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Demystifying and DestigmatizingMood Disorders of Pregnancy
April 19, 2019
Janice Tinsley and Alicia Pollak
“
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
African Americans often feel we are being judged by outsiders, particularly people in authority like doctors. A doctor can’t know us unless they talk to us about life, and express a genuine interest. If they are just paper pushing, asking required questions it will never happen.” –Jessica, mother of 7
Joy Burkard, MBA Presentation at AWHONN 2019Founder & Executive Director, 2020 MOM
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Intersectionality- A change in FrameworkKimerberlé Crenshaw “The urgency of intersectionality” TED Women 2016 https://www.ted.com/talks/kimberle_crenshaw_the_urgency_of_intersectionality.Fusion/discussion#t-1117287
“When facts do not fit with available frames, people have a difficult
time incorporating facts into their way of thinking about a problem”
Why do frames matter? Women are left to “fall through the cracks of
a movement, left to suffer in isolation”
Intersectionality- is a framework issue, frames used are partial and
distorting, is there an alternative narrative
Classism, sexism, racism, ableism, homophobia, heterosexism,
transphobia
“
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
“Becoming “trauma-informed” means recognizing that people often have many different types of trauma in their lives. People who have been traumatized need support and understanding from those around them. Often, trauma survivors can be re-traumatized by well-meaning caregivers and community service providers.”
The Trauma Informed Care Projecthttp://www.traumainformedcareproject.org/index.php
Trauma Informed Care
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Assess, avoid, and respond to
triggers, triggers can CHANGE
care
Starting care involvement with
clients means starting over in
gaining report and their trust
- Go slow, sit down, be genuine
and a good listener
- Continuity in care of clients
smart and best care
Use of Trauma Informed Care
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Stokely CarmichaelMetzl JM, Hansen, H. (2014). “Structural competency: theorizing a new medical engagement with stigma and inequality”. Soc Sci Med Feb; 103: 126-133
“In 1968, the civil-rights activist Stokely Carmichael famously assailed forms of
racial bias embedded, not in actions or beliefs of individuals, but in the functions of
social structures and institutions. “I don’t deal with the individual,” he said. “I think
it’s a cop out when people talk about the individual.” Instead, speaking to a group
of mental-health practitioners, Carmichael protested the silent racism of
“established and respected forces in the society” that functioned above the level of
individual perceptions or intentions, and that worked to maintain the status quo
through such structures as zoning laws, economics, schools, and courts.
Institutionalized racism, he argued, “is less overt, far more subtle, less identifiable
in terms of specific individuals committing the acts, but is no less destructive of
human life” (Carmichael, 2003: 151).
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Cultural Competency vs Structural CompetencyVirtual Mentor. 2014;16(9):674-690. doi: 10.1001/virtualmentor.2014.16.9.spec1-1409
Training to help communicate with persons of different ethnic background vs
“’Structural competency’, contends that many health-related factors previously
attributed to culture or ethnicity also represent the downstream consequences of
decisions about larger structural contexts, including health care and food delivery
systems, zoning laws, local politics, urban and rural infrastructures, structural
racisms, or even the very definitions of illness and health”
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
“…attempt to survive”Metzl JM, Hansen, H. (2014). “Structural competency: theorizing a new medical engagement with stigma and inequality”. Soc Sci Med Feb; 103: 126-133
“These are but a few examples of the types of research that doctors can
now access—at a level of microscopic and macroscopic precision
unimaginable in Carmichael’s time—to understand how diseased or
impoverished economic infrastructures can lead to diseased or
impoverished, or imbalanced bodies or minds. And, how locating race-
based symptoms on the bodies of marginalized or mainstream persons
risks turning a blind eye to the racialized, stratified economies in which
marginalized and mainstreamed bodies live, work, and attempt to survive”
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
• Stigma around mental
health and pregnancy
rises and women can feel
conflicted in their choices
to care for themselves and
for their growing baby
Stigma, Boundaries, Empathy
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The Joint Commission. (2018). Revisions to the National Patient Safety
Goal on Reducing the Risk for Suicide. Retrieved from
- https://www.jointcommission.org/assets/1/6/HAP_Suicide_NPSG_Prepub_emb.pd
f
U.S. Preventive Services Task Force (USPSTF)
- https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummary
Final/perinatal-depression-preventive-interventions
Policy Changes and Current Affairs
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U.S. Preventative Services Task Force (USPSTF)- https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/perinatal-depression-
preventive-interventions
“The USPSTF recommends that clinicians provide or refer pregnant
and postpartum persons who are at increased risk of perinatal
depression to counseling interventions.”
