Incorporating Mental HealthInto Maternal Health: Incorporating Mental Health Into Maternal Health Brian Stafford, MD, MPH Medical Director The Kempe Center’s Postpartum Depression Intervention Program CITYMATCH CONFERENCE Denver, CO Aug, 2007


Outline: Outline Perinatal Mental Health and Mental Illness Barriers to Treatment Public Health’s Role Mental Health’s Role Primary Care’s Role


Perinatal Mental Health: Perinatal Mental Health A developmental crisis A time of increased contact with Medical and Public Health but not necessarily mental health


Pregnancy: Pregnancy High Risk for Medical Complications High Risk for Mental Health Complications


Examples: Examples Most common complications of pregnancy are: Spontaneous Abortion Postpartum Depression Antenatal Depression Diabetes Prematurity Perinatal Loss


Depression: Depression World Health Organization 2020 depression will be 2nd greatest cause of premature death and disability worldwide in both sexes Already number one cause of disease burden in women


Perinatal Mood Disturbance: Perinatal Mood Disturbance Definitions: Antenatal Anxiety Antenatal Depression Postpartum Blues Postpartum Psychosis Postpartum Depression Postpartum PTSD Postpartum Anxiety


“Baby Blues”: “Baby Blues” 50 - 85% of women Hours to days after childbirth lasting up to two weeks Onset typically within 10 days Mild, short-lived: Anger Sense of unworthiness, inadequacy, failure, guilt Crying Irritability/ Impatience Restlessness Sadness Tiredness (fatigue), Insomnia, or both Mood swings


Postpartum Anxiety: Postpartum Anxiety New Onset or Exacerbation Generalized Panic Phobic Social Phobia OCD –like Exacerbation is worse Preoccupation with baby


Postpartum Psychosis: Postpartum Psychosis Rare - Less than 1% of women (1-2/1000) Bipolar Disorder/ Schizophrenia/Schizoaffective Disorder/Psychotic Depression Signs and symptoms even more severe and may occur early (within first 3 months postpartum – usually first 2 weeks) Anger and agitation Insomnia Confusion and disorientation Thoughts of harming self (suicide) or baby (infanticide) Hallucinations and delusions Paranoia Strange thoughts or statements


Postpartum PTSD: Less well understood: Postpartum PTSD: Less well understood Pregnancy and delivery and newborn period is a time of potential trauma Pregnancy Risk to mother Risk to baby Delivery Risk to mother Risk to baby Congenital or other neonatal issue (Anxiety, PTSD, Depression, Grief)


Postpartum Depression (PPD) : Postpartum Depression (PPD) 10 - 20% of women Signs and symptoms more intense and longer lasting Symptoms of baby blues PLUS Emotional numbness, feeling trapped Fear of hurting self or baby Impaired thinking, concentration Lack of joy Less interest in sex Excessive concern/lack of concern for baby Significant weight loss or gain Withdrawal from family and friends “overwhelmed”, “anxious” as common descriptors


Postpartum Depression: Postpartum Depression Not as mild or transient as the blues Not as severely disorienting as psychosis Range of severity Mild to Extreme Impairment The same but different Co-morbidity (Anxiety) Violation of expectation


Major Depressive Episode: Major Depressive Episode Depressed mood Diminished interest or pleasure in everyday activities Insomnia or hypersomnia Significant weight loss or weight gain Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Diminished concentration or indecisiveness Recurrent thought of death, suicidal ideation, or suicide plan Impairment in functioning Five or more of these symptoms present during 2-week period; change in previous functioning Symptoms can not be explained by another condition (substance use, medical condition) or another diagnosis (e.g., Bereavement) (taken from criteria as outlined in DSM-IV)


Prevalence of PPD: Prevalence of PPD 1/8 : average of numerous studies Higher in lower SES and other high-risk groups: Up to 40%


