More than baby blues_Senefeld, Reider, Schooley_10.13.11

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  • The prevalence of stunting (16.8%), underweight (13.2%) and wasting (4.8%) among children was low; nearly a third of mothers (33.2%) had high MD scores. The mean age of mothers was 29 years, and average maternal education was 9 years. More than 20% of household had moderate or severe food insecurity. In bivariate analyses, the prevalence of stunting, underweight and wasting was significantly higher among mothers with a high MD score. However, the significant association only remained for underweight after controlling for child, maternal, and HH level confounders
  • Mothers with a high MD score have a lower rate of optimal infant and young child feeding. Multivariate models confirm these results and the statistical significance of associations remain for early initiation of breastfeeding and achieving a minimum acceptable diet.
  • High maternal MD was associated with lower child WAZ (-0.11, 95% CI: -0.18, -0.04) and WHZ (-0.13, 95% CI: -0.19, -0.07) after controlling for several confounding factors (child level, maternal level and household level) and adjusting for sample clustering
  • More than baby blues_Senefeld, Reider, Schooley_10.13.11

    1. 1. More Than the Baby Blues Effects of Depression on Pregnant and Post-Partum Women and the Mother-Infant-Child Relationship
    2. 2. CORE Group Panel <ul><li>Shannon Senefeld, Psy.D. Director of Health and HIV, CRS </li></ul><ul><li>Kathryn Reider, MS, Sr. Nutrition Advisor, World Vision US </li></ul><ul><li>Janine Schooley, MPH, Sr Vice President for Programs, PCI </li></ul><ul><li>Panel Facilitator: Carolyn Kruger, PH.D. </li></ul><ul><li>Sr. Advisor for MCHN, PCI </li></ul>
    3. 3. Maternal Depression: Introduction <ul><li>The combination of women’s vulnerability to depression, their responsibility for child care, and the high prevalence in developing countries means that maternal mental health has a substantial influence on growth (underweight and stunting) and development during infancy and childhood (WHO 2010) </li></ul><ul><li>The global need for mental health care is large- up to 25% of population requiring it at some point and global spending is less than $0.25 per person per year in low-income countries. (Mental Health Atlas 2011, WHO). </li></ul><ul><li>Depression in women in developing countries has a complex etiology, is heavily stigmatized within many cultures and women may be reluctant to seek help </li></ul><ul><li>Health care providers in developing countries are not trained to recognize, assess and treat maternal depression </li></ul>
    4. 4. Maternal Depression: Current Status <ul><li>PPD remains under-diagnosed and under-treated with limited assessment in current health and nutrition programs </li></ul><ul><li>We have the tools- -- </li></ul><ul><li>It is possible to identify women with increased risk factors- early screening and treatment is associated with a better prognosis for the mother and less impact on the infant/child </li></ul><ul><li>Available antenatal and post-partum screening tools are available but not tested with multi-cultural populations </li></ul><ul><li>There are studies of interventions that can prevent or mitigate the impact, i.e., home visiting, telephone counseling, interactive coaching, group interventions and message therapy. </li></ul><ul><li>But we are slow to implement </li></ul><ul><li>The potential adverse effect of PPD on the maternal/infant relationship and child growth and development reinforces the need for early identification and effective treatment models (Stewart, 2003) </li></ul>
    5. 5. Understanding Post-partum Depression (PPD) <ul><li>Shannon Senefeld, Psy.D. </li></ul><ul><li>Director of Health and HIV, CRS </li></ul>
    6. 6. Prevalence <ul><li>More than 150 million people suffer from depression globally. </li></ul><ul><li>Depression and anxiety disorders are most prevalent amongst women when they are in their childbearing years. </li></ul><ul><li>WHO estimates that 1 in 3 to 1 in 5 women in developing countries and 1 in 10 in developed countries experience a significant mental health problem during pregnancy or after childbirth. </li></ul><ul><li>While nearly 80% of women experience the ‘baby blues’, 10% to 20% actually go on to meet the criteria for a major depressive episode as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). </li></ul>