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AB 1893 Maternal mental health: federal funding. (2017-2018)
- Requires DPH to investigate and apply for federal funds and notify the Legislature before
1/1/2020 of efforts to secure and utilize funding
- https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180AB1893
AB 3032 Maternal mental health conditions. (2017-2018)
- Requires hospitals with perinatal services to develop and implement a maternal mental health
program and require education and information for patient, families, and hospital perinatal
employees
- https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180AB3032
CA Legislation 2018
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AB 2193 Maternal mental Health
- Requires a provider caring for women during the perinatal period to screen at least once for
mental health
- https://leginfo.legislature.ca.gov/faces/billAnalysisClient.xhtml?bill_id=201720180AB2193
CA Legistation 2018
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AB 3032 Maternal Mental Health Conditions
123615.5. The Legislature hereby finds and declares all of the following:
(a) Maternal depression is a common complication of pregnancy. Maternal mental health disorders encompass
a range of mental health conditions, such as depression, anxiety, and postpartum psychosis.
(b) Maternal mental health conditions affect one in five women during or after pregnancy, but all women are at
risk of suffering from maternal mental health conditions.
(c) Untreated maternal mental health conditions significantly and negatively impact the short- and long-term
health and wellbeing of affected women and their children.
(d) Untreated maternal mental health conditions cause adverse birth outcomes, impaired maternal-infant
bonding, poor infant growth, childhood emotional and behavioral problems, and significant medical and
economic costs, estimated to be $22,500 per mother.
(e) Lack of understanding and social stigma of mental health conditions prevent women and families from
understanding the signs, symptoms, and risks involved with maternal mental health conditions and
disproportionately affect women who lack access to social support networks.
(f) It is the intent of the Legislature to raise awareness of the risk factors, signs, symptoms, and treatment
options for maternal mental health conditions among pregnant women and their families, the general public,
primary health care providers, and health care providers who care for pregnant women, postpartum women,
and newborn infants.
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Case Report #1Janice’s patient
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Case Report #2History
First time mom
Hx GAD, Childhood ADHD
1 episode of Major Depressive Disorder 5-8 years ago, when
she was overworked
Presents PP, “I have run out of coping strategies” and feels
she needs help
Reports anxiety in keeping baby safe
Reports insomnia
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Case #2Diagnosis
Major Depressive Disorder
For our hospital, diagnosis: Gaps in care revealed!
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Structural Assets:
- Legal status
- Access to care
- Educated
Structural Vulnerabilities:
- Lack of support at home
- Hospital without immediate
in-house psych care
- Partial coverage for care in
psych at UCSF
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Case #2Treatment
Kept in house at BCH, infant allowed to visit. If tx to other
campus, no visits from newborn
- Very few locked facilities that allow moms with babes
- Women with episodes, especially postpartum shown to have
potential stress and issues with bonding/relationship with
newborn
- Does separating women at this crucial bonding time benefit the
dyad? No right answer here, it’s done many different ways, but
often in separation of dyad for mom’s care
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Case #2Treatment
Suicide leading cause of maternal death PP. Case reviews show between 50-80% of
cases had potential to prevent if treated patient differently
Titration of Lexapro upwards, need to go slowly,
Used Klonopin as temp plan while primary med had effect
- Pt concerned for dependency/addiction-reassured not an issue in short term use
- Klonopin and breastfeeding-pregnancy it’s contraindicated, but PP low dose
acceptable, can monitor infant for drowsiness and adequate weight gain. It has a
longer half life and aware of potentiation with CNS depression psych meds
(LactMED App)
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Case #2Clinical Pearls from conversation with Dr. Robertson!
Watch for red flags! Some psychiatrists will w/d clients from SSRIs at 36 weeks to avoid issues
with infant PP. If this is your patient and they need meds they are at a higher risk for incident PP
and takes time to titrate the meds back! GAP in care and exposure to risk
Watch for insomnia, as many clients need respite care to help with the mood disorders. Does
your hospital provide respite at night?
Breastfeeding can happen with most meds, it’s a question of which one…NOT to Tx or not to Tx.
These clients need the pharmacologic assistance if that is what they have been using
Screening question for PP presentation: “Is this what you thought it would like?”
UCSF past OB psychiatrist, Dr. Anna Glezer’s website www.mindbodypregnancy.com
- “One study found that women who discontinue medications and are postpartum have three times the risk of relapse compared to
non-postpartum women.”
