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Implementing the MIHP Depression Interventions


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Title: Implementing the MIHP Depression Interventions

Implementing the MIHP Depression Interventions
Making Best Use of this Webcast
  • Print out the slides before you continue.
  • Make notes as you go along.
  • If you have questions after watching this
    webcast, contact
  • Joni Detwiler
  • MIHP State Consultant
  • 517 335-6659

Learning Objectives
  • Review findings of MIHP Program Fidelity Study.
  • Define perinatal depression and describe its
    impact on the mother and her infant.
  • Discuss role of MIHP professional staff in
    addressing perinatal depression.
  • Discuss how to access mental health treatment and
    support services in your community for women
    suffering from perinatal depression.


(No Transcript)
MIHP Program Fidelity Study
  • Record Review (Program Fidelity)
  • MSU review of client records completed by MIHP
    providers to assess program fidelity
  • (extent to which services are provided
    consistently and according to policy).
  • Findings
  • Plan of Care 2 (POC 2) depression domain
  • Inconsistent
  • Absent

QI Response to Fidelity Study Results
  • Develop online training on implementing the MIHP
    depression interventions
  • Require staff to view trainings on depression and
    infant mental health at
  • Develop tools to assist staff to help women
    navigate the mental health services systems


Depression Overview
  • Lets start at the beginning

Depression is a Worldwide Public Health Issue
  • Unipolar (clinical) depression is one of the top
    leading 5 causes of disability on our planet.
    Together with bipolar disorder (manic
    depression), it is costlier and more burdensome
    than any other ailment except cardiovascular
    disease. (1)
  • Depression affects twice as many women as men,
    regardless of racial and ethnic background and
    income. (2)
  • One in four women will experience severe
    depression at some point in life. (3)

Depression in the Perinatal Period
  • There are three types of depression women may
    experience during the period from start of
    pregnancy to 12 months after giving birth
  • The Baby Blues
  • Perinatal Depression
  • Postpartum Psychosis
  • NOTE Prenatal Depression, Postpartum
    Depression, Postnatal Depression, Maternal
    Depression, and Perinatal Depression generally
    refer to the same mental health disorder.

Definition Baby Blues
  • Common reaction the first few days after
  • Crying, worrying, sadness, anxiety, mood swings.
  • Usually lifts in about 2 or 3 weeks.
  • Experienced by 50 80 of women.

Definition Perinatal Mood Disorder
  • Major and minor episodes of clinical depression
    during pregnancy or within first year after
  • More than the Baby Blues
  • Lasts longer and is more severe
  • Symptoms
  • Sad, anxious, irritable
  • Trouble concentrating, making decisions
  • Sleeping or eating too much or too little
  • Frequent crying and worrying

Definition Perinatal Mood Disorder
  • Symptoms (continued)
  • Loss of interest in self care
  • Loss of interest in things that used to be
  • Shows too much or two little concern for baby
  • Not up to doing everyday tasks
  • Feelings of inadequacy
  • Suicidal thoughts
  • Symptoms last more than 2 weeks

Definition Perinatal Mood Disorder
  • Co-occurs with anxiety disorder for 2/3 of women
  • Generalized Anxiety Disorder
  • Panic Disorder
  • Obsessive-compulsive Disorder
  • Other
  • Often co-occurs with substance use disorder

Definition Postpartum Psychosis
  • A rare disorder (one or two in 1,000 women).
  • A severe form of perinatal depression that can be
  • Symptoms extreme confusion, hopelessness, cant
    sleep or eat, distrusts others, sees or hears
    things that arent there, thoughts of harming
    self, baby or others.
  • A medical emergency requiring urgent care.

Prevalence of Perinatal Depression
  • 10-20 of all women experience depression during
    the perinatal period. (5)
  • Prevalence in low-income and black women is
    estimated at almost double that of white women.
  • Analysis of depression rates across 6 home
    visiting (HV) programs found that the of women
    exceeding clinical cutoff for depression at
    enrollment ranged from 28.5 61. (7)

Prevalence in MIHP Population July 01, 2012
July 01, 2013
MRI Depression Scores MRI Depression Scores of Total Screened
0 Low 0 0.00
1 Moderate 7,660 36.18
2 High 3,243 15.32
3 Unknown 0 0.00
4 No Risk 10,268 48.50
Total Screened 21,171 100.00

Total Mod High Risk 10,903 51.50
Total No Risk 10,268 48.50
Total Unknown 0 0.00
Total Low Risk 0 0.00
Total Screened 21,171 100.00
Risks for Perinatal Depression
  • Can affect any woman regardless of age, race,
    income, culture, or education.
  • Factors that increase the risk (8)
  • History of depression
  • Use of alcohol and tobacco during pregnancy
  • Unemployed/low-income
  • Without a partner
  • Lower level of education

