Maternal Depression: Background & Emerging Considerations Joy Burkhard California Maternal Mental Health Collaborative California Association of Health Plans Seminar: Behavioral Health Across the Continuum August 1, 2012 (updated with NCQA Maternity Care Measures and OBGYN Psychiatrist Consult Line Recommendation )

The Federal Affordable Care Act requires coverage for preventive treatment including postpartum depression screening at no cost to women. Yet given the need for additional research, there are no national standard screening guidelines. TREATMENT OPTIONS Treatment for MD includes psychotherapy or pharmacotherapy or a combination of both. © 2012 CA Maternal Mental Health Collaborative 2 Formed in 2011 at the suggestion of the legislature through ACR 105 (2010), sponsored by the Junior Leagues of Ca. ACR 105 also declared May of every year as Perinatal Mental Health Awareness month. The Mission of the Collaborative is to bring stakeholders together to exchange ideas and form collaborative relationships to increase and improve awareness, diagnosis and treatment of maternal mental health disorders in California. Formed in 2011 at the suggestion of the legislature through ACR 105 (2010), sponsored by the Junior Leagues of Ca. ACR 105 also declared May of every year as Perinatal Mental Health Awareness month. The Mission of the Collaborative is to bring stakeholders together to exchange ideas and form collaborative relationships to increase and improve awareness, diagnosis and treatment of maternal mental health disorders in California. The American College of Obstetricians and Gynecologists (ACOG) has been a strong advocate for recognition and treatment of maternal mental health disorders and is proud to have a member, Judy Mikacich, serve as the Co-Chair of the California Maternal Mental Health Collaborative (CMMHC). In a short time it's become quite clear that the CMMHC is a force to be recognized in peripartum mental health. Because of their collaborative work with many different organizations they have identified barriers and solutions and are breaking down these barriers one-by-one. -Laurie Gregg, M.D., Chair ACOG District IX (California) The American College of Obstetricians and Gynecologists (ACOG) has been a strong advocate for recognition and treatment of maternal mental health disorders and is proud to have a member, Judy Mikacich, serve as the Co-Chair of the California Maternal Mental Health Collaborative (CMMHC). In a short time it's become quite clear that the CMMHC is a force to be recognized in peripartum mental health. Because of their collaborative work with many different organizations they have identified barriers and solutions and are breaking down these barriers one-by-one. -Laurie Gregg, M.D., Chair ACOG District IX (California) The California Maternal Mental Health Collaborative

The Federal Affordable Care Act requires coverage for preventive treatment including postpartum depression screening at no cost to women. Yet given the need for additional research, there are no national standard screening guidelines. TREATMENT OPTIONS Treatment for MD includes psychotherapy or pharmacotherapy or a combination of both. © 2012 CA Maternal Mental Health Collaborative (but please still share this PowerPoint or independent ideas!) 3 Women in their childbearing years account for the largest group of Americans with Depression. Postpartum depression is the most common complication of childbirth. Despite the Prevalence Maternal Depression goes largely undiagnosed and untreated. Women in their childbearing years account for the largest group of Americans with Depression. Postpartum depression is the most common complication of childbirth. Despite the Prevalence Maternal Depression goes largely undiagnosed and untreated. Did you know…

Maternal Mental Health Highlights Up to 80% of mothers will experience the ‘baby blues’ which resolve untreated within two weeks % of women will experience maternal depression (MP) during pregnancy or postpartum. Psychosis is extremely rare but serious (effecting less than.2% of women). Up to 80% of mothers will experience the ‘baby blues’ which resolve untreated within two weeks % of women will experience maternal depression (MP) during pregnancy or postpartum. Psychosis is extremely rare but serious (effecting less than.2% of women). WHO MD onset generally occurs within the first 6 weeks postpartum though can be diagnosed within a year. DSM V recognizes onset within 6 months. Evidence suggests that women who experience maternal depression are more vulnerable to changing hormones levels including increase stress response. Additionally genetics, psychosocial factors and life stressors play a role. Risk factors include prior depression or family history, substance abuse problems, lack of social support or absence of community network, poor marital relationship, unwanted pregnancy, fertility challenges & financial instability. African Americans are 35% likely to suffer from MD & adolescents also face higher risk. Evidence suggests that women who experience maternal depression are more vulnerable to changing hormones levels including increase stress response. Additionally genetics, psychosocial factors and life stressors play a role. Risk factors include prior depression or family history, substance abuse problems, lack of social support or absence of community network, poor marital relationship, unwanted pregnancy, fertility challenges & financial instability. African Americans are 35% likely to suffer from MD & adolescents also face higher risk. 4 Maternal Depression is a mood disorder with symptoms similar to the ‘blues’ that persist beyond 2 weeks. Symptoms can be mild to severe. MD is treatable. WHAT WHEN WHY SYMPTOMS Irritability, Significant changes in appetite, Poor concentration, Fatigue, Feeling overwhelmed, Persistent sadness, Anxiety, Insomnia or in some cases hyperinsomnia, Obsessive thoughts and fears such as thoughts of harm to the baby, Recurrent thoughts of death or suicide. Women generally also feel confusion and shame and consequently may not share their feelings. 4