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
DepressionPerinatal period and up to one year postpartum
Up to 1 in 5, 20% incidence in perinatal period
Depression is the most common pregnancy complication
Postpartum is period of highest risk
Up to 50% of women are those in poverty
Vulnerable populations: teens, single moms, military women,
low income, socially isolated, recent immigrants, women with
high risk pregnancies, infertility, NICU moms
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
S/Sx:
- Big 3: depressed mood,
anhedonia and low energy (and
SI)
- hopelessness
- persistent sadness
- lack of pleasure or no joy
- change in appetite
- issues sleeping and/or extreme
fatigue not due to the changes of
new care of baby
- Recurrent thoughts of harm or
death
- Feeling agitated or possibly
slowed
Depression
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Preterm birth
Low birth weight infants
Fetal growth restrictions
Substance use
Depression effects
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DepressionTreatment
SSRI antidepressants
-Often recommended as a long-term anxiety solution
-Many medications originally approved for the treatment of depression are also
prescribed for anxiety. In comparison to benzodiazepines, the risk for dependency
and abuse is smaller. Medications are:
- Prozac (Fluoxetine)
- Zoloft (Sertraline)
- Paxil (paroxetine)
- Lexapro (Escitalopram)
- Celexa (Citalopram)
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Common side effects of
SSRIs include:
- Fatigue
- Nausea
- Agitation
- Drowsiness
- Weight gain
- Diarrhea
- Sexual dysfunction
- Nervousness
- Headaches
- Dry mouth
- Increased sweating
- Insomnia
Depression Treatment
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SSRI’s and Breastfeeding
SSRI’s effect on pregnancy and breastfeeding
- Women already taking antidepressants should be encouraged to continue
treatment post-natally and for at least six months after resolution of the
depression depending on the number of previous episodes of depression, as the
risk of relapse is linked to stopping treatment.
- Overall, there is a lack of safety data (particularly long-term safety) on the use of
antidepressants in pregnancy
- The SSRI of choice for depression in women who are breastfeeding is sertraline
because of its relatively shorter half-life compared with fluoxetine or citalopram,
which have the potential to accumulate in the child
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Perinatal Anxiety(OCD, PTSD, Panic Disorder, Generalized Anxiety Disorder
6-15% incidence in perinatal period
About 6% of pregnant women and 10% of postpartum women
develop an anxiety disorder which may be associated with
depression
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
S/Sx:
Excessive worry
Restlessness
Fatigue
Irritability
Insomnia
Fear of being alone with the baby
Reexperience of traumatic event
Feeling detatched
Anxiety in the Perinatal Period
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Preterm Birth
Low birth weight infants
Fetal growth restriction
Prolonged labor
Fetal distress
Anxiety Effects
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Anxiety Treatment
Treatment
- Benzodiazepines (also known as tranquilizers) are the most widely prescribed
type of medication for anxiety. Because they work quickly—typically bringing relief
within 30 minutes to an hour—they’re very effective when taken during a panic
attack or another overwhelming anxiety episode.
anax (alprazolam)
Klonopin (clonazepam)
Valium (diazepam)
Ativan (lorazepam)
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Anxiety Treatment
Mode of Action
- Benzodiazepines work by slowing down the nervous system, helping you relax
both physically and mentally. But it can also lead to unwanted side effects
- The higher the dose, the more intense these side effects typically are. However,
some people feel sleepy, foggy, and uncoordinated even on low doses, which can
cause problems with work, school, or everyday activities such as driving. The
medication hangover can last into the next day.
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Common side effects of
benzodiazepines include:
Drowsiness
Dizziness
Poor balance or coordination
Slurred speech
Trouble concentrating
Memory problems
Confusion
Stomach upset
Headache
Blurred vision
Anxiety Treatment
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Anxiety Treatment
Safety concerns
- According to the FDA, benzodiazepines can worsen cases of pre-existing
depression, and more recent studies suggest that they may potentially lead to
treatment-resistant depression. Furthermore, benzodiazepines can cause
emotional blunting or numbness and increase suicidal thoughts and feelings.
- benzodiazepines lead to physical dependence and tolerance, with increasingly
larger doses needed to get the same anxiety relief as before. This happens
quickly—usually within a couple of months, but sometimes in as little as a few
weeks.
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Anxiety Treatment
If you abruptly stop taking your medication, you may experience severe withdrawal
symptoms such as:
- Increased anxiety, restlessness, shaking
- Insomnia, confusion, stomach pain
- Depression, confusion, panic attacks
- Pounding heart, sweating, and in severe cases, seizure
Many people mistake withdrawal symptoms for a return of their original anxiety
condition, making them think they need to restart the medication. Gradually tapering
off the drug will help minimize the withdrawal reaction.
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Anxiety TreatmentClinical Pearls
Don’t drink on benzodiazepines. When mixed with alcohol, benzodiazepines can
lead to fatal overdose.
