Perinatal Depression Project Enhanced Teen Services and Child & Family Health Services Fall Meeting October 29, 2009 Cleveland Regional Perinatal Network (CRPN) Perinatal Depression Project Presented by Avril S Albaugh LISW CRPN Perinatal Depression Project Coordinator Cleveland Regional Perinatal Network Cedar, Suite 320B Cleveland, Ohio, Ph: (216)

Presentation Outline  Cleveland Healthy Family Healthy Start (HFHS) 2002 Perinatal Depession Study Goals and Outcomes  Cleveland Regional Perinatal Network (CRPN) 2005 Perinatal Depression Project Awareness Training Linkages

Project Goals  Estimate occurrence of perinatal depression in African- American women, ages 15 – 44 residing in city of Cleveland  Identify screening and referral practices among health care and social service providers  Identify mental health services for women with perinatal depression  Make recommendations

Results: Occurrence  386 participants  248 prenatal, 138 postpartum  313 in person, 73 by phone  Using EPDS* Score 13 +, 19% (72 of 386) screened at risk for perinatal depression *Edinburgh Postnatal Depression Scale

Results: Screened at risk  Prenatal 21%  Postpartum 14%  Telephone respondents 23%  In person 18% As number of pregnancies increases, risk of depression increases

Results: Screening and Referral Practices  Telephone surveys of 29 healthcare and social service agencies  28 used no formal screening tool consistently

Results: Mental Health Services Telephone surveys of 79 mental health agencies (First Call for Help)  Half would see women experiencing perinatal depression  No agency contacted had specific program for perinatal depression(2002)

Provider Focus Group Findings:  Services for Perinatal Depression seen as:  Fragmented  Confusing  Complex  No Continuity  Gaps and Barriers: Providers  Providers reluctant to screen  Inconsistent screening  Limited knowledge of resources  Poor referral mechanism

Gaps and Barriers : Client  Stigma/ Labeling  Cultural Issues  Mistrust of system  Fear of DCFS  Fear of medications  Mental health in separate setting  Transportation  Wait time  Lack of public information about symptoms and treatment

Perinatal Depression can present as a serious disorder prevalent in pregnancy and post partum with negative consequences for women and their infants Gaps in identification Gaps in access to care Gaps in services

Recommendations  Increase awareness level about perinatal depression among providers and consumers  Provide education and training in identification and referral  Establish clear guidelines/care path for screening and referral  Develop provider and consumer materials  Explore best practice models with perinatal and mental health providers  Improve referral process  Data collection

is commtted to… Raising public awareness Training providers to identify women at risk Providing linkages to community services Perinatal Depression Project The Cleveland Regional Perinatal Network

Identification: Screening and Referral  2005 CFHS funding to develop training model and provide on site training free for all providers in Cuyahoga County and the region.  1200 providers trained regionally and across state.

ODMH/ODH Maternal Depression Project  Fifteen sites selected across the state  Collaborative effort between Help Me Grow and Mental Health providers  HMG Service Coordinator screen 4-20 weeks postpartum using EPDS  Referrals to local mental heath providers  Data collection  Future plan to expand project across Ohio to include 88 counties with mandatory screening  HMG at State to adopt CRPN web-based training packet

Training Outline Perintal Depression: Background  Symptoms  Overview of Depressive Disorders  Effects of Untreated Maternal Depression on Infant Development Screening for Perinatal Depression  Edinburgh Postnatal Depression Scale (EPDS)  Scripts for Administering EPDS  Review of Screening and Referral Process: Sample Care Path and Fax Referral Form Resources for Providers  Guide for Moms  Maternal Depression tablet  Poster

Edinburgh Postpartum Depression Scale Scoring: 1. 1 of 4 possible responses that comes the closest to symptoms during the previous 7 days. 2. All 10 items must be completed. 3. Items are scored 0,1,2,3 with * items reversed (3,2,1,0). 4. Item 10 warrants immediate discussion if score is >1 (i.e., suicide risk).

