US National Institutes of Health (NIH)

through grants UL1 TR000002 and 1K23MH101157-01A1, and by a grant

from the University of California Davis Department of Pediatrics Chil-

dren’sMiracle Network. Dr Fernandez y Garcia was supported by the Uni-

versity of California Davis Office of the Dean, as an institutional scholar.

Dr Kravitz was supported by 5K24MH07275605. The funding organiza-

tions had no role in the design and conduct of the study; collection, man-

agement, analysis, or interpretation of the data; or preparation, review, or

approval of the manuscript. We would like to thank Daniel Joseph Tan-

credi, PhD, University of California Davis Department of Pediatrics and

Center for Healthcare Policy and Research, for his assistance in random-

ization procedures, and Colleen Tweed Wong, MFT, for assistance in

enrolling patients and delivering interventions. We would also like to

thank the University of California Davis Department of Neonatal Medical

Social Workers, specifically Tamara Louis, MSW, Courtney Corbitt,

MSW, and JulieWeckstein, LCSW, for their assistance in editing the com-

munity resources included in both intervention guides.

SUPPLEMENTARY DATA

Supplementary data related to this article can be found athttp://dx.doi.org/10.1016/j.acap.2014.11.008

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