Peripartum Mood Disorders and Postpartum Depression Screening: For Primary Care Providers Caring for Children in Oregon

Peripartum Mood Disorders and Postpartum Depression Screening: For Primary Care Providers Caring for Children in Oregon

A Project Of The Oregon Pediatric Society Oregon Chapter of the American Academy of Pediatrics (AAP) Sponsored by: Ford Family Foundation Healthy Eastern Oregon Consortium Project an OHA Community Prevention Grant Multnomah Project LAUNCH NW Newborn

DISCLAIMER The Oregon Pediatric Society (OPS), a Chapter of the American Academy of Pediatrics, has no conflict of interest, and is not affiliated with any other organization, vendor or company. Reasonable attempts have been made to provide accurate and complete information. The practitioner or provider is responsible for use of this educational material, and any information provided should not be a substitution for the professional judgment of the practitioner or provider.

CME This event is a joint providership between Bay Area Hospital and the Oregon Pediatric Society. Bay Area Hospital s Continuing Medical Education (CME) Program is accredited by the Oregon Medical Association to sponsor Category 1 medical education activities for physicians. As an accredited institution, Bay Area Hospital s Medical Education Committee designates this live educational activity for a maximum of 1.00 AMA PRA Category 1 Credit(s) Physicians should only claim credit commensurate with the extent of their participation in the activity. Bay Area Hospital fully complies with the legal requirements of the ADA and the rules and regulations thereof. If any participant in this educational activity is in need of accommodation, please call 503-334-1591, x101. OPS Trainers and planners of these events have disclosed they have no financial relationship with a commercial entity producing health-care related products or services.

Goals & Objectives START BASIC IMPROVE postpartum depression screening in pediatric practices ENHANCE provider understanding, utilization, and implementation of standardized screening tools EDUCATE providers in proper documentation, coding, and billing of screening tools BUILD provider awareness of local community resources for evaluation and intervention

AGENDA 1: POSTPARTUM DEPRESSION AND ANXIETY: The Science Behind It & Recommended, Standardized Tools 2: COMMUNITY RESOURCES 3: IMPLEMENTING STANDARDIZED SCREENING In Your Practice Adjourn

PART 1 The Science & Tools OF POSTPARTUM DEPRESSION & ANXIETY SCREENING

Importance of Screening WHY SCREEN MOM DURING WELL-CHILD VISITS? Primary care providers for children see moms early and often. Mom s and father s mental health affects well-being of baby and family. Child s developmental health is directly influenced by early relationship history. Screening new moms for depression can prevent a host of childhood problems.

Oregon by the Numbers 24% 48% 7-8% of women reported that they were depressed during and/or after pregnancy. of those women were still depressed when their child was 2 years old. of adults in Oregon meet the criteria for current depression.

PRAMS: PREGNANCY RISK ASSESSMENT MONITORING SYSTEM Demographic characteristics significantly associated with postpartum depression were: Young maternal age (13.4 % point variance youngest and oldest mothers) Single marital status (9.7% greater) Maternal education (13.6% difference) Medicaid recipient (11% greater) Race/Ethnicity showed lower risk for non-hispanic white compared to other groups.

Behaviors of Depressed Mothers LESS RESPONSIVE TO BABY S CUES AND NEEDS REDUCED EMOTIONAL RANGE REDUCED CARE OF BABY LESS EMPATHY AND INTERACTIVE BEHAVIOR LESS LIKELY TO OBTAIN PREVENTIVE HEALTHCARE FOR BABY

PHYSIOLOGIC IMPACT DUE TO PERINATAL MOOD DISORDERS Increased incidence of premature labor Increased incidence of low birth weight Hypertension Increased cortisol response in infants Increased incidence of drug and alcohol use

Maternal Depression ANXIETY AFFECTS INFANTS Decreased cognitive stimulation and bonding may cause: Irritability Lower activity level Irregular sleep and feeding behaviors Impeded growth during first year of life Lifelong decreased ability to handle stress Difficulty in developing trusting relationships Increased depression, anxiety, and attention deficit

The Still Face Experiment Copyright 2007 ZERO TO THREE http://www.zerotothree.org Ed Tronick (http://www.umb.edu/why_umass/ed_tronick), director of UMass Boston's new Infant-Parent Mental Health Program

MIRROR NEURONS Interaction through relationships builds the foundation of brain development and social emotional capacity. Bruce Perry, Ph.D

RISK FACTORS For Postpartum Depression & Anxiety POVERTY SUBSTANCE ABUSE SLEEP DEPRIVATION IMMIGRANT STATUS DOMESTIC VIOLENCE YOUNG MATERNAL AGE TRAUMATIC EXPERIENCES PREGNANCY COMPLICATIONS HISTORY OF FAMILY DEPRESSION