Few Pregnant Women Access Depression Treatment
  • U of M Depression Center study 20 of pg women
    scored hi on standard depression survey, but of
    those, only 14 received any MH treatment. (9)
  • Northwestern Univ. screened 10,000 PP women 14
    screened of those, 19 thought of harming
    selves. Recurrent episodes. Vast majority of
    PPD women in US not treated. (10)
  • Effective treatments have been identified -
    Cognitive Behavioral Therapy, Interpersonal
    Therapy, meds.
  • Few women access depression treatment.

Why Low-Income Women Dont Access Depression
  • The illness itself gets in the way
  • Shame about not being strong
  • Guilt Youre supposed to be happy when youre
  • Stigma around using MH services being seen at
  • Fear of being labeled crazy lumped in with
    people with psychoses
  • Partner, parent or community (e.g., faith or
    cultural group) prohibits it
  • Family or friends say its all in your head -
    snap out of it

Why Low-Income Women Dont Access Depression
  • 8. Fear that she will be judged, especially if
    shes young
  • 9. Fear of taking medications, especially
    during pregnancy
  • 10. Belief that psychotherapy wont help because
    trauma, loss and stress are so prevalent in
    low-income community
  • 11. Isolation
  • 12. Hoops to jump and long wait times to get an
  • 13. Logistical barriers (e.g., transportation,
    child care)
  • 14. Previous negative experience with MH
  • 15. Too overwhelmed caring for infant and working

Why Low-Income Women Dont Access Depression
  • 16. Mistrust of system
  • 17. Fear MH treatment will be used against her
    in custody battle
  • 18. Fear that confidentiality will be violated,
    resulting in
  • CPS referral
  • Domestic violence
  • Be upfront about when a CPS report is mandated,
    but maintain a warm relationship so that the
    mother feels understood and trusts that what she
    may say about her own MH wont be misconstrued.

Adverse Effects of Untreated Perinatal Depression
  • Untreated depression among pregnant and
    postpartum women is of concern due to its adverse
    effects on the health of the mother, the health
    of the infant, and the mother-infant
    relationship. (11)

Adverse Effects of Untreated Perinatal Depression
  • Depressed women are more likely to engage in risk
    taking behaviors (12)
  • More likely to use substances.
  • Less likely to comply with prenatal care, putting
    self and baby at risk for complications and poor
    birth outcomes.
  • Less likely to use contraception consistently.

Adverse Effects of Untreated Perinatal Depression
  • 2. Pregnant, depressed women are 3.4 times more
    likely to deliver preterm and 4 times more likely
    to deliver a baby with low birth weight than
    non-depressed women. (13)
  • 3. Undiagnosed and untreated maternal depression
    is associated with increased rates of maternal
    suicide. (14)

Adverse Effects of Untreated Perinatal Depression
  • 4. Maternal depressive symptoms in early infancy
    contribute to unfavorable patterns of health care
    seeking for children.
  • Increased use of acute care at 30-33 months,
    including Emergency Department visits in past
  • Decreased receipt of preventive services,
    including age-appropriate well child visits and
    up-to-date immunizations. (15)

Adverse Effects of Untreated Perinatal Depression
  • 5. Maternal depression, alone, or in combination
    with other risks can pose serious, but typically
    unrecognized barriers to healthy early
    development and school readiness, particularly
    for low-income young children. (16)
  • The cumulative impact of depression in
    combination with other risks to healthy parenting
    (e.g., low educational achievement) is greater.

Adverse Effects of Untreated Perinatal Depression
  • 6. Postpartum depression can impair early
    relationships (17)
  • Secure attachment, or healthy emotional bond,
    between an infant and primary caregiver is key to
    the future emotional development of the infant.
  • Depression threatens the mothers emotional and
    physical ability to care for her child and to
    foster a healthy relationship with her child.

Still Face Experiment Video
  • Still Face Experiment Dr. Edward Tronick
    YouTube (249)
  • A phenomenon in which an infant, after 3 minutes
    of interaction with a non-responsive
    expressionless mother, rapidly sobers and grows
    wary. He makes repeated attempts to get the
    interaction into its usual reciprocal pattern.
    When these attempts fail, the infant withdraws
    and orients his face and body away from his
    mother with a withdrawn, hopeless facial
    expression. (18)

Adverse Effects of Untreated Perinatal Depression
  • 7. Children born to a women who suffers from
    postpartum depression are (19)
  • More likely to lack secure attachment and are
    therefore at increased risk for delayed or
    impaired cognitive, emotional and linguistic
  • More likely to have behavioral problems.
  • More likely to experience worse long-term mental
    health problems.

