Incorporating Mental Health Into Maternal Health

Incorporating Mental Incorporating Mental HealthHealth

Into Maternal HealthInto Maternal HealthBrian Stafford, MD, MPHBrian Stafford, MD, MPHMedical Director Medical Director The Kempe Center’s The Kempe Center’s Postpartum Depression Intervention Postpartum Depression Intervention ProgramProgram

CITYMATCH CONFERENCEDenver, CO Aug, 2007

Brian Stafford, MD, MPH

OutlineOutline

Perinatal Mental Health and Mental Perinatal Mental Health and Mental IllnessIllness

Barriers to TreatmentBarriers to Treatment Public Health’s RolePublic Health’s Role Mental Health’s RoleMental Health’s Role Primary Care’s RolePrimary Care’s Role


Perinatal Mental HealthPerinatal Mental Health

A developmental crisisA developmental crisis A time of increased contact with A time of increased contact with

Medical and Public HealthMedical and Public Health

but not necessarily mental healthbut not necessarily mental health


PregnancyPregnancy

High Risk for Medical ComplicationsHigh Risk for Medical Complications

High Risk for Mental Health High Risk for Mental Health ComplicationsComplications


ExamplesExamples

Most common complications of Most common complications of pregnancy are:pregnancy are: Spontaneous AbortionSpontaneous Abortion Postpartum DepressionPostpartum Depression Antenatal DepressionAntenatal Depression DiabetesDiabetes PrematurityPrematurity Perinatal LossPerinatal Loss


DepressionDepression

World Health OrganizationWorld Health Organization• 2020 2020

depression will be 2nd greatest cause of premature death and disability worldwide in both sexes

• Already Already number one cause of disease burden in

women


Perinatal Mood DisturbancePerinatal Mood Disturbance

Definitions:Definitions: Antenatal AnxietyAntenatal Anxiety Antenatal DepressionAntenatal Depression Postpartum BluesPostpartum Blues Postpartum PsychosisPostpartum Psychosis Postpartum DepressionPostpartum Depression Postpartum PTSDPostpartum PTSD Postpartum AnxietyPostpartum Anxiety


““Baby Blues”Baby Blues” 50 - 85% of women 50 - 85% of women Hours to days after childbirth lasting up to two weeksHours to days after childbirth lasting up to two weeks

Onset typically within 10 daysOnset typically within 10 days Mild, short-lived:Mild, short-lived:

AngerAnger• Sense of unworthiness, inadequacy, failure, guiltSense of unworthiness, inadequacy, failure, guilt• CryingCrying• Irritability/ ImpatienceIrritability/ Impatience• RestlessnessRestlessness• SadnessSadness• Tiredness (fatigue), Insomnia, or bothTiredness (fatigue), Insomnia, or both• Mood swingsMood swings


Postpartum AnxietyPostpartum Anxiety New Onset or ExacerbationNew Onset or Exacerbation

GeneralizedGeneralized PanicPanic PhobicPhobic Social PhobiaSocial Phobia OCD –likeOCD –like

Exacerbation is worseExacerbation is worse Preoccupation with babyPreoccupation with baby


Postpartum PsychosisPostpartum Psychosis Rare - Less than 1% of women (1-2/1000)Rare - Less than 1% of women (1-2/1000) Bipolar Disorder/ Schizophrenia/Schizoaffective Bipolar Disorder/ Schizophrenia/Schizoaffective

Disorder/Psychotic DepressionDisorder/Psychotic Depression Signs and symptoms even more severe and may occur Signs and symptoms even more severe and may occur

early early (within first 3 months postpartum – usually first 2 weeks)(within first 3 months postpartum – usually first 2 weeks)

• Anger and agitationAnger and agitation• InsomniaInsomnia• Confusion and disorientationConfusion and disorientation• Thoughts of harming self (suicide) or baby (infanticide)Thoughts of harming self (suicide) or baby (infanticide)• Hallucinations and delusionsHallucinations and delusions• ParanoiaParanoia• Strange thoughts or statementsStrange thoughts or statements