Factors to Consider in Determining Risk: Factors to Consider in Determining Risk Mental Health History (major depression, psychosis) Previous Pregnancy Experience Loss SES Family/ Marital Relationship Childhood Experiences Mood During Pregnancy & Post-Delivery Experience During Pregnancy/ Delivery Infant Variables Multiples Societal/Cultural Influences/ Expectations Risk is Cumulative Additive effects


Protective Factors: Protective Factors Early Recognition and Seeking Help Previous Pregnancy Experience Peer/Marital Support Respite Care Focus on Mother Enhanced feelings of Competence SLEEP $$$$$$$$$


What causes Postpartum Depression?: What causes Postpartum Depression? Hormonal Stress Loss Sleep Untreated anxiety Role transition Support Expectation Own receipt of care Personality features


Qualitative Experience (CT BECK): Qualitative Experience (CT BECK) Violation of an expectation Thief that steals motherhood Horrifying Anxiety Relentless Obsessive Thinking Enveloping Fogginess Death of Self Struggle to Survive Regaining Control


Consequences of Postpartum Depression: Consequences of Postpartum Depression Maternal Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord Somatic Sx Health Care Consequences Less frequent HSV More Urgent Care /ER Ineffective Anticipatory Guidance Behind on immunizations


PPD and Infant Development: PPD and Infant Development PPD directly impacts the infant’s experience and may have longer-term consequences on development Social Emotional Cognitive Language Attention Mother-Infant Relationship/ Interaction


Treatment Approaches: Biological: Treatment Approaches: Biological Biological: Medication: Antidepressants Anti-anxiety Hormone Therapy Estrogen patch Sleep Massage Exercise Sunlight


Treatment Approaches: Psychological: Treatment Approaches: Psychological Psychological Psychotherapies: Cognitive Behavioral Interpersonal Therapy Psychodynamic Supportive Individual Family Group DBT/EMDR


Treatment Approaches: Social: Treatment Approaches: Social Social: Family Friends Church Nurse Visitors


Treatment Approaches: Alternative: Treatment Approaches: Alternative Alternative Narrative Journaling Meditation Art Music


Treatment Approaches: Integrative: Treatment Approaches: Integrative Perspectives: Lead to treatment Bio-Psycho-Social Approach


Treatment Approaches: Treatment Approaches Two general approaches Alleviation of maternal symptoms Improvement of mother-infant relationship Are interventions targeted only at mom enough to protect against negative child outcomes?


Treatment Approaches: Treatment Approaches Studies show that individual therapies may provide significant improvement in maternal mood and stress level Little evidence that such treatments benefit infants of mothers with PPD Lower attachment security status Higher negative affect More internalizing and externalizing problems


Treatment Approaches: Treatment Approaches Are PPD interventions targeted only at mom enough to protect against negative child outcomes?


Dyadic Treatment Approaches: Dyadic Treatment Approaches Concept of PPD as mother-infant relationship disorder (Cramer, 1993) Dyadic therapy as preferred model for PPD treatment Mother-infant relationship as focal point of treatment Goal to increase maternal sensitivity, responsivity, engagement Promote positive attachment behaviors


Dyadic Treatment Approaches: Dyadic Treatment Approaches General Findings Improved child outcomes even when maternal sx don’t improve Buffering effect against future episodes of maternal depression Those infants with dyadic PPD tx more closely resemble infants of non-depressed mothers in terms of cognitive ability


Integrative Approach: Integrative Approach Psychiatric Evaluation Medication Management MITG: Group Therapy Infant Developmental Group Mother’s Group Dyadic (Mother-baby Group) Open Groups Social Support Individual therapy Family Therapy


Step-Wise Interventions: Step-Wise Interventions Not all people need meds Not all moms need individual psychotherapy Not all moms need group psychotherapy Some moms need education and have supportive adaptive environments Some moms need meds Some moms need psychotherapy Some moms need group psychotherapy Some moms need all of the above


Number of Women Treated Front Range Counties: Number of Women Treated Front Range Counties


