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PPd presentation PCA NJ conference


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PPd presentation PCA NJ conference

  1. 1. Postpartum Depression Screening & Education
  2. 2. Brooke Shields
  3. 3. Tom Cruise
  4. 4. Andrea Yates
  5. 5. Mary Jo Codey
  6. 6. Overview <ul><li>New Jersey Postpartum Depression Screening Legislation </li></ul><ul><li>Overview of Postpartum Mood Disorders </li></ul><ul><li>Understand the effects of PPD on the mother, infant, family, and friends </li></ul><ul><li>Screening </li></ul><ul><li>Treatment & Resources </li></ul>ACOG Education Pamphlet AP091 Postpartum Depression. New Jersey Department of Health and Human Services, 2004 Statistics
  7. 7. New Jersey Statistics <ul><li>110, 000 Live Births </li></ul><ul><li>800 Fetal Deaths </li></ul><ul><li>Assuming 10-15% incidence of PPD </li></ul><ul><li>Between 11,000-16,620 cases of PPD expected annually </li></ul><ul><li>How many people in this room are affected? </li></ul>ACOG Education Pamphlet AP091 Postpartum Depression. New Jersey Department of Health and Human Services, 2004 Statistics
  8. 8. Historical Perspective <ul><li>First Recognized in France </li></ul>1838 <ul><li>Continued in NY by Mac Donald </li></ul>1847 <ul><li>Hospital specific for postpartum mental illnesses founded in France </li></ul>1858 <ul><li>True link found between the postpartum experience and mental illness </li></ul>1888 <ul><li>NO LINK between postpartum and mental illness </li></ul>1926 <ul><li>First edition of DSM: no postpartum related illnesses listed </li></ul>1952 <ul><li>4th Edition postpartum appears as a specifier </li></ul>1994
  9. 9. <ul><li>The Post Partum Depression Screening Legislation was enacted by the Senate and General Assembly and approved on April 13, 2006. </li></ul><ul><li>The law, P.L. 2006, c. 12 amends N.J.S.A. 26: 2-175 et seq. and took effect on October 10, 2006. </li></ul>Legislation
  10. 10. <ul><li>Physicians, nurse midwives and other licensed health care professionals providing prenatal care to women shall provide: </li></ul><ul><li>education to women and their families about postpartum depression in order to lower the likelihood that new mothers will continue to suffer from this illness in silence </li></ul>Perinatal Period
  11. 11. <ul><li>All birthing facilities in the State shall: </li></ul><ul><li>screen new mothers for PPD symptoms prior to discharge </li></ul><ul><li>shall provide departing new mothers and fathers and other family members, as appropriate, with complete information about PPD, including its symptoms, methods of coping with the illness and treatment resources </li></ul>Prior to discharge from birthing facility
  12. 12. <ul><li>Physicians, nurse midwives and other licensed health care professionals providing prenatal and postnatal care to women shall: </li></ul><ul><li>include fathers and other family members, as appropriate, in both the education and treatment processes to help them better understand the nature and causes of PPD </li></ul>Patient & Family Education
  13. 13. <ul><li>Physicians, nurse midwives and other licensed health care professionals providing postnatal care to women shall: </li></ul><ul><li>screen new mothers for PPD symptoms prior: </li></ul><ul><ul><li>to discharge from the birthing facility </li></ul></ul><ul><ul><li>at the first few postnatal check-up visits </li></ul></ul>Postnatal Visits
  14. 14. Postpartum Mood Disorders Maternity blues Adjustment Disorder Postpartum Depression Postpartum Psychosis/ Mania Disorder 26 to 85% About 20% 10 to 20% 0.2% Incidence Support and reassurance Support/reassurance psychotherapy Antidepressants, mood stabilizers & psychotherapy Hospitalization; antipsychotics; mood stabilizers; benzodiazepines; antidepressants; ECT Treatment 80% resolve by week 2; 20% evolve to PPD Excessive difficulties adjusting to motherhood Onset within 1 year Agitated Major depression often with obsessions. Onset after PP day 3. Mixed/rapid cycling. Risk of infanticide. Presentation
  15. 15. Severity of Symptoms Transient, nonpathologic Medical emergency Serious, disabling Postpartum Blues Postpartum Depression Postpartum Psychosis 50% to 70% 10% 0.01%
  16. 16. Maternity or “Baby” Blues Symptoms <ul><li>Mood fluctuation, tearfulness, heightened reactivity </li></ul><ul><li>Occurs within 3-5 days after delivery </li></ul><ul><li>Appears unrelated to environmental stressors </li></ul><ul><li>Not a psychiatric illness, but a frequently experienced physiological event for most new mothers </li></ul><ul><li>No clinical intervention needed; usually resolves within 2 weeks of birth </li></ul>
