Transcript WHY THE POSTPARTUM DEPRESSION PROJECT?

WHY THE POSTPARTUM
DEPRESSION PROJECT?
MATERNAL DEPRESSION,
ESPECIALLY PERINATAL
DEPRESSION, IS A PUBLIC HEALTH
PROBLEM
PPD as a Public Health Problem
• Major public health concern
– Objective of Healthy People 2010 (Objective 16-5c) as well as an
area of focus for Healthy Start Initiative Grants (US Department
HHS, MCH Bureau).
• Depression is the leading cause of disease-related disability among
women (Kessler 2003)
• One of every 8 new mothers experience depression
– Nearly 4 million women give birth in America; therefore, half a
million women will suffer postpartum depression each year
– Most common complication of childbearing
• “Depression is a communicable disease between mother and
child.”
• Serious and lasting effects on child health and family functioning
Wisner K et al. N Engl J Med. 2002;347:194-199;
Wisner K et al. J Clin Psychiatry. 2001;62:82-86.
DEPRESSION DURING PREGNANCY
• Between 10-20% of women will
experience significant
depression during pregnancy
• This will be a first episode for
one third
SIGNIFICANCE
Untreated depression during
pregnancy is associated with
serious risks for mother and
her baby.
RISKS OF UNTREATED DEPRESSION
DURING PREGNANCY
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Premature delivery
Low birth weight
More likely to be colicky, irritable babies
Poor compliance with prenatal care
Poor nutrition
Lower APGAR scores
Increased rate of stillborns (six times in one study)
Increased admissions to neonatal ICU
RISKS OF UNTREATED DEPRESSION
DURING PREGNANCY
•Higher rates of miscarriage
•Higher risk of bleeding
•More painful labor and higher use
of analgesia
•Increased alcohol and tobacco use
•SUICIDE
•POSTPARTUM DEPRESSION
•Recurrent Major depressions
THE MOST COMMON
COMPLICATION OF
CHILDBIRTH IS
DEPRESSION
70
Epidemiology of
Postpartum Episodes
Admissions/Month
60
50
40
30
20
Pregnancy
10
0
–2 Years
– 1 Year
Childbirth
+1 Year
+2 Years
Kendell RE et al. Br J Psychiatry. 1987;150:662-673.
Postpartum Depression
Peak lifetime prevalence for
psychiatric disorders and
hospital admissions for women
occurs in the first 3 months after
childbirth (Kendall et al, 1981,
1987)
Duration of PPD
Untreated depression often persists for months to
years after childbirth, with lingering effects on
physical and psychological functioning following
recovery from depressive episodes (England, Ballard
& George, 1994).
– 25%-50% women have episodes lasting 7 months
or longer (O’Hara, 1987).
– The most significant factor in the duration of PPD
is delay in receiving treatment (England, Ballard
& George, 1994).
Risks of Untreated PPD
To mother:
• Stressful impact on relationship between woman and her
partner.
• Suicidal thoughts more likely to be accompanied by
homicidal thoughts
• Kindling phenomenon---development of a chronic low
grade depression with more susceptibility to repeated
episodes of MDD
• Severe postpartum psychiatric disorder is associated with a
high rate of death from natural and unnatural causes,
particularly suicide
• Suicide risk in the first postnatal year is increased 70-fold
Risks of Untreated PPD
To child:
• Poor weight gain
• Sleep problems
• Less breastfeeding-depressed mothers more likely
to discontinue breastfeeding
• Impaired mother infant interactions leading to poor
attachment
• Impaired maternal health and safety practices
Risks of Untreated PPD
Attuned infant-caregiver interactions promote
brain neurological “wiring”.
• Future , hyperactivity, conduct disorders and
school behavior problems
• Delays in language and social development
• Increased risk of depression
• Maternal depression is an “Adverse childhood
experience” ACE, often it is not the only
adversity
MATERNAL POST PARTUM
MOOD IS ONE OF THE
STRONGEST PREDICTORS OF
NEUROCOGNITIVE
DEVELOPMENT IN CHILDREN
MEASURED UP TO AGE SIX
Perinatal depression has a significant impact
on the current and future health of mother
and child and stresses the functioning of the
family.
TREATMENT OF DEPRESSION IN
THE MOTHER IS AN EARLY
INTERVENTION OR PREVENTION
FOR THE CHILD
Need for Patient Education
• Lack of knowledge about PPD, treatment options, and
community resources is common in postpartum women and
their families, and frequently leads to delay in seeking
treatment
• Delay in treatment for PPD results in a longer illness
• Information about PPD should be provided to women in the
prenatal period, soon after delivery, and further encounters
with healthcare providers in the first postpartum year.
