Maternal Mental Health Interventions in LAMIC A few diverse thoughts about global implementationCORE presentation, 2012CORE presentation, 2011
More than “Baby Blues” Under diagnosed Under treated Often misunderstood Beliefs and practices are often culture bound Making global implementation of interventions complex
Treatment, generalThe World Health Organization (WHO) offers hopeful statistics related to maternal mental health, estimating that 70% to 80% of women with maternal mental disorders can be treated successfully and recover.• Earlier treatment is associated with a better prognosis.• The woman and her partner should be involved in the full continuum of care, including education and treatment options.• Screening may best occur at primary healthcare facilities• Antidepressants have been shown to be effective in treating perinatal depression.• Non-pharmacologic treatment strategies have been useful for women with mild to moderate depressive symptoms. – Individual or group psychotherapy (cognitive-behavioral and interpersonal therapy) – Psycho-educational or support groups may also be helpful. – These modalities may be especially attractive to mothers who are nursing and who wish to avoid taking medications. CORE Presentation Fall 2011
A FEW OBSERVATIONS ON GLOBALTREATMENT APPROACHES…
Maternal Child Mental Health (MCMH) Working GroupA recently formed multidisciplinary and cross agency group developed to facilitate attention, policies, and practice in maternal care globally.At present, the Working Group’s core members in the United States come from various disciplines, including psychologists, nutritionists, public health experts, and others, as well as diverse organizationsIncluding the CORE Group, Catholic Relief Services, CARE, Duke University, Johns Hopkins University, Post-partum Support International, University of Maryland, and World Vision.
MCMH databaseNanmathi Manian (URC) is creating a database of perinatal mental health publications related to LAMICExhaustive Primarily effects of maternal depression on child growth and development Very few studies on intervention, one RCT
Psychoeducation: International Resources• Marcé Society • Postpartum Support• Founded in 1980 International• Mission- to promote, • Founded in 1987 facilitate and communicate • Mission- to increase about research into all awareness among public aspects of mental health of and professional women, their infants and communities about the partners connected with emotional difficulties that childbirth. women can experience• www.marcesociety.com during and after pregnancy. • www.postpartum.net
Step by Step A Guide to Organizing a Postpartum Support Network in your Community Available from the authorI’m ListeningA Guide to Support Books by Jane I. Honikman, M.S.Postpartum Families Founder, Postpartum Support InternationalAvailable from Amazon
Global application in Bangladesh: Facilitator’s Training Guide: How to help families cope with postpartum depressionThis guide can be downloaded at:http://thewindowofopportunity.info/resources
Addressing Maternal Depression within the Context of a Nutrition ProgramWindow of Opportunity Infant Feeding Project Ann DiGirolamo, CARE – Goal: Protect, promote, and support related maternal nutrition (rMN) and infant and young child feeding (IYCF) practices in resource poor settings in 5 countries – Main strategies: • Mother-to-Mother Support Groups (MtMSGs) • Nutrition Counseling • Participatory Group Education
Window of Opportunity in BangladeshDesire to build in education and support on maternal depression •Mechanism: existing nutrition counselors and MtMSGs •Training on how to support women suffering from post-partum depression (PPD) •Identify resources for more intensive services when necessary and where availableOngoing Birth Cohort Study In Bangladesh •Purpose: Provide data to evaluate the Window of Opportunity program •Measurement of maternal depressive symptoms at 9 months postpartum (EPDS, UNICEF 6-item screener) to assess prevalence of PPD
Example with US Immigrants from Mexico: Support groups The HEAL ProjectHealth Education Action for Latinas Janine Schooley, MPH PCI
Support Groups• The HEAL Educator lead a series of six small group sessions designedaround the theme of “Es Dificil Se Mujer?” (“Is it Difficult to be a Woman?”)to help women identify areas of their lives they wish to change or improve.• Sessions address stress, depression and provide women with theinformation, skills, and support necessary to deal appropriately with theseissues.• Curriculum is designed to reduce stigma around mental health issues andpromote communication, empowerment and expanded self-care, includingproper nutrition, exercise and general well-being. CORE Presentation Fall 2011
How does HEAL work?Group settingGuided discussion around specific topicsTime set aside for women to reflect & dialogueA program that builds self esteemEducational, psychological, reflexiveGender-specific CORE Presentation Fall 2011
Does HEAL work? OutcomesImproved depressionscores by 40%Pregnant womenimproved depressionscores by 60% CORE Presentation Fall 2011
Primary example of global implementation: An RCT in PakistanLay health visitors used CBT to treat postnatal depression in rural Pakistan (Rahman et al, Lancet 2008)By building the intervention into the routine of community based primary health care Randomized by region Task shifting – training lay health workers
The RCT in rural Pakistan16-45 year old married womenIdentified with depression in 3rd trimesterAll women received visits Trained lay counselors compared to Untrained, routine health visits
Results6 months postnatally maternal depression reduced: 53% versus 23%12 months postnatally maternal depression reduced: 59% versus 27%No differences in weight for age at either time
The approach: SUNDARSimplify the messageUNpack the treatment andDeliver it where people present to thehealth care system, usingAffordable and available humanresources, whom youtRain and supervise effectivelyRahman et al., 2008
Not just “blues”Perinatal conditons were ranked 1st anddepression 4th as contributors to the globalburden of disease (GBD) experienced bywomen globally.
A couple of provocative questions• Is it POST partum?• Is it depression?
Lessons learned• Traditional perinatal practices can be protective or create increased risk or both (Hanlon et al., 2010 BJP; Ethiopia) – Prohibitions, prescribed practices – Celebratory, respect for transition• So deeply embedded in cultural beliefs – U.S.- “It’s all hormones, so it cannot be treated psychologically?” – Vodou in Haiti- Lait passe
• Consider the ethnographic approach for assessing – Local idioms: How do you enter the discussion? – “Blue?”; “overwhelmed?”• Assess in more than one way – Entry idiom – Short series of questions – Locally adapted tools, e.g., PHQ9; Edinburgh• LAMIC implementation requires task shifting, but that is not so bad – May be easier to train to deliver a proscribed protocol with fidelity – May be more acceptable as embedded in community practice
Perinatal mental ill health may not be as “preventable” by single interventionsas polio or iodine deficiency, but given High prevalence of problems for child bearing women, including suicide Known untoward effects of mothers’ functioning and child development And relative ease of intervention within naturally occurring health care WHAT ARE WE WAITING FOR?