    7. 7. Etiology <ul><li>The etiology of mental health problems is as diverse as the mental health problems themselves. </li></ul><ul><li>Physiological changes that occur during pregnancy may be linked with a change in mood. </li></ul><ul><li>Other risk factors include being single, being in an unsupportive relationship, a previous history of stillbirth or repeated miscarriages, poverty and economic hardship, and a lack of practical support. </li></ul><ul><li>Biological vulnerability: family history, previous history of PPD </li></ul>
    8. 8. Etiology- Relationship of Abuse <ul><li>One significant predictor of mental health problems during the perinatal period is a history of abuse. </li></ul><ul><ul><li>Studies estimate that women who have been exposed to intimate partner violence are 3 to 5 times more likely to experience a mental health problem than those who have not experienced such violence. Violence against women (intimate partner and childhood) are associated with depressive symptoms </li></ul></ul><ul><li>Women exposed to GBV have a higher incidence of depressive and anxiety symptoms, PTSD and thoughts of suicide. </li></ul><ul><li>When violence is experienced during pregnancy, this has a negative effect on the infant’s health and mother-to-child bonding- leading to low birth weight, attachment disorders and behavioral disorders later in life. </li></ul><ul><li>Women exposed to psychological/sexual violence have a higher severity of depressive symptoms. </li></ul>
    9. 9. Assessment <ul><li>Loads of assessment tools and techniques, choice often determined by population (cultural considerations) </li></ul><ul><li>National Institute of Health and Clinical Excellence (NICE) recommends that two main questions are asked of women during prenatal visits to identify possible peri-natal depression. </li></ul><ul><ul><ul><li>During the last month, have you often been bothered by feeling down, depressed or hopeless? </li></ul></ul></ul><ul><ul><ul><li>During the last month have you often been bothered by having little interest or pleasure in doing things? </li></ul></ul></ul><ul><ul><li>If a woman responds that she has been bothered by such feelings, NICE recommends that she is then asked a third question: </li></ul></ul><ul><ul><ul><li>Is this something you feel you need or want help with? </li></ul></ul></ul>
    10. 10. Clinical Presentation <ul><li>Signs and symptoms of postpartum depression are clinically indistinguishable from major depression that occurs in women at other times.   </li></ul><ul><li>PDD develops over the first 3 postpartum months,   is more persistent and debilitating than postpartum blues, often interfering with the mother's ability to care for herself or her child.   </li></ul><ul><li>Symptoms may include depressed mood, tearfulness, anhedonia, insomnia, fatigue, appetite disturbance, suicidal thoughts, and recurrent thoughts of death.   </li></ul><ul><li>PPD is often characterized as intense sadness, anxiety, or despair. These interfere with the mother’s ability to function with risk of harm to mother or infant. </li></ul><ul><li>Anxiety is often prominent, including worries or obsessions about the infant's health and well-being.   The mother may have ambivalent or negative feelings toward the infant. She may also have intrusive and unpleasant fears or thoughts about harming the infant. </li></ul>
    11. 11. Treatment <ul><li>The 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. </li></ul><ul><li>Earlier initiation of treatment is associated with a better prognosis. </li></ul><ul><li>The woman and her partner should be involved in the full continuum of care, including education and treatment options. </li></ul><ul><li>Screening can occur at primary healthcare facilities and oftentimes be integrated into ongoing, standardized care. </li></ul><ul><li>Antidepressants have been shown to be effective in treating perinatal depression. </li></ul><ul><li>Non-pharmacologic treatment strategies are useful for women with mild to moderate depressive symptoms. </li></ul><ul><ul><li>Individual or group psychotherapy (cognitive-behavioral and interpersonal therapy) are effective. </li></ul></ul><ul><ul><li>Psycho-educational or support groups may also be helpful. </li></ul></ul><ul><ul><li>These modalities may be especially attractive to mothers who are nursing and who wish to avoid taking medications. </li></ul></ul>
    12. 12. Effect on the Mother-Infant-Child Relationship and Impact on Growth and Development <ul><li>Kathryn Reider, MS. </li></ul><ul><li>Sr. Nutrition Advisor, World Vision US </li></ul>
    13. 13. Effect of Depression on the Mother <ul><li>Maternal depression is associated with: </li></ul><ul><li>Compromised parenting behavior, nonresponsive care giving practices </li></ul><ul><li>Less able to give maternal stimulation to infant </li></ul><ul><li>Less positive in interaction and less affective behavior </li></ul><ul><li>More variable behavior, i.e., anxiety, fatigue, insomnia, decreased appetite, substance abuse </li></ul><ul><li>Lower likelihood or shorter duration of breastfeeding and problems with complementary feeding practices </li></ul>
