Incorporating Mental Health Into Maternal Health

1. Incorporating Mental HealthInto Maternal Health Brian Stafford, MD, MPH Medical Director The Kempe Center’s Postpartum Depression Intervention Program CITYMATCH CONFERENCE Denver, CO Aug, 2007

2. Outline • Perinatal Mental Health and Mental Illness • Barriers to Treatment • Public Health’s Role • Mental Health’s Role • Primary Care’s Role

3. Perinatal Mental Health • A developmental crisis • A time of increased contact with Medical and Public Health but not necessarily mental health

4. Pregnancy • High Risk for Medical Complications • High Risk for Mental Health Complications

5. Examples • Most common complications of pregnancy are: • Spontaneous Abortion • Postpartum Depression • Antenatal Depression • Diabetes • Prematurity • Perinatal Loss

6. Depression World Health Organization • 2020 • depression will be 2nd greatest cause of premature death and disability worldwide in both sexes • Already • number one cause of disease burden in women

7. Perinatal Mood Disturbance • Definitions: • Antenatal Anxiety • Antenatal Depression • Postpartum Blues • Postpartum Psychosis • Postpartum Depression • Postpartum PTSD • Postpartum Anxiety

8. “Baby Blues” • 50 - 85% of women • Hours to days after childbirth lasting up to two weeks • Onset typically within 10 days • Mild, short-lived: • Anger • Sense of unworthiness, inadequacy, failure, guilt • Crying • Irritability/ Impatience • Restlessness • Sadness • Tiredness (fatigue), Insomnia, or both • Mood swings

9. Postpartum Anxiety • New Onset or Exacerbation • Generalized • Panic • Phobic • Social Phobia • OCD –like • Exacerbation is worse • Preoccupation with baby

10. Postpartum Psychosis • Rare - Less than 1% of women (1-2/1000) • Bipolar Disorder/ Schizophrenia/Schizoaffective Disorder/Psychotic Depression • Signs and symptoms even more severe and may occur early (within first 3 months postpartum – usually first 2 weeks) • Anger and agitation • Insomnia • Confusion and disorientation • Thoughts of harming self (suicide) or baby (infanticide) • Hallucinations and delusions • Paranoia • Strange thoughts or statements

11. Postpartum PTSD: Less well understood • Pregnancy and delivery and newborn period is a time of potential trauma • Pregnancy • Risk to mother • Risk to baby • Delivery • Risk to mother • Risk to baby • Congenital or other neonatal issue • (Anxiety, PTSD, Depression, Grief)

12. Postpartum Depression (PPD) • 10 - 20% of women • Signs and symptoms more intense and longer lasting • Symptoms of baby blues • PLUS • Emotional numbness, feeling trapped • Fear of hurting self or baby • Impaired thinking, concentration • Lack of joy • Less interest in sex • Excessive concern/lack of concern for baby • Significant weight loss or gain • Withdrawal from family and friends • “overwhelmed”, “anxious” as common descriptors

13. Postpartum Depression • Not as mild or transient as the blues • Not as severely disorienting as psychosis • Range of severity • Mild to Extreme Impairment • The same but different • Co-morbidity (Anxiety) • Violation of expectation

14. Major Depressive Episode • Depressed mood • Diminished interest or pleasure in everyday activities • Insomnia or hypersomnia • Significant weight loss or weight gain • Fatigue or loss of energy • Feelings of worthlessness or excessive or inappropriate guilt • Diminished concentration or indecisiveness • Recurrent thought of death, suicidal ideation, or suicide plan • Impairment in functioning • Five or more of these symptoms present during 2-week period; change in previous functioning • Symptoms can not be explained by another condition (substance use, medical condition) or another diagnosis (e.g., Bereavement) (taken from criteria as outlined in DSM-IV)

15. Prevalence of PPD • 1/8 : average of numerous studies • Higher in lower SES and other high-risk groups: • Up to 40%

16. Factors to Consider in Determining Risk • Mental Health History (major depression, psychosis) • Previous Pregnancy Experience • Loss • SES • Family/ Marital Relationship • Childhood Experiences • Mood During Pregnancy & Post-Delivery • Experience During Pregnancy/ Delivery • Infant Variables • Multiples • Societal/Cultural Influences/ Expectations Risk is Cumulative Additive effects

17. Protective Factors • Early Recognition and Seeking Help • Previous Pregnancy Experience • Peer/Marital Support • Respite Care • Focus on Mother • Enhanced feelings of Competence • SLEEP $$$$$$$$$

18. What causes Postpartum Depression? • Hormonal • Stress • Loss • Sleep • Untreated anxiety • Role transition • Support • Expectation • Own receipt of care • Personality features

19. Qualitative Experience(CT BECK) • Violation of an expectation • Thief that steals motherhood • Horrifying Anxiety • Relentless Obsessive Thinking • Enveloping Fogginess • Death of Self • Struggle to Survive • Regaining Control

20. Maternal Consequences Suffering Lack of joy in child Missed work Suicide attempts Social Impairment Marital discord Somatic Sx Health Care Consequences Less frequent HSV More Urgent Care /ER Ineffective Anticipatory Guidance Behind on immunizations Consequences of Postpartum Depression

21. PPD and Infant Development • PPD directly impacts the infant’s experience and may have longer-term consequences on development • Social • Emotional • Cognitive • Language • Attention • Mother-Infant Relationship/ Interaction

22. Treatment Approaches: Biological • Biological: • Medication: • Antidepressants • Anti-anxiety • Hormone Therapy • Estrogen patch • Sleep • Massage • Exercise • Sunlight

23. Treatment Approaches: Psychological • Psychological • Psychotherapies: • Cognitive Behavioral • Interpersonal Therapy • Psychodynamic • Supportive Individual • Family • Group • DBT/EMDR

24. Treatment Approaches: Social • Social: • Family • Friends • Church • Nurse Visitors

25. Treatment Approaches: Alternative • Alternative • Narrative Journaling • Meditation • Art • Music

26. Treatment Approaches: Integrative • Perspectives: • Lead to treatment • Bio-Psycho-Social Approach

27. Treatment Approaches • Two general approaches • Alleviation of maternal symptoms • Improvement of mother-infant relationship • Are interventions targeted only at mom enough to protect against negative child outcomes?