Don’t mix with painkillers or sleeping pills. Taking benzodiazepines with
prescription pain or sleeping pills can also lead to fatal overdose.
Antihistamines amplify their effects. Antihistamines—found in many over-the-
counter sleep, cold, and allergy medicines—are sedating on their own. Be cautious
when mixing with benzodiazepines to avoid over-sedation.
Be cautious when combining with antidepressants. SSRIs such as Prozac and
Zoloft can heighten benzodiazepine toxicity. You may need to adjust your dose
accordingly.
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Anxiety Treatment
SSRIs have been used to treat:
- SSRIs have been used to treat generalized anxiety disorder
(GAD)
- obsessive-compulsive disorder (OCD)
- panic disorder
- social anxiety disorder
- and post-traumatic stress disorder
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Posttraumatic Stress Syndrome
PTSD 7.7% in socioeconomically disadvantaged patients
Approximately 18% of women experience a traumatic birth
and 5-9 % of these women will develop PTSD
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Obsessive/Compulsive Disorder
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Panic DisorderFaruk Uguz (2016) A pharmacological approach to panic disorder during pregnancy. The Journal of Maternal-Fetal & Neonatal Medicine, 29(9), 1468-1475
Characterized by repeated panic attacks
Women twice likely as me and mean age for presentation is
childbearing years
Prevalence during pregnancy 0.2-5.2% (same as general
population) but pregnancy may exacerbate up to 33%
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Panic Disorder EffectsFaruk Uguz (2016) A pharmacological approach to panic disorder during pregnancy. The Journal of Maternal-Fetal & Neonatal Medicine, 29(9), 1468-1475
Preterm birth
SGA
Anemia
Polyhydramnios
More negative effects on birth weight then depression or GAD
Increase in congenital abnormalities and increase in cleft lip with or without cleft
palate
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Bipolar
1-3% in general population, typical diagnosis 18-30 years
Sometimes misdiagnosed as depression, which delays
proper treatment, increases risks for poor outcomes
Highest risk for adverse outcomes, imperative these women
have collaborative plan in place for pregnancy, especially
going into the postpartum period
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Periods of severely depressed mood and
irritability
Mood much better than normal
Rapid speech
Little need for sleep
Racing thoughts, trouble concentrating
Continuous high energy
Overconfidence
Delusions (often grandiose, but including
paranoid)
Impulsiveness, poor judgment,
distractibility
Grandiose thoughts, inflated sense of self-
importance
In the most severe cases, delusions and
hallucinations
Bipolar Type IS/Sx (https://www.postpartum.net/learn-more/bipolar-mood-disorders/)
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Periods of severe depression
Periods when mood much better than
normal
Rapid speech
Little need for sleep
Racing thoughts, trouble concentrating
Anxiety
Irritability
Continuous high energy
Overconfidence
Bipolar Type IIS/Sx (https://www.postpartum.net/learn-more/bipolar-mood-disorders/)
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Bipolar Effects
Conflict of decision making/stigma of whether to continue with medications during
and/or after pregnancy
Increased rate of GHTN
Increased rates of hemorrhage
Increase in IOL
Increase rate of c/s
Increase in mood disorders post-natally
Increase severe SGA
Increase in risk of infants with congenital abnormalites if on mood stabilizers
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Bipolar Treatment
Scrandis, D. (2017). Bipolar disorder in pregnancy: A review of pregnancy outcomes. J Midwifery Women’s Health, 62, 673-683.
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Perinatal Psychosiswww.postpartum.net
1 in 1000-3000 incidence
Increased incidence have personal or family history of bipolar
disease or Hx of psychotic episode (260/1000, 570/1000 fam
hx with psychosis)
Sudden onset, usually first 2 weeks
5% rate of suicide, 4% rate of infanticide
Treat as an emergency
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
S/Sx:
- Delusions
- Hallucinations
- Irritability
- Hyperactivity
- Decrease need for sleep or unable to
sleep
- Paranoia
- Rapid mood swings
- Difficulty communicating
Perinatal Psychosis
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Increased rate of c/s
PROM
AP hemorrhage
Abruption
Preterm delivery
Stillbirth
Perinatal Psychosis Effects
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Psychosis Treatment
Treatment
- Postpartum psychosis constitutes a medical emergency, generally requiring rapid
identification and intervention
- Postpartum psychosis is typically treated with a combination of antipsychotic
medication and a mood stabilizer
- Benzodiazepines and antidepressants are used to treat insomnia or depression
- Treatments for postpartum psychosis, a relatively rare syndrome, have not been
tested in randomized clinical trials
- Women with mild to moderate illness may be able to breastfeed.
