CENTER OF EXCELLENCE MATERNAL AND CHILD MENTAL HEALTH (MCMH)

Transcription

1 CENTER OF EXCELLENCE MATERNAL AND CHILD MENTAL HEALTH (MCMH) The infant and young child should experience a warm, intimate, and continuous relationship with his mother in which both find satisfaction and enjoyment". John Bowlby, J. (1951). Maternal Care and Mental Health. Geneva: World Health Organization

2 MISSION Provide state of the art clinical care for caregiver child dyads at UW Medicine and affiliated organizations training for the next generation of health care providers in evidence-based interdisciplinary care for caregiver child dyads research on quality of care for caregiver child dyads in low income settings in the US and abroad Integrate maternal mental health and early child development interventions into maternal and child health programs

3 HIGH RISK MOMS PROGRAM Support from National Institute of Mental Health (NIMH) Public Health - Seattle & King County (PHSKC) Community Health Plan of Washington (CHPW) Private Philantropy 3

4 DEPRESSION IN MOTHERS WHITEFORD ET AL (2013) GLOBBURDDIS LANCET Common 10% of women in pregnancy/postpartum have serious depression Higher rates in high risk moms Consequences Disability Preterm birth & low birth weight Difficult attachment Poor child and adolescent mental health Benefit of Treatment Healthier moms, children, and families AN INVESTMENT IN OUR FUTURE 4

5 Improving Care for Depression Sites: Roosevelt and Harborview Women s Clinics (funded by R01 MH085668, 1K23 MH National Institute of Mental Health) W. Katon, PI, Susan Reed, Jennifer Melville University of Washington Departments of Psychiatry & Behavioral Sciences and Obstetrics & Gynecology

6 DAWN Study Goals Improve care for the two most common depressive disorders: Major depression Dysthymia Target barriers to care Education Engagement Patient care management Physician decision support LaRoccao-Cockburn A. Contemp Clin Trials, 2013

7 Screening and Monitoring Mood PHQ-9: Depression monitoring tool 0 27 range 10 major depression <5 remission 9-item self-report measure Quick and easy for patients Validated specifically in OB/GYN patients

8 DAWN Study Overview Effectiveness study of 205 women in Ob/Gyn clinics at 2 sites randomized Collaborative Care Management Intervention vs. Usual Care Screening Labs: Hct and TSH Day: Baseline 6 mos 12 mos 18 mos INTERVENTION MAINTENANCE PRIMARY OUTCOME SCL-20 depression score change Percentage with 50% improvement

9 Usual Care Arm Brief patient education, including NIMH booklets and local resources Encouragement to seek treatment Provider notification Access to clinic social worker, psychiatry referral and depression medication prescriptions from provider

10 Collaborative Care Intervention Depression Care Managers (MSW) engagement, then closely monitor patients progress (weekly to monthly contact by phone, or in person) Supervision weekly (psychiatry, DCM, OB/GYN) Patients choose their own treatment: Problem Solving Treatment-Primary Care (PST-PC) conducted by DCMs in primary care clinic Antidepressant Medications If no response at 8 wks, augment with PST-PC or medications, refer psychiatry

11 COLLABORATIVE CARE Effective Collaboration PCP supported by DCM Practice Support Informed, Active Patient Outcome Measurement Caseload-focused Consultation 11 Training

12 Problem Solving Treatment Primary Care (PST-PC) Brief and practical skill-building therapy that treats depression by teaching patients how to systematically solve problems of everyday life Common sense can be delivered by trained lay professional Focused on here and now High patient acceptance

13 DCM Case Manager Role Reduce Barriers to Recovery and Care Participation Housing Shelter for DV Referral for medical or other mental health therapy Alanon Legal Aid Transportation

14 SSRIS: OPTIMIZE DOSAGE Therapeutic Starting Fluoxetine mg 10 mg Sertraline mg 25 mg Paroxetine mg 10 mg Citalopram mg 10 mg Fluvoxamine mg 50 mg Escitalopram mg 10 mg

