peripartum mood disorders and postpartum...
TRANSCRIPT
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Peripartum Mood Disorders and Postpartum Depression Screening:
For Primary Care Providers Caring for Children in Oregon
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A Project Of
The Oregon Pediatric Society
Oregon Chapter of the American Academy of Pediatrics (AAP)
Sponsored by:
Ford Family Foundation
Healthy Eastern Oregon Consortium Project
an OHA Community Prevention Grant
Multnomah Project LAUNCH
NW Newborn
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DISCLAIMER
The Oregon Pediatric Society (OPS), a Chapter of the
American Academy of Pediatrics, has no conflict of interest,
and is not affiliated with any other organization, vendor or
company.
Reasonable attempts have been made to provide accurate
and complete information.
The practitioner or provider is responsible for use of this
educational material, and any information provided should
not be a substitution for the professional judgment of the
practitioner or provider.
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CME This event is a joint providership between Bay Area Hospital and the Oregon Pediatric Society. Bay Area Hospital’s Continuing Medical Education (CME) Program is accredited by the Oregon Medical Association to sponsor Category 1 medical education activities for physicians. As an accredited institution, Bay Area Hospital’s Medical Education Committee designates this live educational activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™ Physicians should only claim credit commensurate with the extent of their participation in the activity. Bay Area Hospital fully complies with the legal requirements of the ADA and the rules and regulations thereof. If any participant in this educational activity is in need of accommodation, please call 503-334-1591, x101.
OPS Trainers and planners of these events have disclosed they have no financial relationship with a commercial entity producing health-care related products or services.
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• IMPROVE postpartum depression screening
in pediatric practices
• ENHANCE provider understanding, utilization,
and implementation of standardized screening
tools
• EDUCATE providers in proper documentation,
coding, and billing of screening tools
• BUILD provider awareness of local community
resources for evaluation and intervention
Goals & Objectives START BASIC
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AGENDA
1: POSTPARTUM DEPRESSION AND ANXIETY:
The Science Behind It & Recommended,
Standardized Tools
2: COMMUNITY RESOURCES
3: IMPLEMENTING STANDARDIZED SCREENING
In Your Practice
Adjourn
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The Science & Tools OF POSTPARTUM DEPRESSION
& ANXIETY SCREENING
PART 1
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• Primary care providers for children see moms early
and often.
• Mom’s and father’s mental health affects well-being
of baby and family.
• Child’s developmental health is directly influenced
by early relationship history.
• Screening new moms for depression can prevent a
host of childhood problems.
Importance of Screening WHY SCREEN MOM DURING WELL-CHILD VISITS?
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Oregon by the Numbers
of women reported that they were
depressed during and/or after
pregnancy.
of those women were still depressed
when their child was 2 years old.
of adults in Oregon meet the criteria
for current depression.
24%
48%
7-8%
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PRAMS: PREGNANCY RISK ASSESSMENT MONITORING
SYSTEM
Demographic characteristics significantly associated with postpartum depression were:
•Young maternal age (13.4 % point variance youngest and oldest mothers)
•Single marital status (9.7% greater)
•Maternal education (13.6% difference)
•Medicaid recipient (11% greater)
•Race/Ethnicity showed lower risk for non-hispanic white compared to other groups.
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Behaviors of Depressed Mothers
REDUCED
EMOTIONAL
RANGE
REDUCED
CARE OF
BABY
LESS RESPONSIVE TO BABY’S CUES AND NEEDS
LESS LIKELY TO OBTAIN PREVENTIVE
HEALTHCARE FOR BABY
LESS EMPATHY AND INTERACTIVE BEHAVIOR
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PHYSIOLOGIC
IMPACT DUE TO PERINATAL MOOD DISORDERS
Increased incidence of premature labor
Increased incidence of low birth weight
Hypertension
Increased cortisol response in infants
Increased incidence of drug and alcohol use
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Maternal Depression
ANXIETY AFFECTS INFANTS
Decreased cognitive stimulation and
bonding may cause:
•Irritability
•Lower activity level
•Irregular sleep and feeding behaviors
•Impeded growth during first year of life
•Lifelong decreased ability to handle stress
•Difficulty in developing trusting relationships
•Increased depression, anxiety, and attention deficit
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The Still Face Experiment
Copyright © 2007 ZERO TO THREE http://www.zerotothree.org
Ed Tronick (http://www.umb.edu/Why_UMass/Ed_Tronick), director of UMass Boston's new Infant-Parent Mental
Health Program
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MIRROR NEURONS
Interaction through
relationships
builds the
foundation of brain
development and
social emotional
capacity.