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Comorbidity with Substance Use Disorders
Psychiatric incidence 29.7/1000 deliveries
Substance Use 17.1/1000 deliveries
Gross underestimate of SUD r/t stigma of substance use
Some psychiatry providers require tx of substance use first,
prior to tx of psychiatric disorders- WHY not treat at the same
time! Common practice to treat at same time in UCSF
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Council on Patient Safety in Women’s Healthcarewww.safehealthcareforeverywoman.org
Postpartum Care Basics for Maternal Safety: From Birth to the Comprehensive
Postpartum Visit
- Readiness for Every Clinical Setting: Develops protocols for screening and treatment for postpartum
concerns, including depression and substance abuse disorders, and establishes relationships with local
specialists for co-management or referral.
- Recognition and Prevention for Every Clinical Setting: Screens for and treats common morbidities,
including mental health issues, smoking, and substance use, as well as concerns such as unstable housing
and food insecurity.
Response for Every Clinical Setting:
- Implements treatment protocols and either provides desired care or facilitates timely referral to an appropriate resource. Whenever
feasible, a warm hand-off is provided, via a face-to-face introduction to the specialist to whom the patient is being referred.
- Maintains an up-to-date inventory of community resources to assist with unmet needs, such as 24-hour hotlines, food banks, diaper
banks, lactation support groups, and home visiting programs.
- Develops strategies to reach women who do not attend the comprehensive postpartum visit.
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Maternal Mental Health Bundlehttps://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Maternal-Mental-Health-Bundle.pdf
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American Academy of Pediatrics recommends screening (2010)
American College of Obstetrics and Gynecology (ACOG) recommends screening
(2015)
The USPSTF recommends screening adults for depression and specifically calls out
the importance of screening pregnant and postpartum women (2016)
- -Draft recommendation related to screening to determine who is at risk to refer counseling.
(Pending, 2018)
CMS recommends states reimburse pediatricians for Medicaid screening by
pediatricians and notes coverage for mother-baby treatment (2016)
AMA recommends screening (2017)
Screening RecommendationsJ. Burkhard. “Maternal mental health”. AWHONN 2019
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• No standard of care, other
then should be screened
• First visit and every
trimester
• PP visit
• Well child visit throughout
first year
When should we be screening?
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
• The greater the score, the increase
potential for depression
• Highly studied for use in population,
Cox et al states >12 for screening,
others lower threshold to capture
more potential
• If pt score >0 on #10, need
immediate intervention
Screening ToolsCox, J.L. Holden J.M. and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburg Postnatal Depression Scale. British Journal of Psychiatry 150:782-786.
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
• “our study demonstrated that the PRIME-MD
PHQ is a useful instrument for assessment of
mental disorders, functional impairment, and
recent psychosocial stressors in the busy
obstetrics-gynecology setting”
• 8 diagnoses- “major depressive disorder, panic
disorder, other anxiety disorder, and bulimia
nervosa) and subthreshold disorders (disorders
for which criteria encompass fewer symptoms
than are required for any specific diagnoses in
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, specifically other
depressive disorder, probable alcohol abuse or
dependence, and somatoform and binge eating
disorders).
Screening ToolsSpitzer, R.L., et al. (2000). Volume 183, Issue 3, pags 759-769. “Validity and utility of the PRIME-MD Patient Health Questionnaire in assessment of 3000 obstetric-gynecologic patients: The PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study”.
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UCSF New Screening in the worksPHQ-9 (www.uspreventiveservicestaskforce.org/Home/GetFileByID/218)
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UCSF New Screening in the worksGAD-7 (http://www.tbh.org/sites/default/files/Generalized_Anxiety_Disorder_Screener_GAD7.pdf)
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Mental Health Resources for Providers and Patientshttps://safehealthcareforeverywoman.org/wp-content/uploads/2016/09/Other-Maternal-Mental-Health-Resources-2-10-16.pdf
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Inpatient Care of Women with Mood Dx
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Tx of care to UC for fetal treatment
Hx:
- active violence in home with current partner, hx violence with past partner
- recent immigrant, limited family support, 11yo daughter from prior relationship staying with her
in house
- Hx suicide attempt in the year prior to pregnancy
Case Report #3M.S. 34yo G3P0111 32+0, monolingual Spanish speaker
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Bright, always cheerful when you entered room
Great hygiene, showered daily
Participated in care and eager to listen to monitoring of FHR
Daughter at BS helping mom with everything, “nurse-like” at age 11
Assumed care of patient, used translator phone and asked for daughter to leave during
assessment, pt hesitant, but arranged for our resource RN to hang out with daughter and take a
walk on unit. Asked patient about hospital stay, needs being met, how her daughter was coping.