Adverse Effects of Untreated Perinatal Depression
  • 8. A study of WIC mothers found that postpartum
    depression resulted in (20)
  • Poor nutrition
  • Poor infant weight gain
  • Childhood obesity and adiposity
  • Poor mother-child interactions

Maternal MH Problems A Challenge to HV Programs
  • Three challenges to HV programs have been
    consistently identified maternal mental health,
    substance abuse, and intimate partner violence.
  • Qualitative research finds that HVs identify
    maternal MH problems as a significant barrier to
    providing HV services in a consistent, continuous
  • More difficult to engage and serve
  • Harder to work with parents who
  • Are perceived as uncommitted or unmotivated
  • Threaten to commit suicide

HVs Feel Inadequately Trained to Address MH
  • In one study, 44 of HVs felt they were
    inadequately trained the help families with MH
    problems. (22)
  • HVs often say they are uncomfortable discussing
    depression with a mother because
  • They dont have the right training and are afraid
    theyll say the wrong thing.
  • When they do bring it up and the women refuses MH
    services, they feel responsible.
  • They feel overwhelmed to be the only lifeline for
    a depressed and perhaps abused woman.

Becoming More Comfortable Discussing Depression
  • If you dont feel prepared, its perfectly
    understandable you would be uncomfortable talking
    about depression.
  • You are not going to make it worse for the mother
    by discussing her depression.
  • Well give you some concrete ways to frame your
    discussion later in this presentation.


What Can MIHP Do?
  • Care coordination
  • Education
  • Support and encouragement
  • Not therapy
  • Exception Infant Mental Health Specialist can
    provide brief mental health interventions

History of Trauma Is Related to Depression
  • Trauma is very common among women in MIHP.
  • Trauma is the personal experience of
    interpersonal violence including (23)
  • sexual abuse
  • physical abuse
  • severe neglect
  • loss
  • and/or the witnessing of violence, terrorism and

What is Trauma-Informed Care?
  • An appreciation for the high prevalence of
    traumatic experiences among persons we serve.
  • A thorough understanding of the profound
    neurological, biological, psychological and
    social effects of trauma and violence on the
    individual, including adoption of health-risk
    behaviors as coping mechanisms (smoking,
    substance abuse SA, self harm, sexual
    promiscuity, violence).
  • Care that addresses these effects, is
    collaborative, supportive and skillbased. (24)

Learn More about Trauma-Informed Care
  • Trauma-informed organizations and programs are
    based on an understanding of the vulnerabilities
    or triggers of trauma survivors that traditional
    service delivery approaches may exacerbate, so
    providers can be more supportive and avoid
  • Trauma-informed care is spreading across health
    and human services MH, child welfare, health
    care, DV, foster care, homelessness, SA, criminal
    justice, military families, refugee services, and
  • http// for learning

Diversity-Informed Practice Community Context
  • Community context affects perception of
  • Many women who live in poverty or experience
    institutional racism may assume theyll be
    depressed (or get diabetes, or be physically
    abused, or be sexually assaulted, etc.) because
    thats just the way it is for the women in this
    neighborhood/housing project/tribal
    community/town. They feel powerless to reduce
    their depression (low sense of self-determination)
  • Or, they may deny their depression. Its not
    me, its my life circumstances.

  • We met with a team of diverse MIHP providers to
    discuss cultural implications of depression and

Diversity-Informed Practice Language and
Cultural Perceptions
  • Be mindful of potential language barriers in
    approaching MH issues (e.g., some
    Spanish-speakers may use the word nervous or
    under pressure instead of depression).
  • Stigma of mental illness affects all groups, but
    may be heightened in some (e.g., some ethnic or
    faith-based groups).
  • Some groups highly respect the authority of the
    MD and may be more likely to accept idea of meds
    or a MH referral from the MD than from you work
    with a womans MD and MHP to help her get what
    she needs.

Diversity-Informed Practice Cultural Affiliation
  • That said, cultural affiliation varies. YOU MUST
  • Not everyone in the same cultural group thinks
    the same way. Young parents may not be connected
    to their group.
  • The only way to really know what a particular
    individual believes about depression (or anything
    else) is to ask her. Be open to having a
    conversation about culture.
  • I dont know how you think or feel about this
    help me learn here. What do you think about
    people who have depression? What does your
    family think? What does your community think?
    These are very telling questions.