Postpartum PTSD: Postpartum PTSD: Less well understoodLess well understood

Pregnancy and delivery and newborn Pregnancy and delivery and newborn period is a time of potential traumaperiod is a time of potential trauma PregnancyPregnancy

Risk to motherRisk to mother Risk to babyRisk to baby

DeliveryDelivery Risk to motherRisk to mother Risk to babyRisk to baby

Congenital or other neonatal issue Congenital or other neonatal issue (Anxiety, PTSD, Depression, Grief)(Anxiety, PTSD, Depression, Grief)


Postpartum Depression Postpartum Depression (PPD) (PPD)

10 - 20% of women10 - 20% of women Signs and symptoms more intense and longer lastingSigns and symptoms more intense and longer lasting Symptoms of baby bluesSymptoms of baby blues PLUSPLUS

• Emotional numbness, feeling trappedEmotional numbness, feeling trapped• Fear of hurting self or babyFear of hurting self or baby• Impaired thinking, concentrationImpaired thinking, concentration• Lack of joyLack of joy• Less interest in sexLess interest in sex• Excessive concern/lack of concern for babyExcessive concern/lack of concern for baby• Significant weight loss or gainSignificant weight loss or gain• Withdrawal from family and friendsWithdrawal from family and friends

““overwhelmed”, “anxious” as common descriptorsoverwhelmed”, “anxious” as common descriptors


Postpartum DepressionPostpartum Depression Not as mild or transient as Not as mild or transient as

the blues the blues Not as severely Not as severely

disorienting as psychosis disorienting as psychosis Range of severityRange of severity

Mild to Extreme ImpairmentMild to Extreme Impairment The same but differentThe same but different

Co-morbidity (Anxiety)Co-morbidity (Anxiety) Violation of expectationViolation of expectation


Major Depressive Major Depressive EpisodeEpisode

Depressed mood Depressed mood Diminished interest or pleasure in everyday activitiesDiminished interest or pleasure in everyday activities

• Insomnia or hypersomnia Insomnia or hypersomnia • Significant weight loss or weight gainSignificant weight loss or weight gain• Fatigue or loss of energyFatigue or loss of energy• Feelings of worthlessness or excessive or inappropriate guiltFeelings of worthlessness or excessive or inappropriate guilt• Diminished concentration or indecisivenessDiminished concentration or indecisiveness• Recurrent thought of death, suicidal ideation, or suicide planRecurrent thought of death, suicidal ideation, or suicide plan

Impairment in functioningImpairment in functioning Five or more of these symptoms present during 2-week Five or more of these symptoms present during 2-week

period; change in previous functioningperiod; change in previous functioning Symptoms can not be explained by another condition Symptoms can not be explained by another condition

(substance use, medical condition) or another diagnosis (substance use, medical condition) or another diagnosis (e.g., Bereavement)(e.g., Bereavement)

(taken from criteria as outlined in DSM-IV)


Prevalence of PPDPrevalence of PPD

1/8 : average of 1/8 : average of numerous studiesnumerous studies

Higher in lower SES Higher in lower SES and other high-risk and other high-risk groups: groups: Up to 40%Up to 40%


Factors to Consider in Factors to Consider in Determining RiskDetermining Risk

Mental Health History (major depression, Mental Health History (major depression, psychosis)psychosis)

Previous Pregnancy ExperiencePrevious Pregnancy Experience Loss Loss SESSES Family/ Marital RelationshipFamily/ Marital Relationship Childhood ExperiencesChildhood Experiences Mood During Pregnancy & Post-DeliveryMood During Pregnancy & Post-Delivery Experience During Pregnancy/ DeliveryExperience During Pregnancy/ Delivery Infant VariablesInfant Variables MultiplesMultiples Societal/Cultural Influences/ ExpectationsSocietal/Cultural Influences/ Expectations

Risk is CumulativeAdditive effects


Protective FactorsProtective Factors Early Recognition and Seeking Early Recognition and Seeking

HelpHelp Previous Pregnancy ExperiencePrevious Pregnancy Experience Peer/Marital SupportPeer/Marital Support Respite CareRespite Care Focus on MotherFocus on Mother Enhanced feelings of CompetenceEnhanced feelings of Competence SLEEP $$$$$$$$$SLEEP $$$$$$$$$


What causes Postpartum What causes Postpartum Depression?Depression?

