IMPLICIT Focus on Maternal Depression

IMPLICIT Focus on Maternal Depression
Stephen D. Ratcliffe, MD, MSPH Lancaster General Family Medicine Residency Ian M. Bennett, MD University of Washington February 2016

Welcome to the Network…
Jessica Garber Pennsylvania Network Coordinator Based at LGH Focus: Project Coordination/CQI at LGH Network support for Eastern PA Tabitha Reefer Practice Facilitator Based at UPMC Focus: Case management at UPMC Network dissemination in Western PA She attended Messiah College where she majored in Biopsychology. She is currently in her final semester of a Masters in Public Health program at Penn State Hershey. She worked as a research assistant intern for Nurse Family Partnership at LGH. In this position, she monitored and compiled data from the Moving Beyond Depression program (a home visiting treatment program for women with postpartum depression) There, she gained valuable experience working with two programs that help improve the health and well-being of mothers and their children! She is also currently working as a research assistant for the PaTH Network at Penn State Hershey. In this position, she has recruited and maintained contact with participants, am in the process of co-writing a research article, and continuously work with the other institutions involved in the PaTH Network (UPMC, Temple University, and Johns Hopkins University). In her free time, she enjoy baking, running, and spending time with family and friends. She also just completed my first half-marathon at Disney this past Sunday! Tabitha recently graduated her Master in Public Health at the University of Pittsburgh Graduate School of Public Health. She completed her Bachelors of Arts in anthropology with a minor in applied statistics at Indiana University of Pennsylvania in 2012. After completing her undergraduate education, she obtained her Master of Business Administration in healthcare administration from Ashford University in 2013. She sits on the Steering Committee for HEALTHY Armstrong in Ford City as a volunteer and consultant to the program. She also volunteers at Orphans of the Storm Animal Shelter and the Armstrong Rails to Trails Association in Kittanning. In addition, she works as a consultant for the Pennsylvania Department of Health Bureau of Epidemiology.

Objectives Review evidence on maternal depression and depression screening Present IMPLICIT ICC Phase 2 depression data Facilitate discussion and share best practice strategies

IMPLICIT ICC Model 4 behavioral risks affecting future birth outcomes
Smoking Depression Family planning & birth spacing Multivitamin with folic acid use IMPLICIT ICC Model

Treatment of Perinatal Depression
Ian M. Bennett MD PhD University of Washington, Departments of Family Medicine & Psychiatry and Behavioral Sciences IMPLICIT Perinatal Depression Working Group

Outline Categories of Treatment Options
Non Intensive Intensive Matching Diagnosis to Treatment Emotional Distress, Minor Depression Major Depressive Disorder, Dysthymia Pharmacologic Management in Pregnancy The IMPLICIT Perinatal Depression Care System

Perinatal Depression A Common Disorder Affecting High Burden
10% of women in pregnancy/postpartum with major depressive disorder or dysthymia 5% with minor depression High Burden Major source of disability Associated with PTB/LBW Association with child mental health Great Benefit of Treatment Increase in function

Depression Toolkit Screening measures Diagnostic Instruments
2-stage Screening Diagnostic Instruments SCID Treatment Tools Self Management Contracts Symptom Monitoring Medication Monitoring

Depression Care Steps 3 (transition) Screening Diagnosis Initiating
Treatment Acute Phase Continuation Phase Variance points: From Croghan et al (2006)

Treatments & Diagnoses
Minor Depression (5-15%) Self-Management Contract Increased physical activity Activation of personal support network Brief supportive counseling Major Depressive Disorder (10% of Population) and Dysthymia Above treatments + Antidepressant Medication Intensive Psychotherapeutic Counseling (CBT or IPT) Combination of approaches

DSM IV-TR Criteria for Major Depression
5 or more major symptoms (of 9) Must include depressed mood or anhedonia (one of first two) Present for 2 weeks in the last month Most of the day nearly every day Change from previous functioning Severity/significant disability Marked severity – affecting life significantly

