Development of a Statewide Perinatal Depression Initiative in Illinois

1
Development of a Statewide Perinatal Depression
Initiative in Illinois 

• Laura J. Miller MD
• Womens Mental Health Program
• University of Illinois at Chicago

2
Perinatal depression in Illinois before the
initiative

• About 9.4 12.7 of pregnant women have a major
  depressive episode
• Up to 21.9 of women giving birth develop
  postpartum depression
• In 2001, only 607 of the 81,000 women with
  Medicaid-funded deliveries (0.75) were diagnosed
  with depression
• Gavin NJ et al Obstet Gynecol 1061071-83, 2005

3
Illinois Perinatal Depression Task Forces

• How can we improve detection of perinatal
  depression statewide?
• How can we improve delivery quality of
  treatment for perinatal depression statewide?

4
Illinois task force findings obstacles to early
detection and treatment

• Mental health system lacked capacity to treat
  most women with perinatal depression
• Most primary/prenatal care providers lacked
  knowledge and skills to diagnose and treat
  perinatal depression
• No reimbursement for screening

5
Illinois strategy to improve detection and
treatment of perinatal depression

• Central focus
• Increase primary care provider capacity to
  detect, diagnose and treat perinatal depression
• Promote screening and public awareness in tandem
  with increasing provider capacity

6
Illinois strategy to improve detection and
treatment of perinatal depression

• Provider support
• Training
• Tools for screening, assessment treatment
• Consultation available to providers
• Systemic support
• Reimbursement for screening
• Models of integrative care
• Tools for self-care

7
UIC Perinatal Mental Health Project primary care
provider training workshops

• Basic workshop
• Advanced skills workshops
• Screening and assessment
• Psychopharmacology during pregnancy and
  postpartum
• Assessment and intervention for mother-infant
  relationship problems caused by perinatal
  depression

8
Screening and assessment workshop

• Based on data showing that most women accept
  screening but not outside assessment
• Highlights EPDS PHQ-9
• Uses assessment tools developed by project (1 for
  EPDS, 1 for PHQ-9)
• Uses case scenarios to practice scoring screens
  and interpreting assessments

9
Psychopharmacology workshop

• Lecture plus case vignettes
• Discussion uncovers obstacles to prescribing
• Misinformation
• Liability fears
• Attitudinal barriers
• Includes section on engaging patients
• Multidisciplinary audience promotes cohesive
  message to patients

10
Mother-infant workshop

• Lecture, video clips, discussion
• Includes observational guide to identifying
  potential mother-infant relationship problems
  linked to maternal depression or anxiety
  disorders
• Includes information on interventions
• Primary care interventions
• Parenting coaching dyadic therapy

11
Primary care provider trainings teaching
modalities

• Talks (lecture format)
• Interactive workshops (role play, practice)
• Case presentation workshops
• Video teleconference
• Audio conference with on line slides
• Documentary showing (Descent into Desperation)
  and group discussion
• http//descentintodesperation.com/

12
Reaching mental health providers

• Findings from UIC project state task forces
  show
• many mental health providers dont feel
  adequately trained to treat perinatal depression
• if detection improved, state mental health system
  lacks capacity to treat all women identified as
  having perinatal depression
• Long-term goals
• identify and fill major service gaps
• develop regional mental health experts

13
Reaching mental health providers

• Developed advanced workshop geared to mental
  health providers
• Target this workshop to potential regional
  experts in diverse geographic areas
• Survey mental health delivery sites to
• assess ability to treat perinatal women
• identify areas where training is desired/needed
• Add mental health providers to a resource
  database, with notation if theyve received our
  training

14
Mental health resources

• NorthShore University HealthSystems Perinatal
  Depression Program survey
• 236 out of 290 total community mental health
  centers contacted in 67 counties
• Profiles obtained for 156 of these sites
• Mental health expertise of respondents
• 59 have psychiatrist available on-site
• 25 have staff trained or experienced in
  perinatal depression, per self-report

15
UIC Perinatal Mental Health Project scope of
training (11/04 6/08)

• 4,927 health care providers trained
• Provider types
• Physicians Ob/Gyn, Family Medicine, Pediatrics,
  Psychiatry
• Nurses RN, APN, midwives, home visitors
• Therapists psychologists, social workers
• Health extenders birth doulas, lactation
  consultants, home visitors, case managers