Diversity-Informed Practice Legal Undocumented
  • Legal and undocumented immigrants face different
    realities in the United States.
  • Persons living under political asylum and
    undocumented persons working in migrant camps
    have very different experiences here, but both
    may have history of trauma.
  • Pregnant non-citizens qualify only for the MOMS
    program, which offers fewer benefits than other
    Medicaid programs.
  • Be willing to track down info on what a
    particular immigrant is eligible for and what
    laws pertain to her.

Primary MIHP Activities to Address Depression
  • Screen every pregnant and postpartum woman with
    infant, using standardized, validated tools
    embedded within MIHP Risk Identifier.
  • (RN, SW)
  • Educate all women about Perinatal Depression
    utilizing POC 1.
  • (RN, SW, RD, IMH Spec.)

Primary MIHP Activities to Address Depression
  • Refer women at mod or high risk to treatment
    (including IMH services) provide education and
    support coordinate care, utilizing POC 2.
  • (RN, SW, RD, IMH Spec.) NOTE RD must
    follow up with SW or RN to engage them in
    addressing depression.
  • 4. Assess need for IMH services (depression is
    a factor). If parent refuses, provide brief,
    direct parent-infant intervention. (IMH Spec.)

Screen for Depression and Stress
  • The standardized MIHP Maternal Risk Identifier is
    administered at intake. It includes
  • Edinburg Postnatal Depression Scale (EPDS)
  • Perceived Stress Scale 4 (PSS 4)

POC 1 Educate All Women on Perinatal Depression
  • POC 1 documents that beneficiary received one or
    both of the following items from RN or SW at
    administration of Risk Identifier
  • MIHP Maternal Infant Education Packet
    Pregnancy Infant Health
  • Instructions on how to sign up for text4baby
  • Education Packet includes basic info on all of
    the MIHP domains to guide discussion with
  • At administration of Risk Identifier (RN, SW)
  • At later visit(s), depending on the beneficiarys
    individual situation (RN, SW, RD, IMH Spec.)

POC 1 Educate All Women on Perinatal Depression
  • Education Packet is a 44-page booklet posted on
    the MIHP web site.
  • The Stress, Depression and Mental Health domain
    is covered on pages 22-23.

Stress, Depression and MH Pregnancy Infant
  • What is perinatal depression?
  • Its depression that occurs during pregnancy or
    postpartum. Postpartum means within a year
    after giving birth.
  • It is VERY common.
  • It can be mild, moderate or severe.

Stress, Depression and MH Pregnancy Infant
  • How do I know if I might be depressed?
  • Women with perinatal depression usually sense
    that somethings not right.

Stress, Depression and MH Pregnancy Infant
  • Would you answer yes to any following
  • I feel very sad and hopeless more days than not.
  • Im not enjoying life like I used to.
  • I blame myself for everything.
  • I worry about everything.
  • Im afraid and I dont know why.
  • I feel overwhelmed and have a hard time coping.

Stress, Depression and MH Pregnancy Infant
  • I cry a lot.
  • I have trouble sleeping because Im so unhappy.
  • I want to sleep all the time.
  • Im confused and distracted.
  • I get angry very easily.
  • I dont think I will be a good mother.
  • I have thoughts of harming myself or others.
  • I hear voices or see things that arent there.

Stress, Depression and MH Pregnancy Infant
  • If you answered yes to any of these statements,
    you may be depressed.
  • Reiterate
  • You are not alone.
  • Many pregnant women and new moms have these same
    thoughts and feelings.

Stress, Depression and MH Pregnancy Infant
  • How does perinatal depression affect my baby?
    Your baby could
  • Be born too small or too early.
  • Be fussy and jittery.
  • Have feeding or sleeping problems.
  • End up with learning problems.
  • End up with behavior problems, such as

Stress, Depression and MH Pregnancy Infant
  • Its harder for you and your baby to form a
    strong emotional attachment to each other.
    Attachment is important to your babys

(No Transcript)
Stress, Depression and MH Pregnancy Infant
  • Where can I get more information about perinatal
  • Your doctor.
  • Your MIHP worker
  • Your Medicaid Health Plan.
  • Online at http//

text4baby Alternative to Education Packet
  • Free text message service to promote MCH.
  • Includes intermittent messages on depression
  • similar to those in Education Packet.
  • Resource info is linked to mothers zip code.
  • Bring Education Packet to visits for discussion
    purposes, even if beneficiary chose the text4baby
  • Education Packet and text4baby both good tools.