  17. 17. Adjustment Disorder Symptoms <ul><li>Development of emotional or behavioral symptoms, occurring within 3 months </li></ul><ul><li>An identifiable stressor, the birth of a baby, causes a great deal of stress in the mother's life resulting in diminishing her coping mechanisms </li></ul><ul><li>Psychotherapy is the treatment of choice for adjustment disorder, as it is seen as a normal reaction to a situational event. </li></ul><ul><li>Adapted from DSM IV-TR, Washington, D.C.: American Psychiatric Association; 2000. </li></ul>
  18. 18. <ul><li>Sadness or down mood </li></ul><ul><li>Diminished interest / pleasure </li></ul><ul><li>Appetite problems or unexplained weight change </li></ul><ul><li>Sleep problems </li></ul><ul><li>Agitation and anxiety </li></ul><ul><li>Fatigue or low energy </li></ul><ul><li>Feeling worthless or guilty </li></ul><ul><li>Suicidal or infanticidal ideation </li></ul>Postpartum Depression Symptoms
  19. 19. Risk Factors for PPD <ul><li>Prenatal depression / history of depression </li></ul><ul><li>Prenatal anxiety / history of anxiety </li></ul><ul><li>Experiencing stress in life </li></ul><ul><li>Teen pregnancy </li></ul><ul><li>Marital satisfaction / relationship </li></ul><ul><li>Socioeconomic factors </li></ul><ul><li>Obstetrical complications </li></ul>
  20. 20. Poverty and Depressed Mothers <ul><li>11% of infants living in poverty have Mom suffering from depression </li></ul><ul><li>Moms can also be struggling with DV, substance abuse, and report fair health </li></ul><ul><li>Moms breastfeed for shorter periods </li></ul><ul><li>Although treatable depressed Moms do not receive care </li></ul><ul><li>Depressed Moms in poverty already connected to services; therefore opportunity to identify depression and help seek treatment </li></ul><ul><ul><ul><li>Vericker Tracy et al. (2010) “Infants of Depressed Mothers Living in Poverty: Opportunities to Identify and Serve” Brief of The Urban Institute </li></ul></ul></ul>
  21. 21. Social Isolation, Contributing Factor <ul><li>Woman perceives herself as not supported; has low self esteem </li></ul><ul><li>Family lives at a distance, physically unavailable or culturally in conflict </li></ul><ul><li>Cut off from friends </li></ul><ul><li>Relationship discord, including emotional or physical abuse; desertion of spouse or significant other </li></ul><ul><li>History of childhood sexual abuse </li></ul>Bulst & Janson, 2001 Crockenberg & Leerkes, 2003
  22. 22. Non-contributing Risk Factors to Postpartum Depression <ul><li>Maternal Age </li></ul><ul><li>Level of Education </li></ul><ul><li>Number of Children </li></ul><ul><li>Length of relationship with partner </li></ul><ul><li>Gender of the child </li></ul>
  23. 23. Obstetrical Risks <ul><li>Complications during the present pregnancy </li></ul><ul><li>Frequent visits to the antenatal clinic </li></ul><ul><li>Lack of prenatal care </li></ul><ul><li>Increased number of sick days </li></ul><ul><li>History of 2 or more elective terminations </li></ul><ul><li>Delivery by cesarean section </li></ul><ul><li>Hyperemesis </li></ul><ul><li>Preterm labor (not delivery) </li></ul><ul><li>Depression in antenatal period </li></ul>
  24. 24. Potential Effects of Postpartum Mood Disorders <ul><li>Negative Mother/Infant Relationship </li></ul><ul><li>Delayed Child Development </li></ul><ul><li>Altered Partner Relationship </li></ul>
  25. 25. Long-term Effects of Maternal Depression on Children <ul><li>Longitudinal study of 5,000 mother/child pairs </li></ul><ul><ul><li>Severity and chronicity of maternal depression related to child behavior problems and lower vocabulary scores at age 5 </li></ul></ul><ul><ul><ul><li>Brennan, PA et al. (2000). Developmental Psychology, 36, 759-766 Luoma, I et al. (2001) Journal of the American Academy of Child & Adolescent Psychiatry, 40,1367-1374 </li></ul></ul></ul>
  26. 26. How Depression Can Influence Breastfeeding <ul><li>Depression can: </li></ul><ul><ul><li>decrease maternal sensitivity and responsiveness </li></ul></ul><ul><ul><li>cause a lack of persistence in the face of difficulties </li></ul></ul><ul><ul><li>be related to some maladaptive cognitions regarding the baby (e.g., “the baby is sucking the life out of me”) </li></ul></ul>
  27. 27. About Maternal Depression Still Face Paradigm
  28. 28. Postpartum Psychosis or Mania Common Symptoms <ul><li>Psychosis </li></ul><ul><ul><li>Delusions </li></ul></ul><ul><ul><li>Hallucinations </li></ul></ul><ul><ul><li>Disorganized speech </li></ul></ul><ul><ul><li>Disorganized behavior </li></ul></ul><ul><li>Symptoms are typically related to the infant, often with a religious flavor </li></ul><ul><li>Marked changes of moods </li></ul><ul><li>Mania </li></ul><ul><ul><li>Euphoria </li></ul></ul><ul><ul><li>Decreased need for sleep </li></ul></ul><ul><ul><li>More talkative </li></ul></ul><ul><ul><li>Racing thoughts </li></ul></ul><ul><ul><li>Distractibility </li></ul></ul><ul><ul><li>Increased involvement in activities </li></ul></ul><ul><ul><li>Excessive involvement in pleasurable but risky activities </li></ul></ul>Adapted from DSM IV-TR, Washington, D.C.: American Psychiatric Association; 2000.