Question 10 has response : 1. Hardly Ever 2. Sometimes 3. Yes, quite often Discuss need for further assessment and referral Document interventions in patient’s record Score of 11 or less  Provide Maternal Depression tear off sheet.  Re-screen at later point if necessary Screening Results Patient Refusal If client refuses social work or mental health referral, document in patient record  Provide patient with “Guide for Moms”  Review differences between baby blues and perinatal depression  Address issue at next visit Intervention Discuss with patient her responses and the need to assess her safety  Coordinate on site psychiatric evaluation  Contact MHS Inc at (216) for crises phone evaluation  Document safety plan in patient record Score of 12 or more Depression Screening EPDS to be completed by the frontline provider  Prenatal (24-26 weeks)  Postpartum (after 4 weeks)  Anytime there is a concern  Copy of EPDS kept in chart Cleveland Regional Perinatal Network (CRPN) Perinatal Depression Screening and Referral Carepath (Sample) On-Site Referrals Social Work Mental Health Patient Refuses Screen Document refusal in chart Attempt to re-screen next visit Community Mental Health Referral Complete Maternal Behavioral Health Referral Fax Form and fax to appropriate Behavioral Health Agency Patient must sign consent to release and share Also notify mental health provider via telephone about referral Copy of fax form kept in record “Guide for Moms” provided Patient Self- Referral Offer referral options “Guide for Moms” Developed by: Avril S Albaugh LISW, Perinatal Depression Project Coordinator Cleveland Regional Perinatal Network, Cedar, Suite 320B, Cleveland, Ohio, Ph: (216) Copyright 2009

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Improvement in Provider Linkages Perinatal Depression Task Force consisting of multi-agency perinatal and mental health and medicaid managed care providers:  Address problems with current referral and intake system and make improvements.  Mental Health Fax Referral Sheet developed and currently being utilized.  Wait time for appointments reduced to less than 2 weeks.  In-home intake available.

Evaluation of Providers Screening and Referral Practices for Perinatal Depression A Report of Initial Site Findings Avril S Albaugh LISW Perinatal Depression Project Coordinator Cleveland Regional Perinatal Network University Hospitals Case Medical Center University MacDonald Womens Hospital Cleveland, Ohio

Objectives The specific objective of this descriptive study was to determine the effectiveness of implementation of a perinatal care path to guide identification and referral of perinatal depression. This study assessed: a) incidence of health care provider screening for depression among pregnant clients, b) the number of screened clients who are at risk for depression, and, c) the number of clients referred to mental health services

Study Findings Number of Pregnant Women Screened for Depression

Trimester of Pregnancy the EPDS was Administered:

On Site Referrals

Conclusions According to the data collected, implementation of a provider perinatal care path appeared to be effective in guiding identification and referral of perinatal depression. Furthermore, the study was able to collect data on:  a) the incidence of health care provider screening for depression among pregnant women,  b) the number of screened women who are at risk for depression, and,  c) the number of women referred to mental health services.

Next Steps  Data to be collected in Lorain County at 2 nd site  Number of women at risk higher since screening  Task force formed  Fax sheet developed

Issues Needing to be Addressed  Some agencies who have been trained no formal care path: Need to educate administrators.  Care should be equal across socio-economic classes: Private OB providers need education/awareness.  Cuts in Mental Health services affect service delivery Task force to examine issues of high no show rate; where to deliver care.  Reduce stigma More public education about perinatal depression to target partners, family, community who support pregnant depressed women.  Training and Retraining Expansion of ODH maternal depression project, train the trainer, staff turnover.

Issues (Cont)  More Research Collect data on impact of mental health treatment and outcome of pregnancy.  Adolescent Population Some agencies without child/adolescent psychiatrist. Ohio law, 14 year old seek counseling only up to 30 days/6 sessions without parental consent. (American Academy of Pediatrics: March 2006 Issue)

Contact Information Avril S Albaugh LISW Coordinator, Perinatal Depression Project Cleveland Regional Perinatal Network Address: Cedar Road Suite 320B Cleveland, Ohio, Phone: (216) Website: