What Can MIHP Providers Do?

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1 MIHP Webcast MATERNAL DEPRESSION / STRESS December 1, 2009 What Can MIHP Providers Do? Catherine Kothari Maternal-Child Research, MSU/KCMS (269) (cell) kothari@kcms.msu.edu Mary Ludtke Mental Health Services to Children and Families, MDCH (517) ludtkem@michigan.gov

2 MATERNAL DEPRESSION & STRESS Prevalence Identification Best Practices-Treatment Maximizing Community Resources Kalamazoo Maternal Depression Demonstration Project Impact of Maternal Depression Conclusions Resources

3 -PREVALENCE-

4 Prevalence of Major Depressive Disorder Adult Men: 3.6% (previous 12 months) Adult Women: 6.9% Major (previous 12 months) Depression higher Poverty Minority Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of Major Depressive Disorder. Archives of General Psychiatry. 2005; 62:

5 Prevalence of Major Depressive Disorder Adult Women: 6.9% Major Pregnant Women: 7.5% Major Postpartum (3 mos): 6.5% Major Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of Major Depressive Disorder. Archives of General Psychiatry. 2005; 62: 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-E Rockville MD: Agency for Healthcare Research & Quality. Fegruary 2005.

6 Perinatal Depression ONSET: Three times more likely during postpartum DURATION: About half develop into lifetime conditions 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-E Rockville MD: Agency for Healthcare Research & Quality. Fegruary 2005.

7 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

8 Suicidality o Pregnancy & postpartum periods tend to be protective against suicide & suicidal ideation o Exception: Postpartum Psychosis

9 Suicidal Feelings (n=318, community postpartum sample) Depression n=15% Suicidal Ideation n=11% n=7% n=4%

10 -IDENTIFICATION-

11 Depression & Stress 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

12 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

13 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

15 Follow-up Questions to Assess Suicide Risk 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?

16 -TREATMENT-

17 Best Practices--Treatment Medication Talk Therapy Social Support

18 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

19 Best Practices- Talk Therapy MHP provides up to 20 outpatient visits per year Cognitive Behavioral Therapy Psychotherapy Motivational Interviewing

20 Best Practices- Social Support Alert her family / friends Continue to provide MIHP support Refer to support groups

21 What else can you do? Safety Planning Psychoeducation Ongoing assessment Encourage healthy behaviors (sleeping, eating, exercising) Assess for other stressors & help link to resources

22 -Barriers to Receiving Help- Not identified Lack of community Tx resources Lack of follow-up

23 MOTHER S MIND MATTERS: RECOGNIZING & TREATING PERINATAL MOOD DISORDERS A Kalamazoo County Demonstration Project* *Establishing a Comprehensive System for Identifying and Treating Perinatal Depression is funded by the Blue Cross Blue Shield of Michigan Foundation

24 COMMUNITY-BASED COLLABORATIVE PROJECT Project Leadership: MSU/KCMS Michael Liepman (PI) Catherine Kothari (co-pi) Ruqiya Shama Tareen (co-pi) Project Major Partners: Healthy Babies-Healthy Start, Carmen Sweezy Family & Children Svcs, Phyllis Florian Western Michigan University Ferris State University College of Pharmacy 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

25 MODEL FOR A COMPREHENSIVE SYSTEM OF CARE FOR IDENTIFYING & TREATING PERINATAL DEPRESSION -Shaded areas are elements added through BCBSM Grant- SCREENING TREATMENT CONSULTATION MSU/KCMS Psychiatry Women s Behavioral Health Clinic Postpartum Population... Where: PCP Office When: Postpartum Visit Prenatal Population... Where: PCP Office When: (1) Intake visit (2) 28 or wks Mental Health/Social Service Network -Individual Therapy -Support Groups -Help-line 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 KCMS Psychiatry Women s Behavior Health Clinic PROVIDER EDUCATION COMMUNITY EDUCATION

26 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

27 Change in Provider Behavior-Screening -Preliminary Findings- 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%)

28 Change in Provider Behavior-Treatment -Preliminary Findings- 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)

29 KCMS Psychiatry: Women s Behavioral Health Clinic -Preliminary Findings- 147 Referred by PCPs 133 Eligible 124 Scheduled 81 Treated

30 Mental Health Provider Network & Depression Support Groups -Preliminary Findings- 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

31 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

32 -IMPACT of MATERNAL DEPRESSION-

33 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.

34 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.

35 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.

36 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.

37 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.

38 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).

39 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.

40 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

41 -CONCLUSIONS-

42 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.

43 -RESOURCES-

44 Resources PSI Postpartum Depression Helpline PPD National Helpline Network Referral service links women with PPD to volunteer mentors (women who have overcome PDD) PPD-MOMS

45 Resources MedEdPPD.org A 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. Web site in English and Spanish.

46 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.

Maternal Emotional Wellness Resource Guide

2017 Maternal Emotional Wellness Resource Guide Page 0 Service Providers 2-1-1 is a collaborative effort and we need your partnership. Your agency is responsible to get your information to 2-1-1 and provide