Symptoms Depressed mood
Markedly diminished interest in usual activities Significant increase/loss in appetite/weight Insomnia/hypersomnia Psychomotor retardation or agitation Fatigue or loss of energy Worthlessness or inappropriate guilt Difficulty with thinking/concentration/making decisions Recurrent thoughts of death or suicide

Dysthymia Usually less severe than MDD
Never had an episode of Major Depression Depressed mood for most of the day and for most days Self report or through report of others Chronic at least 2 years without a break of 2 months or more 2 or more of 6 other major symptoms of depression Not anhedonia or suicidal ideation

Minor Depression 2-4 of the 9 criteria of depression
May not have one of the “A” criteria Not previously diagnosed with MDD 2-5% prevalence More likely to develop MDD If have an “A” criteria then more likely to develop MDD ADM not effective in RCT

Suicidal Ideation EPDS and PHQ-9 both have self harm questions
Risk evaluation for severity is needed if thoughts of suicidality are identified Protocols and instruments are available (see Macarthur Toolkit - page 15) If threat is significant then an evaluation for possible in-patient treatment must be offered to patients

Medical Evaluation Thyroid Abnormalities Substance Abuse
Send a TSH Substance Abuse Alcohol or other substances Assess for bipolar disease and consider psychosis Mania screening Intimate Partner Violence

APA-ACOG Guidelines Yonkers et al, 2009
Connection with Psychiatrist Suicidality, Psychosis, Bipolar Disorder Preconception Current Major Depressive Episode (MDE) Delay of pregnancy until symptoms under control Symptoms Under Control Consider discontinuation Pregnancy with MDE On Medications Consider continuation (if history of relapse) Not on Medications Consider psychotherapy if available and initiation of meds

Non-Pharmacologic Therapy
Guideline alone for mild to moderate depression As part of therapy for severe depression Self-Management Increased Physical Activity Healthy Lifestyle (diet, pleasant activities) Psychotherapy Individual or group Supportive counseling Can be carried out by prenatal provider or mid-level provider Intensive psychotherapy (in person or by phone) cognitive behavioral therapy Interpersonal therapy

Pharmacologic Therapy
Include a discussion of the risk benefit ratio of treatment versus untreated depression (and document) Avoid in first trimester if not already on them Withdrawal syndrome is well documented Agitation for first several weeks after delivery Evidence is weak for poor outcomes Cardiac anomalies (paroxetine – black box warning “D”) Preterm birth (SSRI in 3rd trimester) Persistent pulmonary hypertension (6-12/1,000)

Antidepressant Medications
SSRIs Fluoxetine Sertraline Citalopram Paroxetine (Category D) SNRIs (less evidence) Venlafaxine Other Buproprion – for smokers Contraindicated in cases of seizure disorder or bulimia

Contraindications to Stopping Meds
Severe depression with: Suicide attempts Functional incapacitation Weight loss Candidates for ECT No response to antidepressants, psychotic, suicidal, or severely disabled Patient preference with severe depression (because of rapid response)

AHCPR Treatment Guidelines (For MDD)
Acute Phase (4-6 weeks) Reduce symptoms Continuation Phase (4-9 months) Prevent Relapse Maintenance Phase (at least 9 months) Prevent Recurrence

Acute Phase - medications
If Positive for MDD Goal is relief of symptoms (expect 50% in 4-6 weeks) Continue Treatment if see partial response First follow up within one week, etc. Make use of telemedicine Response Partial response in 5-6 weeks – continue No response at 6 weeks – increase dose or switch med Partial response in 12 weeks – increase dose or switch med

Initiating Medications
Choice of Meds History Previous benefits of a particular med Risk profile (avoif paroxetine) Fluoxetine and Sertraline have best overall Less evidence of negative effects including withdrawal Escalation of Dose Fluoxetine – get to 40 mg sooner rather than later Sertraline – get to 150 mg plus Follow up

