MIHP Webcast MATERNAL DEPRESSION / STRESS

December 1, 2009

What Can MIHP Providers Do?

Catherine Kothari

Maternal-Child Research, MSU/KCMS

(269) 501-4149 (cell) kothari@kcms.msu.edu

Mary Ludtke

Mental Health Services to Children and Families, MDCH

(517) 241-5769 ludtkem@michigan.gov

MATERNAL DEPRESSION & STRESS

• Prevalence

• Identification

• Best Practices-Treatment

• Maximizing Community Resources

– Kalamazoo Maternal Depression Demonstration Project

• Impact of Maternal Depression

• Conclusions

• Resources

-PREVALENCE-

Prevalence of Major Depressive Disorder

Adult Men: 3.6% (previous 12 months)

Adult Women: 6.9% Major (previous 12 months)

Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of Major Depressive Disorder. Archives of General Psychiatry. 2005; 62: 1097-1106.

Depression higher…

Poverty

Minority

Adult Women: 6.9% Major

Pregnant Women: 7.5% Major

Postpartum (3 mos): 6.5% Major

Prevalence of Major Depressive Disorder

Gaynes BN, Gavin N, Meltzer-Brody S, Lohr KN, Swinson T, Gartlehner G, Brody S, Miller WC. Perinatal Depression :Prevalence Screening Accuracy, and Screening Outcomes. AHRQ Publication No. 05-E006-2. Rockville MD: Agency for Healthcare Research & Quality. Fegruary 2005.

Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of Major Depressive Disorder. Archives of General Psychiatry. 2005; 62: 1097-1106.

Perinatal Depression

ONSET:

Three times more likely during postpartum

Gaynes BN, Gavin N, Meltzer-Brody S, Lohr KN, Swinson T, Gartlehner G, Brody S, Miller WC. Perinatal Depression :Prevalence Screening Accuracy, and Screening Outcomes. AHRQ Publication No. 05-E006-2. Rockville MD: Agency for Healthcare Research & Quality. Fegruary 2005.

DURATION:

About half develop into lifetime conditions

PREVALENCE OF DEPRESSION* OVER THE FIRST 18

MONTHS POSTPARTUM(Among community postpartum sample, n=318)

14.8% DEPRESSED (n=47)

*12+ on Edinburgh Postnatal Depression Scale

o Pregnancy & postpartum periods tend to be protective against suicide & suicidal ideation

o Exception: Postpartum Psychosis

Suicidality

Suicidal Feelings (n=318, community postpartum sample)

Suicidal Ideation n=11%

Depression n=15%

n=7% n=4%

-IDENTIFICATION-

Perceived Stress Scale- 4 Item

The questions in this scale ask you about your feelings and thoughts during the last month. In each case,

please indicate with a check how often you felt or thought a certain way.

1. In the last month, how often have you felt that you were unable to control the important things in your life?

___0=never ___1=almost never ___2=sometimes ___3=fairly often ___4=very often

2. In the last month, how often have you felt confident about your ability to handle your personal problems?

___0=never ___1=almost never ___2=sometimes ___3=fairly often ___4=very often

3. In the last month, how often have you felt that things were going your way?

___0=never ___1=almost never ___2=sometimes ___3=fairly often ___4=very often

4. In the last month, how often have you felt difficulties were piling up so high that you could not overcome

them?

___0=never ___1=almost never ___2=sometimes ___3=fairly often ___4=very often

Depression & Stress

Signs of Depression

• Not everybody cries– Anger & irritability can be signs

• Any significant changes– Behavior

– Hygiene

– Affect

• Observe eye-contact & affect

• But, you CANNOT tell by just looking

Screening for Depression

• Several tools available

– Edinburgh Postnatal Depression Screener (EDPS)

– Postpartum Depression Screening Scale (PDSS)

• Detect Major Depressive Disorder

• Less effective at detecting minor depression

– Have you had any recent thoughts about death

or suicide?

– Have you ever attempted suicide in the past?

– How are you feeling right now; are you feeling

suicidal now?

Follow-up Questions to Assess Suicide Risk

-TREATMENT-

Best Practices--Treatment

• Medication

• Talk Therapy

• Social Support

Best Practices- Medications

Anti-Depressants

– Return to Psychiatrist

– Referral to primary care provider

• Tx, medication consult, referral to psychiatrist

– Community Mental Health

• Severe & persistent

• Crisis

Best Practices- Talk Therapy

• MHP provides up to 20 outpatient visits per year– Cognitive Behavioral Therapy

– Psychotherapy

• Motivational Interviewing

Best Practices- Social Support

• Alert her family / friends

• Continue to provide MIHP support

• Refer to support groups

What else can you do?