    14. 14. Effect of Depression on the Infant <ul><li>Infant affect changes and insecure attachment (5.4% times greater in PPD mothers </li></ul><ul><li>Less interest in exploring environment </li></ul><ul><li>Sleep problems </li></ul><ul><li>Increase in crying –frequency and duration </li></ul><ul><li>GBV and depression during pregnancy is associated with low birth weight </li></ul>
    15. 15. Effect of Maternal Depression on the Young Child <ul><li>Greater cognitive, behavioral and interpersonal problems </li></ul><ul><li>Impaired concentration </li></ul><ul><li>Irritability, aggressiveness </li></ul><ul><li>Social withdrawal </li></ul><ul><li>Neurobiological changes </li></ul><ul><li>Affects cognitive development: perceptual, motor and verbal skills </li></ul>
    16. 16. Effect of Maternal Depression on Child Nutrition <ul><li>Depression in women may be a risk factor for poor growth (underweight and stunting) in young children (WHO, 2011) </li></ul><ul><li>PPD leads to problems with breastfeeding, early cessation, and association with underweight at six months </li></ul><ul><li>Less interactive infant feeding </li></ul>
    17. 17. Association between maternal MD and child undernutrition ** p<0.05; *p<0.01 Maternal mental distress is associated with child feeding practices and anthropometry in Vietnam Phuong H. Nguyen 1 , Purnima Menon 2 , Rawat Rahul 3 and Marie T. Ruel 3 1 International Food Policy Research Institute (IFPRI), Hanoi, Viet Nam; 2 IFPRI, New Delhi, India; 3 IFPRI, Washington, DC. Poster presentation at the Experimental Biology conference in 2011
    18. 18. Association between maternal MD and IYCF practices Maternal mental distress is associated with child feeding practices and anthropometry in Vietnam Phuong H. Nguyen 1 , Purnima Menon 2 , Rawat Rahul 3 and Marie T. Ruel 3 1 International Food Policy Research Institute (IFPRI), Hanoi, Viet Nam; 2 IFPRI, New Delhi, India; 3 IFPRI, Washington, DC. Poster presentation at the Experimental Biology conference in 2011
    19. 19. Coefficients for associations between high maternal MD and child undernutrition (multivariate regression analysis) Maternal mental distress is associated with child feeding practices and anthropometry in Vietnam Phuong H. Nguyen 1 , Purnima Menon 2 , Rawat Rahul 3 and Marie T. Ruel 3 1 International Food Policy Research Institute (IFPRI), Hanoi, Viet Nam; 2 IFPRI, New Delhi, India; 3 IFPRI, Washington, DC. Poster presentation at the Experimental Biology conference in 2011
    20. 20. MD Research Conclusions <ul><li>Maternal distress is associated with poor anthropometric outcomes among children <5 years of age in a Vietnamese population, where food insecurity, poverty and overall undernutrition rates are low. </li></ul><ul><li>Poorer IYCF among high MD mothers suggest that child feeding practices may mediate this association for infants and younger children. </li></ul><ul><li>Further research is needed to unpack these associations more fully and identify intervention strategies in this context. </li></ul>Maternal mental distress is associated with child feeding practices and anthropometry in Vietnam Phuong H. Nguyen 1 , Purnima Menon 2 , Rawat Rahul 3 and Marie T. Ruel 3 1 International Food Policy Research Institute (IFPRI), Hanoi, Viet Nam; 2 IFPRI, New Delhi, India; 3 IFPRI, Washington, DC. Poster presentation at the Experimental Biology conference in 2011
    21. 21. Example of Program Implementation <ul><li>The HEAL Project </li></ul>Janine Schooley, MPH Sr. Vice President for Programs Health Education Action for Latinas
    22. 22. What is HEAL? Health Education Action for Latinas A Guide A Curriculum A Discussion What are the roles a woman plays in her life, family, community, work, church, etc.?
    23. 23. HEAL’s History <ul><li>Methodology originally developed and conducted by PCI from 2001-2004. </li></ul><ul><li>Overall goal: to improve the health and well-being of Latina women by focusing on the area of mental health, while integrating community needs & empirically-based “best practices” for Latinas. </li></ul><ul><li>In this model, community health workers (“promotoras”) lead a series of six small group sessions designed around the theme of “Es Dificil Ser Mujer?” (“Is it Difficult to be a Woman?)” </li></ul>
    24. 24. Group setting Guided discussion around specific topics Time set aside for women to reflect & dialogue A program that builds self esteem Educational, psychological, reflexive Gender-specific How does HEAL work?