Untreated Maternal Depression can… Lead to health risks for the baby including: Pre-term birth Increase risk of Infant Neglect Lack of healthy infant-mother bonding which can lead to long-term effects on child development and well-being. Increased risk of infanticide. Have a other negative far-reaching implications including negative impact on: Increasing risk of Pre-eclampsia, which can be life- threatening The well-being of other children, Marriage stability, Ability to work, The mother’s long-term well-being and sense of worthiness. Increased risk of substance abuse. Increased risk of psychiatric hospitalizations. Increased risk of abortion or adoption. Increased risk of suicide. 5 Untreated Depression Increases Health Risks to Mothers, Infants & Families © 2012 CA Maternal Mental Health Collaborative (but please still share this PowerPoint or independent ideas!) © 2012 CA Maternal Mental Health Collaborative

Depression: The Bottom Line 6 DEPRESSION COSTS The cost of depression totaled $83.1 billion dollars in the U.S. in $26.1 billion in direct medical cost, $5.4 for suicide related mortality cost, &$51.5 billion for workplace costs (disability, absenteeism & presenteeism) The costs of MD specifically have not been reported, however: women with depression generally have more expensive medical claims than men pregnant women with untreated depression are at risk for costly pre-term birth complications. UNTREATED DEPRESSION COSTS Women with moderate to severe untreated maternal depression are at risk for ER & inpatient stays. We don’t have data that suggests how many women go to the ER or are admitted for psychiatric trouble during the peripartum period. One case cost her insurer $54,000 (including a readmission). In 2004 there were 240,000 inpatient stays for a maternal condition that also had at least one diagnosis for a mental health or substance abuse condition. Long Term Costs of Medical Care for Children Children with depressed mothers often have adversely affected health and spend more on medical care than healthy counterparts. Evidence shows these children have higher office & ER usage than children of healthy mothers. Cost of Prematurity Pregnant women with depression are 3.4 times more likely to deliver preterm and 4 times as like to deliver a low birth weight baby. In 2005, the average cost for every infant born prematurely was $51,600 Loss in productivity of parents of premature infants comprised of 22% of this figure First year Medical Costs are 10 times that of full term infants. DEPRESSION COSTS The cost of depression totaled $83.1 billion dollars in the U.S. in $26.1 billion in direct medical cost, $5.4 for suicide related mortality cost, &$51.5 billion for workplace costs (disability, absenteeism & presenteeism) The costs of MD specifically have not been reported, however: women with depression generally have more expensive medical claims than men pregnant women with untreated depression are at risk for costly pre-term birth complications. UNTREATED DEPRESSION COSTS Women with moderate to severe untreated maternal depression are at risk for ER & inpatient stays. We don’t have data that suggests how many women go to the ER or are admitted for psychiatric trouble during the peripartum period. One case cost her insurer $54,000 (including a readmission). In 2004 there were 240,000 inpatient stays for a maternal condition that also had at least one diagnosis for a mental health or substance abuse condition. Long Term Costs of Medical Care for Children Children with depressed mothers often have adversely affected health and spend more on medical care than healthy counterparts. Evidence shows these children have higher office & ER usage than children of healthy mothers. Cost of Prematurity Pregnant women with depression are 3.4 times more likely to deliver preterm and 4 times as like to deliver a low birth weight baby. In 2005, the average cost for every infant born prematurely was $51,600 Loss in productivity of parents of premature infants comprised of 22% of this figure First year Medical Costs are 10 times that of full term infants. © 2012 CA Maternal Mental Health Collaborative (but please still share this PowerPoint or independent ideas!)