28. Treatment Approaches • Studies show that individual therapies may provide significant improvement in maternal mood and stress level • Little evidence that such treatments benefit infants of mothers with PPD • Lower attachment security status • Higher negative affect • More internalizing and externalizing problems

29. Treatment Approaches Are PPD interventions targeted only at mom enough to protect against negative child outcomes?

30. Dyadic Treatment Approaches • Concept of PPD as mother-infant relationship disorder (Cramer, 1993) • Dyadic therapy as preferred model for PPD treatment • Mother-infant relationship as focal point of treatment • Goal to increase maternal sensitivity, responsivity, engagement • Promote positive attachment behaviors

31. Dyadic Treatment Approaches • General Findings • Improved child outcomes even when maternal sx don’t improve • Buffering effect against future episodes of maternal depression • Those infants with dyadic PPD tx more closely resemble infants of non-depressed mothers in terms of cognitive ability

32. Psychiatric Evaluation Medication Management MITG: Group Therapy Infant Developmental Group Mother’s Group Dyadic (Mother-baby Group) Open Groups Social Support Individual therapy Family Therapy Integrative Approach

33. Not all people need meds Not all moms need individual psychotherapy Not all moms need group psychotherapy Some moms need education and have supportive adaptive environments Some moms need meds Some moms need psychotherapy Some moms need group psychotherapy Some moms need all of the above Step-Wise Interventions

34. Number of Women Treated Front Range Counties

35. Mental Health Centers Nurse Home Visiting Kaiser study: 2.8% of women received medication for depression or anxiety in 1 yr past delivery In Colorado? Mostly mid and high SES with support and resources Individual Psychotherapy Psycho-tropics Group Who gets treated?

36. The FACTS: • Postpartum Depression is highly prevalent • Postpartum Depression is not time-limited • Postpartum Depression is a major risk factor for an infant’s development • Postpartum Depression is highly treatable • Postpartum Depression does not get treated

37. Lack of Awareness Lack of Formal Screening Lack of Resources Lack of Training Mental Health Parity Public Awareness Professional Training Satellite Support Groups Mandatory Screening Conference Barriers

38. Barriers to Treatment • Public Awareness • Stigma • Professional Education • System Barriers • Resources • System Linkages

39. Barriers To Treatment • Public Awareness and Stigma

40. The Media’s View

41. The Common View of the Postpartum Period

42. The Reality • Tired • Alone at home • Most friends are at work • Lots of care for baby • Little time for self • Lack of sleep • Overwhelmed

43. Barriers to Treatment • Professional Training and Practice • lack of primary care identification • lack of professional awareness of condition • lack of expertise in perinatal and infant mental health issues • lack of awareness regarding psychopharmacological issues

44. Barriers to Treatment • Public Health: • Screening in WIC • Screening in Nurse Visitation • Primary Care: • Screening at OB • Screening at FP • Screening at Pediatric

45. Challenges of Detecting PPD • Depressed mood • Lack of pleasure/ interest • Feelings of worthlessness/ guilt • Agitation or retardation • Feelings of worthlessness/ guilt • Thoughts of death or suicide • Weight loss * • Loss of energy * • Sleep Disturbance * • Diminished concentration/ Indecisiveness * • Reports of “overwhelmed”, “anxious” • (60% PPD have co-morbid anxiety meeting diagnostic criteria) Symptoms often confused with more typical reactions to childbirth. BE AWARE- these may be indicators of the presence of PPD

46. Screening for PPD • Relationship-based? • Educate and Normalize PPD • Very Common and Very Treatable • Include Assessment of Partner

47. Early Identification Crucial • Need to rule out medical concerns (e.g., thyroid, anemia) • Attend to risk factors in prenatal period • Routine postnatal screening • Observation • Interview (ASK and LISTEN) • Do not minimize reports of symptoms • Consider Timing/ Circumstances • Screening: • Self-Report Measures • CES-D • Edinburgh Postnatal Depression Scale (EPDS) • Beck Depression Inventory (BDI) • Postpartum Depression Predictors Inventory (Beck,1998)

48. Barriers to Treatment • Perinatal Mental Health Expertise • Infant Mental Health Expertise • System Issues with MH Access in both the public and private sector

49. Assessment of Postpartum Mood Disturbance • Empathic and Relationship Based • Normalize the overwhelming and frightening experience • Subjective Experience • Safety • Mom and baby • Obsessive ruminations versus psychotic preoccupation • Assessment of Other Pathology • Worries • Thoughts • Assessment as Intervention

50. Barriers to Treatment • System Organizational and Infrastructural • Unknown referral sources • Medicaid funding • Institutional barriers • Engagement • Stigma • Phone Centers • Transportation • Time