At the end of our sit down talk with translator, asked about feelings about harming herself. +SI,
+forming plan
Case #3 Assessment
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Structural Assets:
- Enganged in care
- Great mother
- Honest about her diagnosis and
history
Structural Vulnerabilities:
- New immigrant
- Limited support system
- Monolingual
- Hx violence
- Financial security
Case #3
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Case #3
Intervention:
- Remained with patient 1:1
- Notified charge RN and resident/attending who notified nursing supervisor and we
got a sitter ordered asap, our PCA filled in until next shift
- Room turned into “safe room”
- Psychiatry notified and to patient that day, in house, medication started
- Got an in person hospital interpreter to the BS
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If patient is screened to be at risk for suicide/self-harm:
- Notify provider
- Notify charge RN
- Initiate 1:1 observation using safety attendant or unit staff
- Develop safety plan of care with provide and charge RN (see safety huddle)
- Initiate risk mitigation interventions, as appropriate (see risk mitigation
interventions)
- Initiate Suicide/Self-Harm nursing care plan
UCSF Patient at Risk for Suicide of Self-harm
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SAFETY HUDDLE
1. A safety huddle is a meeting of multidisciplinary clinicians and support staff for developing a plan of care for the
patient who is at risk for injury to self or others. It can be used for patients displaying behaviors posing safety concerns
or behavioral challenges (e.g., patient who is at risk for self-harm, suicide, elopement, or potential for injury to others).
• Responsibilities of the safety huddle group are to develop short-term plans for care and contingencies, ensure
appropriate orders are written and implemented, and achieve consensus and understanding of care priorities.
• The makeup of a safety huddle group will depend on the specifics of the patient’s situation and location. Members
include the primary RN, charge RN, and a primary care provider. Other members, such as the Risk Manager, Social
Worker, or Security officer, may be needed participants.
2. A safety huddle can be initiated by any member of the care team but is usually initiated by an RN. The huddle time is
coordinated between clinicians.
3. Huddle discussion details and outputs may include:
a. Current safety risks
• Hold status
• Harm to self or others
b. History of behavioral or safety concerns
c. Priorities of care and patient care needs
d. Appropriate risk mitigation strategies and plan for maintaining safety.
4. The safety plan is communicated through the APEX care plan, provider orders, and an FYI alert. In addition to the
elements in the safety checklists (Appendix A) the plan may include:
a. Known triggers for escalation
b. De-escalation interventions
c. Provisions for safety during transport to, from, and during off-unit procedures/activities or transfers.
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
CONVERTING AN INPATIENT ROOM FOR SAFETY1. Converting a room for safety may be done in conjunction with other interventions to prevent self-harm or harm to others. Room conversion is
not a stand-alone safety measure.
• Other preventive interventions used prior to conversion of a room for safety or after room conversion may include: assigning a safety attendant,
removing patient belongings that may be used to cause self-harm, providing meal trays with disposable items, conducting periodic safety room
checks, and placing the patient in hospital clothing.
2. The decision to convert a room for increased safety entails:
a. Considering the risks versus benefits of removing routine equipment and supplies used for patient care.
b. Collaborative input from RNs, the primary provider, and as needed, staff from supporting services/ departments (e.g., Psychiatry, Social Work,
Security).
3. Conversion of a room for safety and back to a regular room is accomplished by coordinating resources from Nursing,
Clinical Technologies (Engineering), Information Technologies, Facilities Maintenance, and Hospitality.
4. Locate the patient in a room that maximizes safety such as near a nursing station when appropriate.
5. Remove items that may be used by the patient to inflict self-harm or harm to others (See Appendix B and Appendix C). Additional items to
remove (or reconfigure) include:
a. Alcohol based hand rub container from within its dispenser.
b. Computer and tablet arm
i. Call IT 415-514-4100. Do not enter an IT ticket. (IT will initiate a work order to Facilities Maintenance for assistance in removing large monitors
from the wall.)
ii. Indicate STAT need for Safe Room.
c. Physiologic monitor, lift equipment, ophthalmoscope/otoscope
i. Call Clinical T echnologies (Engineering) 415-514-3570
ii. Place service request ticket and mark “STAT” (Priority 1). iii. State need to remove specific equipment for Safe Room.
d. Pillow speaker cord (shorten and zip tie to bed frame)
i. Call and submit a Medical Center Support Services (MCSS) ticket requesting Facilities Maintenance support for the safe room.
6. Review how to open a patient room bathroom door if lockable.
7. When patient is no longer a risk of harm to self, or is discharged, call the same numbers to have the room converted back to a regular room.