AHCPR Psychological Counseling Guidelines
Mild-Moderate Severity of MDD – 6-8 week trial Severe – Only use psychological counseling in conjunction with antidepressant medications

Assessment of Initial Response
Following adequate treatment period 6 weeks of psychological counseling 4 weeks of adequate dose of antidepressant Use of PHQ-9 to assess response At least 5 points = Adequate 2-4 points = Possibly inadequate 0-1 point = Inadequate

IMPLICIT Care Systems Case Finding Treatment Protocols
Screening and diagnosis Treatment Protocols MDD and other depressive disorders Clinical Care Support From Telephone Consult Continuous Quality Improvement Data reports on how things are going

Ideal Sequence of Care Screening Diagnosis Guideline Consistent
Treatment Monitoring Symptoms PHQ SCID Antidepressant PHQ-9 + Psychotherapy PHQ or Combination

Collaborative Care Patient Prenatal Care Provider Depression Care
Manager “Cornerstone of the care team” Mental Health Specialist Modified from Fortney et al (2009)

Resources Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders National Academies Press at: Macarthur Depression Toolkit United States Preventive Services Task Force (AHRQ) Yonkers et al (2009) The management of depression during pregnancy, Gen Hosp Psych and OB&GYN

Thanks! IMPLICIT depression working group Please give us feedback

Evidence Summary Primary Care Screening for and Treatment of Depression in Pregnant and Postpartum Women Evidence Report and Systematic Review for the US Preventive Services Task Force JAMA 2016;315(4)

Evidence Summary The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. (B recommendation)

Evidence Summary KQ 1: Do depression screening programs in pregnant and postpartum women result in improved outcomes? Reductions of 18 to 59% in risk of depression at follow-up compared with usual care (from 1.5 months to 15 months) using EPDS tool This effect was not sustained at 16 or greater months 45% of intervention pts reported a 5-point or greater drop in their PHQ-9 scores versus 34% of those receiving usual care (OR 1.74) (CI ) Yawn, et al.TRIPPD practices. Ann Fam Med 2012;10(4):

Evidence Summary KQ 2: What is the test performance of the most commonly used depression screening instruments in pregnant and post-partum women in primary care? 23 studies (n= 5398) using the Edinburg Postpartum Depression Screen (EPDS) Sensitivity Specificity 0.88 – 0.99 1 study using the PHQ-9 Sensitivity Specificity 0.91 Gjerdingen D, et al. validity of a 2-question screen and the PHQ-9 Ann Fam Fed. 2009;7 (1):63-70. Smith MV, et al. Do the PHQ-8 and the PHQ-2 accurately screen for depressive disorders in a sample of pregnant women? Gen Hosp Psychiatry. 2010;32(5):

Evidence Summary KQ 3: What are the harms associated with primary care depression screening programs in pregnant and postpartum women? One trial (n=462) reported no adverse effects of screening. Remaining 5 trials did not report on harms Leung et al. Outcome of a postnatal depression screening programme using the EPDS: a randomized controlled trial. Lancet. 2002;359:

Evidence Summary KQ 4: Does treatment result in improved health outcomes? (decreased depression, suicide attempts/ideation, and improved functioning) 10 trials using CBT all showed remission with rx in the short term All trials showed greater symptom reduction in the intervention in the intervention groups One trial that used fluoxetine reported a 10 point reduction in the EPDS after 12 weeks compared to 7 point reduction in the placebo group. Appleby et al. A controlled study of fluoxetine and cognitive-bahavioral counselling in the rx of postnatal depression. BMJ.1997;314:

Evidence Summary KQ 5: What are the harms of treatment in pregnant and postpartum women who screen positive for depression in primary care? Treatment of depression with SSRI and SNRAs in pregnancy associated with increased incidence of a number of conditions although the absolute risk to the infant remained quite small Preeclampsia, PPH, miscarriage, perinatal mortality, PTB, neonatal respiratory distress, persistent pulmonary hypertension Reported neonatal respiratory distress was 13.9% in exposed versus 7.8% of non-exposed fetuses McDonagh, et al. Treatment of Depression During Pregnancy and the Postpartum Period. AHRQ, 2103.

