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Development of a Statewide Perinatal Depression Initiative in Illinois 

Development of a Statewide Perinatal Depression Initiative in Illinois . Laura J. Miller MD Women’s Mental Health Program University of Illinois at Chicago. Perinatal depression in Illinois before the initiative. About 9.4 – 12.7% of pregnant women have a major depressive episode

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Development of a Statewide Perinatal Depression Initiative in Illinois 

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  1. Development of a Statewide Perinatal Depression Initiative in Illinois  Laura J. Miller MD Women’s Mental Health Program University of Illinois at Chicago

  2. Perinatal depression in Illinois before the initiative • About 9.4 – 12.7% of pregnant women have a major depressive episode • Up to 21.9% of women giving birth develop postpartum depression • In 2001, only 607 of the 81,000 women with Medicaid-funded deliveries (0.75%) were diagnosed withdepression Gavin NJ et al: Obstet Gynecol 106:1071-83, 2005

  3. Illinois Perinatal Depression Task Forces • How can we improve detection of perinatal depression statewide? • How can we improve delivery & quality of treatment for perinatal depression statewide?

  4. Illinois task force findings: obstacles to early detection and treatment • Mental health system lacked capacity to treat most women with perinatal depression • Most primary/prenatal care providers lacked knowledge and skills to diagnose and treat perinatal depression • No reimbursement for screening

  5. Illinois’ strategy to improve detection and treatment of perinatal depression Central focus: • Increase primary care provider capacity to detect, diagnose and treat perinatal depression • Promote screening and public awareness in tandem with increasing provider capacity

  6. Illinois’ strategy to improve detection and treatment of perinatal depression • Provider support • Training • Tools for screening, assessment & treatment • Consultation available to providers • Systemic support • Reimbursement for screening • Models of integrative care • Tools for self-care

  7. UIC Perinatal Mental Health Project: primary care provider training workshops • Basic workshop • Advanced skills workshops • Screening and assessment • Psychopharmacology during pregnancy and postpartum • Assessment and intervention for mother-infant relationship problems caused by perinatal depression

  8. Screening and assessment workshop • Based on data showing that most women accept screening but not outside assessment • Highlights EPDS & PHQ-9 • Uses assessment tools developed by project (1 for EPDS, 1 for PHQ-9) • Uses case scenarios to practice scoring screens and interpreting assessments

  9. Psychopharmacology workshop • Lecture plus case vignettes • Discussion uncovers obstacles to prescribing • Misinformation • Liability fears • Attitudinal barriers • Includes section on engaging patients • Multidisciplinary audience promotes cohesive message to patients

  10. Mother-infant workshop • Lecture, video clips, discussion • Includes observational guide to identifying potential mother-infant relationship problems linked to maternal depression or anxiety disorders • Includes information on interventions • Primary care interventions • Parenting coaching & dyadic therapy

  11. Primary care provider trainings: teaching modalities • Talks (lecture format) • Interactive workshops (role play, practice) • Case presentation workshops • Video teleconference • Audio conference with on line slides • Documentary showing (“Descent into Desperation”) and group discussion http://descentintodesperation.com/

  12. Reaching mental health providers • Findings from UIC project & state task forces show: • many mental health providers don’t feel adequately trained to treat perinatal depression • if detection improved, state mental health system lacks capacity to treat all women identified as having perinatal depression • Long-term goals: • identify and fill major service gaps • develop regional mental health experts

  13. Reaching mental health providers • Developed advanced workshop geared to mental health providers • Target this workshop to potential regional experts in diverse geographic areas • Survey mental health delivery sites to • assess ability to treat perinatal women • identify areas where training is desired/needed • Add mental health providers to a resource database, with notation if they’ve received our training

  14. Mental health resources • NorthShore University HealthSystems Perinatal Depression Program survey • 236 out of 290 total community mental health centers contacted in 67 counties • Profiles obtained for 156 of these sites • Mental health expertise of respondents • 59% have psychiatrist available on-site • 25% have staff trained or experienced in perinatal depression, per self-report

  15. UIC Perinatal Mental Health Project:scope of training (11/04 – 6/08) • 4,927 health care providers trained • Provider types • Physicians: Ob/Gyn, Family Medicine, Pediatrics, Psychiatry • Nurses: RN, APN, midwives, home visitors • Therapists: psychologists, social workers • “Health extenders”: birth doulas, lactation consultants, home visitors, case managers

  16. Provider training: baseline knowledge (pre-training) • Of all participants: • 27.2% could name a PPD screening tool • Of physician & nurse participants: • 18.3% knew the obstetric risks of untreated antenatal depression • 9.4% correctly understood FDA Pregnancy Risk Categories • 30% knew a place to find evidence-based information about antidepressants during pregnancy and/or breast-feeding

  17. Provider training workshops: evaluation data • Participant satisfaction: average score 3.6 (scale 1 – 4) • Knowledge acquisition: • Antenatal risks: 87.2% knowledge improved • Screening tools: 96.2% knowledge improved • FDA categories: 79.2% knowledge improved • Medication information: 78.5% knew reliable sources in post-test

