Point of Care Screening and Intervention for Postpartum Depression at Well Child Visits Tanner Nissly DO, Laura Miller MD, Emily Kidd MD PGY-3 Stephanie Trudeau MS, Andrew Slattengren DO, Jerica Berge PhD, MPH, LMFT University of Minnesota-North Memorial Family Medicine Residency Program

Disclosures Speaker & Faculty Disclosures The speakers and faculty disclose no relevant financial relationship or interest with a proprietary entity producing health care goods or services. We received financial and administrative support from the Minnesota Department of Health for this project. This program does not include any discussion or demonstration of any pharmaceuticals or medical devices that are not approved by the Food and Drug Administration (FDA) or that are considered “off-label.” This is from the template emailed out – not sure if the first part is supposed to be included??

Learning Objectives On completion of this session, the participants should be able to: Describe the benefits of screening for postpartum depression at well child checks Evaluate current practices of screening for postpartum depression at one’s own institution Propose ways in which this or similar projects may be implemented at one’s own institution

Postpartum Depression - Background Affects 10-15% of women in the first year after delivery1 Highest rates among urban low-socioeconomic status minority women (as high as 1 in 4)2 Morbidity of undiagnosed and undertreated postpartum depression3: Children: less effective parenting, more negative interactions, fewer positive parenting behaviors Mothers: impaired relationships and attachment -Prevalence 10-15% after delivery, rates highest among poor and minority women. (as high as 1 in 4). Estimated 50% undiagnosed (Yawn) -Can occur up to 1 yr after birth but typically occurs within 3mos post-delivery -Effects on children: less effective parenting, more negative interactions, fewer positive parenting behaviors

Postpartum Depression - Screening Mothers with depressive symptoms4: Are more likely to seek care for their children than for themselves Are less likely to attend their own postpartum medical visits Studies have shown increased detection of postpartum depression by screening at well child visits, as well as improved outcomes when women receive medical and mental health treatment in response to being screened5,6 -Previous method: provider-based referral for mental health services prn without integration of care coordination or mental health services -Intervening with mothers during well-child visits is ideal opportunity for screening and treatment of postpartum depression

Research Questions Do depression scores reduce from baseline to 6-month, 1-year and 18-month follow-up when patients receive mental health services of postpartum depression? Do depression scores reduce more for patients who receive point- of-care mental health interventions for postpartum depression and follow-up compared to those who receive internal referrals, external referrals or choose to receive no mental health services? New information we are obtaining: -12mos outcomes shown to improve with primary care screening/diagnosis management: we are looking at and beyond 12mos. -Point of care intervention effectiveness -Feasibility of screening in an FM residency setting (could be spread to other residencies)

All well child checks 2 weeks – 6 months: Process All well child checks 2 weeks – 6 months: Medical assistant gives PHQ-9 to mother PHQ-9 < 10 PHQ-9 > 10 -Offer point-of-care intervention -Consider antidepressant and/or therapy -Asked if want to participate in study (PHQ-9 at 6, 12 and 18mos postpartum) -Educate on self-care, PPD, and resources -Re-screen at future visits -Done with MDH -BFM overview: residency in North Minneapolis, underserved, 40-60 well child visits monthly on children 6 mos of age or younger -Behavioral health: point of care interventions Receives ongoing care coordination and behavioral health follow up

Warm Handoff/BH Point-of-Care Intervention When PHQ-9 score is > 10: Provider introduces patient to Behavioral Health provider BH provider assesses symptom severity Stabilizes symptoms Engages in point-of-care care therapy session (if patient has time) Schedules therapy appointment in-house or facilitates setting up external referral/appointment

Evaluation Feasibility of integrating maternal PHQ-9 screens into well child visits Impact of point of care interventions and follow up on postpartum depression over time, as measured by PHQ-9 scores Timeline: Data collection: July 2015 – June 2016 Long term follow up: through December 2017 1) Feasibility – eliciting MA and provider feedback on flow

Data Total WCC 36 49 33 59 Negative Screen 22 31 29 24 45 November December January February March Total WCC 36 49 33 59 Negative Screen 22 31 29 24 45 Positive Screen 10 9 7 8 Warm Hand Off 1 4 2 Therapy

Resources Altshuler LL, et al. Course of mood and anxiety disorders during pregnancy and the post-partum period. J Clin Psychiatry 1998;59:29. Chaudron LH, et al. Accuracy of Depression Screening Tools for Identifying Postpartum Depression Among Urban Mothers. Pediatrics. 2010 March; 125(3): e609-e617. Lovejoy MC, et al. Maternal depression and parenting behavior: a meta-analytic review. Clin Psychol Rev. 2000;20:561-592. McLennan JD, Kotelchuck M. Parental prevention practices for young children in the context of maternal depression. Pediatrics. 2000;105:1090-1095. Yawn B P, et al. TRIPPD: A practice-based network effectiveness study of postpartum depression screening and management. Ann Fam Med 2012: vol.10, no.4. Gjerdingen D, et al. Postpartum depression screening at well-child visits: validity of a 2-question screen and the PHQ-9. Ann Fam Med 2009: vol.7, no.1.

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