Support Babies by Screening Mommas: How to implement postpartum depression screening in well child Checks Tessa Wetjen, MPA, Minnesota Department of Health Dr. Brian Lynch, Mayo Clinic MNAAP Hot Topics 9/19/2018

Postpartum Depression Screening within Well Infant Visits Rationale Basic Expectations Implementation Questions and Recommendations Resources

Language disclaimer Not all mothers are women, not all primary caregivers are mothers Anxiety is co-occurring and possibly more prevalent than depression Body of research is mothers and depression

Stories Dark Side of the Fuller Moon, Trailer 9/19/2018

What are Perinatal Mood and Anxiety Disorders (PMAD)? PMADs encompass a number of mental health disorders that can affect women before, during and after pregnancy. - Prenatal and postpartum depression - Prenatal and postpartum anxiety disorders - Postpartum Psychosis - Intrusive thoughts Disruptive to care of self and others Not necessarily hormonal – can be father, adoptive mother, etc. 9/19/2018

Postpartum Depression (PPD) vs. Baby Blues The Baby Blues Postpartum Depression Impacts 10-15% of new mothers Signs: tearfulness, feelings of sadness, irritability, similar to symptoms of major depressive disorder—thoughts of harming herself or child Occurs anytime within the first 12 months after birth Symptoms persist and require treatment May impact up to 80% of new mothers Signs: emotional instability, crying spells, irritability, anxiety– does NOT interfere with caring for infant Occurs in the first month after birth Symptoms resolve within two weeks 9/19/2018

Maternal Deaths by Suicide in MN In 2015, 1/3 of maternal deaths in Minnesota were by suicide. Often, there are risk factors or signs that may be identified before a crisis. Screening and assessment, that leads to treatment, is a best practice to prevent suicide. MN continues to work to increase access to screening, treatment, and community support for all moms. A mother seeking support for suicide may call the National Suicide Prevention Lifeline at 1-800-273-8255. 9/19/2018

Effect of Maternal Depression on Child Prenatal Inadequate prenatal care, poor nutrition, higher preterm birth, low birth weight, pre-eclampsia and spontaneous abortion. Infant Behavioral: Anger and protective style of coping, passivity, withdrawal, self-regulatory behavior, and dysregulated attention and arousal Cognitive: Lower cognitive performance Toddler Behavioral: Passive noncompliance, less mature expressions of autonomy, internalizing and externalizing problems, and lower interaction Cognitive: Less creative play and lower cognitive performance 9/19/2018

Effect on Child, Cont. School Age Adolescent Behavioral: Impaired adaptive functioning, internalizing and externalizing problems, affective disorders, anxiety disorders and conduct disorders Academic: Attention deficit/hyperactivity disorder and lower IQ scores Adolescent Behavioral: Affective disorders (depression), anxiety disorders, phobias, panic disorders, conduct disorders, substance abuse and alcohol dependence Academic: Attention deficit/hyperactivity disorder and learning disorders 9/19/2018

April 21, 2017

PPD and Breastfeeding Early postpartum depressive symptoms appear to be related to ceasing breastfeeding, but either as a cause or consequence. Mothers with symptoms of PPA (anxiety) are less likely to breastfeed exclusively, more likely to stop breastfeeding earlier, less likely to initiate, more likely to supplement with formula in the hospital Salivary oxytocin is released across breastfeeding cycle and has a temporary calming effect on mood. Research does support using medication while breastfeeding, but isn’t absolute. 9/19/2018

AAP Recommendation 1, 2, 4, and 6 month visit Discusses the Edinburgh (EPDS) and the brief screener (PHQ2) Highlights importance of issue, impact on baby and family Recommends dyad services – therapy for parent and baby together- common for infant mental health Provider in every county in MN, find at https://edocs.dhs.state.mn.us/lfserver/Public/DHS-5448D-ENG 9/19/2018

Screening Best Practices: Screen all primary caregiver with baby Use a tool to screen Patient Health Questionnaire-9 (PHQ-9) Edinburgh Postnatal Depression Scale (EPDS) Option- Generalized Anxiety Disorder – 7 (GAD 7) Screens are most effective around 3 weeks after birth – so helpful at 1 month visit Screen at first visit and at regular intervals – adjust as needed for population GADs-7 plus EPDS. 9/19/2018