POC 1 Documentation
  • POC 1
  • Check off box (Education Packet or text4baby)
  • Signature of RN and SW within 10 business days
  • 2. Professional Visit Progress Note
  • Depression/stress written on line after education
    packet box checked
  • Other visit information

POC 2 Supporting Women at Mod-Hi Risk of
  • Next well look at
  • How to implement the standardized POC 2
  • How to document POC 2 interventions effectively

POC 2 Services Determined in Two Ways
  • 1. Results of the Risk Identifier
  • Womans situation matches risk criteria in the
    Risk Information column (2) of the POC 2

POC 2 Intervention Levels in Stress/Depression/MH
  • Services stratified by anticipated intervention
  • Domain intervention levels
  • Moderate (scores 9 - 12 on EPDS or scores 9 - 16
    on PSS 4 or is in treatment)
  • High (scores 13 or above on EPDS or is in
  • Emergency (risk of imminent harm to self or

Developing the POC 2 Stress/Depression/MH Domain
  • Once Risk Identifier is completed
  • Enter data into SSO data base
  • Print out Score Sheet
  • Pull Stress/Depression/Mental Health POC 2 if
    Risk Identifier Score Sheet indicates a risk.

Developing the POC 2 Stress/Depression/MH Domain
  • 3. SW and RN must sign POC 3 within 10 business
    days of each other.
  • 4. No visits may be completed or billed until 2
    and 3 above are done, unless an emergency

Implementing the Stress/ Depression/ MH
  • Follow the numbered interventions based on risk
    level (low, mod, high, emergency).
  • MIHP Certification Tool Cycle 4 requires you to
    address any risk domain that scores out high
    within the first three visits.
  • All of the numbered interventions will not apply
    to every beneficiary.

Were Not in this Alone
  • Medicaid Health Plans and medical care providers
    are active partners in MIHP services delivery.

Foundations of Intervention Delivery
  • Use
  • Motivational Interviewing
  • Coaching for Self Sufficiency
  • Perinatal Periods of Risk
  • Life Course Theory
  • (See Motivational Interviewing and the Theory
    Behind MIHP Interventions webcast at MIHP web

Be Prepared to Talk with a Woman about her
  • Learn as much as you can about depression, its
    effects, and treatment.
  • Be extremely familiar with the HRSA booklet.
    Depression During After Pregnancy A Resource
    for Women, Their Families, Friends.
  • Watch the MIHP online training Depression,
    Mental Health, Stress (Kothari and Ludtke).
  • Remind yourself that talking about depression can
    only help it cant hurt.

Talking with a Woman about Mod/Hi EPDS or Hi PSS4
  • Before discussing her score
  • Focus on her symptoms
  • She may shut down if you begin by using MH labels
    (names of disorders) and reject idea of having a
    MH problem, which she equates with being crazy
  • Focus on her experience with depression (self and
  • Focus on her understanding of depression

Talking with a Woman about Mod/Hi EPDS or Hi PSS4
  • 1. Ask her about her symptoms by following up on
    some of her EPDS responses. Remember when we
    asked you all those questions when you first
    signed up for MIHP? Fourteen of those questions
    asked about how you recently felt (enjoying
    life, anxious, sad, able to control important
    things in life, etc.). Can we talk about some of
    your answers to the questions? Can you tell more
    a little more about them?

Talking with a Woman about Mod/Hi EPDS or Hi PSS4
  • 2. Have you ever known anyone with depression or
    who was very stressed out?
  • Was it a family member?
  • What do you think it was like for that person?
  • What was it like for you to be with that person?
  • How did other people treat that person?
  • 3. What is your understanding of depression?
  • Did you ever feel that you might have had
    depression at any time in your life?
  • If so, what was that time like for you?

Low Risk Intervention 1
  • Review written material on stress, baby blues,
    and/or perinatal depression/anxiety.
  • Maternal/Infant Education Packet (POC 1).
  • HRSA booklet or other comparable booklet. (Free
    HRSA booklet Depression During After Pregnancy
    A Resource for Women, Their Families, Friends,
    English and Spanish)
  • Emphasize that depression is common treatable.
  • Explain what intrusive thoughts are (next slide).
  • Explain that physical symptoms are common in
    depression (slide after next).

Asking About Intrusive Thoughts
  • Many women have intrusive thoughts that really
    bother them. Intrusive thoughts seem to enter
    your mind against your will and are very hard to
    get rid of. E.g., you might find yourself
    worrying that youre not doing everything right
    for your baby, or you might do something wrong to
    your baby, or something might happen to your
    baby. All moms worry, but its really hard when
    youre worrying so much you cant sleep and you
    just want the thoughts to stop but you cant
    figure out how. Does this ever happen to you?