7 Why Aren’t Mothers Being Diagnosed? The Screening Tool Dilemma © 2012 CA Maternal Mental Health Collaborative (but please still share this PowerPoint or independent ideas!) TOOL ACCURACY QUESTIONED Most studies examining the accuracy of tools conclude that additional research is needed to identify the ideal tool and further suggest that the most useful tools are: Brief, Inexpensive, easy to administer, and capable of measuring change in severity over time. Additionally the tools that may identify depression may not identify psychosis. INTERIM RECOMMENATIONS & MOST UTILIZED TOOLS Until such time, some studies suggest a 2-stage procedure works best: The PHQ-2* (simple two question tool) used as the initial screening test Those who test positive complete the PHQ-9 to validate diagnosis. The PHQ-9 has been referred to by some researchers as “the best available depression screening tool for primary care.” ACOG has endorsed use of the PHQ-2, but not use of other tools. PHQ-2 also endorsed by the US Preventive Services Task Force The Edinburgh screening tool is the most widely used tool *There is disagreement among experts about the validity of the PHQ-2 since it has not been validated for use in maternal depression. Therefore some recommend direct use of the PHQ-9. See AHRQ reports for additional background. TOOL ACCURACY QUESTIONED Most studies examining the accuracy of tools conclude that additional research is needed to identify the ideal tool and further suggest that the most useful tools are: Brief, Inexpensive, easy to administer, and capable of measuring change in severity over time. Additionally the tools that may identify depression may not identify psychosis. INTERIM RECOMMENATIONS & MOST UTILIZED TOOLS Until such time, some studies suggest a 2-stage procedure works best: The PHQ-2* (simple two question tool) used as the initial screening test Those who test positive complete the PHQ-9 to validate diagnosis. The PHQ-9 has been referred to by some researchers as “the best available depression screening tool for primary care.” ACOG has endorsed use of the PHQ-2, but not use of other tools. PHQ-2 also endorsed by the US Preventive Services Task Force The Edinburgh screening tool is the most widely used tool *There is disagreement among experts about the validity of the PHQ-2 since it has not been validated for use in maternal depression. Therefore some recommend direct use of the PHQ-9. See AHRQ reports for additional background.

8 Why Aren’t Mothers Being Diagnosed? The “Who Should Screen” Dilemma ACOG/AAP recommend a review of MD symptoms to determine if intervention is needed. THE ROLE OF THE OBGYN OBGYN Prenatal Visits Occur Frequently. OBGYN Postnatal visit occurs just once for a normal delivery, at 4-6 weeks. 44% of OBGYNs report they always or often screen, but may not use a validated tool (i.e. PHQ-9). Many indicate they: do not feel qualified to screen, do not have enough time to screen, don’t know where to refer for behavioral health therapy, have concerns about prescribing anti-depressants during pregnancy or lactation, lack financial incentive to screen (reimbursement is for an office visit). WHAT ABOUT THE PEDIATRICIAN? Some believe pediatricians should screen given their frequent interaction with mothers during well-child visits. However, pediatricians raise similar concerns as OBGYNs and also note concerns about scope of practice (i.e. child is the doctor’s patient, not the mom) ACOG/AAP recommend a review of MD symptoms to determine if intervention is needed. THE ROLE OF THE OBGYN OBGYN Prenatal Visits Occur Frequently. OBGYN Postnatal visit occurs just once for a normal delivery, at 4-6 weeks. 44% of OBGYNs report they always or often screen, but may not use a validated tool (i.e. PHQ-9). Many indicate they: do not feel qualified to screen, do not have enough time to screen, don’t know where to refer for behavioral health therapy, have concerns about prescribing anti-depressants during pregnancy or lactation, lack financial incentive to screen (reimbursement is for an office visit). WHAT ABOUT THE PEDIATRICIAN? Some believe pediatricians should screen given their frequent interaction with mothers during well-child visits. However, pediatricians raise similar concerns as OBGYNs and also note concerns about scope of practice (i.e. child is the doctor’s patient, not the mom) © 2012 CA Maternal Mental Health Collaborative (but please still share this PowerPoint or independent ideas!)