PROTECTIVE FACTORS Against Poor Outcomes Breastfeeding Child s disposition Routine health events Familial warmth and cohesiveness Support from other family members and community

OVERVIEW OF MATERNAL MOOD DISORDERS Maternal Mood Disorders 50-80% 10-25% <1% Baby Blues Postpartum Depression Postpartum Psychosis Usually resolves without treatment Requires treatment Immediate treatment, may require hospitalization

BABY BLUES Normal condition in postpartum mothers Occurs in 50-80% of new mothers Symptoms include feelings of loss, anxiety, confusion, fear, or being overwhelmed Symptoms peak ~5 days after birth and resolve within a few weeks Does not disrupt function or daily routines

Symptoms of Postpartum Depression & Anxiety (same DSM-5 criteria as major depression) Lack of interest in baby, friends or family Decreased energy and concentration Thoughts of harming self or child Feelings of being a bad mother Changes in appetite and weight Feeling blue and crying Anger and irritability Anxiety and worry Sleep problems

Postpartum Depression and Postpartum Anxiety (PPD and PPA) 10-25% of childbearing women affected. Many women are unable to recognize symptoms of PPD. Negative effects on infant behavior and development. Up to 50% of partners develop PPD, if mother is symptomatic. Occurs any time during first 12 months postpartum. Symptoms persist in half of untreated mothers one year postpartum. Symptoms last from 2 weeks to more than a year.

Postpartum Psychosis Relatively uncommon (1-3 out of 1000 women) Onset as early as one day after delivery, through baby s first year Peak incident of onset is within first month Onset may be abrupt Characterized by hallucinations, paranoia, possible suicidal/infanticidal thoughts Requires immediate treatment and possible hospitalization

Primary Prevention Model Risk factors are known Problem is common Population is known and present Identifying high-risk mothers by screening is inexpensive Screening is also educational Many risk factors are amenable to change Screening leads to appropriate and timely referral

Summary and Conclusions Postpartum depression & anxiety: Is a clinically significant illness that may have long-lasting effects on the well-being of the mother and her family Distinct from baby blues, a normative condition that resolves within a few weeks following birth Is treatable and can be easily screened during well-child visits and routine checkups

Assessment, Treatment & Support CAN prevent long-term negative consequences for infants

When to Screen Screen all mothers Per ABCD Academy Recommendations: 2 weeks and repeat 2 4 months Bright Futures recommendations not set Subsequent screening as needed throughout child s first year of life

Maternal Depression Screening Tools Patient Health Questionnaire (PHQ-2) can be used as prescreener Edinburgh Postnatal Depression Scale (EPDS) is more thorough and includes safety assessment

Recommended Schedule for Standardized Screening Developmental Screening (AAP 2006) 9 months ASQ/PEDS 18 months ASQ/PEDS & M-CHAT R/F 24/30 mo. ASQ/PEDS & M-CHAT R/F 3-5 years ASQ/PEDS as needed Maternal Depression Screening ** (Earls, et.al. 2010) 2 weeks Edinburgh 2 months Edinburgh 4 months as needed 6 mo./ 1 yr. as needed Social-Emotional Screening Recommendations Pending

Patient Health Questionnaire (PHQ-2) A brief two-item standardized tool that screens for parental depression, to be followed up with a more comprehensive screening or in-person evaluation.

PHQ-2 Scoring Less than one minute; self administered or done through interview Over the past two weeks how often have you had little interest or pleasure in doing things? Over the past two weeks how often have you been feeling down, depressed, or hopeless? Answers range 0-3: 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day USE SECONDARY SCREEN IF SCORE IS GREATER THAN 3.

The Edinburgh Postnatal Depression Scale (EPDS) A 10-item Self-Report Questionnaire Identifies depressive symptoms in pregnant women/new mothers Validated cross-culturally Available in 21 languages (Cox & Holden) Can be used throughout the first first At a mean of 12 weeks postpartum, the EPDS had a sensitivity of 100% and specificity of 90% for major depression with a cutoff score of 10

Using EPDS to DETERMINE RISK OF HARM Any patient who scores > 0 on question #10 ( The thought of harming myself has occurred to me ) requires a discussion about potential for immediate harm and referral to: Mental Health Crisis Hotline QMHP for Mental Health Evaluation/Services If imminent self-harm is a concern, patient should not be left alone and should be immediately referred or escorted to Emergency Room.

