We have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. We do not intend to discuss an unapproved/investigative use of a commercial product/device in this presentation. Parental Depression Screening Implementation Bill Stratbucker, MD, MS, FAAP Amy Williams, LMSW Preventive Services Improvement Project Learning Session January 21-22, 2011

2 Objectives  Understand the expectations of primary care clinicians for parental depression screening  Discuss appropriate timing, tools, referral, referral tracking and follow-up  Develop a plan for establishing community linkages for parents with depression

Clinician Expectations  What do Bright Futures 3 rd Edition and the AAP say?  What is the prevailing sentiment among pediatric clinicians?  Who else is worrying about parental depression?

Background  One of the greatest risk factors for child behavioral and mental health problems  Short and long-term effects of parental depression  Lifetime prevalence is 16.6%  Postpartum depression occurs in 10-20%

Risk Factors for Perinatal Depression  Personal history of depression  Family history  History of substance abuse  Teenage parent  Stressful pregnancy, delivery  Low-income  Spouse without depression is protective factor

Barriers to Screening  Time  Lack of reimbursement  Ownership of problem  Lack of community mental health resources  Lack of training on screening methods and implementation strategies

Case for Pediatric Clinician Screening  Early access to parent-infant dyad  Established continuity of care  Understand the divergent outcomes  OB colleagues not necessarily convinced  Benefits outweigh the risks  The right thing to do

Implementation  When? How frequent?  What tool? Back-up tool? Diagnostic tool?  Who delivers the questionnaire?  Who scores?  Who responds to the result?

Pre-implementation steps  Staff education  Community linkages awareness  Work flow established  Make office screen-friendly  Educate parents Prenatal visits Birth hospitalization First Week Well Visit

Pre-implementation steps  Billing Set charge amount What if insurance doesn’t cover? Can’t selectively charge patients

Maternal Depression: PHQ-9

Maternal Depression: PHQ-2

15 Positive Screens  Discussion with parent  Reassurance (blues)  Demystification  Education  *Diagnostic evaluation and treament  Resource referral  Mental health, OB, PCP referral  Emergent disposition  Follow-up

Spectrum Health Example  Screening at birth hospitalization  Prenatal and postnatal MOMS program  Perinatal Mood Disorders Team  Perinatal Mood Disorders Support Group  Pine Rest Mental Health day program for affected mother-infant dyads  General Pediatrics, PHQ-2 screening Co-located LMSWs 16

Resourse Available to Anyone  Postpartum Support International  Early Intervention  Early Head Start  Mother’s Morning Out programs 

Establishing Community Linkages  Networking  Establish contacts Community organizations Hospital (nursing, social work) administration Obstetricians Mental health institutions, providers Insurance companies Support groups