SCREENING FOR PERINATAL DEPRESSION
• Postpartum depression is often not recognized
• Despite the availability of validated screening
tools, PPD remains under diagnosed
• Absence of screening often means untreated
depression and poor outcomes for the mother, her
newborn, and family
• Postpartum depression can be screened for with
simple and validated screening tools
• It is possible to screen for antenatal depression
Validated Screening Tools
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EPDS- Edinburgh postnatal Depression Screen
PHQ-9 Patient Health Questionnaire
PHQ-2
PPDS Postpartum Depression Scale
Beck Depression Inventory-II Center for
Epidemiological Studies-Depression Scale
(CES-D)
PHQ-2
Over the past two weeks, how often have you been bothered by any of the following
problems?
Little interest or pleasure in doing things:
0 –Not at all
1—Several days
2—More than half the days
3—Nearly every day
Having little interest or pleasure in doing things:
0 –Not at all
1—Several days
2—More than half the days
3—Nearly every day
NAME______________________________________________DATE______________
The Edinburgh Postnatal Depression Scale (EDPS) was developed in 1987 to help doctors determine whether a
mother may be suffering from postpartum depression. The scale has since been validated, and evidence
from a number of research studies has confirmed the tool to be both reliable and sensitive in detecting
depression. During the postpartum period, 10 to 15% of women develop significant symptoms of
depression or anxiety. Unfortunately, many moms are never treated, and although they may be coping,
their enjoyment of life and family dynamics may be seriously affected
Please UNDERLINE the answer that comes closest to how you have felt in the last seven days, not just how you
are feeling today.
1. I have been able to laugh and see the funny side of things.
As much as I always could
Not so much now
Definitely not so much now
Not at all
2. I have looked forward with enjoyment to things.
As much as I always could
Not so much now
Definitely not so much now
Not at all
3. I have blamed myself unnecessarily when things went wrong.
Yes, most of the time
Yes, some of the time
Not very often
No, never
4. I have been anxious or worried for no good reason.
No, not at all
Hardly ever
Yes, sometimes
Yes, very often
5. I have felt scared or panicky for not very good reason.
Yes, quite a lot
Yes, sometimes
No, not much
No, not at all
6. Things have been overwhelming me.
Yes, most of the time I haven’t been able to cope at all
Yes, sometimes I haven’t been coping as well as usual
No, most of the time I have coped quite well
No, I have been coping as well as ever
7. I have been so unhappy I have had difficulty sleeping.
Yes, most of the time
Yes, sometimes
No, not much
No, not at all
8. I have felt sad or miserable.
Yes, most of the time
Yes, sometimes
No, not much
No, not at all
9. I have been so unhappy that I have been crying.
Yes, most of the time
Yes, sometimes
No, not much
No, not at all
10. The thought of harming myself has occurred to me.
Yes, quite often
Sometimes
Hardly ever
Never
Adapted from the Edinburgh Postnatal Depression Scale taken from The British Journal of Psychiatry, June, 1987, Vol. 150, by J. L. Cox, J. M.
Holden, R. Sagovsky
SCORING
Questions 1,2, and 4
0-3 in ascending order
All other questions
0-3 in descending order
Perinatal Depression Screening
•
Antenatal early risk assessment and screening during pregnancy.
ACOG recommends the PHQ-2 once per trimester
•
If at high risk (prior history, neonatal loss, obstetrical complications, etc):
Upon discharge from hospital. Need to assess support plan post
discharge
Visiting nurse follow-up visit a good time
•
At postpartum visit with OB/Midwife
At early (2 week) follow up appointment if high risk
At routine 6-7 week visit
•
Well-child visit is an ideal time to look for signs of PPD in the mother (See
pediatric provider frequently first year) The American Academy of Pediatrics
recommends "routine, brief, maternal depression screening conducted during
well-child visits”
•
Other possibilities are visiting nurse visits, lactation consultants
Obstacles to Screening
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Lack of time
Lack of familiarity with screening tools
Lack of protocols for positive screen
Lack of easy assess to mental health
resources
• Lack of reimbursement
Obstacles to Treatment
For women:
• Stigma
• Shame
• Fear of losing children
• Fear of medication
• Over half of women referred to mental health
services do not get there
Obstacles to Treatment
For providers:
• Lack of easy access to mental health referral
resources
• Discomfort with prescribing
• “Safer” not to treat with medication
• Lack of access to psychiatric resources
• Lack of clear treatment guidelines
• Lack of collaboration
APA/ACOG Guidelines
The Management of Depression During
Pregnancy: A Report from the American
Psychiatric Association and The American
College of Obstetricians and Gynecologists,”
Obstetrics & Gynecology (September 2009) and
General Hospital Psychiatry
(September/October 2009).