Bruce Perry, Ph.D
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RISK FACTORS For Postpartum Depression & Anxiety
POVERTY
SUBSTANCE ABUSE
SLEEP DEPRIVATION
IMMIGRANT STATUS
DOMESTIC VIOLENCE
YOUNG MATERNAL AGE
TRAUMATIC EXPERIENCES
PREGNANCY COMPLICATIONS
HISTORY OF FAMILY DEPRESSION
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PROTECTIVE FACTORS Against Poor Outcomes
Breastfeeding
Child’s disposition
Routine health events
Familial warmth and cohesiveness
Support from other family members and community
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OVERVIEW OF MATERNAL MOOD DISORDERS
Maternal
Mood Disorders
“Baby Blues” Postpartum
Depression
Postpartum
Psychosis
Usually resolves
without treatment
Requires
treatment
Immediate treatment,
may require
hospitalization
10-25% 50-80% <1%
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BABY BLUES
• Normal condition in postpartum mothers
• Occurs in 50-80% of new mothers
• Symptoms include feelings of loss, anxiety, confusion, fear, or being overwhelmed
• Symptoms peak ~5 days after birth and resolve within a few weeks
• Does not disrupt function or daily routines
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Symptoms of Postpartum Depression & Anxiety
(same DSM-5 criteria as major depression)
Lack of interest in baby, friends or family
Decreased energy and concentration
Thoughts of harming self or child
Feelings of being a bad mother
Changes in appetite and weight
Feeling “blue” and crying
Anger and irritability
Anxiety and worry
Sleep problems
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Postpartum Depression and Postpartum
Anxiety (PPD and PPA)
• 10-25% of childbearing women affected.
• Many women are unable to recognize
symptoms of PPD.
• Negative effects on infant behavior and
development.
• Up to 50% of partners develop PPD, if
mother is symptomatic.
• Occurs any time during first 12 months
postpartum.
• Symptoms persist in half of untreated mothers one year postpartum.
• Symptoms last from 2 weeks to more than a year.
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Postpartum Psychosis
• Relatively uncommon (1-3 out of 1000 women)
• Onset as early as one day after delivery, through baby’s first year
• Peak incident of onset is within first month
• Onset may be abrupt
• Characterized by hallucinations, paranoia, possible suicidal/infanticidal thoughts
• Requires immediate treatment and possible hospitalization
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Primary Prevention Model
Risk factors are known
Problem is common
Population is known and present
Identifying high-risk mothers by screening is
inexpensive
Screening is also educational
Many risk factors are amenable to change
Screening leads to appropriate and timely referral
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Summary and Conclusions Postpartum depression & anxiety:
Is a clinically significant illness that may have
long-lasting effects on the well-being of the
mother and her family
Distinct from “baby blues,” a normative
condition that resolves within a few weeks
following birth
Is treatable and can be easily screened during
well-child visits and routine checkups
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CAN prevent long-term
negative consequences for
infants
Assessment, Treatment &
Support
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When to Screen
Screen all mothers
Per ABCD Academy Recommendations:
2 weeks and repeat 2 – 4 months
Bright Futures recommendations not set
Subsequent screening as needed throughout child’s
first year of life
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Maternal Depression
Screening Tools
• Patient Health Questionnaire
(PHQ-2) can be used as pre-
screener
• Edinburgh Postnatal
Depression Scale (EPDS) is
more thorough and includes
safety assessment
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Recommended Schedule for
Standardized Screening
Developmental
Screening (AAP 2006)
9 months
ASQ/PEDS
18 months
ASQ/PEDS
&
M-CHAT R/F
24/30 mo.
