incorporating mental health into maternal health

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Incorporating Mental Health Into Maternal Health. Brian Stafford, MD, MPH Medical Director The Kempe Center’s Postpartum Depression Intervention Program. CITYMATCH CONFERENCE Denver, CO Aug, 2007. Outline. Perinatal Mental Health and Mental Illness Barriers to Treatment - PowerPoint PPT Presentation

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  • Incorporating Mental HealthInto Maternal HealthBrian Stafford, MD, MPHMedical Director The Kempe Centers Postpartum Depression Intervention ProgramCITYMATCH CONFERENCEDenver, CO Aug, 2007

    Brian Stafford, MD, MPH

    OutlinePerinatal Mental Health and Mental IllnessBarriers to TreatmentPublic Healths RoleMental Healths RolePrimary Cares Role

    Brian Stafford, MD, MPH

    Perinatal Mental HealthA developmental crisisA time of increased contact with Medical and Public Healthbut not necessarily mental health

    Brian Stafford, MD, MPH

    PregnancyHigh Risk for Medical Complications

    High Risk for Mental Health Complications

    Brian Stafford, MD, MPH

    ExamplesMost common complications of pregnancy are:Spontaneous AbortionPostpartum DepressionAntenatal DepressionDiabetesPrematurityPerinatal Loss

    Brian Stafford, MD, MPH

    DepressionWorld Health Organization2020 depression will be 2nd greatest cause of premature death and disability worldwide in both sexesAlready number one cause of disease burden in women

    Brian Stafford, MD, MPH

    Perinatal Mood DisturbanceDefinitions:Antenatal AnxietyAntenatal DepressionPostpartum BluesPostpartum PsychosisPostpartum DepressionPostpartum PTSDPostpartum Anxiety

    Brian Stafford, MD, MPH

    Baby Blues50 - 85% of women Hours to days after childbirth lasting up to two weeksOnset typically within 10 daysMild, short-lived:AngerSense of unworthiness, inadequacy, failure, guiltCryingIrritability/ ImpatienceRestlessnessSadnessTiredness (fatigue), Insomnia, or bothMood swings

    Brian Stafford, MD, MPH

    Postpartum AnxietyNew Onset or ExacerbationGeneralizedPanicPhobicSocial PhobiaOCD likeExacerbation is worsePreoccupation with baby

    Brian Stafford, MD, MPH

    Postpartum PsychosisRare - Less than 1% of women (1-2/1000)Bipolar Disorder/ Schizophrenia/Schizoaffective Disorder/Psychotic DepressionSigns and symptoms even more severe and may occur early (within first 3 months postpartum usually first 2 weeks)Anger and agitationInsomniaConfusion and disorientationThoughts of harming self (suicide) or baby (infanticide)Hallucinations and delusionsParanoiaStrange thoughts or statements

    Brian Stafford, MD, MPH

    Postpartum PTSD: Less well understoodPregnancy and delivery and newborn period is a time of potential traumaPregnancyRisk to motherRisk to babyDeliveryRisk to motherRisk to babyCongenital or other neonatal issue (Anxiety, PTSD, Depression, Grief)

    Brian Stafford, MD, MPH

    Postpartum Depression (PPD) 10 - 20% of womenSigns and symptoms more intense and longer lastingSymptoms of baby bluesPLUSEmotional numbness, feeling trappedFear of hurting self or babyImpaired thinking, concentrationLack of joyLess interest in sexExcessive concern/lack of concern for babySignificant weight loss or gainWithdrawal from family and friends

    overwhelmed, anxious as common descriptors

    Brian Stafford, MD, MPH

    Postpartum DepressionNot as mild or transient as the blues Not as severely disorienting as psychosis Range of severityMild to Extreme Impairment The same but differentCo-morbidity (Anxiety)Violation of expectation

    Brian Stafford, MD, MPH

    Major Depressive EpisodeDepressed mood Diminished interest or pleasure in everyday activitiesInsomnia or hypersomnia Significant weight loss or weight gainFatigue or loss of energyFeelings of worthlessness or excessive or inappropriate guiltDiminished concentration or indecisivenessRecurrent thought of death, suicidal ideation, or suicide planImpairment in functioningFive or more of these symptoms present during 2-week period; change in previous functioningSymptoms can not be explained by another condition (substance use, medical condition) or another diagnosis (e.g., Bereavement)(taken from criteria as outlined in DSM-IV)

    Brian Stafford, MD, MPH

    Prevalence of PPD1/8 : average of numerous studiesHigher in lower SES and other high-risk groups: Up to 40%

    Brian Stafford, MD, MPH

    Factors to Consider in Determining RiskMental Health History (major depression, psychosis)Previous Pregnancy ExperienceLoss SESFamily/ Marital RelationshipChildhood ExperiencesMood During Pregnancy & Post-DeliveryExperience During Pregnancy/ DeliveryInfant VariablesMultiplesSocietal/Cultural Influences/ ExpectationsRisk is CumulativeAdditive effects

    Brian Stafford, MD, MPH

    Protective FactorsEarly Recognition and Seeking HelpPrevious Pregnancy ExperiencePeer/Marital SupportRespite CareFocus on MotherEnhanced feelings of CompetenceSLEEP $$$$$$$$$

