Transcript Perinatal Mood and Anxiety Disorders:

Next Steps in Health Policy
Sharon Fickley
GNUR 6056
July 27 th , 2010
 Articulate the percentage of women in industrialized
world who experience postpartum depression
 Recognize challenges facing the U.S. healthcare system
relating to screening, diagnosis, treatment, and future
health policies
 State potential focus areas for future research on
Perinatal Mood Disorders
Perinatal Mood and Anxiety Disorders:
Encompass a variety of psychiatric disorders that occur
during or soon after pregnancy. Include several types
of depression, anxiety, obsessive-compulsive disorder,
and psychosis
(Gaynes, et al., 2005; Postpartum Support International,
accessed on 7/1/10)
Presentation to focus primarily on what has historically
been called postpartum depression.
Postpartum or “Baby” Blues:
 Affects approximately 60-80 % new mothers
 Temporary condition characterized by emotional lability
 Onset usually 1-3 days after delivery, resolution within 2 weeks
Postpartum Psychosis:
 Affects 0.1% - 0.2% women
 Onset generally within 2 weeks of giving birth
 Characterized by hallucinations, paranoia, and mental break from reality
 Medical emergency requiring aggressive treatment and hospitalization
(Baker-Ericzen, Mueggenborg, Hartigan, Howard & Wilke, 2008; Gjerdingen,
Katon, & Rich, 2008; Postpartum Support Virginia, accessed on 7/1/10;
Hearings on Research on Postpartum Depression, 2007)
Postpartum Depression:
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Affects 8% - 20% new mothers in industrialized countries
Prevalence for adolescent mothers higher – 26%-32%
Prevalence statistics vary widely
Onset ranges from 2 weeks – 1 year after giving birth
Contributing factors:
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Difficult labor, delivery, or birth
Difficult Baby
Poor social support
Difficulty breastfeeding
Significant life stressors
Unplanned pregnancy
Unrealistic expectations of motherhood
(Baker-Ericzen et al., 2008; Gjerdingen, Katon, & Rich, 2008; March, 2005; Postpartum
Support Virginia, accessed 7/1/10; Hearings on Research on Postpartum Depression,
2007)
 Less than a college education
 Low socioeconomic status
 Single
 Poor health in mother
 History of intimate partner violence
 Hormonal changes occurring after giving birth
 (Gjerdingen & Yawn, 2007; Goyal, Gay & Lee, 2010; National
Survey for Child and Adolescent Well-Being, Hearings on
Research on Postpartum Depression, 2007)
 Early Head Start Study – high rates of depression in these at-risk
families
(Early Head Start Research and Evaluation Project, 2006)
 Difficult to identify true breadth of problem
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No routine screening
No one tool tested and proven for sensitivity and specificity
Prevalence rates vary widely – when, how, what population assessed
Lack of adequate research to demonstrate treatment outcomes
(American College of Obstetricians and Gynecologists (ACOG), 2010;
Baker-Ericzen, et al., 2008; Gaynes, et al., 2005 )
 Exact causes not known – probably multifaceted
 Biochemical
 Hypothyroid
 Environmental
(Gjerdingen & Yawn, 2007; Postpartum Support Virginia, accessed
7/1/10)
 Barriers to accessing screening and treatment
 Care Delivery Model
 Financial barriers related to insurance coverage
 Stigma
 Concerns regarding medications and breastfeeding
 Patients’ ability and willingness to continue follow-up care
(ACOG, 2008; Baker-Ericzen, et al., 2008; Gjerdingen &Yawn, 2007;
Stowe, Hostetter & Newport, 2005)
 Inadequate systems to accomplish meaningful follow-up care
 Study published in the Journal of the American Medical Association
in 2003 (Kessler) estimated that fewer than 22% of all patients in
general population who are diagnosed with depression receive what
is considered to be adequate care
( Institute for Clinical Systems Improvement, 2008)
Women
 May be unable to care for themselves, their family, and their baby
 Increased risk of relapse & suicide
 Poor quality of life when depressed
(Hearings on Research on Postpartum Depression, 2007)
Families
 Infants of depressed mothers demonstrate: more crying, poor
attachment, less social interaction
 Children of depressed mothers demonstrate: increased aggressive
behaviors, decrease in motor, mental, and language development,
behavior problems, and increased risk for psychiatric illness
(ACOG, 2008; Baker-Ericzen, et al., 2008; National Survey of Child
and Infant Well-Being)
Society
 Unipolar depression is the leading condition in years lost to
disease in both the developed and underdeveloped world
(World Health Organization, 2008)
 As cited in the Agency for Healthcare Research and
Quality’s 2005 report on Perinatal Depression, Kessler
notes that depression is the #1 cause of disease-related
disability in women (Gaynes, et al., 2005)
 Estimates of lost productivity range from $30 - $50 billion
annually in the United States (Gjerdingen & Yawn, 2007)
 U.S. Healthcare and Labor Markets
 U.S. Public Health System
 American College of Obstetricians and Gynecologists
 Health Care Providers – Including Obstetricians,
Pediatricians, Family Physicians, and Nurses
 Insurance Companies
Virginia – House Bill 2310
 2003 - Requires hospital staff and physicians to distribute
information and statistics regarding perinatal depression
United States
 June 2001 - H.R. 20 – Melanie Blocker Stokes Act – first
introduced in the U.S. House of Representatives in Rep.