IMPLICIT ICC Model: Depression
Sxs occur in 20-40% of women during or PP Depression has a peripartum recurrence of 40% White lettering on a color block is especially effective for catching attention and for retention. Screen women for depression with PHQ-2  PHQ-9 if + PHQ-2 If positive risk for depression: Assess for safety and severity of symptoms Refer immediately if any suicidality or homicidality is present Arrange for follow-up and services Untreated postpartum depression is associated with poor parenting practices and infant behavioral development2, 3 Risk of psychopathology in infants is reduced by effective treatment of depression in mothers4 Bennett IM, et al, 2010/Chung EK, et al, 2004/ Murray L, et al, 2003/Weissman MM, et al, 2006

IMPLICIT ICC PROGRAMS Active ICC/Entering Data: Lancaster General Mid-Hudson Family Practice Mountain Area Health Education Center (MAHEC) University of Pennsylvania UPMC McKeesport UPMC Shadyside UPMC St. Margaret Active ICC/Not Sharing Data: Lawrence U Mass Middlesex University of Rochester White lettering on a color block is especially effective for catching attention and for retention. With support from

IMPLICIT ICC Data Collection: Depression
Maternal Demographic Form: ICC Visit Form: Depression - Phase 1

IMPLICIT ICC Data Collection: Depression
Depression– Phase 2

IMPLICIT Interconception Care Data
White lettering on a color block is especially effective for catching attention and for retention. IMPLICIT Interconception Care Data

ICC Screen Rate Opportunities ICC Screen Rate Mom Present
Site Mom/ Baby Dyads Total WCV ICC Opportunities WCV Mom Present All ICC Partial ICC ICC Screen Rate Opportunities ICC Screen Rate Mom Present Rate Mom Present Lancaster General FM Residency 471 891 874 314 231 79 35.5 98.7 94.9 Mid-Hudson Family Practice 399 597 517 423 87 98.6 86.6 Mountain Area Health Education Center (MAHEC) 892 2209 2197 1206 315 54.9 100.0 99.0 UPMC McKeesport 212 406 370 249 14 71.1 91.1 UPMC Shadyside 237 496 468 465 374 12 82.5 83.0 94.3 UPMC St. Margaret 381 780 724 720 413 29 61.0 61.4 92.8 All Sites 2592 5379 5150 3592 2581 536 60.5 86.8 94.0 White lettering on a color block is especially effective for catching attention and for retention. ICC Phase 2 Data January 2015-January 2016

ICC Screen Rate Opportunities ICC Screen Rate Mom Present
Site Dates of WCV Mom/ Baby Dyads Total WCV ICC Opportunities WCV Mom Present All ICC Partial ICC ICC Screen Rate Opportunities ICC Screen Rate Mom Present Rate Mom Present Lancaster General FM Residency Jun Dec 2015 471 891 874 314 231 79 35.5 98.7 94.9 Mid-Hudson Family Practice May Jan 2016 399 597 517 423 87 98.6 86.6 Mountain Area Health Education Center (MAHEC) Mar Dec 2015 892 2209 2197 1206 315 54.9 100.0 99.0 UPMC McKeesport Dec Jan 2016 212 406 370 249 14 71.1 91.1 UPMC Shadyside Nov Dec 2015 237 496 468 465 374 12 82.5 83.0 94.3 UPMC St. Margaret Dec Dec 2015 381 780 724 720 413 29 61.0 61.4 92.8 All Sites Total 2592 5379 5150 3592 2581 536 60.5 86.8 94.0 White lettering on a color block is especially effective for catching attention and for retention. . The ICC opportunities column includes all of the WCV except those where we know the mom was not present (i.e. it includes all of the unknown). The ICC Screen Rate Opportunities is the screen rate that uses the ICC opportunities as the denominator and the All ICC + Partial ICC as the numerator: this was our conclusion to use this as our overall rate for the network. I then retained the ICC screen rate mom present which only calculates the rate when we know the status of the mom and she was at the visit. I then added a column which calculates the mom present divided by the mom present + mom not present. ICC Phase 2 Data January 2015-January 2016