HormonalHormonal StressStress LossLoss SleepSleep Untreated anxietyUntreated anxiety Role transitionRole transition SupportSupport ExpectationExpectation Own receipt of careOwn receipt of care Personality featuresPersonality features


Qualitative ExperienceQualitative Experience (CT BECK)(CT BECK)

Violation of an expectation Violation of an expectation Thief that steals motherhoodThief that steals motherhood Horrifying AnxietyHorrifying Anxiety Relentless Obsessive Thinking Relentless Obsessive Thinking Enveloping Fogginess Enveloping Fogginess Death of SelfDeath of Self Struggle to SurviveStruggle to Survive Regaining ControlRegaining Control


Consequences of Consequences of Postpartum DepressionPostpartum DepressionMaternalMaternal

ConsequencesConsequences Suffering Suffering Lack of joy in childLack of joy in child Missed work Missed work Suicide attempts Suicide attempts Social ImpairmentSocial Impairment Marital discordMarital discord Somatic SxSomatic Sx

Health Care Health Care ConsequencesConsequences Less frequent HSVLess frequent HSV More Urgent Care More Urgent Care

/ER/ER Ineffective Ineffective

Anticipatory Anticipatory GuidanceGuidance

Behind on Behind on immunizationsimmunizations


PPD and Infant PPD and Infant DevelopmentDevelopment PPD directly impacts the infant’s PPD directly impacts the infant’s

experience and may have longer-experience and may have longer-term consequences on developmentterm consequences on development

• SocialSocial• EmotionalEmotional• CognitiveCognitive• Language Language • AttentionAttention• Mother-Infant Relationship/ Mother-Infant Relationship/

InteractionInteraction


Treatment Approaches: Treatment Approaches: BiologicalBiological

Biological:Biological: Medication:Medication:

AntidepressantsAntidepressants Anti-anxietyAnti-anxiety

Hormone TherapyHormone Therapy Estrogen patch Estrogen patch SleepSleep MassageMassage ExerciseExercise SunlightSunlight


Treatment Approaches: Treatment Approaches: PsychologicalPsychological

PsychologicalPsychological Psychotherapies:Psychotherapies:

Cognitive BehavioralCognitive Behavioral Interpersonal TherapyInterpersonal Therapy PsychodynamicPsychodynamic Supportive IndividualSupportive Individual FamilyFamily Group Group DBT/EMDRDBT/EMDR


Treatment Approaches: Treatment Approaches: SocialSocial

Social:Social: FamilyFamily FriendsFriends ChurchChurch Nurse VisitorsNurse Visitors


Treatment Approaches: Treatment Approaches: AlternativeAlternative

AlternativeAlternative Narrative JournalingNarrative Journaling MeditationMeditation ArtArt MusicMusic


Treatment Approaches: Treatment Approaches: IntegrativeIntegrative

Perspectives:Perspectives: Lead to treatmentLead to treatment

Bio-Psycho-Social ApproachBio-Psycho-Social Approach


Treatment ApproachesTreatment Approaches Two general approachesTwo general approaches

Alleviation of maternal symptomsAlleviation of maternal symptoms Improvement of mother-infant Improvement of mother-infant

relationshiprelationship

Are interventions targeted only Are interventions targeted only at mom enough to protect at mom enough to protect against negative child against negative child outcomes?outcomes?


Treatment ApproachesTreatment Approaches Studies show that individual therapies Studies show that individual therapies

may provide significant improvement may provide significant improvement in maternal mood and stress levelin maternal mood and stress level

Little evidence that such treatments Little evidence that such treatments benefit infants of mothers with PPDbenefit infants of mothers with PPD Lower attachment security statusLower attachment security status Higher negative affectHigher negative affect More internalizing and externalizing More internalizing and externalizing

problemsproblems


Treatment ApproachesTreatment Approaches

Are PPD interventions Are PPD interventions targeted only at mom targeted only at mom

enough to protect enough to protect against negative child against negative child

outcomes?outcomes?