  29. 29. <ul><li>PPD Screening Tool </li></ul><ul><li>A reliable and validated screening tool, such as the Edinburgh Postnatal Depression Scale (EPDS), or other appropriate test that assists in identifying warning signs for postpartum conditions. </li></ul><ul><li>Screening is designed to assist, not replace, clinical judgment. Women should be further assessed before deciding on treatment. </li></ul><ul><li>Consider additional mitigating factors, such as environmental and family issues, when considering patient risk levels. </li></ul><ul><li>Document screening results & risk status on the medical record. </li></ul><ul><li>Women should initially be screened at the 28-week prenatal office visit </li></ul>PPD Screening
  30. 30. <ul><li>Give a copy of the results of the screening to the mother. </li></ul><ul><li>Provide counseling regarding the implications of their risk status to the mother along with other family members as appropriate. </li></ul><ul><li>Distribute educational, self care and local resource materials. </li></ul><ul><li>Encouraging participation in further evaluation for diagnosis and, if necessary, treatment from an appropriate primary care or mental health provider. </li></ul><ul><li>Supplying referral information for services clinically appropriate up to and including emergency intervention. </li></ul>PPD Screening
  31. 31. Screening Tools Postpartum Depression Predictors Inventory – Cheryl Beck Postpartum Depression Screening Scale – also Cheryl Beck – Self-administered followed by a clinician interview, copyright issues, reliability studied have been done but are not yet published Ante Partum Questionnaire – self-report, not widely used Zung Self-Rating Depression Scale – 20 item, self report (Aaron) Beck Depression Inventory – not specifically for PPD, used in psychiatry, cost associated Edinburgh Postnatal Depression Scale (EPDS)
  32. 32. <ul><li>Taken from the British Journal of Psychiatry </li></ul><ul><li>June, 1987, Vol. 150 by J.L. Cox, J.M. Holden, R. Sagovsky </li></ul><ul><li>Instructions </li></ul><ul><li>The mother is asked to underline the response that comes closest to how she has been feeling in the previous 7 days. </li></ul><ul><li>All ten items must be completed. </li></ul><ul><li>Care should be taken to avoid the possibility of the mother discussing her answers with others. </li></ul><ul><li>The mother should complete the scale herself, unless she has limited English or has difficulty with reading. </li></ul>Edinburgh Postnatal Depression Scale
  33. 33. <ul><li>The thought of harming myself has occurred 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>Question 10
  34. 34. <ul><li>Inaccurate self-report </li></ul><ul><ul><li>Undiagnosed mood disorders </li></ul></ul><ul><ul><li>Denial of illness </li></ul></ul><ul><li>Fear of involvement of child protection agencies </li></ul><ul><li>Ability to mask symptoms especially if highly functional </li></ul><ul><li>Motherhood myth </li></ul>False Negatives Despite Screening
  35. 35. Cultural Considerations <ul><li>Cultural learning- explore & understand the health beliefs, perceptions, practices, & preferences of the patient’s culture </li></ul><ul><li>Cultural competence -incorporate patient’s preferences & practices, and respect patient’s beliefs, values & perceptions </li></ul><ul><li>Don’t stereotype a culture </li></ul><ul><li>Don’t assume from a persons name or appearance that they belong to / practice a certain culture / religion </li></ul>
  36. 36. Cultural Considerations <ul><li>Acculturation (cultural relativism) : acquiring the norms, values, ideas, & behaviors of the dominant society </li></ul><ul><li>Enculturation (ethnocentric) : individuals retaining identification with their traditional ethnic group </li></ul><ul><li>Culture impacts </li></ul><ul><ul><li>How a woman experience/ describe the experience of PMD </li></ul></ul><ul><ul><li>How she copes with the illness </li></ul></ul><ul><ul><li>How much stress she experiences </li></ul></ul><ul><ul><li>Her willingness to seek care, adopt treatment or follow up </li></ul></ul>