    25. 25. Screening <ul><li>All clients are screened for depression 3X by Patient Navigators (PNs) </li></ul><ul><li>Antenatal: Center for Epidemiological Studies Depression Scale (CES-D 10) </li></ul><ul><li>Postpartum: Edinburgh Postpartum Depression Scale at post-partum and 6 months </li></ul><ul><li>Both screening tools are designed for the initial screening of symptoms related to depression or psychological distress </li></ul><ul><li>A score of 10 or higher on either screening tool generates an automatic referral to the HEAL component of the program </li></ul><ul><li>PHQ-9 screening tool used in HEAL sessions </li></ul>
    26. 26. <ul><li>Center for Epidemiologic Studies Short Depression Scale (CES-D 10) </li></ul><ul><li>Below is a list of some of the ways you may have felt or behaved. Please indicate how often you have felt this way during the past week : (circle one number on each line) </li></ul><ul><li>Rarely or none of the time (less than 1 day) = 0 </li></ul><ul><li>Some or a little of the time (1-2 days) = 1 </li></ul><ul><li>Occasionally or a moderate the time (3-4 days) = 2 </li></ul><ul><li>All of the time (5-7days) = 3 </li></ul><ul><li>During the past week... </li></ul><ul><li>1. I was bothered by things that usually don’t bother me 0 1 2 3 </li></ul><ul><li>2. I had trouble keeping my mind on what I was doing 0 1 2 3 </li></ul><ul><li>3. I felt depressed 0 1 2 3 </li></ul><ul><li>4. I felt that everything I did was an effort 0 1 2 3 </li></ul><ul><li>5. I felt hopeful about the future 0 1 2 3 </li></ul><ul><li>6. I felt fearful 0 1 2 3 </li></ul><ul><li>7. My sleep was restless 0 1 2 3 </li></ul><ul><li>8. I was happy 0 1 2 3 </li></ul><ul><li>9. I felt lonely 0 1 2 3 </li></ul><ul><li>10. I could not “get going” 0 1 2 3 </li></ul><ul><ul><li>Scoring </li></ul></ul><ul><li>Items 5 & 8 3 2 1 0 </li></ul><ul><li>All other items: 0 1 2 3 </li></ul><ul><li>A score of 10 or greater is considered depressed. </li></ul>
    27. 27. Edinburgh Postnatal Depression Scale (EPDS) <ul><li>In the past week I have been able to laugh and see the funny side of things: </li></ul><ul><li>- As much as I always could </li></ul><ul><li>- Not quite so much now </li></ul><ul><li>- Definitely not so much now </li></ul><ul><li>- Not at all </li></ul><ul><li>In the past week I have looked forward with enjoyment to things: </li></ul><ul><li>- As much as I ever did </li></ul><ul><li>- Rather less than I used to </li></ul><ul><li>- Definitely less than I used to </li></ul><ul><li>- Hardly at all </li></ul><ul><li>* In the past week I have blamed myself unnecessarily when things went wrong: </li></ul><ul><li>- Yes, most of the time </li></ul><ul><li>- Yes, some of the time </li></ul><ul><li>- Not very often </li></ul><ul><li>- No, never </li></ul><ul><li>In the past week I have been anxious or worried for no good reason: </li></ul><ul><li>- No, not at all </li></ul><ul><li>- Hardly ever </li></ul><ul><li>- Yes, sometimes </li></ul><ul><li>- Yes, very often </li></ul><ul><li>* In the last week I have felt scared or panicky for no very good reason </li></ul><ul><li>- Yes, quite a lot </li></ul><ul><li>- Yes, sometimes </li></ul><ul><li>- No, not much </li></ul><ul><li>- No, not at all </li></ul><ul><li>* In the past week things have been getting on top of me: </li></ul><ul><li>- Yes, most of the time I haven't been able to cope at all </li></ul><ul><li>- Yes, sometimes I haven't been coping as well as usual </li></ul><ul><li>- No, most of the time I have coped quite well </li></ul><ul><li>- No, I have been coping as well as ever </li></ul><ul><li>* In the past week I have been so unhappy that I have difficulty sleeping: </li></ul><ul><li>- Yes, most of the time </li></ul><ul><li>- Yes, sometimes </li></ul><ul><li>- Not very often </li></ul><ul><li>- No, not at all </li></ul><ul><li>* In the past week I have felt sad or miserable: </li></ul><ul><li>- Yes, most of the time </li></ul><ul><li>- Yes, quite often </li></ul><ul><li>- Not very often </li></ul><ul><li>- No, not at all </li></ul><ul><li>* In the past week I have been so unhappy that I have been crying: </li></ul><ul><li>- Yes, most of the time </li></ul><ul><li>- Yes, quite often </li></ul><ul><li>- Only occasionally </li></ul><ul><li>- No, never </li></ul><ul><li>* In the past week the thought of harming myself has occured to me: </li></ul><ul><li>- Yes, quite often </li></ul><ul><li>- Sometimes </li></ul><ul><li>- Hardly ever </li></ul><ul><li>- Never </li></ul>QUESTIONS 1, 2, & 4 (without an *) Are scored 0, 1, 2 or 3 with top box scored as 0 and the bottom box scored as 3. QUESTIONS 3, 5-10 (marked with an *) Are reverse scored with the top box scored as a 3 and the bottom box scored as 0. Maximum score: 30 Possible Depression: 10 or greater Always look at item 10 (suicidal thoughts)