Dyadic Treatment Dyadic Treatment ApproachesApproaches

Concept of PPD as mother-infant Concept of PPD as mother-infant relationship disorder (Cramer, 1993)relationship disorder (Cramer, 1993)

Dyadic therapy as preferred model Dyadic therapy as preferred model for PPD treatmentfor PPD treatment Mother-infant relationship as focal Mother-infant relationship as focal

point of treatmentpoint of treatment Goal to increase maternal Goal to increase maternal

sensitivity, responsivity, sensitivity, responsivity, engagementengagement

Promote positive attachment Promote positive attachment behaviorsbehaviors


Dyadic Treatment Dyadic Treatment ApproachesApproaches

General Findings General Findings Improved child outcomes even when Improved child outcomes even when

maternal sx don’t improvematernal sx don’t improve Buffering effect against future episodes of Buffering effect against future episodes of

maternal depressionmaternal depression Those infants with dyadic PPD tx more Those infants with dyadic PPD tx more

closely resemble infants of non-depressed closely resemble infants of non-depressed mothers in terms of cognitive ability mothers in terms of cognitive ability


Integrative ApproachIntegrative Approach

Psychiatric EvaluationPsychiatric Evaluation Medication Medication

ManagementManagement MITG: Group TherapyMITG: Group Therapy

Infant Developmental Infant Developmental GroupGroup

Mother’s GroupMother’s Group Dyadic (Mother-baby Dyadic (Mother-baby

Group)Group)

Open GroupsOpen Groups Social SupportSocial Support

Individual therapyIndividual therapy Family TherapyFamily Therapy


Step-Wise InterventionsStep-Wise Interventions Not all people need Not all people need

medsmeds Not all moms need Not all moms need

individual individual psychotherapypsychotherapy

Not all moms need Not all moms need group group psychotherapypsychotherapy

Some moms need Some moms need education and have education and have supportive adaptive supportive adaptive environmentsenvironments

Some moms need medsSome moms need meds Some moms need Some moms need

psychotherapypsychotherapy Some moms need group Some moms need group

psychotherapypsychotherapy Some moms need all Some moms need all

of the aboveof the above


Number of Women Treated Number of Women Treated Front Range CountiesFront Range Counties

CountyCounty Live Births 2004Live Births 2004 Estimated Estimated Depressed (12%) Depressed (12%)

DenverDenver 10,43810,438 13001300

Colorado*Colorado* 68,00068,000 81608160

Number Number TreatedTreated

300300


Who gets treated?Who gets treated?

Mental Health Mental Health CentersCenters

Nurse Home VisitingNurse Home Visiting

Kaiser study:Kaiser study: 2.8% of women 2.8% of women

received medication received medication for depression or for depression or anxiety in 1 yr past anxiety in 1 yr past deliverydelivery

In Colorado?In Colorado?

Mostly mid and high Mostly mid and high SES with support SES with support and resourcesand resources Individual Individual

PsychotherapyPsychotherapy Psycho-tropicsPsycho-tropics GroupGroup


The FACTS:The FACTS:

Postpartum Depression is highly prevalentPostpartum Depression is highly prevalent Postpartum Depression is not time-limitedPostpartum Depression is not time-limited Postpartum Depression is a major risk Postpartum Depression is a major risk

factor for an infant’s developmentfactor for an infant’s development Postpartum Depression is highly treatablePostpartum Depression is highly treatable Postpartum Depression does not get Postpartum Depression does not get

treatedtreated


BarriersBarriers Lack of AwarenessLack of Awareness

Lack of Formal Lack of Formal ScreeningScreening

Lack of ResourcesLack of Resources

Lack of TrainingLack of Training

Mental Health ParityMental Health Parity

Public AwarenessPublic Awareness

Professional TrainingProfessional Training

Satellite Support Satellite Support GroupsGroups

Mandatory ScreeningMandatory Screening

ConferenceConference


Barriers to TreatmentBarriers to Treatment

Public AwarenessPublic Awareness StigmaStigma Professional EducationProfessional Education System BarriersSystem Barriers ResourcesResources System LinkagesSystem Linkages


