Maternal Depression: Causes, Consequences, and Intervention

1. Maternal Depression: Causes, Consequences, and Intervention Robert T. Ammerman, Ph.D, ABPP Every Child Succeeds and Cincinnati Children’s Hospital Medical Center Delaware Healthy Mother and Infant Consortium Annual Summit April 9, 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. 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

4. 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

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

6. 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%

7. 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%

8. 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.

9. 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.

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

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

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

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

14. Causes of Depression • Genetics • Disruptions in HPA axis and stress response • Sensitivity to hormonal changes • Social disconnection • Cognitive distortions

15. 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.

16. 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.

17. 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.

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 Characteristics of Depressed Mothers • Withdrawn: disengaged, flat, unresponsive, little support.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

19. 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.

20. 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

21. 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

22. Exposure to Maternal Depression in Infancy & IQ BOYS AT AGE 11 15 points Hay et al., 2001

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

24. Treatment Options • Antidepressant medications • Interpersonal Psychotherapy • Cognitive Behavioral Therapy • Non-traditional and emerging: Listening Visits, yoga, mindfullness therapy, lay counselors

25. 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

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

27. 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.

28. 74.8% with trauma history Ammerman et al., 2009 12% receive mental health treatment

29. 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

30. 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

31. 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

32. 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

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

34. 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

35. 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%

36. 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)

37. 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

38. Current and Lifetime Comorbid Psychiatric Disorders

39. Not affected by therapist or home visiting model F=7.9, p<.01

40. MDD Diagnosis at Pre- & Post-Treatment & Follow-Up Χ2=19.0, p<.001

41. MDD Diagnosis at Pre-treatment, Post-treatment, & Follow-Up for Completers, Partial Completers, & THV

42. Social Support Using ISEL Scale (Total) F=5.1, p<.01

45. Predictors of symptom status at post-treatment BDI-II at post-txt: ≥9 ≤8 Ammerman, R.T., Peugh, J.L., Putnam, F.W., & Van Ginkel, J.B. (2012). Predictors of treatment response in depressed mothers receiving In-Home Cognitive Behavioral Therapy and concurrent home visiting. Behavior Modification, 36, 462-481.

46. Dissemination Massachusetts (4 sites) Kentucky (6 sites) Connecticut (4 sites) Kansas (1 site) www.movingbeyonddepression.org

47. Acknowledgments • Frank W. Putnam, M.D. & Judith B. Van Ginkel, Ph.D. • Jack Stevens, Ph.D., Mekibib Altaye, Ph.D., James Peugh, Ph.D. • Jodie Short, Margaret J. Clark, M.P.A., Lawson Wulsin, M.D., Jennie Noll, Ph.D., Chad Shenk, Ph.D., Neil Richtand, M.D., Ph.D., Nicole Bosse, M.A., Angelique Teeters, Psy.D. • Healthy Families America and Nurse-Family Partnership • Grant support: National Institute of Mental Health (R34MH073867 & R01MH087499) • Every Child Succeeds agencies and home visitors! • Health Foundation of Greater Cincinnati • Kentucky H.A.N.D.S. & Ohio Help Me Grow • United Way of Greater Cincinnati • Xavier University, Dept. of Psychology www.everychildsucceeds.org