    28. 28. PRIME-MD Patient Health Questionnaire- PHQ-9 <ul><li>Scoring Method For Diagnosis Major Depressive Syndrome is suggested if: </li></ul><ul><li>• Of the 9 items, 5 or more are circled as at least &quot;More than half the days&quot; </li></ul><ul><li>• Either item 1a or 1b is positive, that is, at least &quot;More than half the days&quot; </li></ul><ul><ul><ul><li>Minor Depressive Syndrome is suggested if: </li></ul></ul></ul><ul><ul><ul><li>• Of the 9 items, b, c, or d are circled as at least &quot;More than half the days&quot; </li></ul></ul></ul><ul><li>• Either item 1a or 1b is positive, that is, at least &quot;More than half the days&quot; </li></ul><ul><li>For question 1: </li></ul><ul><li>Score Action </li></ul><ul><li>< 4 The score suggests the patient may not need depression treatment. </li></ul><ul><li>> 5-14 Physician uses clinical judgment about treatment, based on patient’s duration of symptoms and functional impairment. </li></ul><ul><li>> 15 Warrants treatment for depression, using antidepressant, psychotherapy and/or a combination of treatment </li></ul>
    29. 29. Depression screenings 2007-2010 <ul><li>Total screened: 484 </li></ul><ul><li>Antenatal- CESD-10 and </li></ul><ul><li>* Post partum- Edinburgh </li></ul><ul><li>Total referred to HEAL: </li></ul><ul><li>162 (34%) </li></ul><ul><li>* PHQ-9- pre and post sessions </li></ul>
    30. 30. Support Groups <ul><li>The HEAL Educator lead a series of six small group sessions designed around 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. </li></ul><ul><li>Sessions address stress, depression and provide women with the information, skills, and support necessary to deal appropriately with these issues. </li></ul><ul><li>Curriculum is designed to reduce stigma around mental health issues and promote communication, empowerment and expanded self-care, including proper nutrition, exercise and general well-being. </li></ul>
    31. 31. 6 Weekly Sessions <ul><li>What is depression? </li></ul><ul><li>Why do we get depressed? </li></ul><ul><li>Our childhood </li></ul><ul><li>Major life events </li></ul><ul><li>A woman’s upbringing </li></ul><ul><li>What to do? & Where to go? </li></ul>
    32. 33. What to do? <ul><li>Define what is happening </li></ul><ul><li>Re-evaluate self: how to handle mistakes and good qualities </li></ul><ul><li>Change in beliefs: role, love, suffering </li></ul><ul><li>Expressing fear, sadness & anger </li></ul><ul><li>New ways to perceive environment </li></ul><ul><li>New ways to behave: share, </li></ul><ul><li>communicate & ask for help </li></ul>
    33. 34. Where to Go? Discuss community resources and referrals <ul><li>The HEAL Educator provide referrals for treatment and other support services, follow up to ensure client compliance </li></ul><ul><li>PNs coordinate mental health referrals with core partner clinics as well as private practitioners and other programs in the community </li></ul><ul><li>The PN and HEAL Educator screen provides for cultural and linguistic competence before making referral </li></ul>
    34. 35. Barriers <ul><li>Women prefer home sessions vs. group sessions as they get more individualized attention/staff time </li></ul><ul><li>Missed sessions due to competing priorities </li></ul><ul><li>Spouses/ partners may see sessions as threat and women are afraid of their anger & disapproval </li></ul>
    35. 36. Outcomes General Latina women: Improved depression scores by 40% Pregnant women: Improved depression scores by 60%
    36. 37. <ul><li>Thanks/Gracias! </li></ul>
    37. 38. Buzz Group Sessions <ul><li>Questions: </li></ul><ul><li>Each group prepare 2-3 bullets for each question: </li></ul><ul><li>1. How can we integrate Maternal Depression/PPD/mental health into our MNCH and Nutrition programs? </li></ul><ul><li>2. What will it take? </li></ul><ul><li>3. What are the concerns? </li></ul><ul><li>4. Any next steps? </li></ul>
    38. 39. Feedback from Buzz Groups
    39. 40. Thank You

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