16
Provider training baseline knowledge
(pre-training)

• Of all participants
• 27.2 could name a PPD screening tool
• Of physician nurse participants
• 18.3 knew the obstetric risks of untreated
  antenatal depression
• 9.4 correctly understood FDA Pregnancy Risk
  Categories
• 30 knew a place to find evidence-based
  information about antidepressants during
  pregnancy and/or breast-feeding

17
Provider training workshops evaluation data

• Participant satisfaction average score 3.6
• (scale 1 4)
• Knowledge acquisition
• Antenatal risks 87.2 knowledge improved
• Screening tools 96.2 knowledge improved
• FDA categories 79.2 knowledge improved
• Medication information 78.5 knew reliable
  sources in post-test

18
UIC Perinatal Mental Health Consultation Service

• Resource for providers to consult with experts in
  perinatal mental health
• Accessed by toll-free telephone or online
• Consultants are multidisciplinary faculty and
  staff from the UIC Womens Mental Health Program
• Psychiatrists (3)
• Advanced practice nurse (1)
• Social worker (1)
• MPH (2)

19
UIC Perinatal Mental Health Consultation
Service scope

• 933 consults completed between 11/04 and 1/09
• Requests have come from
• 31 other states
• 8 other countries
• Types of providers
• 7.8 primary/perinatal care physicians
• 32.2 primary/perinatal care nurses
• 33.8 mental health professionals
• 26.2 other (e.g. social workers, lactation
  consultants, doulas, case managers)

20
UIC Perinatal Mental Health Consultation
Service query types
21
UIC Perinatal Mental Health Consultation
Service evaluation data

• Pilot data N138 respondents
• 100 reported the information they received was
  helpful
• 91.3 said the information influenced their
  approach to a patient and/or their practice in
  general
• 89.0 said having the service available increases
  their comfort level in treating women with
  perinatal depression or anxiety disorders in
  their practices

22
Detection of perinatal depression by screening

• In a study directly comparing screening scores
  with clinical diagnoses, health care providers
  only recognized 26 of pregnant women who
  screened positive for depression
• Rates of positive screens in published studies
  range from 13 - 25, in keeping with
  epidemiologic data about population rates of
  perinatal depression
• Evins GG et al Am J Obstet Gynecol 1821080-2,
  2000 Birndorf CA et al Int J Psychiatry Med
  31355-65, 2001 Carter FA et al Aust N Z J
  Psychiatry 39255-61, 2005 Marcus SM et al J
  Womens Health 12373-80, 2003 Smith MV et al
  Psychiatr Serv 55407-14, 2004

23
The problem with screening

• Meta-analysis screening does not lead to
• Increased entry into treatment
• Improved clinical outcomes
• Study example
• 92.5 of perinatal women completed the EPDS
• 30.6 of women with positive screens agreed to
  mental health assessment
• Less than half of those attended assessment
• 10 of women with positive screens ended up
  receiving treatment, with few completing
  treatment
• Gilbody S et al CMAJ 178997-1003, 2008 Carter
  FA et al Aust N Z J Psychiatry 39255-61, 2005

24
Screen refer model for detecting perinatal
depression in prenatal/primary care settings

• Screen all patients
• Refer women who screen positive to mental
  health services
• Problems
• Screening is well accepted by patients
• Mental health referral is not
• Mental health resources are limited

25
Screen, assess refer model

• Screen all patients
• Do diagnostic assessment on site for women whose
  scores are above a cut-off
• Refer those who are diagnosed with major
  depression to mental health services for
  treatment
• Increases acceptance reduces false positives

26
Stepped care model for detecting and treating
perinatal depression

• Screen all patients
• Do diagnostic assessment on site for women whose
  scores are above a cut-off
• Identify subset of women to treat on site (based
  on severity, complexity)
• Treat on site track treatment response
• If response is inadequate, refer for mental
  health care

27
Advantages of stepped care model

• Reduces stigma
• Reduces logistical barriers - transportation,
  time, expense
• Promotes continuity of care
• Cost effective
• General depression stepped care models improve
  quality of care, patient provider satisfaction,
  depression outcomes
• Neumeyer-Groman A et al Med Care 421211-21, 2004

28
Perinatal Depression Stepped-Care pilot

• Alivio Medical Center
• FQHC over 16,000 patients per year, over 1200
  births per year
• most patients monolingual Spanish, below 200
  poverty level
• Prior to model
• 0.4 of women of reproductive age diagnosed with
  psychiatric disorder
• After introducing model (March 2005)
• Screening average 58
• 17 screened positive
• 76 assessed on site
• 10 diagnosed with major depression on site
• Quality Monitoring data guides follow-up training