Bobby Rush (D-IL)
 2001-2009 - Reintroduced multiple times by Rep. Rush
 January 2009 - Introduced in Senate as S. 324, Senator Robert
Mendez (D-NJ)
 March 2010 - Incorporated into the Patient Protection and
Affordable Health Care Act, H.R. 3590
Succinctly stated by Gjerdingen & Yawn:
Depression screening plus ‘high-risk’ feedback to providers
improves the recognition of depression. However, for screening
to positively impact clinical outcomes, it needs to be combined
with systems-based enhanced depression care that provides
accurate diagnosis, strong collaborative relationships between
primary care and mental health providers, and longitudinal case
management, to assure appropriate treatment and follow-up.
(Gjerdingen &Yawn, 2007, p.280)
Women, Families, Consumer
Advocates, Healthcare Providers,
Insurers & Employers
Current Healthcare System,
Research
Health Policy Formation, Evaluation
Revised Delivery System and Models
of Care
 As a result of passage of Healthcare Reform, increased
opportunities for research, pilot projects, evaluation of
local and population-based, community programs
 Increased access to services due to Reform Bill’s emphasis
on Mental Health Services as “essential health benefits”
(H.R. 3590, 2010)
 Research emphasis on:
 Accurate and effective screening tools
 Most beneficial timing and method of screening – both ante
and postpartum
 Accurate diagnosis & effective treatment
 Treatment outcomes
(Stowe, et al., 2005)
 Redesigned models of care – primary-care focused
and modeled after the Medical Home concept
 Use of multi-point opportunities to assess and screen
women for postpartum depression
(Gaynes, et al., 2005; Stowe, et al., 2005)
 July 21st, 2010 - U.S. Department of Health and
Human Services announced that it has “allocated
$88 Million for home visiting programs to improve
the wellbeing of children and families”
(http://www.hhs.gov/news/press/2010pres/07/20100721a
.html, retrieved July 24th, 2010)
 Continue to offer inconsistent screening, diagnosis,
access and follow up
 Will not serve the best interest of any stakeholder in the
long run, due to the clear costs to individuals, families,
and society
 Utilize opportunity provided by H.R. 3590 to design
and carry out research that addresses key questions
surrounding screening, diagnosis & treatment
 This alternative offers the most logical & possibly cost-
effective option, as targeted efforts driven by outcomes
research are likely to decrease costs to all
 Stay informed and involved
 Recognize the signs and symptoms
 Offer guidance
 Address legislators
 Apply for grants
 Design innovative programs that work in local community
 Consider racial, ethnic, cultural, and socioeconomic factors
 Publish!
American College of Obstetricians and Gynecologists. (February 2010). Screening for
depression before and after pregnancy. Committee Opinion Number 453. Obstetrics
Gynecology, 115, 394-5.
American College of Obstetricians and Gynecologists. (April 2008). Use of psychiatric
medications during pregnancy and lactation. ACOG Practice Bulletin Number 92.
Obstetrics Gynecology, 111, 1001-20.
Baker-Ericzen, M.J., Mueggenborg, M.G., Hartigan, P, Howard, N, & Wilke, T. (2008).