Presentation Title69
What To Do When You Don’t Know What To Do
A practical guide to managing the complex patient
The medically and socially complex patient that presents to
labor and delivery
- Patients that have substance abuse issues
- Patients that have diagnosed and undiagnosed psychological
problems
- Patients that have homelessness
Presentation Title70
Definition
- Over the last decade, the concept of the “complex patient” has not only
been more widely used in multidisciplinary healthcare teams and across
various healthcare disciplines, but it has also become more empty in
meaning
- The concept of the “complex patient” spans across disciplines, such as
medicine, nursing, and social work, with no consistent definition
- surrogate terms, namely “comorbidity,” “multimorbidity,” “polypathology,”
“dual diagnosis,” and “multiple chronic conditions
- This has implications on how we practice, theory and how we research
What To Do When You Don’t Know What To Do
A practical guide to managing the complex patient
Presentation Title71
What do health providers mean when they talk about a complex patient?
What makes this patient complex?
When does this “label” apply and in what context?
Concept clarification is important because healthcare providers need to
understand each other when they work with so‐called complex patients
This concept can act as a needed bridge to assist clear communication in
multidisciplinary care
Does this mean a patient that abuses drugs, has mental health issues, or
several social issues i.e homeless, domestic violence
Presentation Title72
Patients who have complex health needs require both medical
and social services and support from a wide variety of providers
and caregivers, and the patient-centered medical home (PCMH)
offers a promising model for providing comprehensive,
coordinated care.
Presentation Title73
Nurses are positioned to contribute to and lead the transformative changes
that are occurring in healthcare by being a fully contributing member of the
interprofessional team as we shift from episodic, provider-based, fee-for-
service care to team-based, patient-centered care across the continuum
that provides seamless, affordable, and quality care
These shifts require a new or an enhanced set of knowledge, skills, and
attitudes around wellness and population care with a renewed focus on
patient-centered care, care coordination, data analytics, and quality
improvement.
Presentation Title74
Practical Guide to Patient ManagementDe-escalation of the patient with a psyche or violent history credit to Dr. James Hardy
Recognition of agitation- look for warning signs
- Is the patient angry?
- Ae they pacing?
- Do they have a clenched fist?
- Are they talking loud, louder than others in that environment?
- Is there a history of violence?
- Are other staff members telling you that the patient is agitated?
Presentation Title75
Caring for patient who is psychotic or under the influence of drugs
- Keep 2 arm lengths distance if they are agitated
- Wake patients carefully- never go to the head of the bed many of these
patients live in dangerous situations and wake up protecting themselves,
shake their feet
- Do not get trapped in the room with the patient
- Do not block the doorway
- Don’t try to stop a patient if they run
Presentation Title76
Verbal de-escalation
- Body language – knees bent hands at your side or namestate stance
- Tone of voice- try not to be condensending,
- Stay calm.
- Manage your own response.
- Set limits.
- Handle challenging questions.
- Prevent a physical confrontation.
Presentation Title77
Verbal de-escalation
- One person talks
- Introduce yourself
- Ask questions
- Listen and reflect back
- Keep it simple
- Don’t argue
- Offerf choices
Presentation Title78
California Senate Bill 1152
Background and Purpose
• In order to standardize the level of discharge planning service hospitals provide, California Legislature passed, and the Governor signed SB 1152.
• The law took effect, January 1, 2019
• Purpose is to help prepare the homeless patient for return to the community by connecting him or her with available community resources, treatment, shelter and other supportive services
• The law does not require hospitals to find or create service that do not exist in the community.
• Documented compliance with elements of this legislation are required by 1/1/2019.