9 Why Aren’t Mothers Being Diagnosed? A Mother’s Barriers A MOTHER’S BARRIERS –WHY SHE MAY KEEP CONCERNS TO HERSELF Confusion about what she is feeling Shame or concern over appearing ungrateful for her baby Reluctant to discuss problems with a provider she doesn’t know well or trust Fear of being reported to Child Protective Services Social Stigma of mental illness Concerns about cost of treatment Unsure where to seek treatment (finding therapists who specialist in MD) Uneducated about impact of untreated depression Time constraints and childcare coverage Additional Cultural factors A MOTHER’S BARRIERS –WHY SHE MAY KEEP CONCERNS TO HERSELF Confusion about what she is feeling Shame or concern over appearing ungrateful for her baby Reluctant to discuss problems with a provider she doesn’t know well or trust Fear of being reported to Child Protective Services Social Stigma of mental illness Concerns about cost of treatment Unsure where to seek treatment (finding therapists who specialist in MD) Uneducated about impact of untreated depression Time constraints and childcare coverage Additional Cultural factors The Federal Patient Protection and Affordable Care Act requires health plans and insurers to cover screening for postpartum depression at no cost to the patient. However most HMO plans already cover maternity office visits at $0 co-pay. Insurance plan coinsurance will be modified. However there is no requirement to pay for screening separate from the standard office visit. In 2004 The IL Medicaid Program became the first in the country to provide additional reimbursement for screening using specified tools. The Federal Patient Protection and Affordable Care Act requires health plans and insurers to cover screening for postpartum depression at no cost to the patient. However most HMO plans already cover maternity office visits at $0 co-pay. Insurance plan coinsurance will be modified. However there is no requirement to pay for screening separate from the standard office visit. In 2004 The IL Medicaid Program became the first in the country to provide additional reimbursement for screening using specified tools. © 2012 CA Maternal Mental Health Collaborative (but please still share this PowerPoint or independent ideas!)

10 NCQA, ACOG, PCPI Maternity Care Measures NCQA has a HEDIS measure for Depression, but no nuances are suggested for PPD/MD. Maternity Care Measure #3: Behavioral Risk Assessment *Numerator: Percentage of patients, regardless of age, who gave birth during a 12-month period seen at least once for prenatal care who received a behavioral health screening risk assessment that includes screenings at the first prenatal visit for depression. Denominator: Percentage of patients, regardless of age, who gave birth during a 12-month period seen at least once for prenatal care. *Patients who were screened for depression at the first visit. Questions may be asked either directly by a health care provider or in the form of self-completed paper- or computer administered questionnaires and results should be documented in the medical record. Depression screening may include a self-reported validated depression screening tool (eg, PHQ-2, Beck Depression Inventory, Beck Depression Inventory for Primary Care, Edinburgh Postnatal Depression Scale (EPDS) ) There was agreement that current evidence-based clinical practice guidelines lack concrete evidence regarding guidance for treatment of depression during pregnancy. As a result, there was no consensus to develop a measure assessing the treatment and follow-up for patients identified as being depressed during pregnancy. Maternity Care Measure #3: Behavioral Risk Assessment *Numerator: Percentage of patients, regardless of age, who gave birth during a 12-month period seen at least once for prenatal care who received a behavioral health screening risk assessment that includes screenings at the first prenatal visit for depression. Denominator: Percentage of patients, regardless of age, who gave birth during a 12-month period seen at least once for prenatal care. *Patients who were screened for depression at the first visit. Questions may be asked either directly by a health care provider or in the form of self-completed paper- or computer administered questionnaires and results should be documented in the medical record. Depression screening may include a self-reported validated depression screening tool (eg, PHQ-2, Beck Depression Inventory, Beck Depression Inventory for Primary Care, Edinburgh Postnatal Depression Scale (EPDS) ) There was agreement that current evidence-based clinical practice guidelines lack concrete evidence regarding guidance for treatment of depression during pregnancy. As a result, there was no consensus to develop a measure assessing the treatment and follow-up for patients identified as being depressed during pregnancy. © 2012 CA Maternal Mental Health Collaborative (but please still share this PowerPoint or independent ideas!)

