Maternal Depression Project

Wake County Human Services

Raleigh, North Carolina

Jean C. Smith, MD

jcsmith@co.wake.nc.usCityMatCH Albuquerque, NM

September 23, 2008

“I started to experience a sick sensation in my stomach; itwas as it a vise were tightening around my chest. Insteadof the nervous anxiety that often accompanies panic, afeeling of devastation overcame me. I hardly moved.Sitting on my bed, I let out a deep, slow, guttural wail. Iwasn’t simply emotional or weepy, like I had been told Imight be. This was something quite different. This wassadness of a shockingly different magnitude. It felt as if itwould never go away.”

-from “Down Came the Rain: My Journey ThroughPostpartum Depression” (Brooke Shields)

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

(Lundy et al. 1999; Jacobsen 1999)

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)

Peripartum depression: recognition and treatment in primary care settings Ob/gyn survey (LaRocco-Cockburn et al. 2003):

– Only 32% reported they’d 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 they’d recognize PPD– Only 7% were familiar with screening tools

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)

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: Women’s health Child health Mental health

MDP – WCHS Partners in Planning & Implementation

Women’s 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

MDP - Community collaborators

Center for Perinatal Emotional Wellness University of North Carolina (UNC) School of

Social Work UNC Medical Center’s Perinatal Psychiatry

Program

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

MDP – Objectives & Methods

1. 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

MDP – Objectives& Methods(2)

2. Train staff in peripartum behavioral health issues Train medical staff in child and women’ts 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

MDP – Objectives& Methods(3)

3. Engage broad spectrum of human services in planning and service delivery

4. Develop community resource guide on peripartum mood disorder services

MDP – Objectives& Methods(4)

5. 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)

MDP – Objectives(5)

6. Collect data on EPDS screenings and referrals of identified mothers

Assess process outcomes Secured care outcomes of referrals Longitudinal analysis of scores

“I sat holding my newborn and could not avoid the imageof her flying through the air and hitting the wall in front ofme. I had no desire to hurt my baby and didn’t see myselfas the one throwing her, thank God, but the wall morphedinto a video game, and in it her little body smacked thesurface and slid down onto the floor. I was horrified, andalthough I knew deep in my soul that I would not harmher, the image all but destroyed me.”

From “Down Came the Rain: My Journey ThroughPostpartum Depression”, Brooke Shields, 2005

Outcomes/Results

100% of target population now screened in all WCHS women’s and children’s clinics

Protocols in place for: screening, referral, behavioral health consultation and crisis intervention.

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.

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.

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.

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 UNC’s Perinatal Psychiatry Program.

Overcoming Barriers(2)

2. Clinic staff’s 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

Overcoming Barriers(3)

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

Overcoming Barriers(4)

4. Willingness to share information between women’s 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!

Overcoming Barriers(5)

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.

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 clinic’s routines.

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.

“…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

References

Battle C, Zlotnick C. Prevention of postpartum depression. Psychiatric Annals. 2005;35(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.

Zlotnick C. Prevention of postpartum depression. Psychiatric Annals

References

Heneghan A, Mercer M, Deleone N. Will mothers discuss parenting stress and depressive symptoms with their child’s 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.

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, 1:123, 2007.

Websites

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

Other Resources

North Carolina Postpartum Support International Center for Perinatal Emotional Wellness – Anne

Wimer. Contact #919-889-3221or awimer@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