Peripartum Depression: Organizing a Statewide System of Care Laura J. Miller MD Women s Mental Health Program University of Illinois at Chicago
Peripartum depression (PPD) in Illinois In 2001, several tragic deaths from PPD shocked Illinois citizens into action At that time, a task force found only 0.7% of Medicaid-funded new mothers were diagnosed with depression 10-22% would be expected to have PPD
How can a state improve detection, access to treatment & quality of treatment for women with peripartum depression?
Illinois task force findings Screening programs can substantially increase detection of PPD. HOWEVER These programs fail if the health care system cannot serve women who screen positive Mental health resources are too scarce & expensive to serve all women with PPD Conclusion: design systems to support prenatal & primary care providers (PCP s) to assess & treat women with PPD
What can a state do to increase PCP capacity to assess & treat women with PPD? Train providers Give them ready access to screening, assessment & treatment tools Give them ready access to expert consultation Reimburse for screening
The Illinois Perinatal Mental Health Project Provider training workshops Toll-free, statewide Perinatal Mental Health Consultation Service On-line information, screening & assessment tools, treatment guidelines, patient education materials Medicaid reimbursement for screening Quality monitoring guidelines for PCP s
Illinois Perinatal Mental Health Project: provider training Types of workshops Introductory Advanced skills workshops screening & assessment pharmacotherapy mother-infant assessment & intervention Modes of delivery in person teleconference (phone, video, on line) web-based
Illinois Perinatal Mental Health Project: provider workshops Taught at or near clinic site Begins with a needs assessment Baseline participant knowledge gaps: 19% could name a PPD screening tool 12% knew obstetric risks of depression 4% correctly understood FDA risk categories 21% knew a place to find evidence-based information about antidepressants during pregnancy and/or breast-feeding
Illinois Perinatal Mental Health Project: provider training Over 3000 providers trained since 11/04 Provider types: 23% nurses, midwives, medical assistants 16% obstetrician/gynecologists 13% psychiatrists 14% other mental health professionals 10% family physicians 4% pediatricians 2% home visitors
Illinois Perinatal Mental Health Consult Service Staffed by University-based perinatal mental health experts Not a hot-line or crisis line, but 100% of responses within 1 working day 100% reported the information they received was helpful 800-573-6121
Illinois Perinatal Mental Health Consult Service Over 500 consults completed since 10/04 Requests from 17 other states Types of questions: medication: risks, choice of agent, dosing strategies screening: when to screen, which screening tool to choose for different clinic settings risk assessment: risk of harm to baby engaging women in treatment
Peripartum Antidepressant Medication Guide Based on APA Expert Consensus Guidelines & subsequent published data Distributed at all workshops Mailed to HFS providers & ACOG members statewide www.hfsillinois.com/mch/medchart.html
Models for detecting & treating PPD in prenatal/primary care settings Screen & refer Screen all patients refer women who screen positive to mental health services for assessment & treatment Stepped care Screen & assess Identify subset of women to treat on site (e.g. based on severity, complexity) Treat on site ; track treatment response If response is inadequate, refer for mental health care
Screen & refer model for detecting & treating PPD Screening is well accepted by patients Mental health referral is not Example (Carter et al. 2005) 92.5% of women agreed to complete EPDS 30.6% of women who screened positive agreed to see a mental health professional for assessment less than half of those actually attended the assessment only 10% of the women with positive screens ended up receiving treatment
Stepped care model for detecting Reduces stigma and treating PPD Reduces logistical barriers - transportation, time, expense Promotes continuity of care Cost effective General depression stepped care models improve quality of care, patient & provider satisfaction, & depression outcomes (Neumeyer-Groman 2004)
Screening PHQ<5 MDQ negative PHQ 5-19 MDQ negative PHQ>19 and/or MDQ positive Endorses suicidal thoughts No Intervention Assessment Mental Health Referral Urgent Intervention Team evaluation & disposition MDD not confirmed and/or medication not indicated MDD confirmed; medication indicated No intervention, case management or mental health referral per clinical judgment Medication explained and offered Patient accepts 4-week PHQ Patient declines, but accepts mental health referral Patient declines any intervention PHQ>5 and <5 points lower than pre-tretment Mental Health Referral PHQ<5 or at least 5 points lower than pre-tretment 8-week PHQ PHQ>5 and 50% lower than pre-tretment PHQ<5 or at least 50% lower than pre-tretment Mental Health Referral Maintenance treatment
On-site consultation pilot: Perinatal Depression Management Model Alivio Medical Center FQHC; over 16,000 patients per year, over 1200 births per year most patients monolingual Spanish, below 200% poverty level Prior to model 0.4% of women of reproductive age diagnosed with psychiatric disorder After introducing model (March 2005) Screening average: 58% 17% screened positive 76% assessed on site 10% diagnosed with major depression on site Quality Monitoring data guides follow-up training
Statewide support for PPD screening Medicaid reimbursement if either the woman is the primary patient or her baby is the primary patient Approved tools: EPDS, PHQ-9, BDI PPD screening is a quality indicator for Medicaid providers Charts of Medicaid recipients are audited for PPD screening
Illinois: PPD public awareness & support efforts Descent into Desperation documentary about PPD & PPP shown on local public television shown to groups (with discussion) statewide ENH Perinatal Depression Project statewide crisis & referral line, 24/7 PPD-IL Alliance support groups, information
Illinois Perinatal Mental Health Project: how to find us Based at the University of Illinois at Chicago Women s Mental Health Program Toll-free telephone line 1-800-573-6121 Project web site www.psych.uic.edu/clinical/hrsa Key personnel: Project Director (Laura Miller MD) Project Manager (Michele Shade)