29
Perinatal depression assessment tools

• Help a clinic or system to progress from screen
  and refer to screen, assess and refer or
  stepped-care model
• Tools geared to specific screens
• EPDS (to make a DSM-IV diagnosis)
• PHQ-9 (to rule out confounds)
• Tools designed to be administered by perinatal
  care providers during perinatal clinic visits

30
Limitations of FDA pregnancy risk categories

• No medications are yet FDA-approved specifically
  for use during pregnancy
• Psychotropic medications cross placenta so are
  never no risk (Category A)
• Categories B C based on animal studies, but
  adverse medication effects dont generalize from
  one species to another
• Drugs can get demoted the more theyre studied
  in humans (bupropion, paroxetine)

31
Provider tool Information on antidepressants
during pregnancy and postpartum

• Compiles data from studies in human pregnancy
  breastfeeding
• Updated whenever research warrants
• Available on line at no charge

• www.psych.uic.edu/research/perinatalmentalhealth/

32
Illinois strategies for promoting perinatal
depression screening

• HealthCare and Family Services (HFS) reimburses
  for perinatal depression screening
• Dissemination of screening tools information
• Mailed Provider Notice
• Online (HFS website)
• Provider training sessions
• On-site consultation and monitoring for clinics
  interested in setting up screening programs
• Medicaid Managed Care Organizations (MCO)
• Perinatal depression screening is a quality
  indicator
• Charts are audited for perinatal depression
  screening

33
Introducing screening into a perinatal care
clinic

• Form a planning group
• Choose a screening tool
• Choose a cut-off score
• Choose times to administer the tool e.g. at
  prenatal care entry, third trimester and
  postpartum
• Define who will administer and score the tool
  e.g. medical assistant, provider
• Bill for screens

34
Screening follow-up steps to take

• Decide on screen, assess and refer model or
  stepped-care model
• Arrange a workshop to train providers in
  assessment
• Consider using a formal assessment tool, with
  diagnoses and dispositions listed
• Decide how results of screening and assessment
  will be entered into the medical record
• Mental health confidentiality
• Pediatric charts with maternal health information

35
Initiatives to integrate maternal and infant
mental health care

• Designed and implemented advanced workshop on
  mother-infant relationship problems caused by
  perinatal depression
• Trained Early Intervention (EI) staff to
  recognize and intervene when mother has
  depression
• Developed guides for prenatal/primary care
  providers
• to identify mother-infant problems
• to support effective parenting

36
The MotherCare Circle

• Integrative clinic model
• Psychopharmacology
• Individual psychotherapy
• Facilitated support group
• Parent coaching
• Mother-infant dyadic therapy
• Psychoeducation
• Evaluation
• Psychiatric
• Parenting skills, stresses, goals

37
Perinatal Mental Health Disorders Prevention and
Treatment Act

• Provisions for education/information
• Licensed prenatal care providers shall educate
  women (families) about perinatal mental health
  disorders per ACOG opinions
• Hospitals shall inform mothers (families) about
  perinatal mental health disorders
• DHS will supply written information that can be
  used for this purpose

38
Perinatal Mental Health Disorders Prevention and
Treatment Act

• Provisions for screening and assessment
• Licensed prenatal, postnatal infant care
  providers shall offer formal screening to each
  pregnant patient review screen per ACOG
  opinions
• Assessment must be repeated when patient may have
  a perinatal mental health disorder

39
Strengths of legislation

• Initiated by an advocate who had experienced a
  perinatal mental health problem
• Partnership among advocates, legislators, public
  health agencies, providers
• Promotes awareness of the scope and importance of
  the problem
• Underscores importance of formal screening and
  assessment

40
Weaknesses and areas where further work is needed

• Unfunded mandate
• No back-up resources for providers
• Training
• Tools
• Consultation
• Micromanages medical care
• questionnaire vs verbal screen
• forces physicians of one discipline to use
  guidelines from another

41
Can these mandates be enforced?

• No direct enforcement however
• Having this Act sets a standard of care that
  could be cited in malpractice cases

42
Enhancing Developmentally Oriented Primary Care
(EDOPC)

• Collaborative partnership
• Advocate Health Care, Healthy Steps Program
• Illinois Chapter, American Academy of Pediatrics
• Illinois Academy of Family Physicians
• Illinois Department of HealthCare Family
  Services
• Overall goals
• Improve delivery and financing of preventive
  health and developmental services in primary
  health care settings for children under age 3
• Align goals of physicians and parents around
  high-quality health care

