Addressing Maternal Depression and Trauma in Home Visiting

1. Addressing Maternal Depression and Trauma in Home Visiting Robert T. Ammerman, Ph.D, ABPP Every Child Succeeds and Cincinnati Children’s Hospital Medical Center 3rd Annual Strengthening Families Summit on Parental Depression Concord, New Hampshire March 31, 2014

2. Depression in Mothers • Determined by self-report • Edinburgh Postnatal Depression Scale • Center for Epidemiological Studies Depression Scale (CES-D) • Beck Depression Inventory-II (BDI-II) • Patient Health Questionniare-9 (PHQ-9) • Diagnosis of major depressive disorder (MDD) • Postpartum onset ≤6 months • Prenatal

3. Depression and CMS Claims

4. Symptoms of Major Depressive Disorder (MDD) • Sadness • Crying • Fatigue • Disinterest • Sleep problems • Appetite problems • Agitation or slowness • Poor memory • Poor concentration • Low self-esteem • Guilt • Low motivation • Hopelessness • Suicidal thoughts • Decreased libido CONSISTENT & PERSISTENT ≥2 weeks

5. Phenomenology • Pervasive loss • Loss of control • Loss of self • Social disconnection • Loss of voice • Spiraling downward • Anxiety • Overwhelmed • Rumination • Obsessive thinking • Anger • Guilt From C.T. Beck, 2002

6. Phenomenology (cont.) • Expectations and reality • Shattered dreams • Failure & incompetence • Fear of negative evaluation • Making gains • Surrendering • Despair and hopelessness • Struggle

7. Things have been so rough lately I know you can feel it too I've been through this before But this time I have you Sometimes I feel so down I just want to run away But then I see you my angel & that's what makes me stay From growing in my tummy To practicing to stand Time is going by so fast This was definitely never the plan I've been so tough on myself Because I believe you deserve the best I try to be the perfect mom But on the inside I'm just a mess So bare with me baby girl I'm fighting this depression for you I'm still a little broken But I know I'll make it through Your my strength my pride Everything that's good in me Someday I hope I'll be able To see just what you see But until then I'll continue trying To make all your dreams come true & no matter what happens I'll always love you.

8. Epidemiology of MDD • Lifetime prevalence for the general population is as high as 1 in 3, often begins in childhood or adolescence • Lifetime prevalence in women postpartum: 13-26% • Average length of episode: 3-6 months • Impairment: 87% report significant role impairment (social, home, relationships, work) • Comorbidity: 71% (anxiety disorders, substance use disorders) • Risk for subsequent episodes: 80% • Odds of relapse within 2 years: 50% • First episodes in postpartum period: 50%

9. Associated Features • Nationally, 57% receive treatment. Only 64% get at least minimally adequate treatment. • 20-30% of women depressed postpartum receive treatment, less among low income. • Failure to successfully treat the first episode increases risk for subsequent episodes and increases likelihood of treatment resistant depression. • Suicide risk: between 4-15%

10. Maternal Depression is Expensive Mother Child Preterm birth Cognitive delays, special education Mental health treatment Injury and illness Child abuse and neglect • Employment • Education • Health care utilization • Lifetime earnings Maternal depression is a multigenerational issue.

11. Economic Costs • World Health Organization (2012)—Depression is the leading cause of disability worldwide • Depression in adults costs $83.1 billion annually, including 31% direct medical costs, 62% workplace costs (absenteeism, presenteeism and disability) and 7% for suicide/mortality costs • Depressed employees miss 27.2 days of work per year • Maternal depression is associated with an increase in pre-term births which average $51,600 per birth • Family lifetime loss in income potential is $300,000 due to childhood onset of psychological problems • Identification and effective treatment saves money and protects investments in other programs.