Who gets treated?: Who gets treated? Mental Health Centers Nurse Home Visiting Kaiser study: 2.8% of women received medication for depression or anxiety in 1 yr past delivery In Colorado? Mostly mid and high SES with support and resources Individual Psychotherapy Psycho-tropics Group


The FACTS:: The FACTS: Postpartum Depression is highly prevalent Postpartum Depression is not time-limited Postpartum Depression is a major risk factor for an infant’s development Postpartum Depression is highly treatable Postpartum Depression does not get treated


Barriers: Barriers Lack of Awareness Lack of Formal Screening Lack of Resources Lack of Training Mental Health Parity Public Awareness Professional Training Satellite Support Groups Mandatory Screening Conference


Barriers to Treatment: Barriers to Treatment Public Awareness Stigma Professional Education System Barriers Resources System Linkages


Barriers To Treatment: Barriers To Treatment Public Awareness and Stigma


The Media’s View: The Media’s View


The Common View of the Postpartum Period: The Common View of the Postpartum Period


The Reality: The Reality Tired Alone at home Most friends are at work Lots of care for baby Little time for self Lack of sleep Overwhelmed


Barriers to Treatment: Barriers to Treatment Professional Training and Practice lack of primary care identification lack of professional awareness of condition lack of expertise in perinatal and infant mental health issues lack of awareness regarding psychopharmacological issues


Barriers to Treatment: Barriers to Treatment Public Health: Screening in WIC Screening in Nurse Visitation Primary Care: Screening at OB Screening at FP Screening at Pediatric


Challenges of Detecting PPD: Challenges of Detecting PPD Symptoms often confused with more typical reactions to childbirth. BE AWARE- these may be indicators of the presence of PPD Depressed mood Lack of pleasure/ interest Feelings of worthlessness/ guilt Agitation or retardation Feelings of worthlessness/ guilt Thoughts of death or suicide Weight loss * Loss of energy * Sleep Disturbance * Diminished concentration/ Indecisiveness * Reports of “overwhelmed”, “anxious” (60% PPD have co-morbid anxiety meeting diagnostic criteria)


Screening for PPD: Screening for PPD Relationship-based? Educate and Normalize PPD Very Common and Very Treatable Include Assessment of Partner


Early Identification Crucial: Early Identification Crucial Need to rule out medical concerns (e.g., thyroid, anemia) Attend to risk factors in prenatal period Routine postnatal screening Observation Interview (ASK and LISTEN) Do not minimize reports of symptoms Consider Timing/ Circumstances Screening: Self-Report Measures CES-D Edinburgh Postnatal Depression Scale (EPDS) Beck Depression Inventory (BDI) Postpartum Depression Predictors Inventory (Beck,1998)


Barriers to Treatment: Barriers to Treatment Perinatal Mental Health Expertise Infant Mental Health Expertise System Issues with MH Access in both the public and private sector


Assessment of Postpartum Mood Disturbance: Assessment of Postpartum Mood Disturbance Empathic and Relationship Based Normalize the overwhelming and frightening experience Subjective Experience Safety Mom and baby Obsessive ruminations versus psychotic preoccupation Assessment of Other Pathology Worries Thoughts Assessment as Intervention


Barriers to Treatment: Barriers to Treatment System Organizational and Infrastructural Unknown referral sources Medicaid funding Institutional barriers Engagement Stigma Phone Centers Transportation Time


Barriers To Treatment: Barriers To Treatment Consumer Awareness and Social Stigma nature and incidence is high (most common side effect of pregnancy) condition is highly treatable institutional stigma other socio-cultural factors


Challenges of Detecting/Treating PPD: Challenges of Detecting/Treating PPD Expected period of adjustment (especially for first-time mothers) Stigma associated with being a “good mother” Fear of “going crazy” or being separated from baby Not knowing which doctor to turn to for help Post-delivery in hospital 6 week OB/GYN visit Well baby checks Physician’s minimization of distress Managed care Mental Health Professional Availability Lack of knowledge / appropriate education


