Transcript Presentation

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
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Perinatal Mental Health and Mental Illness
Barriers to Treatment
Public Health’s Role
Mental Health’s Role
Primary Care’s Role
CITYMATCH, 2007
Brian Stafford, MD, MPH
Perinatal Mental Health
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A developmental crisis
A time of increased contact with
Medical and Public Health
but not necessarily mental health
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Brian Stafford, MD, MPH
Pregnancy
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High Risk for Medical Complications
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High Risk for Mental Health Complications
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Brian Stafford, MD, MPH
Examples
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Most common complications of pregnancy
are:
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Spontaneous Abortion
Postpartum Depression
Antenatal Depression
Diabetes
Prematurity
Perinatal Loss
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Brian Stafford, MD, MPH
Depression
World Health Organization
• 2020
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depression will be 2nd greatest cause of
premature death and disability worldwide in
both sexes
• Already
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number one cause of disease burden in
women
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Brian Stafford, MD, MPH
Perinatal Mood Disturbance
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Definitions:
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Antenatal Anxiety
Antenatal Depression
Postpartum Blues
Postpartum Psychosis
Postpartum Depression
Postpartum PTSD
Postpartum Anxiety
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Brian Stafford, MD, MPH
“Baby Blues”
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50 - 85% of women
Hours to days after childbirth lasting up to two
weeks
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Onset typically within 10 days
Mild, short-lived:
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Anger
Sense of unworthiness, inadequacy, failure, guilt
Crying
Irritability/ Impatience
Restlessness
Sadness
Tiredness (fatigue), Insomnia, or both
Mood swings
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Brian Stafford, MD, MPH
Postpartum Anxiety
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New Onset or Exacerbation
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Generalized
Panic
Phobic
Social Phobia
OCD –like
Exacerbation is worse
 Preoccupation with baby
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Brian Stafford, MD, MPH
Postpartum Psychosis
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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)
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Anger and agitation
Insomnia
Confusion and disorientation
Thoughts of harming self (suicide) or baby (infanticide)
Hallucinations and delusions
Paranoia
Strange thoughts or statements
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Brian Stafford, MD, MPH
Postpartum PTSD:
Less well understood
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Pregnancy and delivery and newborn
period is a time of potential trauma
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Pregnancy
Risk to mother
 Risk to baby
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Delivery
Risk to mother
 Risk to baby
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Congenital or other neonatal issue
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(Anxiety, PTSD, Depression, Grief)
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Brian Stafford, MD, MPH
Postpartum Depression
(PPD)
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10 - 20% of women
Signs and symptoms more intense and longer lasting
Symptoms of baby blues
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Emotional numbness, feeling trapped
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Fear of hurting self or baby
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Impaired thinking, concentration
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Lack of joy
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Less interest in sex
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Excessive concern/lack of concern for baby
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Significant weight loss or gain
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Withdrawal from family and friends
“overwhelmed”, “anxious” as common descriptors
Brian Stafford, MD, MPH
Postpartum Depression
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Not as mild or transient
as the blues
Not as severely
disorienting as psychosis
Range of severity
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Mild to Extreme
Impairment
The same but different
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Co-morbidity (Anxiety)
Violation of expectation
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Major Depressive Episode
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Depressed mood
Diminished interest or pleasure in everyday activities
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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)
CITYMATCH, 2007
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Prevalence of PPD
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1/8 : average of
numerous studies
Higher in lower SES
and other high-risk
groups:
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Up to 40%
CITYMATCH, 2007
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Factors to Consider in
Determining Risk
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Risk is Cumulative
Additive effects
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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
Brian Stafford, MD, MPH
Protective Factors
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Early Recognition and Seeking
Help
Previous Pregnancy Experience
Peer/Marital Support
Respite Care
Focus on Mother
Enhanced feelings of
Competence
SLEEP $$$$$$$$$
Brian Stafford, MD, MPH
What causes Postpartum
Depression?