• Safety Planning

• Psychoeducation

• Ongoing assessment

• Encourage healthy behaviors (sleeping, eating, exercising)

• Assess for other stressors & help link to resources

-Barriers to Receiving Help-

• Not identified

• Lack of community Tx resources

• Lack of follow-up

MOTHER’S MIND MATTERS: RECOGNIZING & TREATING

PERINATAL MOOD DISORDERS

*Establishing a Comprehensive System for Identifying and Treating Perinatal Depression is funded by the

Blue Cross Blue Shield of Michigan Foundation

A Kalamazoo County Demonstration Project*

COMMUNITY-BASED COLLABORATIVE PROJECT…

Project Major Partners:

Healthy Babies-Healthy Start, Carmen Sweezy

Family & Children Svcs, Phyllis Florian

Western Michigan University

Ferris State University College of Pharmacy

Project Leadership: MSU/KCMS

Michael Liepman (PI)

Catherine Kothari (co-PI)

Ruqiya “Shama” Tareen (co-PI)

Collaborating Agencies:

Bronson Healthcare Group

Borgess Health Alliance

Family Health Center

Kalamazoo Community Mental Health and

Substance Abuse Services

Kalamazoo County Health & Human Services

Advisory Agencies & Advisors:

Michigan Department of Community Health

MDCH Maternal Depression Work Group

Nancy Roberts, RN, Spectrum Health

Elizabeth Cox, MD

MODEL FOR A COMPREHENSIVE SYSTEM OF CARE FOR

IDENTIFYING & TREATING PERINATAL DEPRESSION

TREATMENT

Primary Care Provider:

-Anti-Depressant Medication(s)

Psychiatrist:

-Anti-Depressant Medication(s)

-Psychotherapy

-Admission to hospital

Private Counselor:

-One-on-One Counseling

-Marital/Family Counseling

Kalamazoo CMH&SAS:

-Crisis intervention

-Psychiatric services for “severe &

persistent mental illness”

SCREENING

Where: PCP Office

When: Postpartum Visit

Postpartum Population...

Where: PCP Office

When: (1) Intake visit

(2) 28 or 36-38 wks

Prenatal Population...

CONSULTATION

KCMS Psychiatry

“Women’s Behavior Health

Clinic”

PROVIDER EDUCATION COMMUNITY EDUCATION

Mental Health/Social Service

Network

-Individual Therapy

-Support Groups

-Help-line

MSU/KCMS Psychiatry

Women’s Behavioral Health Clinic

-Shaded areas are elements added through BCBSM Grant-

Provider Trainings

• Held conferences, grand round lectures, & office based visits

– Trained on screening (universal, prenatal as well as postpartum, use EDPS)

– Referrals (WBHC, MH network, support group)

– Administering Meds

Change in Provider Behavior-Screening

• Majority report screening prenatally

• All report using EDPS

• Two-thirds screening universally

• 600% increase in documentation of screening in medical records (14% 86%)

• 350% increase in women’s recall of being screened by their healthcare provider (15% 53%)

-Preliminary Findings-

Change in Provider Behavior-Treatment

• 10% increase in documented referrals to outside therapy, psychiatry, support group (50% 55% among those screening positive)

• 270% increase in provider-administered meds (6% 16% among those screening positive)

-Preliminary Findings-

KCMS Psychiatry: Women’s Behavioral Health Clinic

147 Referred by PCPs

133 Eligible

124 Scheduled

81 Treated

-Preliminary Findings-

Mental Health Provider Network & Depression Support Groups

• Very few referrals led to new clients for therapists in the Mental Health Network

• The grant-supported therapist connected with the greatest number of women– Facilitated by project administrative staff– Multiple phone calls & follow-up by the therapist

to successfully reach clients

• The support groups were sparsely attended

-Preliminary Findings-

Lessons Learned

• PCPs are willing to screen all of their perinatal patients for depression, and use a formal tool

• Perinatal women are open to this screening

• PCPs are willing to treat their perinatal patients with medications if they have received specific education, and have a consult backup

• Women appear to be significantly more likely to accept treatment by their PCP than to follow-up on therapy or support group referrals– The only exception is if they are severely depressed and need

a psychiatrist; then, they have higher rates of follow-up

-IMPACT of MATERNAL DEPRESSION-

Impact of Maternal Depression

A parent’s mental health can have a profound impact on the social and emotional development of the infant, the parent-infant relationship, and the quality of care that is provided to an infant. The effect will be a function of the severity of the mental health problem rather than of any particular diagnosis.

