1. 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

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

3. 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

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

5. 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

6. 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

7. 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
9/19/2018

8. 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

9. 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

10. April 21, 2017

11. 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

12. 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
9/19/2018

13. 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

14. 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

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

16. 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

17. MN Postpartum visit rates
9/19/2018

18. MN C&TC Rates 2014, 2015

19. 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

20. 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

21. 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

22. 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

23. 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

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

25. 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

26. 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

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

28. Research Cited
Postpartum Anxiety and Infant-Feeding Outcomes: A Systematic Review. Fallon V1, Groves R2, Halford JC2, Bennett KM2, Harrold JA, J Hum Lact Aug 26.
AAP Report
Canadian Paediatirc Society, “Maternal Depression and Child Development.” Paediatrics & Child Health Oct; 9(8): 575–583.
Women Birth Jul 19. pii: S (16)
9/19/2018

29. Questions?
Tessa Wetjen Dr. Brian Lynch Thank you!
9/19/2018