43
EDOPC approach

• Office-based training for providers their teams
• Information in binder pocket guides
• Follow-up technical assistance
• Website
• Includes a provider training module on Perinatal
  Maternal Depression Screening and Referral

44
NorthShore University HealthSystems Perinatal
Depression Program

• Founded in 2002, in memory of Jennifer Mudd
  Houghtaling
• Mission To identify and support families at
  risk for perinatal depression
• Key components
• 866-ENH-MOMS hotline
• Universal perinatal depression screening in third
  trimester and six weeks postpartum
• Mental health provider network
• Health care provider education
• Research

45
NorthShore University HealthSystems Perinatal
Depression Hotline

• Characteristics
• Calls answered live 24 hours a day, 7 days a week
• Staffed by licensed mental health professionals
• Uses interpretive service line
• Free and confidential
• Usage
• 1,359 calls from 1/03 3/08
• Averaged 28 calls per month in 2007
• 85 of callers live in Illinois
• 27 of callers are uninsured or Medicaid
  recipients
• 76 accept referrals
• 75 emergency room referrals to date

46
Perinatal depression initiatives other key
collaborations

• Illinois HealthCare and Family Services (Medicaid
  agency)
• Office of Family Health (Title V agency)
• Postpartum Depression Illinois Alliance (state
  branch of Postpartum Support International)
• Conference of Women Legislators
• Jennifer Mudd Houghtaling Postpartum Depression
  Foundation
• Ounce of Prevention
• Voices for Illinois Children
• Erikson Institute

47
Perinatal depression fostering statewide
collaboration

• Collaboration meetings
• Annual peer review meetings on specific topics
• Perinatal depression
• Interconception care
• Web links

48
The MotherCare Kit

• Many women refuse formal psychotherapy or lack
  access
• MotherCare Kit designed to fill this gap
• Kit translates evidence-based cognitive-behavioral
  and interpersonal self-care strategies into
  user-friendly format
• Kit is designed for use as part of perinatal
  health care

49
MotherCare Kit process

• Kit has modules, each corresponding to a
  self-care topic area
• At each prenatal or postpartum visit, patient
  chooses a topic area and takes that module home
  (in a tote bag)
• In guided self-care (GSC), health care providers
  or extenders maintain regular contact with
  patient to review MotherCare progress

50
MotherCare Kit topic areas

• Food and mood
• Sleep and daily rhythms
• Activity and movement
• Social support
• Problem-solving
• Recognizing feelings
• Assertiveness
• Managing negative thoughts

51
MotherCare Kit contents

• Introductory education
• Self-assessment of strengths and areas patient
  wants to improve
• Specific goal-setting
• Suggestions about reaching the goals
• Anticipating and overcoming obstacles
• Tracking progress
• Props

52
UIC Womens Mental Health Program Clinical
Services

• Components
• Womens Clinic
• Eating Disorders Clinic
• Womens Inpatient Treatment Service
• Womens Consultation Service
• Services
• Preconception planning
• Consultations and treatment for women who are
  pregnant or postpartum
• Consultations and treatment for women with
  premenstrual or perimenopausal psychiatric
  symptoms

53
UIC Womens Mental Health Program Teaching

• Womens Mental Health Fellowship
• Trains leaders in womens mental health
• Womens Mental Health rotations
• Multidisciplinary medical students, psychiatry
  residents, family medicine residents, nursing
  students, psychology interns, social work
  interns, mother-infant specialists
• Womens Mental Health curriculum
• Womens Mental Health tutorial

54
Lessons learned

• Collaborations can accomplish an amazing amount
  with little
• Disparate systems can work together if we
  translate institutional cultures
• Physicians can be engaged if we are mindful of
  their key concerns
• Time constraints
• Liability
• Access to training, tools, consultation, resources

55
Lessons learned

• Introduce screening only in the context of
  increasing provider capacity
• Involve consumers in shaping models of care and
  self-care tools
• Legislation is not really a mandate, but raises
  the bar on standard of care, and raises
  awareness
• With effort, and despite friction, science and
  politics can work in tandem to shape policy

56
Thanks to our funders

• Health Resources and Services Administration
• Michael Reese Health Trust
• Illinois HealthCare and Family Services

57
UIC Perinatal Mental Health Project how to
reach us

• Toll-free telephone [phone]
• Project website
• www.psych.uic.edu/research/perinatalmentalhealth/
  
• UIC Womens Mental Health Program website
• www.psych.uic.edu/clinical/women
• UIC Womens Mental Health Fellowship website
• www.psych.uic.edu/education/residents/fellowships
  
• Project Director Laura Miller MD