Barriers To TreatmentBarriers To Treatment

Public Awareness Public Awareness and Stigmaand Stigma


The Media’s ViewThe Media’s View


The Common View of the The Common View of the Postpartum PeriodPostpartum Period


The RealityThe Reality

TiredTired Alone at homeAlone at home Most friends are at Most friends are at

workwork Lots of care for babyLots of care for baby Little time for selfLittle time for self Lack of sleepLack of sleep OverwhelmedOverwhelmed



- Professional Training and Practice Professional Training and Practice - lack of primary care identificationlack of primary care identificationlack of professional awareness of conditionlack of professional awareness of conditionlack of expertise in perinatal and infant lack of expertise in perinatal and infant

mental health issuesmental health issues- lack of awareness regarding lack of awareness regarding

psychopharmacological issuespsychopharmacological issues



Public Health:Public Health: Screening in WICScreening in WIC Screening in Nurse VisitationScreening in Nurse Visitation

Primary Care:Primary Care: Screening at OBScreening at OB Screening at FPScreening at FP Screening at PediatricScreening at Pediatric


Challenges of Detecting Challenges of Detecting PPDPPD

Symptoms often confused with more typical reactions to childbirth. BE AWARE- these may be indicators of the presence of PPD

Depressed mood Lack of pleasure/ interest Feelings of worthlessness/ guilt Agitation or retardation Feelings of worthlessness/ guilt Thoughts of death or suicide Weight loss * Loss of energy * Sleep Disturbance * Diminished concentration/ Indecisiveness * Reports of “overwhelmed”, “anxious”

(60% PPD have co-morbid anxiety meeting diagnostic criteria)


Screening for PPDScreening for PPD

Relationship-based?Relationship-based? Educate and Normalize Educate and Normalize

PPDPPD Very Common and Very Very Common and Very

TreatableTreatable• Include Assessment of Include Assessment of

PartnerPartner


Early Identification CrucialEarly Identification Crucial

• Need to rule out medical concerns (e.g., thyroid, Need to rule out medical concerns (e.g., thyroid, anemia)anemia)

• Attend to risk factors in prenatal periodAttend to risk factors in prenatal period• Routine postnatal screeningRoutine postnatal screening

• ObservationObservation• Interview (ASK and LISTEN)Interview (ASK and LISTEN)

• Do not minimize reports of symptomsDo not minimize reports of symptoms• Consider Timing/ CircumstancesConsider Timing/ Circumstances

• Screening:Screening:• Self-Report MeasuresSelf-Report Measures

• CES-D CES-D • Edinburgh Postnatal Depression Scale (EPDS)Edinburgh Postnatal Depression Scale (EPDS)• Beck Depression Inventory (BDI)Beck Depression Inventory (BDI)• Postpartum Depression Predictors Inventory (Beck,1998)Postpartum Depression Predictors Inventory (Beck,1998)



Perinatal Mental Health ExpertisePerinatal Mental Health Expertise

Infant Mental Health ExpertiseInfant Mental Health Expertise

System Issues with MH Access in System Issues with MH Access in both the public and private sectorboth the public and private sector


Assessment of Assessment of Postpartum Mood Postpartum Mood

DisturbanceDisturbance Empathic and Relationship BasedEmpathic and Relationship Based

Normalize the overwhelming and frightening experienceNormalize the overwhelming and frightening experience Subjective ExperienceSubjective Experience

SafetySafety Mom and babyMom and baby Obsessive ruminations versus psychotic preoccupationObsessive ruminations versus psychotic preoccupation

Assessment of Other PathologyAssessment of Other Pathology WorriesWorries ThoughtsThoughts

Assessment as InterventionAssessment as Intervention



System Organizational and System Organizational and InfrastructuralInfrastructural

Unknown referral sourcesUnknown referral sources Medicaid fundingMedicaid funding Institutional barriers Institutional barriers

