Perinatal Mental Health in Colorado: What We Know and What We Can Do National PRAMS Conference Atlanta – December 8th & 9th, 2008

Objective Describe a successful public health intervention addressing Perinatal Depression

Perinatal Depression Baby Blues Perinatal Depression up to 2 weeks after birth clears up without treatment prevalence could be as high as 80% Perinatal Depression clinical depression, requires treatment occurs within the first year after birth prevalence estimated at 10-20% Postpartum Psychosis dangerous to mother and child Exceedingly rare: .01% or 1 in 1000 women Three types of mental disturbances that are often discussed. Baby Blues is very common, so much so that it is sometimes considered a “normal” side effect of childbirth. It’s characterized by symptoms similar to depression: sadness, weepiness, irritability, fatigue. Postpartum depression persists beyond the 2-week marker of Baby Blues and can be a very serious and debilitating depression. This does not go away on its own, but can be treated successfully with medication and counseling. We are focusing on postpartum depression in this discussion today. Postpartum psychosis is extremely rare, but it is the disorder that you hear about in the news related to tragic outcomes such as infanticide.

Why Should We Care? Perinatal depression is the most common complication of childbirth, but it can be treated successfully Can be debilitating to mother and cause unnecessary pain and suffering Impact on the child and family: Decreases mothers’ caregiver capacity Studies show increase in child’s risk for: Social/emotional problems Cognitive and linguistic delays Poor self-control, aggression, relationship problems Difficulty in school as older children Though the research is in its infancy, there is a lot that we do know about postpartum depression and we are beginning to understand its impact on children. There is strong research showing that the period from ages zero to three is a crucial time in setting the stage for a child’s social, emotional, and cognitive experience. The mother is often the primary caregiver for her child, and postpartum depression interferes with her ability to provide the best care for her baby. This can have long-term effects on the child’s development. The impact of PPD on the mother alone is significant. When you consider the additional impact on the child and possibly the marriage or partner relationship, the impact is such that it warrants public health investment. Mention the “MCH Action Guide” on Perinatal Depression, which addresses depression during and after pregnancy.

Postpartum Depressive Symptoms (PDS) Colorado PRAMS data for 2004-2006 N=6,000 Prevalence estimated at 13.9% 70,000 births per year in Colorado = almost 10,000 women per year with PDS This is consistent with the estimated rates documented in the literature for the general population of postpartum women.

Main Factors Associated with Postpartum Depressive Symptoms Demographic Characteristics: Maternal Age (Under age 25) Race/Ethnicity (Black/African-American) Education (Lower education attainment) Marital Status (Unmarried) Poverty (Low income) Experience of Abuse Excessive Stress Low Birthweight Low Breastfeeding Duration

Prenatal Plus Demographics 84% are single 41% have less than 12 years of education 31% are teenagers (age < 18) 23% have a history of child abuse 22% have a history of, or are currently experiencing, domestic violence 26% have 4 or more “High Life Stress” indicators 42% have a history of, or a current, psychiatric diagnosis (including depression)

Prenatal Plus Overview Prenatal Plus Program provides case management services to Medicaid-eligible pregnant women in Colorado Services are provided throughout pregnancy and up to 2 months postpartum by a care coordinator, mental health professional and dietitian

Perinatal Depression Screening and Intervention

Purpose of Intervention To begin addressing the issue by identifying, educating and facilitating treatment for women at highest risk for perinatal depression Ultimate goal is to reduce the prevalence and duration of this serious mental health issue

Intervention Preparation Increase skill in staff to provide perinatal depression education to clients and to identify, screen, refer and provide brief counseling to women Increase community awareness of Prenatal Plus and client mental health needs Improve capacity of community resources to treat perinatal depression effectively Training was conducted to address #1, resource manual provided. Mental health resources are lacking in many communities. Agencies were required to find and build relationships with other resources in their community.

Short Term Intervention Outcomes Increase woman’s knowledge of Perinatal Depression Increase her awareness of resources Increase her motivation and self-efficacy to seek help Decrease sense of helplessness and despair In turn these steps would lead to: 1. Increased preparation to protect against PD 2. Increased early self-identification of symptoms 3. Increased # of women seeking and receiving care for PD #4. Decrease in depressive symptoms – Again, ultimate goal is to decrease prevalence of Perinatal Depression

Intervention Protocol Intervention Protocol is mapped out in the Pathway. This pathway provides a standardized method for screening and intervention for all Prenatal Plus women. This tool was developed in a collaborative effort between CDPHE Staff, PN+ Staff and the Mental Health Community. Initial screen is 2-question and based on results, EPDS may be administered at that time. 3rd Trimester and Postpartum period, EPDS is administered to ALL participants in the program. At each period the client receives education on perinatal depression no matter the results of the screen. For those with screening scores above 10, a referral is offered to MHP and/or community mental health center. At all screening periods, suicidal and homicidal ideation are clarified.

The Edinburgh Postnatal Depression Scale Simple 10 item scale Designed to screen for depression in women during childbearing years Does not evaluate physical signs of depression such as sleep difficulties since these symptoms can also be associated with pregnancy and newborn care Does not replace clinical judgment – the scale does not detect moms with anxiety neuroses, phobias or personality disorders. Developed in 1987, the EPDS was developed specifically to address women in childbearing years because it was apparent that the existing self-report scales such as the Beck Depression Inventory evaluated somatic signs of depression such as sleep disturbances and other physiological changes of having a baby.

Evaluation Tools Data Collection Client Exit Survey % women educated % women screened/% screened + % referred to treatment % entering treatment (if known) Type of additional support provided Client Exit Survey To evaluate the intervention we have developed two tools. The first one is a form which collects data on when the screen occurred, what the results of the screen were, and any follow-up action that happened based on the results. The second is a survey given to the client to evaluate client knowledge and awareness. The survey is anonymous.

Conclusion To increase identification and treatment of perinatal depression… Conduct regular and universal screening Provide appropriate education, resources and referrals Facilitate treatment and offer follow-up …For ALL women throughout pregnancy and postpartum.

Resources for Perinatal Depression Women’s Health Perinatal Depression Website: http://www.cdphe.state.co.us/pp/womens/ppd/index.html

Mandy McCulloch, Prenatal Plus Program Director Thank You! Mandy McCulloch, Prenatal Plus Program Director mandy.mcculloch@state.co.us 303-692-2495