Partnership for women’s health: A new-age collaborative program for addressing
maternal depression in the postpartum period. Families, Systems, and Health, 26(1),
30-43. doi:10.1037/1091-7527.26.1.30
Blocker, C. Melanie’s Story. (2003). Retrieved June 8th, 2010 from
http://www.melaniesbattle.org/story.html
Gaynes, B.N., Gavin, N., Meltzer-Brody, S., Lohr, K.N., Swinson, T., Gartlehner, G., . . .
Miller, W.C. (2005). Perinatal depression: Prevalence, screening accuracy, and
screening outcomes. (Summary, Evidence Report/Technology Assessment No. 119).
(Prepared by the RTI-University of North Carolina Evidence Based Practice Center
). Retrieved from Agency for Healthcare Research and Quality
http://www.ahrq.gov/clinic/epcsums/peridepsum.pdf
Gjerdingen, D., Katon, W., & Rich, D. (2008). Stepped care treatment of postpartum
depression: A primary care-based management model. Women’s Health Issues, 18, 44-52.
doi:10.1016/j.whi.2007.09.001
Gjerdingen, D.K., & Yawn, B.P. (2007). Postpartum depression screening: Importance,
methods, barriers, and recommendations for practice. Journal of the American Board of
Family Medicine, 20, 280-88. doi:10.3122/jabfm.2007.03.060171
Goyal, D., Gay, C., & Lee, K. (2010). How much does low socioeconomic status increase the
risk of prenatal and postpartum depressive symptoms in first-time mothers? Women’s
Health Issues, 20, 96-104. doi:10.1016/j.whi.2009.11.003
H. Res. 3590, 111th Congress (2010) (enacted): Summary. Retrieved May 25th,
2010 from http://www.govtrack.us/congress/bill.xpd?bill=h111-3590&tab=summary
Institute for Clinical Systems Improvement. (2008). The DIAMOND initiative: Depression
improvement across Minnesota, offering a new direction (White Paper). Retrieved from
http://www.icsi.org/diamond_white_paper_/diamond_white_paper_28676.html
March, C.L. (2005). The conflicted treatment of postpartum psychosis under
criminal law. William Mitchell Law Review, 32, 243-263. Retrieved from
http://www.wmitchell.edu/lawreview/volume32/issue1/7march.pdf
Melanie Blocker Stokes MOTHERS Act of 2009, H.R. 20, 111th Congress. (2009). Retrieved
May 25th, 2010 from
http://www.govtrack.us/congress/bill.xpd?bill=h111-20
Postpartum Support International. Get the facts: perinatal mood and anxiety disorder
overview. Retrieved from http://www.postpartum.net/Get-the-Facts.aspx
Postpartum Support Virginia. About postpartum depression and pregnancy related mood
disorders. Retrieved from http://www.postpartumva.org/aboutppd.html
Postpartum Support Virginia. Causes of postpartum depression and pregnancy-related
mood disorders. Retrieved from http://www.postpartumva.org/causesriskfactors.html
Research on Postpartum Depression at the National Institute of Mental Health: Hearings
before the Subcommittee on Health, of the House Committee on Energy and Commerce,
111th Congress (2007) (testimony of Catherine Roca, MD, Chief, Women’s Program,
National Institute of Mental Health).
Stowe, Z.N., Hostetter, A.L., & Newport, D.J. (2005). The onset of postpartum depression:
Implications for clinical screening in obstetrical and primary care. American Journal of
Obstetrics and Gynecology, 192, 522-6. doi:10.1016/j.acog.2004.07.054
World Health Organization. (2008). Global burden of disease: 2004 update. Part 3: Disease
incidence, prevalence and disability, 28-36. (ISBN 978 92 4 156371 0 NLM classification: W
74). Retrieved from
http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_part3.
pdf
U.S. Department of Health and Human Services, Administration for Children and
Families.(2006). Depression in the lives of Early Head Start Families: Early Head Start
Research Project. Retrieved from
http://www.acf.hhs.gov/programs/opre/ehs/ehs_resrch/reports/dissemination/research
_briefs/research_brief_depression.pdf
U.S. Department of Health and Human Services, Administration for Children and Families.
National Survey of Child and Adolescent Well-Being. Research Brief No. 13: Depression
among caregivers of young children reported for child maltreatment. Retrieved from
http://www.acf.hhs.gov/programs/opre/abuse_neglect/nscaw/reports/depression_caregi
vers/depression_caregivers.pdf