09-hoffman-pmh 2019 talk cfcc · maternal deaths in colorado from 2004 to 2012 (n=211) metz t,...

Associate Professor, Maternal-Fetal Medicine

Departments of Obstetrics & Gynecology and

Psychiatry University of Colorado School of Medicine,

CO, USA

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Disclosures

Camille Hoffman No commercial or industry disclosures

Represented the Society for Maternal Fetal Medicine (SMFM) on the Council on Patient Safety in Women’s Health Care on this topic (for free)

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Objectives

Summarize the epidemiology of perinatal mood and anxiety disorders (PMADs)

Utilize and implement available screening toolsfor PMADs

Initiate treatment

Engage patients and their support systems indiagnosis, treatment, and continuing support

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M. Camille Hoffman, MD Management of Perinatal Mental Health for Non-Physicians

Council Participation on the Maternal Mental Health Safety Bundle

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Why Worry about Perinatal Depression?

CDC estimates 8-19% of women will experience a depressive episode during or after pregnancy.

www.acog.org/Womens-Health/Depression-and-Postpartum-Depression

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Poor health care Substance abuse Cognitive delays Behavioral problems

Bodnar et al (2009) J Clinical Psychiatry. Cripe et al (2011). Paediatric Perinatal Epid. Flynn & Chermack (2008) J Studies on Alcohol and Drugs. Forman et al (2007) Dev Psychopathology. Grote et al (2010) Archives General Psych. Sohr-Preston & Scaramella, (2006) Clinical Child and Family Psychology Review. Wisner et al (2009) Am J Psychiatry.

Preterm delivery Low birth weight Preeclampsia

©MCPAP For Moms

Why Worry about Perinatal Depression? Affects Mom, Child and Family

Untreated maternal depression can have a devastating effect on women, their infants and their families.

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A leading cause of Maternal Mortality In extreme form, depressive psychosis can lead to maternal suicide

and/or infanticide.

Maternal suicide within a year of birth is emerging as a significant cause of maternal mortality, and is probably underreported.

© 2016 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. Published by Lippincott Williams & Wilkins, Inc.

Maternal deaths in Colorado from 2004 to 2012 (N=211)

Metz T, Rovner P, Hoffman M, Allshouse A, Beckwith K, Binswanger I, Maternal Deaths From Suicide and Overdose in Colorado, 2004-2012. Obstetrics & Gynecology. 2016; 128(6):1233-1240. DOI: 10.1097/AOG.0000000000001695

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Ten-year pregnancy-associated mortality rates for deaths by violence and injury compared with the leading obstetric causes in Illinois, 2002-2011.

Koch A, Rosenberg D, Geller S. Higher Risk of Homicide Among Pregnant and Postpartum Females Aged 10-29 Years in Illinois, 2002-2011. Obstetrics & Gynecology. 2016; 128(3):440-446. DOI: 10.1097/AOG.00000000000015590

Maternal Mortality Risk: Homicide, Suicide

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The perinatal period is ideal for the detection and treatment of perinatal

depression and anxiety. Regular opportunities to screen and

engage women in treatment.

Front line providers have a pivotal role.

De-stigmatize

Educate

Proactively initiate and welcome

conversation.

So, why not address??....

©MCPAP For Moms

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Risk Factors

ACOG CO #630 – May 2015

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Risk Factors for PMADs/PPD

1. Akincigil A et al. SocWork Health Care, 2010; 2. Rich‐Edwards JW et al. J Epidemiol Comm Health, 2006; Howard LM et al. PLoSMed, 2013; 4. Wosu AC et al. Arch WomensMent Health, 2015; 5. Lefkowitz DS et al. J Clin Psychol Med Setting, 2010

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Risk Factors for PMADs/PPDSwedish series (n=700,000, 1997-2008)

Silverman ME et al. Depression Anxiety, 2017

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We Have Guidelines Galore….USPSTF recommendations – Feb 13, 2019

USPSTF Draft recommendation August 2018

USPSTF Recommendation January 2016Recommends depression screening for pregnant women

Screening should be done both antepartum and postpartum.

ACOG published Committee Opinion #630 -May 2015Screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool.

American Academy of Pediatrics guideline -2010Pediatricians to screen mothers for depressive symptoms

at well child visits at 1, 2 and 4 months.

Recognized maternal depression can impact failure-to-thrive and other pediatric issues.

CDC and WHOWithin 12 months Postpartum

Council on Patient Safety in Women’s Health Care (Feb. 2016) Recommends Bundle implementation across settings.

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When should women be screened for Perinatal Mood and Anxiety Disorders (PMAD)?