EngagementEngagement StigmaStigma Phone CentersPhone Centers Transportation Transportation TimeTime


Barriers To TreatmentBarriers To Treatment

Consumer Awareness and Consumer Awareness and Social Stigma Social Stigma

• nature and incidence is high nature and incidence is high • (most common side effect of pregnancy)(most common side effect of pregnancy)

• condition is highly treatablecondition is highly treatable• institutional stigmainstitutional stigma• other socio-cultural factorsother socio-cultural factors


Challenges of Challenges of Detecting/Treating PPDDetecting/Treating PPD

Expected period of adjustment (especially for Expected period of adjustment (especially for first-time mothers)first-time mothers)

Stigma associated with being a “good Stigma associated with being a “good mother”mother”

Fear of “going crazy” or being separated from Fear of “going crazy” or being separated from babybaby

Not knowing which doctor to turn to for helpNot knowing which doctor to turn to for help Post-delivery in hospitalPost-delivery in hospital 6 week OB/GYN visit6 week OB/GYN visit Well baby checksWell baby checks

Physician’s minimization of distressPhysician’s minimization of distress Managed careManaged care Mental Health Professional AvailabilityMental Health Professional Availability Lack of knowledge / appropriate educationLack of knowledge / appropriate education


ResourcesResources

Kempe Center’s Postpartum Depression Kempe Center’s Postpartum Depression Intervention Program: (303-864-5845)Intervention Program: (303-864-5845)

Depression After Delivery (800-944-4773)Depression After Delivery (800-944-4773)

Postpartum Support International Postpartum Support International (805-967-7636)(805-967-7636) National Women’s Health Information Center National Women’s Health Information Center

(NWHIC) (800-994-9662)(NWHIC) (800-994-9662) Postpartum Education for Parents (805-564-3888)Postpartum Education for Parents (805-564-3888) American College of Obstetricians and American College of Obstetricians and

Gynecologists (ACOG) (800-762-2264)Gynecologists (ACOG) (800-762-2264) National Institute of Mental Health (301-496-9576)National Institute of Mental Health (301-496-9576) American Psychological Association (800-374-American Psychological Association (800-374-

2721)2721)


CollaborationCollaboration

The nature of these barriers require:The nature of these barriers require:

specific expertisespecific expertise

unique resourcesunique resources

and collaborative partnerships.and collaborative partnerships.


Our Joint Purpose:Our Joint Purpose:

To target these barriers in a strategic, To target these barriers in a strategic, innovative, collaborative, and innovative, collaborative, and evidenced-based/best-practice evidenced-based/best-practice approach that begins to create clinical approach that begins to create clinical expertise in the treatment of perinatal expertise in the treatment of perinatal mood disorders in local mental health mood disorders in local mental health centers and targets other system centers and targets other system barriers toward the identification, barriers toward the identification, referral, and treatment of these referral, and treatment of these individuals.individuals.


The anticipated benefits of this The anticipated benefits of this project will be as follows:project will be as follows:

to improve services to low-income and other high-risk women to improve services to low-income and other high-risk women and dyadsand dyads

to improve delivery of perinatal mental health services by to improve delivery of perinatal mental health services by community mental health professionals and to link them with community mental health professionals and to link them with infant mental health servicesinfant mental health services

to improve primary care surveillance, screening, counseling, to improve primary care surveillance, screening, counseling, and referraland referral

to improve access to care in local mental health center to improve access to care in local mental health center programsprograms

to educate professionals, organizations, and legislators about to educate professionals, organizations, and legislators about the barriers to appropriate identification and treatmentthe barriers to appropriate identification and treatment


The anticipated benefits:The anticipated benefits:

to adapt an evidence-based intervention to culturally, to adapt an evidence-based intervention to culturally, linguistically, and demographically unique populationslinguistically, and demographically unique populations

to increase community / public awareness of the nature and to increase community / public awareness of the nature and treatability of perinatal mental illnesstreatability of perinatal mental illness

to increase public health surveillance on perinatal mental to increase public health surveillance on perinatal mental illness through collaboration between the BHI, FBH, CDPHE, illness through collaboration between the BHI, FBH, CDPHE, a 1-800 hotline referral system, and local systems of carea 1-800 hotline referral system, and local systems of care

to create system linkages by providing evidenced-based to create system linkages by providing evidenced-based education, a public awareness campaign, and other education, a public awareness campaign, and other technical support through collaboration with strong and technical support through collaboration with strong and uniquely capable public, private, and non-profit uniquely capable public, private, and non-profit organizations organizations