15 DEPRESSION ATTENTION FOR WOMEN NOW STUDY FINDINGS

16 12-mo Intervention 96% of patients had at least one in-person visit Mean # of visits: Antidepressants alone PST alone 12% (n=12) 31% (n=32) Refused 4% (n=4) 53% (n=55) In person Antidepressants and PST Phone Melville JL. Obstet Gynecol, 2014

17 Mean Change in Depressive Sx by Study Group P<0.001 P=0.004 Melville JL. Obstet Gynecol, 2014

18 Response to Treatment 50% Decrease in Depressive Symptoms RR = 1.46 (0.93, 2.28) 57% RR = 1.74 (1.11, 2.73) 62% RR = 1.07 (0.66, 1.74) 34% 37% 33% 43% Melville JL. Obstet Gynecol, 2014

19 Patient Rated Global Improvement Much or Very Much Improved Total N = 205 RR = 2.07 (1.37, 3.11) 78% RR = 1.84 (1.20, 2.82) 74% RR = 1.63 (1.04, 2.55) 35% 53% 37% 43% Melville JL. Obstet Gynecol, 2014

20 Satisfaction with Care Percent Moderately or Very Satisfied RR = 1.70 (1.19, 2.44) RR = 2.26 (1.52, 3.36) 89% 89% 51% 39% Melville JL. Obstet Gynecol, 2014

21 COLLABORATIVE CARE FOR DEPRESSION Team based intervention for depression in primary care Strong evidence base Cochrane review & other meta-analyses >80 RCTs showing benefit Also in obstetric and women s health care settings (Melville et al 2014; Grote et al 2015)

22 MENTAL HEALTH INTEGRATION PROGRAM (MHIP) FOR HIGH RISK MOTHERS 2,500 low-income moms with depression and other mental disorders treated in 6 community health centers (14 community health clinics) from Age range % with thoughts of suicide 35 % with high levels of PTSD symptoms Collaborative Care model adapted for pregnant and parenting women Funded by King County Tax Levy

23 HIGH RATES OF IMPROVEMENT 70 % of Population with Depression Improvement All Latina White Black Asian Huang et al. Family Practice : Outcomes compare to 33 % of moms improved with care as usual. Melville et al, 2014.

24 DEPRESSION IMPROVEMENT BY CLINIC (PHQ-9 <10 OR 50% REDUCTION) 100% 90% 80% 81% 78% 81% 70% 65% 67% 65% 60% 50% 50% 43% 43% 48% 50% 50% 40% 30% 29% 33% 20% 10% 0% Prenatal Clinics (de-identified)

25 COLLABORATIVE CARE TOOLKIT Manual for providers caring for pregnant / postpartum women Information on common behavioral health problems summarized by rapid targeted review Training and information specific to role (Obstetrician, Care manager, Psychiatrist) Common clinical scenarios Guidelines for prescribing antidepressants during pregnancy and lactation Resources

26 COLLABORATIVE CARE IN THE PERINATAL PERIOD

27 UW MEDICINE PERINATAL PSYCHIATRY CLINIC Serves the mental health needs of women during pregnancy and postpartum and in the interconception period Close collaboration with Obstetrics and Pediatrics Attention to mother baby relationship

28 PERINATAL PSYCHIATRY CONSULTATION LINE Any health care provider in Washington State can call the Perinatal Psychiatry Consultation Line with questions regarding mental health problems in patients who are pregnant, in the first year postpartum, or with pregnancyrelated complications. Services provided include telephone consultation, recommendations and referrals.

29 PERINATAL PSYCHIATRY TRAINING Pathway for 3 rd and 4 th year psychiatry residents Goal - to develop the knowledge base and clinical skills of general psychiatry residents in assessment and treatment of psychiatric symptoms during pregnancy, postpartum, and in women wishing to conceive Completion of at least one clinical rotation (maternal infant care clinic, perinatal psychiatry clinic) Regular attendance at pathway meetings Completion of an educational or research project