Maternal Demographics (N=778)
*Completed 30.0% of Maternal Demographics Demographics Percent Medical Assistance 79.6% African American 43.1% Hispanic 32.2% Maternal Education Less than High school degree or equivalent 23.9% High school grad/equivalent 36.5% Maternal Age <19 years old 3.1% White lettering on a color block is especially effective for catching attention and for retention. ICC Phase 2 Data January 2015-January 2016

ICC Phase 2 Data January 2015-January 2016
Results of the 2-item or PHQ2 screen? Response Frequency Percent Positive 252 8.20% Negative 2835 91.80% Total 3087 If PHQ2 is positive, was PHQ9 score greater than or equal to 10? Response Frequency Percent Yes 61 13.70% No, PHQ9 is less than 10 97 21.70% Not done 288 64.60% Total 446 ICC Phase 2 Data January 2015-January 2016

If PHQ2 is positive, was PHQ9 score greater than or equal to 10? Response Frequency Percent Yes 61 13.70% No, PHQ9 is less than 10 97 21.70% Not done 288 64.60% Total 446 If a depression risk was present, was an intervention in place or provided? Response Frequency Percent Yes 51 92.70% No 4 7.30% Total 55 ICC Phase 2 Data January 2015-January 2016

Results of the 2-item or PHQ2 screen? Response Frequency Percent Positive 252 8.20% Negative 2835 91.80% Total 3087 Maternal Safety Screen: Thoughts of self-harm present (PHQ9 #9 = 1 or greater) Response Frequency Percent Yes, mother HAS thoughts of harming self (PHQ9 #9 >= 1) 11 2.50% No, mother has NO thoughts of harming self (PHQ9 #9 = 0) 377 84.20% Not done 60 13.40% Total 448 If mother has thoughts of harming self (PHQ9 #9), was mother assessed for safety and triaged appropriately? Response Frequency Percent Yes 9 90% No 1 10% Total 10 ICC Phase 2 Data January 2015-January 2016

What were the results of the 2-item screen or PHQ2? (N=3,087)
White lettering on a color block is especially effective for catching attention and for retention. ICC Phase 2 Data January 2015-January 2016

If PHQ2 is positive, was PHQ9 score greater than or equal to 10
If PHQ2 is positive, was PHQ9 score greater than or equal to 10? (N=446) White lettering on a color block is especially effective for catching attention and for retention. ICC Phase 2 Data January 2015-January 2016

If a depression risk was present, was an intervention in place or provided? (N=55)

Maternal Safety Screen: Thoughts of self-harm present (PHQ9 #9 = 1 or greater)

If a depression risk was present, was an intervention in place or provided? (N=10)

Results of the 2-item or PHQ2 screen?
ICC Phase 2 Data January 2015-January 2016

Data Summary Missing 70% of maternal demographics
Entering PHQ9 data regardless of PHQ2 results Unable to asses the number of complete screens based on current data report Rate of positive PHQ2 remains constant while rate of PHQ9 greater than 10 is high during 0-1 months At 11 visits moms were identified as homicidal/suicidual Mom was triaged appropriately at 9 of those visits

Project Coordinator: Jessica Brubach (Brubachjl2@upmc.edu)
Discussion Comments/Suggestions What can we do to improve data collection? What can we do to improve depression care for moms? What is your site doing to address depression? Project Coordinator: Jessica Brubach

IMPLICIT Focus on Maternal Depression

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