12. Depression 2 years Postpartum Measure: Edinburgh Postnatal Depression Scale Sample: 1,359 women over 2 years postpartum From Mayberry et al., 2007

13. Center on the Developing Child, Harvard University, 2009

14. Video Example Diagnostic Interview with a Depressed Mother in Home Visiting

15. Risk Factors for Depression • History of depression • Cognitive and emotional vulnerability: pessimism, anxiety, low self-esteem • Stressful life events • Low social support • Poverty • Unmarried • Unwanted pregnancy • Trauma history

16. Trauma Traumatic events are shocking and emotionally overwhelming situations that may involve actual or threaten death, serious injury, or threat to physical integrity. Reactions to traumatic events vary considerably, ranging from relatively mild creating minor disruptions in the person's life to severe and debilitating. International Society for Traumatic Stress Studies http://www.istss.org/WhatisTrauma/4339.htm

17. Types of Interpersonal Traumatic Experiences • Physical abuse • Sexual abuse • Emotional abuse • Witnessing violence • Physical or sexual assault • Intimate partner violence Timing Severity Frequency Duration

18. Trauma experiences of mothers in home visiting N=806 Trauma=74.1% 2+=68.9%

19. Impacts of interpersonal trauma Traumatic Experiences Biological Social Behavioral relationship maladjustment emotional dysregulation fear and avoidance Posttraumatic Stress Disorder Complex trauma

20. The HPA Axis Hyman, 2009 (Nature)

21. Effects of Dysregulated Cortisol Greater or lesser sensitivity to stress cues Greater arousal, more time needed to recover Inattention, distractibility Poor memory Emotional and behavioral dysregulation

22. Biobehavioral Response to Trauma -Genes contribute to how we respond to stress. -Genes can make us more vulnerable to traumatic stress. -Genes can be altered through exposure to traumatic stress, and these changes can be passed on to offspring. -Traumatic stress alters how neurons connect with each other and how they work. -Traumatic stress changes brain architecture. These changes can occur in the developing fetus and remain for a lifetime.

23. Adverse Childhood Experiences (ACE) Study • N=17,337 men and women, varied demographics, recruited 1995-1997 • Lifespan perspective on effects of ACEs on health and well-being • Identified 10 ACEs that were highly predictive of poor outcomes Felitti et al., 1998

24. Increased risk for poor health & social outcomes • Alcoholism and alcohol abuse • Chronic obstructive pulmonary disease (COPD) • Depression • Fetal death • Health-related quality of life • Illicit drug use • Ischemic heart disease (IHD) • Liver disease • Risk for intimate partner violence • Multiple sexual partners

25. Increased risk for poor health & social outcomes (cont.) • Sexually transmitted diseases (STDs) • Smoking • Suicide attempts • Unintended pregnancies • Early initiation of smoking • Early initiation of sexual activity • Adolescent pregnancy • Early death www.cdc.gov/ace/index.htm

26. ACE Score Items • Emotional Abuse • Physical Abuse • Sexual Abuse • Emotional Neglect • Physical Neglect 6. Parents separated or divorced 7. Mother IPV • Household problem drinker or drug user • Household mental illness • Household prison SCORE: 0-10

27. Endorsement of ACE Items (N=94) 1-Emotional Abuse 2-Physical Abuse 3-Sexual Abuse 4- Emotional Neglect 5-Physical Neglect 6-separate/divorce, 7-mother IPV, 8-alcohol/drugs, 9-mental illness, 10-prison

28. ACE Total Score in HV Sample and CDC 2009 Five State Survey, Female (18-24 yrs) Sample

29. Key Features of Infant Social and Emotional Development • Infants can imitate facial expressions and show preferences for caregivers. • Infants have a need to seek out communication with others. • Infants can elicit social and emotional responses from caregivers.

30. Key Features of Infant Social and Emotional Development • Communication between mothers and infants is organized around face, voice, gesture, and gaze--“a dance”. • Secure attachment is the cornerstone of early social and emotional development. • Communication directly influences, and is influenced by, brain development and emerging physiological regulation.

31. Key Features of Infant Social and Emotional Development • In normal mothers’ interactions with babies, 42% of time is spent exhibiting positive affect. For babies, 15% of time. • Mothers “guide” the quality of the interaction and the direction of development. They provide the scaffolding needed for successful development.

32. Characteristics of Depressed Mothers • Withdrawn: disengaged, flat, unresponsive, little support. • Intrusive: rough, angry, interrupt • Unable to read cues. • Rejecting. • Imbalanced, discordant.

33. Characteristics of Depressed Mothers • Don’t enjoy parenting. • View themselves as less competent and ineffective. • View children as more difficult. • Less tolerant. • More likely to attribute inappropriate intent in children. • See their behavior as caused by outside influences. • Preoccupied, less attentive, don’t anticipate. • Slower and less effective problem-solvers.