PostPartum Depression Educational Video
  • Post Partum Depression Educational Video -New
    Jersey YouTube (5.13)
  • Women of different ages, races, and economic
    backgrounds, including the First Lady of New
    Jersey, describe their experiences with
    postpartum depression.

Low Risk Intervention 2
  • Discuss stress reduction/coping strategies and/or
    self-care skills.
  • All moms need a self-care action plan,
    especially if theyre at risk for depression.
    There are simple, everyday things you can do to
    take care of yourself to feel better. Heres a
    self-care action plan form that we can fill out
    together. Its always better to write your plan
    down so you can look at it whenever you want to.

Weekly Self-Care Action Plan
  • Exercise stay active
  • Do something pleasurable every day
  • Spend time with people who make you laugh and
    feel good about yourself

Weekly Self-Care Action Plan
  • Lean on your family, friends and community when
    youre very down or very stressed
  • Ask about emotionally supportive people
    in her life
  • When youre down/stressed, who can
    you turn to?
  • Which family members?
  • Which friends and neighbors?
  • Who else (e.g., godmother, unofficial aunt,
  • Do you have a faith community? Anyone there?
  • Do you belong to another kind of group?
    Anyone there?
  • Do you have enough support from these people?

Weekly Self-Care Action Plan
  • 5. Ask for help with the baby so you can sleep
  • 6. Find a support group or class connect with
  • women experiencing the same things you are
  • 7. Practice relaxation (e.g., slow, deep
  • 8. Any other way to take care of yourself this
  • 9. Give yourself some credit when you do one of
    the steps on this self-care action plan

Low Risk Intervention 3
  • Educate on symptoms of depression and/or anxiety
    to report to health care provider.

Physical Symptoms are Common in Depression
  • Joint pain
  • Limb pain
  • Back pain
  • Gastrointestinal problems
  • Tiredness
  • Sleep disturbances
  • Psychomotor activity changes
  • Appetite changes

What Does Postpartum Depression Feel Like? (25)
  • It feels scary.
  • It feels out of control.
  • It feels like Im never going to feel like
    myself again.
  • It feels like each day is a hundred hours long.
  • It feels like no one understands.
  • It feels like my relationship cannot survive
  • It feels like Im a bad mother.
  • It feels like I should never have had this
  • If feels like if I could only get a good nights
    sleep, everything would be better.
  • It feels like I have no patience for anything
  • It feels like Im going crazy.
  • It feels like I will always feel like this.

Low Risk Intervention 4
  • Provide support and encouragement.

Low Risk Intervention 5
  • Provide information/referral to community
    resources for stress reduction or problem

Talking with a Woman about Mod/Hi EPDS or Hi PSS4
  • Those 14 questions about how you felt around the
    time that you signed up for MIHP were a kind of
    quiz to find out if you could have depression or
    stress or both. Having both is very common.
    Every woman in MIHP takes this quiz. If she gets
    a moderate or high score on the quiz, she may be
    experiencing depression.  
  • Almost HALF of all women in MIHP score moderate
    or high. Thats A LOT of women. This percentage
    is about the same across the US for low-income
    women with young children.

Talking with a Woman about Mod/Hi EPDS or Hi PSS4
  • It makes perfect sense when you think about it.
    Its very hard to raise a family when you dont
    have enough money to make ends meet because you
    cant find a decent job, especially if you are a
    single mom and you arent getting much support
    from other people, and youre worried about
    keeping your children safe. No wonder so many
    women experience depression and stress.

Talking with a Woman about Mod/Hi EPDS or Hi PSS4
  • Your score tells us that you may be experiencing
    depression, stress, or both, so its important
    for you (and your baby) that we explore this
    further so you can decide what to do about it.
    Well work together and figure out best way for

Talking with a Woman about Mod/Hi EPDS or Hi PSS4
  • Depression makes people feel really weighed down
    or stressed out or both. The good news its
    very treatable. Medications work and so does
    counseling. Your doctor or a mental health person
    can do an assessment to see if you really do have
    depression or stress or both. You can find out
    about your medication and counseling options.
    You can feel better, so you can be the mom you
    want to be.

