Maternal Depression Project

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Maternal Depression Project

• Wake County Human Services
• Raleigh, North Carolina
• Jean C. Smith, MD
• jcsmith_at_co.wake.nc.us
• CityMatCH Albuquerque, NM
• September 23, 2008

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Consequences of untreated postpartum depression

• Disturbed mother-infant relationship (elevated
  cortisol found in both)
• Psychiatric morbidity in children later
  (depression, conduct disorder, lower IQ)
• Family tension
• Vulnerability to future depression
• Suicide/homicide

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Effects on offspring of untreated depression
during pregnancy

• Low birth weight (Federenko Wadhwa 2004)
• Preterm birth (Dayan et al. 2002)
• Pre-eclampsia (Kurki et al. 2000)
• Neonatal irritability (Zuckerman et al. 1990)

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Peripartum depression recognition and treatment
in primary care settings

• Ob/gyn survey (LaRocco-Cockburn et al. 2003)
• Only 32 reported theyd been appropriately
  trained to treat depression
• 73 cited time constraints for screening
• Pediatrician survey (Wiley et al. 2004)
• 49 not educated about PPD
• Only 31 felt theyd recognize PPD
• Only 7 were familiar with screening tools

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Peripartum depression recognition and treatment
in primary care settings

• Pediatricians
• -57 believed responsible to recognize
• -only 7 felt responsible for treatment
• Mothers
• -report fearful of judgment by pediatricians
• -most aware of pediatricians role as mandated
  reporter of child abuse
• (Heneghan,Mercer, DeLeone 2004)

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MDP -Key Partners

• Wake County Human Services (WCHS) is a
  consolidated agency including health, mental
  health and social services.
• MDP is shared collaboration between WCHS
• Womens health
• Child health
• Mental health

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MDP WCHS Partners in Planning Implementation

• Womens health Child health
• Child development
• Adult mental health Child mental health
• Perinatal substance abuse
• Maternal outreach care coordination
• Crisis mental health
• Health education
• Child protective services

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MDP - Community collaborators

• Center for Perinatal Emotional Wellness
• University of North Carolina (UNC) School of
  Social Work
• UNC Medical Centers Perinatal Psychiatry Program

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MDP - Purpose

• To address prevalence of perinatal depression and
  impacts on both maternal health and functioning
  and child development in WCHS clinics.
• NC Pregnancy Risk Assessment Monitoring System
  (PRAMS) 2004 19.4 mothers reported moderate to
  severe depression
• 10 mothers scored at risk or higher on the EPDS
  WCHS Child Health Clinic survey 2005

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MDP Objectives Methods

• Identify, support and refer to care depressed
  mothers.
• Develop clinic protocols
• Screen 100 of pregnant women and mothers at 2
  mo.postpartum and 4 mo. well child visit with
  Edinburgh Postnatal Depression Scale (EPDS)
• Triage and refer to care all women scoring at
  risk or positive for depressive symptoms on EPDS

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MDP Objectives Methods(2)

• Train staff in peripartum behavioral health
  issues
• Train medical staff in child and woments clinics
• Train behavioral health staff for assessment,
  crisis intervention, and treatment
• Train other human services program staff working
  with pregnant and post-partum women and their
  children

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MDP Objectives Methods(3)

• Engage broad spectrum of human services in
  planning and service delivery
• 4. Develop community resource guide on peripartum
  mood disorder services

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MDP Objectives Methods(4)

• Develop a protocol to identify children of
  depressed mothers at risk for developmental
  problems
• Screen all children of mothers who scored
  positive for depression using Brigance
• Refer all children with concerns on screenings to
  the Child Developmental Services Agency (CDSA)

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MDP Objectives(5)

• Collect data on EPDS screenings and referrals of
  identified mothers
• Assess process outcomes
• Secured care outcomes of referrals
• Longitudinal analysis of scores

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Outcomes/Results

• 100 of target population now screened in all
  WCHS womens and childrens clinics
• Protocols in place for screening, referral,
  behavioral health consultation and crisis
  intervention.

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Outcomes/Results(2)

• All women with scores above 12 on EPDS referred
  for full behavioral health assessment women
  with scores between 8-12 receive targeted
  follow-up and referral for support services and
  education.
• All clinic medical staff have received training.

