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Development of a Statewide Perinatal Depression Initiative in Illinois

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Title: 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 1-800-573-6121
  • 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
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