34. Course of Depression & Development (illustrative) 4th episode 3 months 1st episode 4 months 2nd episode 9 months 3rd episode 2 months time child 3 years old Age 16 Baby born (age 20) child 1 year old = depressive episode = normal mood

35. Impact on Infants and Development • Avoid mom, look away (for intrusive moms), docile, typically following maternal rejection. • Fussy, cries, focus on self-regulation (for withdrawn moms). • Crystallizing of communication patterns. • Delays in emotional regulation, and physiological organization. • Attentional problems. IMPORTANT: timing, length, severity, frequency, inter-episode functioning, partner support, other adults

36. Video Example Mother-Child Interaction Using Still-Face Paradigm

37. Treatment Challenges • Treatment capacity • Availability of evidence-based treatment • Access and disparities • Choice and engagement • Antidepressant medications: adherence, effect on developing fetus, cost, trauma issues

38. Moving Beyond Depression™ Overcoming barriers, fostering collaboration, and engaging depressed mothers in a non-traditional setting www.movingbeyonddepression.org

39. Unique Opportunity in Home Visiting • Reach mothers who might not otherwise receive treatment. • Appeal to mothers’ interest in their baby’s development. • Lower barriers to treatment. • Identify mothers early in the MDD episode. • Leverage relationship between mother and home visitor. • Leverage ongoing and lengthy home visitation services to optimize outcomes.

40. 74.8% with trauma history Ammerman et al., 2009 12% receive mental health treatment

41. Essential Intervention Elements Ameliorate depressive symptoms Help mother and home visitor/service Collaborate with home visitor, no burden Implement in home to remove barriers Use evidence-based treatment Fit with population, setting, & service

42. IH-CBT: Adaptations to Setting SETTING Overcome barriers to treatment to reach mothers Observe mothers in natural environment Observe important features that would not be evident in office Maximize learning and application of new skills Logistical challenges: privacy, other family, distractions Unexpected challenges and crises POPULATION SERVICE

43. IH-CBT: Adaptations to Population POPULATION New mothers with limited parenting experience Young mothers with few social supports Emerging adulthood Educational underachievement & lower IQ Cultural sensitivity Poverty and hardship Trauma history & intimate partner violence Psychiatric comorbidity POPULATION SERVICE

44. IH-CBT: Adaptations to Service SERVICE Collaborative relationship with home visitor Logistical coordination of multiple services Frequent contacts with home visitor Coordination of care Avoid triangulation POPULATION SERVICE

45. Conceptual representation of IH-CBT collaboration THERAPIST HOME VISITOR primarily depression domains primarily HV domains MOM

46. Inclusionary: ECS participant ≥16 years old Baby 2<10 months EPDS ≥11 MDD using SCID MIDIS Design Exclusionary: Substance depend. Psychosis Current suicidality Meds or therapy Screening: EPDS ≥11 Eligibility/Pre-treatment Assessment SCID Diagnosis of MDD randomization IH-CBT 15 sessions + booster Ongoing home visitation Typical Home Visitation Community resources Ongoing home visitation 34.8% received community treatment Post-treatment Assessment N=93 Retained: 86.8% ≥ 2 points: 95.6% 3 Month Follow-Up Assessment

47. Demographics of Sample (N=93) Mother Age: 22.0 (4.6) years Mother Race: Caucasian 62.6% African American 34.1% Asian American 1.1% Hawaiian/Pacific Islander 1.1% Native American 1.1% Mother Ethnicity: Appalachian 3.3% Hispanic 7.7% Mother Marital Status: Married 13.2% Separated 1.1% Single, never married 85.7%

48. Demographics of Sample (cont.) Mother Education: 11.4 (1.9) years Number of Children 1 92.3% 2 - 3 7.7% Family Income: $ 0- 9,999 54.8% $10,000-19,999 21.1% $20,000-29,999 16.4% $30,000-39,999 3.3% $40,000-49,999 2.2% $50,000-59,999 2.2% Baby Age (days): 154.5 (74.0)

49. MDD: 100% BDI-II: 33.7 (10.1) EPDS: 18.9 (4.0) HDRS: 21.7 (4.6) Severity— Mild: 28.9% Moderate: 46.7% Severe: 24.4% Postpartum onset: 29.2% Recurrent: 75.3% # Episodes: 2.66 (1.59) Suicide attempts: 43.9% Age of 1st episode: 15.1 (5.2) years Clinical Features of MDD

50. Current and Lifetime Comorbid Psychiatric Disorders