Moderate Risk Intervention 6
  • Discuss treatment options for treating depression
    (e.g., meds, CMH, clinics, private providers,
    support groups, IMH Specialist).
  • Primary Care Provider or OB
  • CMH (serious mental illness only)
  • Medicaid HP (20 OP visits/yr for mild-mod
  • Federally Qualified Health Center (FQHC)
  • Private counseling agencies (e.g., Child Family
  • Other (e.g., hospital or university-based
    depression clinic)

Support Services
  • Discuss support services options for dealing with
  • Depression support groups (e.g., Postpartum
    Support International)
  • Other support groups (e.g., anxiety, bereavement
    , etc.)
  • Online support groups and communities
  • Web sites
  • See MIHP Perinatal Depression Resources for
    Consumers and Health Care Providers on web site

Moderate Risk Intervention 7
  • Refer for evaluation and treatment
  • CMH
  • HP or PCP
  • Support Group
  • MIHP IMH Specialist
  • Explain that it may take a while for treatment to

If Beneficiary Has Been a CMH Client in the Past
  • Refer to CMH if beneficiary was previously served
  • If she refuses to return to CMH, get a release of
    information from her so you can discuss her
    status with her CMH worker.

If a Woman Declines to Seek Treatment
  • If woman declines to seek treatment or a support
    group, consider using some of the ideas in the
    next few slides.
  • If she still declines, ask if she would at least
    be willing to keep her mind open and think about
    it some more.
  • Its your decision, of course, but I really hope
    you will think about it because Im concerned
    about you and want the best for you and baby.

Encouraging a Woman to Seek Treatment
  • Some things you could say
  • Explain that a family member or friend who says
    get over it doesnt understand what depression
  • Ask her If you had a friend who was depressed,
    what would you tell her? (Low-income women in
    focus groups said Think about the child - your
    kids shouldnt suffer because of what youre
    going through.)
  • Talk about how depression can make it harder for
    her to achieve her goals for herself and family.

Encouraging a Woman to Seek Treatment
  • More things you could say (26)
  • Mental illness, mental disorder, and
    behavioral disorder are outdated terms.
  • New research Depression is a brain circuit
  • People with depression arent mentally ill or
    crazy or losing their minds their brains
    are wired differently.
  • A brain circuit disorder is a real physical
  • Early treatment is always better.

Encouraging a Woman to Seek Treatment
  • More things you could say
  • Depression is a real physical problem.
  • It messes with your body, not just your emotions.
  • Its like a broken arm, except it cant be fixed
    with a cast.
  • Its not going to go away by itself in a few
    days, like a cold does.
  • Many celebrities have had postpartum depression
  • Jennifer Lopez, Halle Berry, Gwyneth Paltrow,
    Courtney Cox, Bryce Dallas Howard, Brooke
    Shields, etc. They talk about it publicly
    because they want other women to know they arent
    alone, dont need to suffer in silence, and
    treatment works.

Moderate Risk Intervention 8
  • Re-evaluate risk later in pregnancy or postpartum
    (recommend re-administer the EPDS and PSS 4) and
    encourage beneficiary to seek treatment, if
  • Re-administer at any time you feel its
  • If applicable, change and date POC 2.
  • EPDS and PSS 4 are on web site, separate from
    Risk Identifier.

Moderate Risk Intervention 9
  • Provide support and encouragement in adhering to
    mental health provider treatment recommendations
    including psychotropic medication and/or

Moderate Risk Intervention 10
  • Discuss medication schedule and importance of
    taking medication as prescribed.

Moderate Risk Intervention 11
  • Prepare postpartum support plan.
  • How will you address stress and depression after
    your baby is born?

High Risk Intervention 12
  • Ask if beneficiary has suicidal ideation, plan or

High Risk Intervention 13
  • Develop and document emergency safety plan.
  • Discuss how mom, infant and other family members
    will stay safe.
  • Document this discussion.

Key Elements of MIHP Safety Plan
  • What happens
  • What we will do
  • Who will do it
  • By when

MIHP Safety Plan
Strengths of Individual/Family
What Happens What we will do Who will do it? By When
To Prevent from happening .
How will we react
Signature of the MIHP staff Signature of the
MIHP beneficiary

(adapted from community partnerships)
Emergency Intervention 14
  • Assist in going to nearest Emergency Department.

Emergency Intervention 15
  • Call 911.

Emergency Intervention 16
  • Inform MHP and medical care provider.

Demonstrations Discussing Depression with
  • SW Rebecca Wheeler, Consultant/Trainer, MDCH
  • Vignette 1
  • Non-talkative mother (Joni) of 3-mo old boy
    (Tommy) no partner lives with mom. Joni
    Detwiler, MDCH
  • Vignette 2
  • Talkative mother (Brenda) of 6-mo old girl
    (Jasmine) lives with partner no family support.
    Brenda Jegede, MDCH
  • NOTE V2 picks up where V1 leaves off
    beneficiary is different to reflect varying
    communication styles and family situations


Its All About Relationships
  • You must have strong relationships with key
    referral sources in order to provide quality care
  • Especially true in MH domain because
    beneficiaries are reluctant to use MH services
    and knowing how to access services can be

Helping Beneficiary Navigate MHP Mental Health
  • Call the MHP MIHP contact person (see list on web
    site), who is responsible for assisting MHP
    members to access services.
  • If this does not work out for the beneficiary,
    inform your consultant.
  • If beneficiary cant access services, explore
    other options.

