2 MATERNAL DEPRESSION, ESPECIALLY PERINATAL DEPRESSION, IS A PUBLIC HEALTH PROBLEM
3 PPD as a Public Health Problem Major public health concernObjective 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 depressionNearly 4 million women give birth in America; therefore, half a million women will suffer postpartum depression each yearMost common complication of childbearing“Depression is a communicable disease between mother and child.”Serious and lasting effects on child health and family functioningWisner K et al. N Engl J Med. 2002;347: ;Wisner K et al. J Clin Psychiatry. 2001;62:82-86.
4 DEPRESSION DURING PREGNANCY Between 10-20% of women will experience significant depression during pregnancyThis will be a first episode for one third
5 SIGNIFICANCE Untreated depression during pregnancy is associated with serious risks for mother andher baby.
6 RISKS OF UNTREATED DEPRESSION DURING PREGNANCY Premature deliveryLow birth weightMore likely to be colicky, irritable babiesPoor compliance with prenatal carePoor nutritionLower APGAR scoresIncreased rate of stillborns (six times in one study)Increased admissions to neonatal ICUObstetrical risks, neonatal risks, parenting challenges
7 RISKS OF UNTREATED DEPRESSION DURING PREGNANCY Higher rates of miscarriageHigher risk of bleedingMore painful labor and higher use of analgesiaIncreased alcohol and tobacco useSUICIDEPOSTPARTUM DEPRESSIONRecurrent Major depressionsHealth risks, future mental health risks,
8 THE MOST COMMON COMPLICATION OF CHILDBIRTH IS DEPRESSION
9 Epidemiology of Postpartum Episodes 10203040506070Admissions/MonthPregnancy–2 Years– 1 YearChildbirth+1 Year+2 YearsKendell RE et al. Br J Psychiatry. 1987;150:
10 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)
11 Duration of PPDUntreated 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).
12 Risks of Untreated PPD To mother: Stressful impact on relationship between woman and her partner.Suicidal thoughts more likely to be accompanied by homicidal thoughtsKindling phenomenon---development of a chronic low grade depression with more susceptibility to repeated episodes of MDDSevere postpartum psychiatric disorder is associated with a high rate of death from natural and unnatural causes, particularly suicideSuicide risk in the first postnatal year is increased 70-fold
13 Risks of Untreated PPD To child: Poor weight gain Sleep problems Less breastfeeding-depressed mothers more likely to discontinue breastfeedingImpaired mother infant interactions leading to poor attachmentImpaired maternal health and safety practices
14 Risks of Untreated PPDAttuned infant-caregiver interactions promote brain neurological “wiring”.Future , hyperactivity, conduct disorders and school behavior problemsDelays in language and social developmentIncreased risk of depressionMaternal depression is an “Adverse childhood experience” ACE, often it is not the only adversity
15 MATERNAL POST PARTUM MOOD IS ONE OF THE STRONGEST PREDICTORS OF NEUROCOGNITIVE DEVELOPMENT IN CHILDREN MEASURED UP TO AGE SIX
16 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
17 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 treatmentDelay in treatment for PPD results in a longer illnessInformation 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.
18 SCREENING FOR PERINATAL DEPRESSION Postpartum depression is often not recognizedDespite the availability of validated screening tools, PPD remains under diagnosedAbsence of screening often means untreated depression and poor outcomes for the mother, her newborn, and familyPostpartum depression can be screened for with simple and validated screening toolsIt is possible to screen for antenatal depression
19 Validated Screening Tools EPDS- Edinburgh postnatal Depression ScreenPHQ-9 Patient Health QuestionnairePHQ-2PPDS Postpartum Depression ScaleBeck Depression Inventory-II Center for Epidemiological Studies-Depression Scale (CES-D)
20 PHQ-2Over 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 all1—Several days2—More than half the days3—Nearly every dayHaving little interest or pleasure in doing things:
22 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.