Impact of Maternal Depression• Depression places the early attachment

relationship and the development of the infant at risk. A depressed mother will not be consistently available to meet the wants and needs of her infant.

• She may :– Find it difficult to respond with empathy or sensitivity to the infant.– Perceive her infant as difficult to care for and report disturbance in

sleeping or eating and regulatory problems.

• Consequences for the infant may be an insecure attachment, cognitive delays, and behavior difficulties.

Weatherston and Tableman, Infant Mental Health Services: Supporting Competencies/Reducing Risk. Michigan Association for Infant Mental Health. Southgate, MI, 2002.

Accessing Behavioral/Mental Health Services

• For women experiencing depression (per score on the Edinburgh Scale), a referral for assessment by a mental health provider may be warranted (depending on score).

• In addition, supportive relationships, educational materials, support self care activities, development of a safety plan, and other interventions may be of assistance.

Accessing Behavioral/Mental Health Services

• Medicaid beneficiaries have access to behavioral health benefit through their Medicaid Health Plan (20 outpatient visits),

or,

if the beneficiary has a history of serious mental illness, then a referral to the Community Mental Health Services Program for assessment is appropriate.

Accessing Behavioral/Mental Health Services

• Health care visits provide an ideal opportunity to recognize (and secure treatment for) perinatal depression.

• Use of the Edinburgh Postnatal Depression Scale will assist in the identification of depression. In addition, woman can complete the scale periodically and share the results with you, especially if the score changes.

Supportive Approaches…

• Suggested supportive approaches that can make a difference include….

– Be proactive in asking a woman directly about symptoms of depression.

– Be sure to ask in a nonjudgmental and open-ended way (Franko, 2006).

– Know the important warning signs of depression.

– Be sensitive to and understanding of a woman’s viewpoint and feelings to that she has the experience of being “held in mind” (Pawl, 1995).

Supportive Approaches…

• Suggested supportive approaches that can make a difference include….

– Acknowledge a woman’s desire to be a good parent and recognize the challenges she will face in this role.

– Seek agreement so that you can communicate with other involved health professionals/providers.

– Be kind, encouraging, available and supportive.

– Let a woman know that they are not to blame for their depression.

Supportive Approaches…

• Suggested supportive approaches that can make a difference include….– Engage a woman’s partner or other supportive individuals in the

treatment process (Murray, Cooper, Wilson & Romaniuk, 2003).

– Be aware of your own feelings and responses toward mothers with depression, as those reactions can influence how you

respond to these women (Eastwood, Spielvogel & Wile, 1990).

Ostler, Teresa. Mental Illness in Peripartum Period. Journal of Zero to Three, May 2009, Vol. 29.

No. 5

-CONCLUSIONS-

Conclusions

• Prevalence of depression in women

• Depression is treatable (medication, therapy).

• Women with depression need ongoing support/supportive relationships.

• MIHP can be integral in linking, supporting and reducing barriers to treatment for depression.

-RESOURCES-

Resources

• PSI Postpartum Depression Helpline

1-800-944-4PPD

• National Helpline Network

Referral service links women with PPD to volunteer mentors (women who have overcome PDD).

1-800-PPD-MOMS

Resources

MedEdPPD.orgA professional education, peer-reviewed web site developed with the support of the National Institute of Mental Health (NIMH). The site has two objectives: – To further the education of primary care providers (pediatricians,

family physicians, obstetricians, psychiatrists, nurses, physician's assistants, nurse practitioners, nurse midwives, social workers) who treat women who have or are at risk for postpartum depression (PPD)

– To provide information for women with PPD and their friends and family members. The patient-oriented section of the site, Mothers and Others, contains such features as an easy-to-use online diagnostic test; information about the myths and realities of PPD; experiences of real women with PPD; and answers to frequently asked questions from experts in the field. The Provider Search Directory can help site visitors find a local healthcare professional trained in caring for women with PPD.

www.Mededppd.org Web site in English and Spanish.

Resources

• Improving Maternal & Infant Mental Health: Focus on Maternal Depression. Onunaku N. Los Angeles, CA: National Center for Infant & Early Childhood Health Policy at UCLA; 2005.