Edinburgh Postnatal Depression Scale Example: Ima Blue EPDS Screening Tool EPDS instructions for administering and scoring Tool Time : 2 Minutes Score Ima s screening tool Interpret results

EPDS Scoring Response categories are scored: 0, 1, 2, and 3 Items marked with asterisk (*) are reverse scored: 3, 2, 1, and 0 Add all scores for each of the 10 items for the total score Cutoff score is 10

Ima s Score 1. I have been able to laugh and see the funny side of things. 1 2. I have looked forward with enjoyment to things 1 3. * I have blamed myself unnecessarily when things went wrong. 1 4. I have been anxious or worried for no good reason. 2 5. * I have felt scared or panicky for not very good reason. 1 6. * Things have been getting on top of me. 2 7. * I have been so unhappy that I have had difficulty sleeping. 2 8. * I have felt sad or miserable. 2 9. * I have been so unhappy that I have been crying. 2 10. * The thought of harming myself has occurred to me. 0 TOTAL 14

Discussing Screening Results Recognize sensitivity of issue Reinforce how mother s health impacts her child without increasing/promoting feelings of guilt or shame Provide a supportive, non-judgmental environment Consider cultural attitudes toward depression and screening

The Role of the Provider INCREASE awareness & recognition REFER parent to OB or parent s primary care provider (if you aren t already that person) DISCUSS problem with mother s PCP FOLLOW UP with mother and infant sooner than next typical visit OFFER mental health and community resources for parent

Options for Support and Treatment Self Care Social Support Mental Health Referral Medication

Self Care for PPD Encourage simple changes for mother A well-balanced diet Exercise Good sleep habits Stress management Relaxation techniques Suggested Resource: Patient Guide Self-care program for Women with PPD and Anxiety (http://www.bcapop.ca/uploads/9/9/0/1/9901389/reproductivementalhealthselfcareguide.pdf)

Antidepressant Use During Pregnancy and Breastfeeding Believed to be safest: SERTRALINE and FLUOXETINE Both are Pregnancy category C & Lactation category L2 Risk of non treatment needs to be considered

Meds in Pregnancy & Lactation Resources & Consultation LactMed: http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?lact Mass General Women s Health: http://www.womensmentalhealth.org/specialty-clinics/breastfeedingand-psychiatric-medication/ UIC Perinatal Psych Project (Healthcare Provider Consultation Line): 800-573-6121 www.psych.uic.edu/research/perinatalmentalhealth/consultation OTIS: 866-626-OTIS (6847) www.otispregnancy.org MOTHERISK: 877-439-2744 www.motherisk.org/prof/drugs.jsp

Procedure Codes 99420 - Administration and interpretation of health risk assessment instrument Pair with ICD-9 V20.2 if screen normal or 648.42 if abnormal (mental disorders complicating pregnancy childbirth or the puerperium) V79.8 - Special screening for other specified mental disorders and developmental handicaps V61.8 labeled as screening for maternal depression

PART 2 Community PARTNERS & RESOURCES

COMMUNITY RESOURCES & LOCAL SUPPORT Oregon Maternal Mental Health Website www.healthoregon.org/perinatalmentalhealth Information and links to services of Oregon women, families and providers Postpartum Support International (PSI) www.postpartum.net or 1-800-944-4PPD English and Spanish telephone helpline for support and resources 211info Email help@211info.org or text zip code to 898211 or Dial 2-1-1 Free guidance, information and referral Full House Moms http://www.fullhousemoms.com/ Support group for parents of multiples Brief Encounters http://www.briefencounters.org/bewp/ Support group for parents of pregnancy loss or infant loss National Suicide Prevention www.suicidepreventionlifeline.org or 1-800-273-8255 24 hour Lifeline

PART 3 Implementing STANDARDIZED SCREENING IN YOUR PRACTICE

Getting STARTed with Screening Tools Small Steps QUESTIONS: How do you make time for screening? Who administers the screening, scores the tests, and communicates results? Who else needs to be involved in the screening and referral process?

Improvement Methods (from IHI) What are we trying to accomplish? How will we know that a change is an improvement? Act Study Plan Do What changes can we make that will result in improvement?

The PDSA Cycle Act Meet objective Plan What changes are to be made? Develop questions & predictions (why) Next cycle? Create plan to carry out the cycle (who, what, where, when) Complete the analysis of the data Compare data to predictions Carry out the plan Document problems and unexpected observations Study Summarize what was learned Begin analysis of the data Do

Continuous PDSA Cycles ACT PLAN ACT PLAN STUDY DO ACT STUDY PLAN DO STUDY DO Changes that result in improvement Hunches, theories, ideas

PART 4 ADDITIONAL INFORMATION

CME Information This START training is eligible for a maximum of 1.0 hours AMA PRA Category 1 Credit(s) You will receive a START CME completion certificate via email when you complete the follow-up survey

Other START Training Modules ACEs/Trauma-Informed Care Adolescent Depression Screening Adolescent SBIRT with CRAFFT Autism Spectrum Disorders (ASD) 101 Basic Developmental Screening Behavioral Health Integration To schedule a training, please contact Peg King, START Program Manager margaret.king@oraap.org 503-334-1591 x101

To find out more about the Oregon Pediatric Society please visit: www.oraap.org

Thank you.