ASQ/PEDS
&
M-CHAT R/F
3-5 years
ASQ/PEDS
as
needed
Maternal
Depression
Screening**
(Earls, et.al. 2010)
2 weeks
Edinburgh
2 months
Edinburgh
4 months
as needed
6 mo./
1 yr.
as
needed
Social-Emotional
Screening
Recommendations Pending
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Patient Health Questionnaire (PHQ-2)
A brief two-item standardized
tool that screens for parental
depression, to be followed up
with a more comprehensive
screening or in-person
evaluation.
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PHQ-2 Scoring Less than one minute; self administered or done through
interview
• Over the past two weeks how often have you had little
interest or pleasure in doing things?
• Over the past two weeks how often have you been feeling
down, depressed, or hopeless?
Answers range 0-3:
0 = Not at all
1 = Several days
2 = More than half the days
3 = Nearly every day
USE
SECONDARY
SCREEN IF
SCORE IS
GREATER THAN
3.
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The Edinburgh Postnatal
Depression Scale (EPDS) A 10-item Self-Report Questionnaire
• Identifies depressive symptoms in pregnant women/new mothers
• Validated cross-culturally
• Available in 21 languages (Cox & Holden)
• Can be used throughout the first first
• At a mean of 12 weeks postpartum, the EPDS had a sensitivity of 100% and specificity of 90% for major depression with a cutoff score of 10
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Any patient who scores > 0 on question #10
(“The thought of harming myself has occurred to me”) requires a
discussion about potential for immediate harm and referral to:
Mental Health Crisis Hotline
QMHP for Mental Health Evaluation/Services
If imminent self-harm is a concern, patient should not be left
alone and should be immediately referred or escorted to
Emergency Room.
Using EPDS to
DETERMINE RISK OF HARM
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Edinburgh Postnatal Depression Scale
Example: Ima Blue
•EPDS Screening Tool
•EPDS instructions for administering and scoring
“Tool Time”: 2 Minutes
•Score Ima’s screening tool
•Interpret results
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EPDS Scoring
Response categories are scored: 0, 1, 2, and 3
Items marked with asterisk (*)
are reverse scored: 3, 2, 1, and 0
Add all scores for each of the 10 items
for the total score
Cutoff score is 10
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Ima’s Score 1. I have been able to laugh and see the funny side of things. 1
2. I have looked forward with enjoyment to things 1
3. * I have blamed myself unnecessarily when things went wrong. 1
4. I have been anxious or worried for no good reason. 2
5. * I have felt scared or panicky for not very good reason. 1
6. * Things have been getting on top of me. 2
7. * I have been so unhappy that I have had difficulty sleeping. 2
8. * I have felt sad or miserable. 2
9. * I have been so unhappy that I have been crying. 2
10. * The thought of harming myself has occurred to me. 0
TOTAL 14
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Discussing Screening Results
• Recognize sensitivity of issue
• Reinforce how mother’s health impacts her child without increasing/promoting feelings of guilt or shame
• Provide a supportive, non-judgmental environment
• Consider cultural attitudes toward depression and screening
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INCREASE awareness & recognition
REFER parent to OB or parent’s primary care
provider (if you aren’t already that person)
DISCUSS problem with mother’s PCP
FOLLOW UP with mother and infant sooner than
next typical visit
OFFER mental health and community resources
for parent
The Role of the Provider
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Options for Support and Treatment
Self Care
Social Support
Mental Health Referral
Medication
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Self Care for PPD
Encourage simple changes for mother
• A well-balanced diet
• Exercise
• Good sleep habits
• Stress management
• Relaxation techniques
Suggested Resource:
Patient Guide – Self-care program for Women with PPD and Anxiety (http://www.bcapop.ca/uploads/9/9/0/1/9901389/reproductivementalhealthselfcareguide.pdf)
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Antidepressant Use During