GOALS OF THIS
PROJECT
EDUCATION
• Medical providers
• Patients and their families
• Mental health providers,
especially crisis workers
• Pharmacists
PROMOTING SCREENING
• ACCESS TO SCREENING TOOLS
• ALGORITHMS FOR WORKING WITH
THEM
• AWARENESS AT THE OFFICE STAFF LEVEL
• MODEL FOR CREATING A LOCAL MENTAL
HEALTH REFERRAL RESOURCE
• FUNDING FOR SCREENING………
IMPROVING TREATMENT THROUGH
COLLABORATION
• Recognition that most treatment is not done in
a psychiatrists office
• Make resources available through easy access
to information and informal psychiatric
consultation , i.e MAPP’s Consultation Project
• Ideal would full integration of care
Ideal Outcome
• Screen all pregnant and postpartum women for depression using a standard
tool.
• Providers would work as a team including those who are specifically
knowledgeable about psychiatric illness during pregnancy, particularly for
women with recurrent, severe or complex disease
• Nonpharmacologic treatment options such as psychotherapy, support
groups, and other community resources would be identified and included
whenever possible
•
Risks of psychotropic medications would be weighed against the risks of
untreated psychiatric disease, recognizing that untreated psychiatric illness
can have significant adverse effects
• Recognition that pharmacotherapy for some women with moderate or
severe disease may be the most appropriate treatment to treat the disorder
and prevent relapse
EDUCATION
• Administrators
• Insurance companies
• Lawmakers
Melanie Blocker Stokes MOTHERS Act
• The Mom’s Opportunity To Access Help, Education,
Research, and Support for Postpartum Depression
Act.
• increase education through national public
awareness
• access to screenings for new mothers
• to increase research
• grants to health care providers to facilitate the
delivery of treatment
• No mandated screening or treatment, not driven by
the pharmaceutical industry
Melanie Blocker Stokes MOTHERS Act
Some of the supporting organizations:
• American Psychological Association
• American College of Obstetricians and Gynecologists
• Postpartum Support International
• American Psychiatric Association
• Children's Defense Fund
• Association of Women's Health, Obstetric and Neonatal
Nurses
• March of Dimes
• American College of Nurse Midwives
• National Alliance on Mental Illness
• Association of Maternal and Child Health Programs
• National Partnership for Women & Families
• National Women's Law Center
PPD and State Programs
New Jersey**
New York*
Texas
California
New Hampshire
Maryland (HRSA funding)
West Virginia**
Iowa (HRSA fund)
Minnesota*
Oregon
Ohio
**Legislated fully funded
Illinois**
Washington**
Maine*
Pennsylvania (Title V funds)
Indiana (grant)
Minnesota
Colorado (Title 5 grant)
Massachusetts (HRSA grant)
Utah (state funds)
Virginia (Federal grant)
Kentucky (HRSA grant)
*legislature
Maine LD 792 123rd Legislature, 2006
An Act Concerning Postpartum Mental Health Education
• 3 FQHC piloted screening with the PHQ-9
1/8 were positive
easier than expected
have integrated mental health care
• Barriers to screening, treatment and integration
• Other state programs
• Recommendations for screening, treatment, data
collection, resources
Google Maine LD792 to see the report
WEB RESOURCES
www.womensmentalhealth.org MGH Center for Women’s
mental Health
www.postpartum.net Postpartum Support International
Crisis hotline for postpartum depression and psychosis: 1-800PPD-MOMS
www.mededppd.org NIMH supported website
Excellent resource, regularly updated
9 educational modules aimed at different provider categories
offering CME’s
Soon…….
www.mainepsych.org MAPP’s website will have the screening
tools and algorithms, medication information resources, etc
For more information,
resources,
to get involved:
[email protected]
Subject line: MAPP PPD Project
“A small group of thoughtful
people could change the
world. Indeed,
it's the only thing that ever
has.”
Margaret Mead