    Brian Stafford, MD, MPH

    What causes Postpartum Depression?HormonalStressLossSleepUntreated anxietyRole transitionSupportExpectationOwn receipt of carePersonality features

    Brian Stafford, MD, MPH

    Qualitative Experience (CT BECK)Violation of an expectation Thief that steals motherhoodHorrifying AnxietyRelentless Obsessive Thinking Enveloping Fogginess Death of SelfStruggle to SurviveRegaining Control

    Brian Stafford, MD, MPH

    Consequences of Postpartum DepressionMaternalConsequences Suffering Lack of joy in childMissed work Suicide attempts Social ImpairmentMarital discordSomatic Sx

    Health Care ConsequencesLess frequent HSVMore Urgent Care /ERIneffective Anticipatory GuidanceBehind on immunizations

    Brian Stafford, MD, MPH

    PPD and Infant DevelopmentPPD directly impacts the infants experience and may have longer-term consequences on developmentSocialEmotionalCognitiveLanguage AttentionMother-Infant Relationship/ Interaction

    Brian Stafford, MD, MPH

    Treatment Approaches: BiologicalBiological:Medication:AntidepressantsAnti-anxietyHormone TherapyEstrogen patch SleepMassageExerciseSunlight

    Brian Stafford, MD, MPH

    Treatment Approaches: PsychologicalPsychologicalPsychotherapies:Cognitive BehavioralInterpersonal TherapyPsychodynamicSupportive IndividualFamilyGroup DBT/EMDR

    Brian Stafford, MD, MPH

    Treatment Approaches: SocialSocial:FamilyFriendsChurchNurse Visitors

    Brian Stafford, MD, MPH

    Treatment Approaches: AlternativeAlternativeNarrative JournalingMeditationArtMusic

    Brian Stafford, MD, MPH

    Treatment Approaches: IntegrativePerspectives:Lead to treatment

    Bio-Psycho-Social Approach

    Brian Stafford, MD, MPH

    Treatment ApproachesTwo general approachesAlleviation of maternal symptomsImprovement of mother-infant relationship

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

    Brian Stafford, MD, MPH

    Treatment ApproachesStudies show that individual therapies may provide significant improvement in maternal mood and stress levelLittle evidence that such treatments benefit infants of mothers with PPDLower attachment security statusHigher negative affectMore internalizing and externalizing problems

    Brian Stafford, MD, MPH

    Treatment Approaches

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

    Brian Stafford, MD, MPH

    Dyadic Treatment ApproachesConcept of PPD as mother-infant relationship disorder (Cramer, 1993)Dyadic therapy as preferred model for PPD treatmentMother-infant relationship as focal point of treatmentGoal to increase maternal sensitivity, responsivity, engagementPromote positive attachment behaviors

    Brian Stafford, MD, MPH

    Dyadic Treatment ApproachesGeneral Findings Improved child outcomes even when maternal sx dont improveBuffering effect against future episodes of maternal depressionThose infants with dyadic PPD tx more closely resemble infants of non-depressed mothers in terms of cognitive ability

    Brian Stafford, MD, MPH

    Integrative ApproachPsychiatric EvaluationMedication ManagementMITG: Group TherapyInfant Developmental GroupMothers GroupDyadic (Mother-baby Group)

    Open GroupsSocial SupportIndividual therapyFamily Therapy

    Brian Stafford, MD, MPH

    Step-Wise InterventionsNot all people need medsNot all moms need individual psychotherapyNot all moms need group psychotherapy

    Some moms need education and have supportive adaptive environmentsSome moms need medsSome moms need psychotherapySome moms need group psychotherapySome moms need all of the above

    Brian Stafford, MD, MPH

    Number of Women Treated Front Range Counties

    Brian Stafford, MD, MPH

    Who gets treated?Mental Health Centers

    Nurse Home Visiting

    Kaiser study:2.8% of women received medication for depression or anxiety in 1 yr past deliveryIn Colorado?

    Mostly mid and high SES with support and resourcesIndividual PsychotherapyPsycho-tropicsGroup

    Brian Stafford, MD, MPH

    The FACTS:Postpartum Depression is highly prevalentPostpartum Depression is not time-limitedPostpartum Depression is a major risk factor for an infants developmentPostpartum Depression is highly treatablePostpartum Depression does not get treated

    Brian Stafford, MD, MPH

    BarriersLack of Awareness

    Lack of Formal Screening

    Lack of Resources

    Lack of Training

    Mental Health ParityPublic Awareness

    Professional Training

    Satellite Support Groups

    Mandatory Screening

    Conference

    Brian Stafford, MD, MPH

    Barriers to TreatmentPublic AwarenessStigmaProfessional EducationSystem BarriersResourcesSystem Linkages

    Brian Stafford, MD, MPH

    Barriers To TreatmentPublic Awareness and Stigma

    Brian Stafford, MD, MPH

    The Medias View

    Brian Stafford, MD, MPH

    The Common View of the Postpartum Period

    Brian Stafford, MD, MPH

    The RealityTiredAlone at homeMost friends are at workLots of care for babyLittle time for selfLack of sleepOverwhelmed

    Brian Stafford, MD, MPH

    Barriers to TreatmentProfessional Training and Practice lack of primary care identificationlack of professional awareness of conditionlack of expertise in perinatal

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