Resources: Resources Kempe Center’s Postpartum Depression Intervention Program: (303-864-5845) Depression After Delivery (800-944-4773) Postpartum Support International (805-967-7636) National Women’s Health Information Center (NWHIC) (800-994-9662) Postpartum Education for Parents (805-564-3888) American College of Obstetricians and Gynecologists (ACOG) (800-762-2264) National Institute of Mental Health (301-496-9576) American Psychological Association (800-374-2721)


Collaboration: Collaboration The nature of these barriers require: specific expertise unique resources and collaborative partnerships.


Our Joint Purpose:: Our Joint Purpose: To target these barriers in a strategic, innovative, collaborative, and evidenced-based/best-practice approach that begins to create clinical expertise in the treatment of perinatal mood disorders in local mental health centers and targets other system barriers toward the identification, referral, and treatment of these individuals.


The anticipated benefits of this project will be as follows:: The anticipated benefits of this project will be as follows: to improve services to low-income and other high-risk women and dyads to improve delivery of perinatal mental health services by community mental health professionals and to link them with infant mental health services to improve primary care surveillance, screening, counseling, and referral to improve access to care in local mental health center programs to educate professionals, organizations, and legislators about the barriers to appropriate identification and treatment


The anticipated benefits:: The anticipated benefits: to adapt an evidence-based intervention to culturally, linguistically, and demographically unique populations to increase community / public awareness of the nature and treatability of perinatal mental illness to increase public health surveillance on perinatal mental illness through collaboration between the BHI, FBH, CDPHE, a 1-800 hotline referral system, and local systems of care to create system linkages by providing evidenced-based education, a public awareness campaign, and other technical support through collaboration with strong and uniquely capable public, private, and non-profit organizations


Methods of Intervention:: Methods of Intervention: The Colorado / Kempe broad strategic plan for targeting perinatal mental illness includes the following 7 methods of intervention: Embedding Perinatal Mental Health Trainers The expansion and adaptation to unique populations of this intervention Consultation to address service provision barriers Education of primary care, mental health, nursing, etc Improved surveillance, reporting, and tracking Public Awareness / Education 7) Advocacy through political lobbying


The creation of system linkages in cooperation with:: The creation of system linkages in cooperation with: primary care prenatal nursing programs public health social services agencies and community mental health


Slide60: Screening by Collaborative Stakeholder: PHQ, EPDS, OTHER Positive Screen Triggers Call Call 1-800 Kempe PPD number 1) Triage 2) Safety ensured 3) Insurance criteria (if any) met 4) Home visit scheduled Engagement visits performed Relationship formed NFP-KEMPE screening assessment: Safety, Impairment Needs Assessment: Life Skills Progression Psychoeducation Referral to Community Services Engagement in Program Evaluate need for psychiatric assessment


Slide61: Home Visits Psychiatric Evaluation: Maternal DX Qualifies for MITG MITG Evaluation: Infant Dx and Relationship DX 2 2hour sessions Does not qualify for MITG Enters MITG Group Completes MITG OPEN PPD GROUP Other MHC resource Other MHC or Community Resources Domestic Violence Substance Abuse Social Phobia Discharge from system


The Science of Preventionand Perinatal Mood Disturbance: The Science of Prevention and Perinatal Mood Disturbance There is no clear evidence to recommend the implementation of antenatal and postnatal classes, early postpartum follow-up, continuity of care models, psychological debriefing in hospital, and interpersonal psychotherapy. There is emerging evidence, however, to support the importance of additional professional support provided postnatally.


Issues: Issues Universal interventions are offered to all women Selective interventions are offered to women at increased risk of developing postnatal depression Indicated interventions are offered to women who have been identified as depressed or probably depressed.


Preventive Services: Preventive Services


Putting all the pieces together: Putting all the pieces together


Thanks for Listening!: Thanks for Listening! Your Thoughts?