23 4. I have been anxious or worried for no good reason. No, not at all 3. I have blamed myself unnecessarily when things went wrong.Yes, most of the timeYes, some of the time Not very oftenNo, never4. I have been anxious or worried for no good reason.No, not at allHardly everYes, sometimesYes, very often5. I have felt scared or panicky for not very good reason.Yes, quite a lotNo, not much6. Things have been overwhelming me.Yes, most of the time I haven’t been able to cope at allYes, sometimes I haven’t been coping as well as usualNo, most of the time I have coped quite wellNo, I have been coping as well as ever
24 7. I have been so unhappy I have had difficulty sleeping. Yes, most of the timeYes, sometimesNo, not muchNo, not at all8. I have felt sad or miserable.9. I have been so unhappy that I have been crying SCORINGQuestions 1,2, and 4Yes, most of the time in ascending orderNo, not much All other questionsNo, not at all in descending order10. The thought of harming myself has occurred to me.Yes, quite often SometimesHardly everNever 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
27 Perinatal Depression Screening Antenatal early risk assessment and screening during pregnancy.ACOG recommends the PHQ-2 once per trimesterIf at high risk (prior history, neonatal loss, obstetrical complications, etc):Upon discharge from hospital. Need to assess support plan post dischargeVisiting nurse follow-up visit a good timeAt postpartum visit with OB/MidwifeAt early (2 week) follow up appointment if high riskAt routine 6-7 week visitWell-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
28 Obstacles to Screening Lack of timeLack of familiarity with screening toolsLack of protocols for positive screenLack of easy assess to mental health resourcesLack of reimbursement
29 Obstacles to Treatment For women:StigmaShameFear of losing childrenFear of medicationOver half of women referred to mental health services do not get there
30 Obstacles to Treatment For providers:Lack of easy access to mental health referral resourcesDiscomfort with prescribing“Safer” not to treat with medicationLack of access to psychiatric resourcesLack of clear treatment guidelinesLack of collaboration
31 APA/ACOG GuidelinesThe 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).
37 PROMOTING SCREENING ACCESS TO SCREENING TOOLS ALGORITHMS FOR WORKING WITH THEMAWARENESS AT THE OFFICE STAFF LEVELMODEL FOR CREATING A LOCAL MENTAL HEALTH REFERRAL RESOURCEFUNDING FOR SCREENING………
38 IMPROVING TREATMENT THROUGH COLLABORATION Recognition that most treatment is not done in a psychiatrists officeMake resources available through easy access to information and informal psychiatric consultation , i.e MAPP’s Consultation ProjectIdeal would full integration of care
39 Ideal OutcomeScreen 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 diseaseNonpharmacologic treatment options such as psychotherapy, support groups, and other community resources would be identified and included whenever possibleRisks of psychotropic medications would be weighed against the risks of untreated psychiatric disease, recognizing that untreated psychiatric illness can have significant adverse effectsRecognition that pharmacotherapy for some women with moderate or severe disease may be the most appropriate treatment to treat the disorder and prevent relapse
41 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 awarenessaccess to screenings for new mothersto increase researchgrants to health care providers to facilitate the delivery of treatmentNo mandated screening or treatment, not driven by the pharmaceutical industry
42 Melanie Blocker Stokes MOTHERS Act Some of the supporting organizations:American Psychological AssociationAmerican College of Obstetricians and GynecologistsPostpartum Support InternationalAmerican Psychiatric AssociationChildren's Defense FundAssociation of Women's Health, Obstetric and Neonatal NursesMarch of DimesAmerican College of Nurse MidwivesNational Alliance on Mental IllnessAssociation of Maternal and Child Health ProgramsNational Partnership for Women & FamiliesNational Women's Law Center
43 PPD and State ProgramsNew 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
44 Maine LD 792 123rd Legislature, 2006 An Act Concerning Postpartum Mental Health Education3 FQHC piloted screening with the PHQ-91/8 were positiveeasier than expectedhave integrated mental health careBarriers to screening, treatment and integrationOther state programsRecommendations for screening, treatment, data collection, resourcesGoogle Maine LD792 to see the report
45 WEB RESOURCESMGH Center for Women’s mental HealthPostpartum Support InternationalCrisis hotline for postpartum depression and psychosis: PPD-MOMSNIMH supported websiteExcellent resource, regularly updated9 educational modules aimed at different provider categories offering CME’sSoon…….MAPP’s website will have the screening tools and algorithms, medication information resources, etc
46 For more information, resources, to get involved: plopsymd@myfairpoint For more information, resources, to get involved: Subject line: MAPP PPD Project
47 “A small group of thoughtful people could change the world “A small group of thoughtful people could change the world. Indeed, it's the only thing that ever has.” Margaret Mead