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Perinatal Mood and Anxiety Disorders:

Perinatal Mood and Anxiety Disorders: . Next Steps in Health Policy Sharon Fickley GNUR 6056 July 27 th , 2010. Objectives. Articulate the percentage of women in industrialized world who experience postpartum depression

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Perinatal Mood and Anxiety Disorders:

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  1. Perinatal Mood and Anxiety Disorders: Next Steps in Health Policy Sharon Fickley GNUR 6056 July 27th, 2010

  2. Objectives • 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

  3. Definitions 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.

  4. Definitions 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)

  5. Definitions Postpartum Depression: • 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: • 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)

  6. Other Contributing and Risk Factors • 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)

  7. Problems Surrounding the Issue • Difficult to identify true breadth of problem • 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)

  8. Problems Surrounding the Issue • 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)

  9. Major Stakeholders 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)

  10. Major Stakeholder 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)

  11. Other Stakeholders • 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

  12. Health Policy Action 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

  13. Systems Issues 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)

  14. Systems Theory

  15. What the Future Holds • 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)

  16. What the Future Holds • 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)

  17. Policy Alternatives • 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

  18. What Role do Nurses Have Now? • 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!

  19. References 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

  20. References 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

  21. References 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).

  22. References 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_caregivers/depression_caregivers.pdf

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