Depression & Anxiety

At least once during the perinatal period

Depression

At least once during pregnancy and again postpartum

ACOG CO 630 May 2015; USPSTF JAMA 2016, draft recs 2018

Women found at risk should be referred for counseling

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Two-thirds of perinatal depression begins before birth

Pregnancy

33%

Postpartum 40%

Before pregnancy

27%

Wisner et al. JAMA Psychiatry 2013

Optimal screening times and intervals not identified.

Screen at least once during perinatal period using standardized, validated tool.

(ACOG, 2015)

Screen mother at 1, 2, 4 and 6 mo. well-child visits. (Earls, 2010)

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Screening: Implementation

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Distinguish Baby Blues & PPDBaby Blues

• Peaks ~5th day PP

• Resolves within 10-14 days PP w/out treatment

• 50-80% of all new mothers

• Crying, worry/anxiety; feeling sad, moody, irritable, restless; anger or rage; symptoms do not interfere w/newborn care and resolve w/out intervention

Postpartum Depression (PPD)• During pregnancy or w/in first 4

weeks PP (DSM5)

• Can persist if left untreated

• 8-20% (+) of new mothers in US

• Difficulty bonding; crying; worry/anxiety; doubt in ability to care for baby; feeling sad, moody, irritable, restless; anger or rage; anhedonia; sleep and/or appetite abnormalities; difficulty concentrating, withdrawal

Onset

Duration

Prevalence

Symptoms

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ACOG CO #630 – May 2015. Reprinted in Kendig et al, Consensus Bundle on Maternal Mental Health, Obstet Gynecol 2017.

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• Depression AND Anxiety

• Perinatal Populations Only

• >40 languages

http://linkingcare.org/ScreeningTool/EPDS

http://perinatology.com

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In the Ob’s or Midwife’s World:

Screen “positive”

Mild symptomsEPDS 9‐13

Does not meet criteria For clinical depression or anxiety

Moderate SymptomsEPDS 14‐18

Meets criteria for mild to moderate clinical

depression, anxiety, or both

Severe Symptoms EPDS≥19

Meets criteria for severe clinical depression, anxiety, or both

All of the above PLUSFacilitate urgent access to counselingservices

Start on antidepressant medication ifno history of mania

Earlier follow up in one week

Severe SymptomsWith suicidal or homicidal

features or

symptoms of mania or psychosis

At risk for harm to self, others,

or baby?

Education on worsening symptomsHealthy nutrition, physical activitySleepIntegrative strategiesHelp with family chores, childcareAssess available resources

yes

no

no

no

All of the above PLUSArrange follow up in 2 weeksOffer counseling or medications Ensure safety net: re family supportEmergency plan if symptoms worsen

TREATMENTPRESENTATION

Emergent referral for evaluation andpossible hospital admission

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Initiate Treatment

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Manage Suicidal Ideation

Screen patients with depression foro Suicidal thoughts, how often in past 2 weeks?

o Suicidal intent/plan

o What has stopped them so far?

o Availability/lethality of method

Activate emergency referral protocol for women with suicidal/homicidal ideationo Consultation, transportation, admission

o Maintain open communication among team members

o Post event planning for care coordination and follow-up

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When to Seek Consultation

Failed response to medication

Persistent psychosocial problems

Complicated psychological problems

Actively suicidal

Discomfort in managing the problem

“Gut feeling”

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…must consider RISKS of NOT treating to both mother and fetus/child.

‐self‐medication ‐bonding and attachment

‐prematurity ‐human suffering

‐LBW ‐self‐harm

..and the BENEFITs of treatment to

both mother and fetus/child.‐Gestational age, birthweight neurodevelopment

‐NICU avoidance (trauma)

‐Decreased PPD, recurrence

TREATMENT

TWO PATIENTS TO CONSIDER

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TREATMENT:OPTIONS FOR MILD TO MODERATE

SYMPTOMS Internet-based programs Apps Social support Peer support Home visiting programs Addressing core problems

sleep getting outside isolation eating bathing breastfeeding

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Psychotherapy referral CBT, IPT, MBCT

Postpartum.net to find perinatal specialist

Social work/Care coordination referral

Mindfulness/Yoga

Acupuncture

Electroconvulsive therapy

Bright Morning Light Therapy…..

