WHY THE POSTPARTUM DEPRESSION PROJECT MATERNAL DEPRESSION ESPECIALLY

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 -5 c) 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 • • 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 • • • 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. SCORING Questions 1, 2, and 4 Yes, most of the time 0 -3 in ascending order Yes, sometimes No, not much All other questions No, not at all 0 -3 in descending order 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

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 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** Illinois** New York* Washington** Texas Maine* California Pennsylvania (Title V funds) New Hampshire Indiana (grant) Maryland (HRSA funding) Minnesota West Virginia** Colorado (Title 5 grant) Iowa (HRSA fund) Massachusetts (HRSA grant) Minnesota* Utah (state funds) Oregon Virginia (Federal grant) Ohio Kentucky (HRSA grant) **Legislated fully funded *legislature

Maine LD 792 123 rd 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 LD 792 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 -800 PPD-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: plopsymd@myfairpoint. net 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