Methods of Methods of Intervention:Intervention:

The Colorado / Kempe broad strategic plan for targeting perinatal The Colorado / Kempe broad strategic plan for targeting perinatal mental illness includes the following 7 methods of intervention: mental illness includes the following 7 methods of intervention:

1)1) Embedding Perinatal Mental Health Trainers Embedding Perinatal Mental Health Trainers

2)2) The expansion and adaptation to unique populations of this The expansion and adaptation to unique populations of this intervention intervention

3)3) Consultation to address service provision barriersConsultation to address service provision barriers

4)4) Education of primary care, mental health, nursing, etcEducation of primary care, mental health, nursing, etc

5)5) Improved surveillance, reporting, and tracking Improved surveillance, reporting, and tracking

6)6) Public Awareness / EducationPublic Awareness / Education

7)7) Advocacy through political lobbyingAdvocacy through political lobbying


The creation of system The creation of system linkages in cooperation with:linkages in cooperation with:

1)1) primary care primary care

2)2) prenatal nursing programsprenatal nursing programs

3)3) public healthpublic health

4)4) social services agencies social services agencies

5)5) and community mental healthand community mental health


Screening by Collaborative Stakeholder: PHQ, EPDS, OTHERPositive Screen Triggers Call

Call 1-800 Kempe PPD number1) Triage2) Safety ensured3) Insurance criteria (if any) met4) Home visit scheduled

Engagement visits performedRelationship formedNFP-KEMPE screening assessment:

Safety, Impairment

Needs Assessment:Life Skills Progression

PsychoeducationReferral to Community ServicesEngagement in ProgramEvaluate need for psychiatric assessment


Home Visits Psychiatric Evaluation: Maternal DX

Qualifies for MITGMITG Evaluation: Infant Dx and Relationship DX2 2hour sessions

Does not qualify for MITG

Enters MITG GroupCompletes MITG

OPEN PPD GROUP Other MHC resource

Other MHC or Community ResourcesDomestic ViolenceSubstance AbuseSocial Phobia

Discharge from system


The Science of PreventionThe Science of Preventionand Perinatal Mood and Perinatal Mood

DisturbanceDisturbance There is no clear evidence to recommend

the implementation of antenatal and postnatal classes, early postpartum follow-up, continuity of care models, psychological debriefing in hospital, and interpersonal psychotherapy.

There is emerging evidence, however, to support the importance of additional professional support provided postnatally.


IssuesIssues

Universal interventions are offered to all women

Selective interventions are offered to women at increased risk of developing postnatal depression

Indicated interventions are offered to women who have been identified as depressed or probably depressed.


Preventive ServicesPreventive Services

Indicated:Depressed During Pregnancy

Targeted:Multiple Risk Factors

Universal:All women


State-level Coordination, Collaboration, Planning, Funding and Advocacy

Local-level Coordination, Collaboration, Planning, Funding and Advocacy

Universal/Preventive Services

Focused Services for At-Risk Children & Families

Tertiary Intervention ServicesEducation

Intervention

Referral

Risk-specific Assessment

Health & Developmental Screening & Assessment

Parenting Education

Referral

Provision of Care

Case Management

Diagnostic Assessment

Treatment for Parent & Child

Direct Infant Mental Health ServicesConsultation

& Referral

Promotion

Promotion

Promotion


Putting all the pieces Putting all the pieces togethertogether

LegislativeAdvocacy

Mental HealthExpertise

System Linkages

Primary CarePublic Health Screening

Public Awareness


Thanks for Listening!Thanks for Listening!

Your Thoughts?Your Thoughts?

Documents

Incorporating Mental Health Into Maternal Health