TREATMENT:OPTIONS FOR MILD TO MODERATE

SYMPTOMS

Dimidjian,S.J. Consult Clin Psychol, 2016Clin Psychol Rev 2018 Manber et al. Obstet Gynecol. 2010

Bright Morning Light Therapy

10,000 lux commercial UV blocked box

First thing upon awakening for 15-30 minutes Dose-response relationship

<12 inches from face ~$25-75 on Amazon

Epperson et al. J Clin Psych, 2004, Oren DA et al. Am J Psych, 2002

Data support efficacy in non-seasonal depression, pregnancy

Non-pharmacologic augmentation strategy

Lam, JAMA Psychiatry, 2016

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Bright AM Light Therapy in Pregnancy

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‐130 1 2 3 4 5

Week of Treatment

Chan

ge in

HAMD‐17 score (covariate‐ad

justed

) bright light N=24placebo light N=22

*

Wirz‐Justice et al: A randomized, double‐blind, placebo‐controlled study of light therapy for antepartum depression. J Clin Psychiatry 2011;72(7):986‐993

* p<.05

Response Remission

bright placebo placebobright

www.cet.org

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Non-Pharmacologic Treatments: Physical Activity

Systematic Review and Meta-Analysis of the influence of exercise on depressive symptoms and the prevalence of

depression in the postpartum period

• 16 trials, n=1327

• Exercise increased odds of resolving depression by 54% (OR 0.46, 0.25-0.84)

Physical Activity is an important part of treatment (or adjunct to treatment) for

postpartum depression

Slide 30©MCPAP For Moms, www.mcpapformoms.org

PHARMACOLOGIC TREATMENT: MODERATE TO SEVERE SYMPTOMS

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If starting an SSRI, plan to INCREASE dose until symptoms remit

***worry less about minimizing the dose and more about symptom remission BEFORE delivery if starting AP

©MCPAP For Moms, www.mcpapformoms.org

96(3), 259–269.

Is patient currently taking an antidepressant?

Does patient have a history of taking an antidepressant that has helped?

To minimize side effects, half the recommended dose is used initially for 2 days, then increase in small increments as tolerated.

Yes No

If medication has helped and patient is on a low dose: increase dose of current medication (see table below)

If patient is on therapeutic dose for 4‐8 weeks that has not helped: consider changing medication. If questions contact MCPAP for Moms for consultation

Yes No

Use sertraline, fluoxetine or citalopram (see table below)

Prescribe antidepressant that helped patient in the past (see table below)

Antidepressant Treatment Algorithm (use in conjunction with Depression Screening Algorithm for Obstetric Providers)

Slide 32 ©MCPAP For Moms

Seek psychiatric consultation

1Taken from the Composite International Diagnostic Interview-Based Bipolar Disorder Screening Scale (Kessler, Akiskal, Angst et al., 2006)

Quick screen for Bipolar disorder (before starting SSRI monotherapy)

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Novel PPD treatment on the horizon…

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• Lancet 2017

• Allopregnanolone IV infusion (n=10) x 60 hours (vs placebo (n=11)

• Expedited FDA approval requested…..

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• Lancet 2018

• Allopregnanolone IV infusion

• (BRX 60 n=38) & (BRX90 n=41) x 60 hours vs placebo (n=43)

• PO study (14 days) planned

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When Initiating Treatment…

Start treatment, start referral process (for postpartum period and beyond)

Coordinate care between maternity care, mental health, and primary care providers during the prenatal and postpartum period.

Establish a plan for care beyond the postpartum period (and discuss at prenatal visits)

Assure release of information forms are in place.

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Talk About Perinatal Mental Health concerns!

Normalize It!

Include education in new patient packets along with

information on other common complications.

Review common symptoms often.

Include family and support system in educational process.

Help families and support systems understand “Red

Flags.”

Listen, Support, Offer help.

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NICHD “Moms Mental Health Matters”- free peel-off pads and posters for your office :

https://www.nichd.nih.gov/ncmhep/MMHM/Pages/index.aspx

Council on Patient Safety in Women’s Health:

Safecareforeverywoman.org

Postpartum Support International (PSI):

http://www.postpartum.net

Links for Patients/Families & Clinicians

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Establish Local Standards

Consider:

Reach out to Ob/CNM/Ob nursing/PCP and Mental Health

colleagues!

Documentation of screening at specified intervals

Utilize EMR for reminders

Documentation of screening results

Documentation of plan of care

Documentation of referral and follow up

Appropriate diagnostic code(s)

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In Summary….

Discuss “early and often”

Screen in a way that works for you and your level of comfort to counsel regarding treatment Use existing- $free$- resources!

Anyone can recommend evidence-based alternatives to medication

& use them as adjuncts to medication

Make new (interdisciplinary) friends to foster continuity of care

Keep an eye out for FDA approval and labeling of novel therapies designed to treat PPD

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Many Thanks:

Maternal Mental Health: Perinatal Depression and Anxiety Patient Safety Bundle Workgroup

Chairs: Susan Kendig, JD, WHNP-BC

John Keats, MD

• Emily Miller

• Katherine Wisner

• Tiffany Moore-Simas

• Ariela Frieder

• Chris Raines

• Barbara Hackley

• Pec Indman

• Lisa Kay

• Kisha Semenuk

• Lauren Lemieux

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Contact [email protected]

http://motherhoodlotus.webs.com

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