Maternal Depression Project Wake County Human Services Raleigh, North Carolina Jean C. Smith, MD CityMatCH Albuquerque, NM September 23, 2008

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

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

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): (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); 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); Wisner K, Parry B, Piontek C. Postpartum depression. New England Journal of Medicine. 2002; 347(3):

References Dubowitz H, et.al. Screening for Depression in an Urban Pediatric Primary Care Clinic. Pediatrics 119, 3: 435, 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

Other Resources North Carolina Postpartum Support International Center for Perinatal Emotional Wellness – Anne Wimer. Contact # or 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) blues.com