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Outcomes/Results(3)

• Advisory committee expanded to include
  representatives of health clinics adult and
  child behavioral health crisis mental health
  services child welfare child development
  maternal outreach and care coordination and
  community health programs.
• Community outreach subcommittee formed.

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Outcomes/Results(4)

• 360 women participated in the Latina mothers
  depression support group Mamas Apoyando Mamas
  (9/2006-2/2008).
• 589 mothers have received mental health
  assessment and referral to treatment providers.

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Overcoming Barriers

• Clinic providers lack of understanding of
  maternal depression.
• -presentations in clinic staff meetings
• Invitations to initial workgroup
• Free continuing education training exclusively
  for WCHS staff provided on site by UNCs
  Perinatal Psychiatry Program.

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Overcoming Barriers(2)

• Clinic staffs reluctance to change (time and
  patient flow concerns)
• key staff assisted in pilot projects modeling
  EPDS
• EPDS folded into the existing practice of other
  clinic screening protocols

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Overcoming Barriers(3)

• Reluctance to identify maternal depression and
  not have resources for referral.
• Education, education, education
• Identification and introduction of mental health
  staff with contact numbers and on-site
  availability in protocols before screening
  implemented

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Overcoming Barriers(4)

• Willingness to share information between womens
  clinic, child health clinic, mental health
  services, and child welfare.
• Directly addressing communication issues with
  leadership.
• Fostering a sense of shared responsibility and
  accomplishment of all clinic staff.
• Ongoing effort!

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Overcoming Barriers(5)

• Support staff and funding
• Using current clinic and behavioral health
  program budgets.
• Requesting full-time bilingual/bicultural LCSW to
  provide MH services, coordinate program, collect
  data for outcomes reports, and provide
  consultation and education within WCHS and
  community outreach.

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Lessons Learned

• Highly collaborative process across programs and
  staff helps ensure commitment to shared outcomes
  rather than a single program.
• Protocols ensure practice continues as part of
  clinics routines.

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Lessons Learned(2)

• Integration of programs under human services
  department in practice as well as philosophy.
• Designing the MDP to function without additional
  staff or resources actual helps assure program
  continues.
• Allowing a longer time-frame for implementation
  helps ensure better communication collaboration.

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• and when she was done drinking, I eased her
  into her crib, gave her the cachcach blanket, and
  she went straight to sleep. That night I, too,
  slept like a baby. We loved and needed each
  other.
• From Down Came the Rain My Journey Through
  Postpartum Depression (Brooke Shields

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References

• Battle C, Zlotnick C. Prevention of postpartum
  depression. Psychiatric Annals. 200535(7)
  590-604. (NOTE entire July 2005 Psychiatric
  Annals is on postpartum depression)
• Chaudron L, Szilagyi P, Kitzman H, Wadkins H,
  Conwell Y. Detection of Postpartum Depressive
  Symptoms by Screening at Well-Child Visits.
  Pediatrics. 2004 113(3) 551-558.

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References

• Heneghan A, Mercer M, Deleone N. Will mothers
  discuss parenting stress and depressive symptoms
  with their childs pediatrician? Pediatrics.
  2004 113(3) 460-467.
• Wisner K, Parry B, Piontek C. Postpartum
  depression. New England Journal of Medicine.
  2002 347(3) 194-199.

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References

• Dubowitz H, et.al. Screening for Depression in an
  Urban Pediatric Primary Care Clinic. Pediatrics
  119, 3 435, 2007.
• Chaudron L, Szilagyi P, Campbell A, Mounts K,
  McInerny T. Legal and ethical considerations
  Risks and benefits of postpartum depression
  screening at well-child visits. Pediatrics 119,
  1123, 2007.

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Websites

• www.dbpeds.org
• www.illinoisaap.org/socialemotional.htm
• www.hfs.illnois.gov/mch
• www.cdc.gov/PRAMS/PPD

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Other Resources

• North Carolina Postpartum Support International
• Center for Perinatal Emotional Wellness Anne
  Wimer. Contact 919-889-3221or awimer_at_nc.rr.com
• Raleigh and Cary support groups
• Duke Support Group
• UNC Perinatal Mood and Anxiety Disorder Clinic
• Beyond the Blues S. Bennett and P. Indman
  (Spanish also) www.beyondthe blues.com