  18. UIC Perinatal Mental Health Consultation Service • Resource for providers to consult with experts in perinatal mental health • Accessed by toll-free telephone or online • Consultants are multidisciplinary faculty and staff from the UIC Women’s Mental Health Program • Psychiatrists (3) • Advanced practice nurse (1) • Social worker (1) • MPH (2)

  19. UIC Perinatal Mental Health Consultation Service: scope • 933 consults completed between 11/04 and 1/09 • Requests have come from • 31 other states • 8 other countries • Types of providers: • 7.8% primary/perinatal care physicians • 32.2% primary/perinatal care nurses • 33.8% mental health professionals • 26.2% other (e.g. social workers, lactation consultants, doulas, case managers)

  20. UIC Perinatal Mental Health Consultation Service: query types

  21. UIC Perinatal Mental Health Consultation Service: evaluation data • Pilot data: N=138 respondents • 100% reported the information they received was helpful • 91.3% said the information influenced their approach to a patient and/or their practice in general • 89.0% said having the service available increases their comfort level in treating women with perinatal depression or anxiety disorders in their practices

  22. Detection of perinatal depression by screening • In a study directly comparing screening scores with clinical diagnoses, health care providers only recognized 26% of pregnant women who screened positive for depression • Rates of positive screens in published studies range from 13% - 25%, in keeping with epidemiologic data about population rates of perinatal depression Evins GG et al: Am J Obstet Gynecol 182:1080-2, 2000; Birndorf CA et al: Int J Psychiatry Med 31:355-65, 2001; Carter FA et al: Aust N Z J Psychiatry 39:255-61, 2005; Marcus SM et al: J Womens Health 12:373-80, 2003; Smith MV et al: Psychiatr Serv 55:407-14, 2004

  23. The problem with screening • Meta-analysis: screening does not lead to: • Increased entry into treatment • Improved clinical outcomes • Study example: • 92.5% of perinatal women completed the EPDS • 30.6% of women with “positive” screens agreed to mental health assessment • Less than half of those attended assessment • 10% of women with “positive” screens ended up receiving treatment, with few completing treatment Gilbody S et al: CMAJ 178:997-1003, 2008; Carter FA et al: Aust N Z J Psychiatry 39:255-61, 2005

  24. “Screen & refer” model for detecting perinatal depression in prenatal/primary care settings • Screen all patients • Refer women who “screen positive” to mental health services • Problems • Screening is well accepted by patients • Mental health referral is not • Mental health resources are limited

  25. “Screen, assess & refer” model • Screen all patients • Do diagnostic assessment on site for women whose scores are above a cut-off • Refer those who are diagnosed with major depression to mental health services for treatment • Increases acceptance; reduces “false positives”

  26. “Stepped care” model for detecting and treating perinatal depression • Screen all patients • Do diagnostic assessment on site for women whose scores are above a cut-off • Identify subset of women to treat on site (based on severity, complexity) • Treat on site ; track treatment response • If response is inadequate, refer for mental health care

  27. Advantages of “stepped care” model • Reduces stigma • Reduces logistical barriers - transportation, time, expense • Promotes continuity of care • Cost effective • General depression stepped care models improve quality of care, patient & provider satisfaction, & depression outcomes Neumeyer-Groman A et al: Med Care 42:1211-21, 2004

  28. Perinatal Depression Stepped-Care pilot • Alivio Medical Center • FQHC; over 16,000 patients per year, over 1200 births per year • most patients monolingual Spanish, below 200% poverty level • Prior to model • 0.4% of women of reproductive age diagnosed with psychiatric disorder • After introducing model (March 2005) • Screening average: 58% • 17% screened positive • 76% assessed on site • 10% diagnosed with major depression on site • Quality Monitoring data guides follow-up training

  29. Perinatal depression assessment tools • Help a clinic or system to progress from “screen and refer” to “screen, assess and refer” or stepped-care model • Tools geared to specific screens • EPDS (to make a DSM-IV diagnosis) • PHQ-9 (to rule out confounds) • Tools designed to be administered by perinatal care providers during perinatal clinic visits

  30. Limitations of FDA pregnancy risk categories • No medications are yet FDA-approved specifically for use during pregnancy • Psychotropic medications cross placenta so are never “no risk” (Category A) • Categories B & C based on animal studies, but adverse medication effects don’t generalize from one species to another • Drugs can get “demoted” the more they’re studied in humans (bupropion, paroxetine)

  31. Provider tool: Information on antidepressants during pregnancy and postpartum • Compiles data from studies in human pregnancy & breastfeeding • Updated whenever research warrants • Available on line at no charge www.psych.uic.edu/research/perinatalmentalhealth/

  32. Illinois strategies for promoting perinatal depression screening • HealthCare and Family Services (HFS) reimburses for perinatal depression screening • Dissemination of screening tools & information • Mailed Provider Notice • Online (HFS website) • Provider training sessions • On-site consultation and monitoring for clinics interested in setting up screening programs • Medicaid Managed Care Organizations (MCO) • Perinatal depression screening is a quality indicator • Charts are audited for perinatal depression screening