11 What Happens if we Start Diagnosing? © 2012 CA Maternal Mental Health Collaborative (but please still share this PowerPoint or independent ideas!) Those who have developed community maternal mental health programs, including the State of NJ, have reported the first step that must be taken is ensuring trained and identifiable therapists are available to treat patients. Most Mental Health Therapists haven’t been educated on the nuances of Maternal Depression, which can often make matters worse for suffering women who seek treatment from them. In partnership with representatives from the Collaborative and Postpartum Support International, Magellan is working to develop a credentialing program that will allow members and providers to identify therapist who have received specified training with a standardized credential. It’s our hope that all plans will adopt these designations. Those who have developed community maternal mental health programs, including the State of NJ, have reported the first step that must be taken is ensuring trained and identifiable therapists are available to treat patients. Most Mental Health Therapists haven’t been educated on the nuances of Maternal Depression, which can often make matters worse for suffering women who seek treatment from them. In partnership with representatives from the Collaborative and Postpartum Support International, Magellan is working to develop a credentialing program that will allow members and providers to identify therapist who have received specified training with a standardized credential. It’s our hope that all plans will adopt these designations.

12 Treatment Options There are no standardized guidelines on treatment of maternal depression. However ACOG and the APA have issued joint recommendations for treating depression during pregnancy. Treatment includes psychotherapy or pharmacotherapy or a combination of both. Research suggests that as few as 6-10 sessions talk therapy including interpersonal, cognitive-behavioral, group and family therapy is as effective as drug therapy. Talk therapy is the preferred initial course of treatment for women who aren’t currently undergoing drug therapy for depression. Women appreciate group therapy, as they are able to recognize they are not alone. Drug therapy has been proven effective in treating moderate to severe depression. SSRIs and antidepressants are the most commonly prescribed drugs for treating maternal depression. As of 2010 the FDA had not approved any antidepressants for use during pregnancy. Medication usage during pregnancy must be balanced with the risks of untreated depression. Though not incorporated in these recommendations, non invasive brain stimulation such as TMS are emerging treatment options. There are no standardized guidelines on treatment of maternal depression. However ACOG and the APA have issued joint recommendations for treating depression during pregnancy. Treatment includes psychotherapy or pharmacotherapy or a combination of both. Research suggests that as few as 6-10 sessions talk therapy including interpersonal, cognitive-behavioral, group and family therapy is as effective as drug therapy. Talk therapy is the preferred initial course of treatment for women who aren’t currently undergoing drug therapy for depression. Women appreciate group therapy, as they are able to recognize they are not alone. Drug therapy has been proven effective in treating moderate to severe depression. SSRIs and antidepressants are the most commonly prescribed drugs for treating maternal depression. As of 2010 the FDA had not approved any antidepressants for use during pregnancy. Medication usage during pregnancy must be balanced with the risks of untreated depression. Though not incorporated in these recommendations, non invasive brain stimulation such as TMS are emerging treatment options. © 2012 CA Maternal Mental Health Collaborative (but please still share this PowerPoint or independent ideas!)