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Hormonal
Stress
Loss
Sleep
Untreated anxiety
Role transition
Support
Expectation
Own receipt of care
Personality features
CITYMATCH, 2007
Brian Stafford, MD, MPH
Qualitative Experience
(CT BECK)
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Violation of an expectation
Thief that steals motherhood
Horrifying Anxiety
Relentless Obsessive Thinking
Enveloping Fogginess
Death of Self
Struggle to Survive
Regaining Control
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Brian Stafford, MD, MPH
Consequences of
Postpartum Depression
Maternal
Consequences
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Suffering
Lack of joy in child
Missed work
Suicide attempts
Social Impairment
Marital discord
Somatic Sx
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Health Care
Consequences
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Less frequent HSV
More Urgent Care /ER
Ineffective Anticipatory
Guidance
Behind on
immunizations
Brian Stafford, MD, MPH
PPD and Infant
Development
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PPD directly impacts the infant’s
experience and may have longerterm consequences on development
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Social
Emotional
Cognitive
Language
Attention
Mother-Infant Relationship/
Interaction
Brian Stafford, MD, MPH
Treatment Approaches:
Biological
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Biological:
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Medication:
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Hormone Therapy
Estrogen patch
Sleep
Massage
Exercise
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Sunlight
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Antidepressants
Anti-anxiety
Brian Stafford, MD, MPH
Treatment Approaches:
Psychological
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Psychological
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Psychotherapies:
Cognitive Behavioral
 Interpersonal Therapy
 Psychodynamic
 Supportive Individual
 Family
 Group
 DBT/EMDR
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Brian Stafford, MD, MPH
Treatment Approaches:
Social
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Social:
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Family
Friends
Church
Nurse Visitors
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Treatment Approaches:
Alternative
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Alternative
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Narrative Journaling
Meditation
Art
Music
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Treatment Approaches:
Integrative
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Perspectives:
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Lead to treatment
Bio-Psycho-Social Approach
CITYMATCH, 2007
Brian Stafford, MD, MPH
Treatment Approaches
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Two general approaches
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Alleviation of maternal symptoms
Improvement of mother-infant
relationship
Are interventions targeted only
at mom enough to protect
against negative child
outcomes?
Brian Stafford, MD, MPH
Treatment Approaches
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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
Brian Stafford, MD, MPH
Treatment Approaches
Are PPD interventions
targeted only at mom
enough to protect against
negative child outcomes?
CITYMATCH, 2007
Brian Stafford, MD, MPH
Dyadic Treatment
Approaches
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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
Brian Stafford, MD, MPH
Dyadic Treatment
Approaches
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General Findings
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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
Brian Stafford, MD, MPH
Integrative Approach
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Psychiatric Evaluation
Medication
Management
MITG: Group Therapy
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Open Groups
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Social Support
Individual therapy
Family Therapy
Infant Developmental
Group
Mother’s Group
Dyadic (Mother-baby
Group)
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Brian Stafford, MD, MPH
Step-Wise Interventions
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Not all people need
meds
Not all moms need
individual
psychotherapy
Not all moms need
group psychotherapy
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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
Brian Stafford, MD, MPH
Number of Women Treated
Front Range Counties
County
Live Births 2004
Estimated Depressed
(12%)
Denver
10,438
1300
Colorado*
68,000
8160
Number Treated
CITYMATCH, 2007
300
Brian Stafford, MD, MPH
Who gets treated?
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Mental Health Centers
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Nurse Home Visiting
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Kaiser study:
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2.8% of women
received medication
for depression or
anxiety in 1 yr past
delivery
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In Colorado?
Mostly mid and high
SES with support and
resources
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Individual
Psychotherapy
Psycho-tropics
Group
Brian Stafford, MD, MPH
The FACTS:
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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
CITYMATCH, 2007
Brian Stafford, MD, MPH
Barriers
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Lack of Awareness
Lack of Formal
Screening
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Public Awareness
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Professional Training
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Lack of Resources
Satellite Support
Groups
Lack of Training
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Mandatory Screening
Mental Health Parity
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Conference
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Brian Stafford, MD, MPH
Barriers to Treatment
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Public Awareness
Stigma
Professional Education
System Barriers
Resources
System Linkages
CITYMATCH, 2007
Brian Stafford, MD, MPH
Barriers To Treatment
Public
Awareness
and Stigma
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Brian Stafford, MD, MPH
The Media’s View
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Brian Stafford, MD, MPH
The Common View of the
Postpartum Period
CITYMATCH, 2007
Brian Stafford, MD, MPH
The Reality
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Tired
Alone at home
Most friends are at
work
Lots of care for baby
Little time for self
Lack of sleep
Overwhelmed
CITYMATCH, 2007
Brian Stafford, MD, MPH
Barriers to Treatment
Professional Training and Practice
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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
CITYMATCH, 2007
Brian Stafford, MD, MPH
Barriers to Treatment
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Public Health:
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Screening in WIC
Screening in Nurse Visitation
Primary Care:
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Screening at OB
Screening at FP
Screening at Pediatric
CITYMATCH, 2007
Brian Stafford, MD, MPH
Challenges of Detecting PPD
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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”
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(60% PPD have co-morbid anxiety
meeting diagnostic criteria)
Symptoms often confused
with more typical reactions
to childbirth. BE AWAREthese may be indicators of
the presence of PPD
Brian Stafford, MD, MPH
Screening for PPD
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Relationship-based?
Educate and Normalize
PPD
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Very Common and Very
Treatable
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Include Assessment of
Partner
CITYMATCH, 2007
Brian Stafford, MD, MPH
Early Identification Crucial
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Need to rule out medical concerns (e.g., thyroid, anemia)
Attend to risk factors in prenatal period
Routine postnatal screening
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Observation
Interview (ASK and LISTEN)
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Do not minimize reports of symptoms
Consider Timing/ Circumstances
Screening:
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Self-Report Measures
• CES-D
• Edinburgh Postnatal Depression Scale (EPDS)
• Beck Depression Inventory (BDI)
• Postpartum Depression Predictors Inventory (Beck,1998)
Brian Stafford, MD, MPH
Barriers to Treatment
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Perinatal Mental Health Expertise
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Infant Mental Health Expertise
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System Issues with MH Access in both the
public and private sector
CITYMATCH, 2007
Brian Stafford, MD, MPH
Assessment of Postpartum
Mood Disturbance
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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
CITYMATCH, 2007
Brian Stafford, MD, MPH
Barriers to Treatment
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System Organizational and Infrastructural
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Unknown referral sources
Medicaid funding
Institutional barriers
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Engagement
Stigma
Phone Centers
Transportation
Time
Brian Stafford, MD, MPH
Barriers To Treatment
Consumer Awareness and
Social Stigma
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nature and incidence is high
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(most common side effect of pregnancy)
condition is highly treatable
institutional stigma
other socio-cultural factors
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Brian Stafford, MD, MPH
Challenges of
Detecting/Treating PPD
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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
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Post-delivery in hospital
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6 week OB/GYN visit
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Well baby checks
Physician’s minimization of distress
Managed care
Mental Health Professional Availability
Lack of knowledge / appropriate education
Brian Stafford, MD, MPH
Resources
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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)
Brian Stafford, MD, MPH
Collaboration
The nature of these barriers require:
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specific expertise
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unique resources
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and collaborative partnerships.
CITYMATCH, 2007
Brian Stafford, MD, MPH
Our Joint Purpose:
To target these barriers in a strategic,
innovative, collaborative, and evidencedbased/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.
CITYMATCH, 2007
Brian Stafford, MD, MPH
The anticipated benefits of this
project will be as follows:
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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
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to improve primary care surveillance, screening, counseling, and referral
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to improve access to care in local mental health center programs
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to educate professionals, organizations, and legislators about the
barriers to appropriate identification and treatment
CITYMATCH, 2007
Brian Stafford, MD, MPH
The anticipated benefits:
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to adapt an evidence-based intervention to culturally,
linguistically, and demographically unique populations
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to increase community / public awareness of the nature and
treatability of perinatal mental illness
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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
CITYMATCH, 2007
Brian Stafford, MD, MPH
Methods of Intervention:
The Colorado / Kempe broad strategic plan for targeting perinatal mental illness
includes the following 7 methods of intervention:
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Embedding Perinatal Mental Health Trainers
The expansion and adaptation to unique populations of this
intervention
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Consultation to address service provision barriers
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Education of primary care, mental health, nursing, etc
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Improved surveillance, reporting, and tracking
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Public Awareness / Education
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Advocacy through political lobbying
CITYMATCH, 2007
Brian Stafford, MD, MPH
The creation of system linkages in
cooperation with:
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primary care
prenatal nursing programs
public health
social services agencies
and community mental health
CITYMATCH, 2007
Brian Stafford, MD, MPH
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
CITYMATCH, 2007
Brian Stafford, MD, MPH
Home Visits
Psychiatric Evaluation: Maternal DX
Qualifies for MITG
MITG Evaluation: Infant Dx
and Relationship DX
2 2hour sessions
Enters MITG Group
Completes MITG
Does not qualify
for MITG
Other MHC or Community Resources
Domestic Violence
Substance Abuse
Social Phobia
OPEN PPD GROUP
Other MHC resource
Discharge from system
CITYMATCH, 2007
Brian Stafford, MD, MPH
The Science of Prevention
and Perinatal Mood Disturbance
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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.
CITYMATCH, 2007
Brian Stafford, MD, MPH
Issues
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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.
CITYMATCH, 2007
Brian Stafford, MD, MPH
Preventive Services
Indicated:
Depressed During Pregnancy
Targeted:
Multiple Risk Factors
Universal:
All women
CITYMATCH, 2007
Brian Stafford, MD, MPH
State-level Coordination,
Collaboration, Planning,
Funding and Advocacy
Local-level Coordination,
Collaboration, Planning,
Funding and Advocacy
Universal/Preventive Services
Health & Developmental Screening & Assessment
Case Management
Parenting Education
Provision of Care
Focused Services
Promotion
for At-Risk Children & Families
Referral
Risk-specific Assessment
Intervention
Education
Promotion
Referral
Tertiary Intervention Services
Direct Infant Mental Health Services
Diagnostic Assessment
Consultation
&
Referral
Treatment for Parent & Child
Promotion
CITYMATCH, 2007
Brian Stafford, MD, MPH
Putting all the pieces together
Legislative
Advocacy
Mental Health
Expertise
Public Awareness
Primary Care
Public Health Screening
System
Linkages
CITYMATCH, 2007
Brian Stafford, MD, MPH
Thanks for Listening!
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Your Thoughts?
CITYMATCH, 2007
Brian Stafford, MD, MPH