  37. 37. Cultural Considerations-Hispanic <ul><li>15% U.S. population </li></ul><ul><li>Language barriers </li></ul><ul><li>Literacy issues/level of education </li></ul><ul><ul><li>Teen pregnancy idealized </li></ul></ul><ul><li>Employment/insurance </li></ul><ul><ul><li>2.5x more likely to begin PNC in 3 rd trimester on no PNC </li></ul></ul><ul><li>Source of health information </li></ul><ul><li>Source of medication </li></ul>
  38. 38. Cultural Considerations-Hispanic <ul><li>Social isolation </li></ul><ul><li>Breastfeeding </li></ul><ul><li>Mental Health </li></ul><ul><ul><li>1 in 11 seek treatment for depression </li></ul></ul><ul><ul><li>Prefer counseling to medication </li></ul></ul><ul><ul><li>Misconceptions of antidepressants </li></ul></ul>
  39. 39. Cultural Considerations- Asian Indian <ul><li>Diverse within itself – foreign to each other </li></ul><ul><ul><li>Language </li></ul></ul><ul><ul><li>Religion </li></ul></ul><ul><ul><li>Family centered culture </li></ul></ul><ul><li>Medical care </li></ul><ul><ul><li>Combination of traditional & western medicines </li></ul></ul><ul><ul><li>Perceived as being misunderstood & disrespected </li></ul></ul><ul><ul><li>Difficulty finding culturally competent physician </li></ul></ul>
  40. 40. Cultural Considerations- Asian Indian <ul><li>Breastfeeding </li></ul><ul><li>Cross cultural misunderstanding </li></ul><ul><ul><li>Assertiveness/direct eye contact=disrespectful </li></ul></ul><ul><ul><li>Agreeing=respectful </li></ul></ul><ul><ul><li>Avoid yes or no questions </li></ul></ul><ul><ul><li>Modesty </li></ul></ul><ul><li>Mental illness associated with serious social stigma, personal failure, & family shame </li></ul><ul><ul><li>Conceal diagnosis </li></ul></ul><ul><ul><li>Refuse counseling/treatment </li></ul></ul>
  41. 41. Cultural Considerations- Asian Indian <ul><li>Role of woman </li></ul><ul><li>Respect/humility </li></ul><ul><li>Promote compliance </li></ul><ul><ul><li>Accommodate traditional therapies </li></ul></ul><ul><ul><li>Use spirituality as a strength </li></ul></ul><ul><ul><li>Refer to culturally competent providers </li></ul></ul>
  42. 42. Treatment & Resources <ul><li>Resource Directory </li></ul><ul><ul><li>Support groups, websites, therapists </li></ul></ul><ul><li>Family Health Line </li></ul><ul><ul><li>The 800-328-3838 telephone number is answered on a 24 hour/7 day per week basis. Calls can come from women experiencing distress, family members asking for information, and clinicians requesting teaching materials. The hotline has the ability to directly link callers with a provider agency through a “warm line transfer” feature. </li></ul></ul>
  43. 43. Hotline Process Call Family Health Line Request information Woman needing further assessment Brochures mailed Call transferred to UBHC Clinician triages call Immediate Danger Notify crisis center Needs Assessment and uninsured or underinsured Appointment arranged with community mental health center Needs Assessment and has private insurance Referred to her insurance company
  44. 44. Case Study #1-- Eileen <ul><li>35 yo with long hx of anxiety; ambivalent to 2 nd pregnancy </li></ul><ul><li>During 1 st pregnancy described sadness & anxiety </li></ul><ul><li>Daily crying spells, panic attacks, & anhedonia </li></ul><ul><li>Post delivery put on Rx and participated in a mother’s group </li></ul><ul><li>One year tx; stopped. </li></ul><ul><li>Ambivalent feelings and self-esteem </li></ul><ul><li>Began drinking daily for the last 2 yrs. </li></ul>
  45. 45. Case Study #2—Laura <ul><li>40 yo with twins; sad, anxious, and tearful </li></ul><ul><li>New in town, no friends or family </li></ul><ul><li>Hx of anorexia, restrictive diet, over exercising, laxatives </li></ul><ul><li>Does not engage with twins </li></ul><ul><li>Diet issues, nursing </li></ul><ul><li>??Thoughts of hurting herself or the baby </li></ul>