  33. Introducing screening into a perinatal care clinic • Form a planning group • Choose a screening tool • Choose a cut-off score • Choose times to administer the tool – e.g. at prenatal care entry, third trimester and postpartum • Define who will administer and score the tool – e.g. medical assistant, provider • Bill for screens

  34. Screening follow-up: steps to take • Decide on “screen, assess and refer” model or “stepped-care” model • Arrange a workshop to train providers in assessment • Consider using a formal assessment tool, with diagnoses and dispositions listed • Decide how results of screening and assessment will be entered into the medical record • Mental health confidentiality • Pediatric charts with maternal health information

  35. Initiatives to integrate maternal and infant mental health care • Designed and implemented advanced workshop on mother-infant relationship problems caused by perinatal depression • Trained Early Intervention (EI) staff to recognize and intervene when mother has depression • Developed guides for prenatal/primary care providers • to identify mother-infant problems • to support effective parenting

  36. The MotherCare Circle • Integrative clinic model • Psychopharmacology • Individual psychotherapy • Facilitated support group • Parent coaching • Mother-infant dyadic therapy • Psychoeducation • Evaluation • Psychiatric • Parenting skills, stresses, goals

  37. Perinatal Mental Health Disorders Prevention and Treatment Act • Provisions for education/information • Licensed prenatal care providers shall educate women (families) about perinatal mental health disorders per ACOG opinions • Hospitals shall inform mothers (families) about perinatal mental health disorders • DHS will supply written information that can be used for this purpose

  38. Perinatal Mental Health Disorders Prevention and Treatment Act • Provisions for screening and assessment • Licensed prenatal, postnatal & infant care providers shall offer formal screening to each pregnant patient & review screen per ACOG opinions • Assessment must be repeated when patient may have a perinatal mental health disorder

  39. Strengths of legislation • Initiated by an advocate who had experienced a perinatal mental health problem • Partnership among advocates, legislators, public health agencies, providers • Promotes awareness of the scope and importance of the problem • Underscores importance of formal screening and assessment

  40. Weaknesses and areas where further work is needed • Unfunded mandate • No back-up resources for providers • Training • Tools • Consultation • Micromanages medical care • questionnaire vs verbal screen • forces physicians of one discipline to use guidelines from another

  41. Can these mandates be enforced? • No direct enforcement; however… • Having this Act sets a standard of care that could be cited in malpractice cases

  42. Enhancing Developmentally Oriented Primary Care (EDOPC) • Collaborative partnership • Advocate Health Care, Healthy Steps Program • Illinois Chapter, American Academy of Pediatrics • Illinois Academy of Family Physicians • Illinois Department of HealthCare & Family Services • Overall goals • Improve delivery and financing of preventive health and developmental services in primary health care settings for children under age 3 • Align goals of physicians and parents around high-quality health care

  43. EDOPC approach • Office-based training for providers & their teams • Information in binder & pocket guides • Follow-up technical assistance • Website • Includes a provider training module on Perinatal Maternal Depression Screening and Referral

  44. NorthShore University HealthSystems Perinatal Depression Program • Founded in 2002, in memory of Jennifer Mudd Houghtaling • Mission: To identify and support families at risk for perinatal depression • Key components: • 866-ENH-MOMS hotline • Universal perinatal depression screening in third trimester and six weeks postpartum • Mental health provider network • Health care provider education • Research

  45. NorthShore University HealthSystems Perinatal Depression Hotline • Characteristics • Calls answered live 24 hours a day, 7 days a week • Staffed by licensed mental health professionals • Uses interpretive service line • Free and confidential • Usage • 1,359 calls from 1/03 – 3/08 • Averaged 28 calls per month in 2007 • 85% of callers live in Illinois • 27% of callers are uninsured or Medicaid recipients • 76% accept referrals • 75 emergency room referrals to date

  46. Perinatal depression initiatives: other key collaborations • Illinois HealthCare and Family Services (Medicaid agency) • Office of Family Health (Title V agency) • Postpartum Depression Illinois Alliance (state branch of Postpartum Support International) • Conference of Women Legislators • Jennifer Mudd Houghtaling Postpartum Depression Foundation • Ounce of Prevention • Voices for Illinois Children • Erikson Institute

  47. Perinatal depression: fostering statewide collaboration • Collaboration meetings • Annual peer review meetings on specific topics • Perinatal depression • Interconception care • Web links

  48. The MotherCare Kit • Many women refuse formal psychotherapy or lack access • MotherCare Kit designed to fill this gap • Kit translates evidence-based cognitive-behavioral and interpersonal self-care strategies into user-friendly format • Kit is designed for use as part of perinatal health care

  49. MotherCare Kit process • Kit has modules, each corresponding to a self-care topic area • At each prenatal or postpartum visit, patient chooses a topic area and takes that module home (in a tote bag) • In guided self-care (GSC), health care providers or “extenders” maintain regular contact with patient to review MotherCare progress

  50. MotherCare Kit topic areas • Food and mood • Sleep and daily rhythms • Activity and movement • Social support • Problem-solving • Recognizing feelings • Assertiveness • Managing negative thoughts

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