California Senate Bill 1152
Services that Must be Offered to Homeless Patients Before Discharge
• Physician Examination and determination of stability for discharge
• Referral for follow up care
• Referral for behavioral health care if it’s determined that the patient requires behavioral health care
• Food
• Weather appropriate clothing
• Discharge medications (prescriptions)
• Infectious disease screening
• Vaccinations appropriate to the presenting medical condition
• Transportation within 30 minutes or 30 miles of the hospital
• Screening for and assistance to enroll in affordable health insurance coverage
Presentation Title81
UCSFBEHAVIORAL HEALTH COLLABORATIVE
Formed in the fall of 2018 in response to approximately 5-6 patients with
complex medical and social histories
These patients were seen in triage several times a week or month
Some seen with substance abuse, homelessness, violence on the street or
psyche issues
Triage staff very frustrated with the behavior of the patients
Residents and attendings upset with no formalized plan of care for patient’s
being discharged at night
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Pharmacologic (preference to history of use)
Psychotherapy (CBT treatment most affective and/or
interpersonal therapy, preference to history of use)
Community Referrals
Case management
Supplemental- Rest, exercise, change in diet, assistance with
childcare
Outpatient Care of Women with Mood DxInterventions
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Impact Model of CareUnützer J, Katon W, Callahan CM, et al. Collaborative Care Management of Late-Life Depression in the Primary Care Setting: A
Randomized Controlled Trial. JAMA. 2002;288(22):2836–2845. doi:10.1001/jama.288.22.2836
RCT that demonstrated collaborative care doubled the effectiveness of
treatment in primary care of older adults with depression
- 45% of intervention group had at least 50% reduction in depressive sx compared
to 19% in typical group
- greater rates of depression treatment, more satisfaction with depression care,
lower depression severity, less functional impairment, and greater quality of life
- Synonymous with collaborative care
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Integration Projects
Screen all women
Partner with disciplines
Assessment of all positive screens
Risk stratification based on assessment
Interventions: education, case mgmt, OT, psychotherapy,
med consultation
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
Team Lily as one intervention
for our moms
LILY
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
• Takes a village and many resources-
BE CREATIVE
• Know where to find policies as any
other emergency
• Be alert PP for presentations
• Document and think of a care map,
especially for screening that’s
interdisciplinary
• Begin to learn community resources
and start to make those connections
“Release the creativity of
our communities”
-Dr. Monica McLemore
Clinical Pearls
“
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
“We have to bare witness…hold them up…sit with
them…bare witness to them…to bring them into the
light…”
Kimberlé Crenshaw“The urgency of intersectionality” TED Women 2016
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
References
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Metzl, J.M., Hansen, H. (2014)Structural Competency: Theorizing a new medical engagement with stigma and inequality. Social Science Medicine,
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http://www.traumainformedcareproject.org/
https://www.2020mom.org
Committee on Obstetric Practice. (2017)ACOG committee Opinion no. 757: Screening for perinatal depression. Obstet Gynecol, 132(5): e208-e212.
Unützer, J., et al. (2002). Collborative care management of late-life depression in the primary care setting- A randomized controlled trial. Jama,
288(22): 2836-2845.
Stewart, D.E., Robertson, E., Dennis, C-L., Grace, S.L., & Wallington, T. (2003). Postpartum depression: Literature review of risk factors and
interventions. Electronic Document. https://www.who.int/mental_health/prevention/suicide/lit_review_postpartum_depression.pdf?ua=1
Julian, Z. (February, 2019). Psychiatric care of OB patients @ZSFG. UCSF Grand round presentation, San Francisco, CA.
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
References
Council on patient safety in women’s health care. Maternal mental health: Depression and anxiety. Electronic document. 2016, February.
https://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Maternal-Mental-Health-Bundle.pdf.
Council on patient safety in women’s health care. Postpartum care basics for maternal safety from birth to the comprehensive postpartum visit
(+AIM). 2017, March. Electronic document. https://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Postpartum-Care-Basics-
Bundle.pdf.
Metzl, J, and Roberts, D.E.(2014). Structural competency meets structural racism: Race, politics, and the structure of medical knowledge. AMA
Journal of Ethics, 16(9):674-690.
Jones, I. & Craddock, N. (2001). Familiality of the puerperal trigger in bipolar disorder: results of a family study. Am J Psychiatry, 158, 913-917.
Kelly, E. and Sharma, V. (2010). Diagnosis and treatment of postpartum bipolar depression. Expert Review of Neurotherapeutics,10(7), 1045-1051.
Meltzer-Brody, S. and Jones, I. (2015). Optimizing the treatment of mood disorders in the perinatal period. Dialogues Clin Neurosci, 17(2), 207-218.
Scrandis, D. (2017). Bipolar disorder in pregnancy: A review of pregnancy outcomes. J Midwifery Women’s Health, 62, 673-683.
https://www.postpartum.net/learn-more/bipolar-mood-disorders/
Rusner, M., Berg, M., and Begley, C. (2016). Bipolardisorder in pregnancy and childbirth: a systemative review of outcomes. BMC Pregnancy and
Childbirth, 16(1), 331.
Destmystifying and Destigmatizing Mood Disorders of Pregnancy
References
Maina, G. et. al. (2014). Recurrence rates of bipolar disorder during the postpartum period: a study on 276 medication-
free Italian women. Archives Womens Mental Health, 17, 367-372.
www.mindbodypregnancy.com
Faruk Uguz (2016). A pharmacological approach to panic disorder during pregnancy. The Journal of Maternal-Fetal &
Neonatal Medicine, 29(9), 1468-1475
Uguz, F., Et al. (2019). Prevalence of mood and anxiety disorders during pregnancy: A case –control study with a large
sample size. Psychiatry Research, 272, 316-8.