Pregnancy and Breastfeeding
SERTRALINE and FLUOXETINE
• Both are Pregnancy category C & Lactation
category L2
• Risk of non treatment needs to be considered
Believed to be safest:
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Meds in Pregnancy & Lactation
Resources & Consultation
LactMed: http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Mass General Women’s Health: http://www.womensmentalhealth.org/specialty-clinics/breastfeeding-and-psychiatric-medication/
UIC Perinatal Psych Project (Healthcare Provider Consultation Line): 800-573-6121 www.psych.uic.edu/research/perinatalmentalhealth/consultation
OTIS: 866-626-OTIS (6847) www.Otispregnancy.org
MOTHERISK: 877-439-2744 www.motherisk.org/prof/drugs.jsp
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Procedure Codes
99420 - Administration and interpretation of health
risk assessment instrument
Pair with ICD-9 V20.2 if screen normal or 648.42 if
abnormal (mental disorders complicating pregnancy
childbirth or the puerperium)
V79.8 - Special screening for other specified mental
disorders and developmental handicaps
V61.8 – labeled as screening for maternal
depression
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Community PARTNERS & RESOURCES
PART 2
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• Oregon Maternal Mental Health Website
www.healthoregon.org/perinatalmentalhealth
Information and links to services of Oregon women, families and providers
• Postpartum Support International (PSI)
www.postpartum.net or 1-800-944-4PPD
English and Spanish telephone helpline for support and resources
• 211info
Email [email protected] or text zip code to 898211 or Dial 2-1-1
Free guidance, information and referral
• Full House Moms
http://www.fullhousemoms.com/
Support group for parents of multiples
• Brief Encounters
http://www.briefencounters.org/bewp/
Support group for parents of pregnancy loss or infant loss
• National Suicide Prevention
www.suicidepreventionlifeline.org or 1-800-273-8255
24 hour Lifeline
COMMUNITY RESOURCES & LOCAL SUPPORT
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Implementing STANDARDIZED SCREENING
IN YOUR PRACTICE
PART 3
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Getting STARTed with Screening Tools Small Steps…
QUESTIONS:
• How do you make time for screening?
• Who administers the screening, scores
the tests, and communicates results?
• Who else needs to be involved in the
screening and referral process?
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Improvement Methods (from IHI)
What are we trying to accomplish?
How will we know that a change is
an improvement?
What changes can we make that
will result in improvement?
Plan
Do Study
Act
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Meet objective Develop questions & predictions (why) Create plan to carry out the cycle (who, what, where, when)
Plan
Do
Act
Study
The PDSA Cycle
Carry out the plan Document problems and unexpected observations Begin analysis of the data
What changes are to be made?
Next cycle?
Complete the analysis of the data
Compare data to
predictions
Summarize what was learned
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Continuous PDSA Cycles
ACT
STUDY
PLAN
DO
ACT
STUDY
PLAN
DO
ACT
STUDY
PLAN
DO
Hunches,
theories,
ideas
Changes that
result in
improvement
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ADDITIONAL INFORMATION
PART 4
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CME Information
• This START training is eligible for a
maximum of 1.0 hours AMA PRA
Category 1 Credit(s)™
• You will receive a START CME completion
certificate via email when you complete
the follow-up survey
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Other START Training Modules
ACEs/Trauma-Informed Care
Adolescent Depression Screening
Adolescent SBIRT with CRAFFT
Autism Spectrum Disorders (ASD) 101
Basic Developmental Screening
Behavioral Health Integration
To schedule a training, please contact Peg King, START Program Manager
[email protected] 503-334-1591 x101
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To find out more about the
Oregon Pediatric Society
please visit:
www.oraap.org
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Thank you.