Why Universal Screening? 1/5 moms with postpartum depression will have no history of mental illness Can occur with adoptive parents, with one pregnancy and not others, with fathers April 21, 2017

PRAMS PPD Data All categories except Hispanic included “non-Hispanic” in option on the survey. 9/19/2018

MN Public Plan Billing Data Medicaid billing data from Minnesota shows that in 2012, 18.09% of women who had given birth had a diagnosis of depression within a year of giving birth. Rates for Depression for Mothers within 1 year after delivery   Total Births with at least one Well Child Visit in first year of life Counts of Mothers with Postpartum Depression Percent 2011 26,183 4,705 17.97% 2012 26,654 4,822 18.09% 2013 26,393 4,632 17.55% 7/27/2016

MN Postpartum visit rates 9/19/2018

MN C&TC Rates 2014, 2015

Responding to Screen Crisis Low to no concern Maternal Wellbeing Plan, Fact Sheet Mild/Moderate concern -Create referral/next steps plan with mom -Designate staff to follow up within 1 week Crisis What is your crisis plan for a mom who is suicidal/homicidal? How will you contact family to provide support for children? Who will stay with mom to ensure safe transfer? 9/19/2018

Education Materials for Everyone My Maternal Wellbeing Plan Sleep/rest, Connection with others, Healthy food, Movement, Support Fact Sheet: Depression and/or Anxiety During Pregnancy and Postpartum Both Available in 7 languages: Amharic, English, Hmong, Karen, Russian, Somali, Spanish 9/19/2018

Treatment options Support Psychotherapy Medication Peer, or community support programs Family home-visiting Support First line treatment for PPD DYAD therapy for infant and parent Cognitive behavioral therapy Interpersonal Psychotherapy Group, 1-1, workbook option (CBT) Psychotherapy Use of medication should be based on risk/benefit analysis, including during breastfeeding. Consult available. Medication 7/27/2016

Options for Referrals Set crisis plan- who will manage children? Connect parent with primary care and/or therapist Within your own network Figure out process ahead of implementation Community Supports Family home visiting, therapists, support groups Who is parent willing to see? Practice scripting Talk with parent about what they is willing to do and take it from there Ask about insurance status, use county mental health services if needed 9/19/2018

Consider Child in Response If primary caregiver screens positive, initiate increased developmental screening with child Consider MN Follow Along Program Consider Early Children’s Mental Health System – Dyad therapy April 21, 2017

Implementation Challenges Lessons from Implementation with 13 clinics around Minnesota 9/19/2018

When and How Selecting a tool: PHQ 9 or EPDS if billing Deciding which visits Selecting just one or two visits What fits in work flow, what fits with other screens Best all up to 6 months or 1 year Who distributes screen, scores, follows-up Terminology- PPD may mean TB screen for some staff 9/19/2018

Biggest Barriers Liability? Not biggest issue… DOCUMENTATION How to know it’s been done and followed up on but not put too much parent information in child record Options All in child’s record Only “screen done” in child’s and all other notes In stand alone non-EMR record In parent record made for that purpose 9/19/2018

Resources Clinical Guidelines for Implementation Child and Teen Check Ups Periodicity Schedule www.womensmentalhealth.org compiles latest research on this topic, from UMass. http://www.infantrisk.com/categories/breastfeeding useful for medication questions. Minnesota’s consultation service for children is available to for medication for breastfeedign consults- 1-855-431-6468 HCMC Mother-Baby Center Postpartum Support MN – text/phone peer support Postpartum Support International- web info in English and Spanish 9/19/2018

Research Cited Postpartum Anxiety and Infant-Feeding Outcomes: A Systematic Review. Fallon V1, Groves R2, Halford JC2, Bennett KM2, Harrold JA, J Hum Lact. 2016 Aug 26. AAP Report http://pediatrics.aappublications.org/content/pediatrics/early/2010/10/25/peds.2010-2348.full.pdf Canadian Paediatirc Society, 2004. “Maternal Depression and Child Development.” Paediatrics & Child Health. 2004 Oct; 9(8): 575–583. Women Birth. 2016 Jul 19. pii: S1871-5192(16)30047-6. https://www.ncbi.nlm.nih.gov/pubmed/28103103 9/19/2018

Questions? Tessa Wetjen Tessa.Wetjen@state.mn.us 651-201-3625 Dr. Brian Lynch Lynch.Brian@mayo.edu Thank you! 9/19/2018