13 Considerations -Impact of overall health and wellness of women and families -Shortage of psychiatrists and looming shortage of primary care providers -Screening shouldn’t be left to chance or be a luxury. All women deserve to be screened. -We can’t reduce a woman’s risk factors or triggers, with a few possible exceptions: Social Support, Sleep Support and teaching Baby Care Skills. -Most women deliver at a hospital (i.e. Hospital and ‘hub’). Many hospitals offer birth classes - could add Maternal Mental Health curriculum, could offer mom-and-me classes providing instant social support, could offer or even simply host PPD support groups. -Hospitals could play a significant roll in the critical days after delivery by considering ‘Protected sleep’ ( hour, blocks of disturbance free sleep), teaching parents baby soothing techniques to reduce anxiety, etc. -Six Sigma Quality theory suggests that removing variability (or improving consistency) in systems leads to fewer “defects.” There is substantial variability in the current system. Health plans have a unique opportunity to bring consistency to the process in simple and innovative ways. -Impact of overall health and wellness of women and families -Shortage of psychiatrists and looming shortage of primary care providers -Screening shouldn’t be left to chance or be a luxury. All women deserve to be screened. -We can’t reduce a woman’s risk factors or triggers, with a few possible exceptions: Social Support, Sleep Support and teaching Baby Care Skills. -Most women deliver at a hospital (i.e. Hospital and ‘hub’). Many hospitals offer birth classes - could add Maternal Mental Health curriculum, could offer mom-and-me classes providing instant social support, could offer or even simply host PPD support groups. -Hospitals could play a significant roll in the critical days after delivery by considering ‘Protected sleep’ ( hour, blocks of disturbance free sleep), teaching parents baby soothing techniques to reduce anxiety, etc. -Six Sigma Quality theory suggests that removing variability (or improving consistency) in systems leads to fewer “defects.” There is substantial variability in the current system. Health plans have a unique opportunity to bring consistency to the process in simple and innovative ways. © 2012 CA Maternal Mental Health Collaborative (but please still share this PowerPoint or independent ideas!)

14 So, what specifically can health plans do? Possible Solutions: Health plan conducted screening (PHQ-9) throughout pregnancy and 1-year postpartum & collection of mental health history during 1 st trimester. Positive Screens, identification of qualified mental health treatment programs to OB/PCP and patient. Screening for all, not offered on a buy-up basis. Monitoring treatment and follow-up, offer incentives for receiving treatment. Consider minimal treatment offering for women who don’t have a behavioral health benefit given impact on medical outcomes. Talk Therapy: Consider e-therapy and tele-therapy given childcare needs, time constraints and other mental health factors. Consider benefits of group therapy. Women need to see first hand that they are not alone. Consider reimbursing hospitals that offer PPD group therapy programs. Consider improving social support by: Forming on-line birth clubs allowing pregnant and new mothers to connect. Then pushing a on-line mental health assessment and repeat screenings, along with sharing other important health information. Consider partnerships with BabyCenter, WebMD, MomsPrevail, etc. Current on-line group therapy provider: Regroup. Consider reimbursing hospitals and providing incentives to moms who enroll in hospital-based birth classes and hospital-based new mom/parent classes (6-8 weeks). Given shortage of Psychiatrists, particularly those with expertise in drug use during pregnancy, consider staffing/contracting with a consult line for OBGYNs. Possible Solutions: Health plan conducted screening (PHQ-9) throughout pregnancy and 1-year postpartum & collection of mental health history during 1 st trimester. Positive Screens, identification of qualified mental health treatment programs to OB/PCP and patient. Screening for all, not offered on a buy-up basis. Monitoring treatment and follow-up, offer incentives for receiving treatment. Consider minimal treatment offering for women who don’t have a behavioral health benefit given impact on medical outcomes. Talk Therapy: Consider e-therapy and tele-therapy given childcare needs, time constraints and other mental health factors. Consider benefits of group therapy. Women need to see first hand that they are not alone. Consider reimbursing hospitals that offer PPD group therapy programs. Consider improving social support by: Forming on-line birth clubs allowing pregnant and new mothers to connect. Then pushing a on-line mental health assessment and repeat screenings, along with sharing other important health information. Consider partnerships with BabyCenter, WebMD, MomsPrevail, etc. Current on-line group therapy provider: Regroup. Consider reimbursing hospitals and providing incentives to moms who enroll in hospital-based birth classes and hospital-based new mom/parent classes (6-8 weeks). Given shortage of Psychiatrists, particularly those with expertise in drug use during pregnancy, consider staffing/contracting with a consult line for OBGYNs. © 2012 CA Maternal Mental Health Collaborative (but please still share this PowerPoint or independent ideas!)

For More Information National Institute for Health Care Management Issue Brief “Identifying and Treating Maternal Depression: Strategies and Considerations for Health Plans.” Postpartum Support International CA Maternal Mental Health Collaborative (Two annual forums, pioneer awards, barriers and suggestions + Member groupshare –coming soon) Please consider contacting me to share ideas: 15 © 2012 CA Maternal Mental Health Collaborative (but please still share this PowerPoint or independent ideas!)