Helping Beneficiary Navigate CMH Services
  • If you already have a CMH contact, work through
    him or her.
  • If not, see
  • CMH Contacts for Mental Health Services for
    Infants and their Families (including Infant
    Mental Health)
  • Using CMH Contacts to Navigate Mental Health
    Services for MIHP Infants and Their Families
  • Possible Reasons for Referral to an MIHP Infant
    Mental Health Specialist or to CMH for an

Other Options if Beneficiary Declines MHP, PCP,
CMH Services
  • If beneficiary does not wish to seek MH services
    through her MHP, primary care provider/OB or CMH,
    look for other options.
  • See MIHP web site for
  • MIHP Perinatal Depression Resources for
    Consumers and Health Care Providers
  • Connect her with groups (parent groups,
    faith-based groups, etc.) that are not

  • Findings Magazine, Fall/Winter 2005, Volume 21,
    Number 1, University of Michigan School of Public
  • National Institute of Mental Health
  • Ibid.
  • Wisner KL, Sit DK, McShea MC, et al. Onset
    timing, thoughts of self-harm, and diagnoses in
    postpartum women with screen-positive depression
    findings. JAMA Psychiatry 2013 doi10.1001/JAMA
    Psychiatry, 2013.87.
  • Identifying and Treating Maternal Depression
    Strategies Considerations for Health Plans,
    NIHCM Foundation Issue Brief, June 2010
  • Leis JA, Mendelson T, Perry DF, Tandon D.
    Perceptions of mental health services among
    low-income, perinatal African American women.
    Womens Health Issues. 2011 21314-319
  • Ammerman T, Putnam F, Bosse N, Teeters A, Van
    Ginkel J. Maternal depression in home visitation
    A systematic review. Aggression and Violent
    Behavior 15191-200.
  • Marcus SM, Flynn HA, Blow FC, Barry KL.
    Depressive symptoms among pregnant women screened
    in obstetrics settings. Journal of Womens
    Health. 2003 May 12(4)373-380.
  • Ibid.
  • Wisner KL, Sit DK, McShea MC, et al. Onset
    timing, thoughts of self-harm, and diagnoses in
    postpartum women with screen-positive depression
    findings. JAMA Psychiatry 2013 doi1001/JAMA
    Psychiatry, 2013.87.

References (continued)
  • 11. Identifying and Treating Maternal
    Depression Strategies Considerations for
    Health Plans, NIHCM Foundation Issue Brief, June
  • 12. Ibid.
  • 13. Ibid.
  • 14. Ibid.
  • 15. Minkovitz C, Strobino D, Scharfstein D, et
    al. Maternal depressive symptoms and children's
    receipt of health care in the first 3 years of
    life. Pediatrics Vol. 115 No.2 pp 306-314 (doi
  • 16. Knitzer J, Theberge S, Johnson K. Reducing
    Maternal Depression and its Impact on Young
    Children Toward a Responsive Early Childhood
    Policy Framework. National Center for Children
    and Poverty, Project Thrive, Issue Brief 2.
  • 17. Identifying and Treating Maternal
    Depression Strategies Considerations for
    Health Plans, NIHCM Foundation Issue Brief, June
  • 18. Jason Goldman, ScienceBlogsLLC, October 18,
  • 19. Identifying and Treating Maternal
    Depression Strategies Considerations for
    Health Plans, NIHCM Foundation Issue Brief, June
  • 20. Pooler J, Perry D, Ghandour R. (2013).
    Prevanlence and risk factors for postpartum
    depressive symptoms among women enrolled in WIC.
    Maternal and Child Health Journal. Advance
    online publication. doi 10.1007/s109956-013-1224-

Referenced (continued)
  • Tandon SD, Parillo KM, Jenkins C, Duggan AK.
    Formative evaluation of home visitors role in
    addressing poor mental health, domestic violence,
    and substance abuse among low-income pregnant and
    parenting women. Maternal and Child Health.
    2005 9273-283.
  • Ibid.
  • National Association of State Mental Health
    Programs Directors, 2004.
  • Jennings, A. Models for Developing
    Trauma-Informed Behavioral Health Systems and
    Trauma-Specific Services. 2004.
  • 25. Spectrum Health Womens Services web site
  • 26. Thomas Insel, Mental Disorders as Brain
    Disorders at TEDxCaltech, Feb. 8, 2013

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