Nancy Byatt, DO, MBA Liz Friedman, MFA Linda Jablonski, RNC

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• Impact of Perinatal Mood Disorders (PMD) on mothers and children • Barriers to Care and Treatment • Intervention Models • Community-Based Perinatal Support Model Component Overview – case study and results

Up to 20% of women during pregnancy

10-15% of women the postpartum period

25% of women pregnant in the past year meet criteria for a psychiatric diagnosis

Maternal depression can lead to

Low birth weight Preterm delivery Cognitive delays Behavioral problems Poor maternal health behaviors Maternal substance abuse Maternal suicide

Untreated Women

Symptom Detection Assessment Engagement Treatment Improvement

Improved Outcomes (daily functioning, parenting, well-being, quality of life, health, offspring health, relationships, family, prognosis) Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved

• Individual-level barriers

• Provider-level barriers

• Stigma

• Misconceptions

• Lack of understanding

• Fear of failing as a mother

• Four 90 minute focus groups • Each group had 8 to 10 mothers • Analysis: Verbatim transcripts analyzed qualitatively to identify themes Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved

Individual-level

Provider-level

• Individual-level

• Provider-level

Perceive barriers Support screening but need guidance Lack of adequate guidance, follow up and referral sources Report inadequate mental health training

• Four 90 minute focus groups

• Each group had 8 to 10 providers/staff

• Shame

• Stigma

• Inadequate training

• Limited mental health resources

• Discomfort

“

Limited training among mental health providers

OB and mental health care not integrated

Lack of collaboration with mental health providers

Psychoeducation

Destigmatize

Positive feedback from provider

Training

Structured screening and referral

Provider confidence

Training for mental health providers

Integration of mental health and obstetric care

Immediate back up from mental health providers

PES Perinatal Emotional Spectrum

PEC Perinatal Emotional Complications

PECr Perinatal Emotional Crisis

Public health concerns

Changes in treatment strategy to address individual, provider and systems-level barriers

Individual level Clinical level Program level System level

• Medical Model • Community Mental Health Theory • Social Justice Theory • Life Course Theory • Survivor Movement Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved

Perspective: individual medical condition Appropriate Intervention: medication, psychotherapy

Onset of major depressive episode must be within 4 weeks after delivery.

DSM-IV

Perspective: Public health issue

Appropriate Intervention

• Organizing families • Activating support systems • Community support groups • Creating coalitions and task forces

Perspective: issues of inequity, oppression and social policy are determinants to health outcomes

Appropriate Intervention

Addressing health disparities • community • organizational • legislative

Perspective: Focuses on health equity and social determinants to understand health outcomes for individuals over a lifetime and across generations

Appropriate Intervention

• Identify critical • Offer strategic interventions

Perspective: Mothers are critical leaders in the development of comprehensive understanding and effective interventions

Appropriate Intervention • Empowerment and inclusion of “survivors” • Understanding of “survivor” perspective • Inclusion in leadership Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved

• Clinical • Program-level • System-level

Initiated and led by the clinician/provider • Motivational enhancement • Psycho-education • Psychotherapy • Medication

Initiated and/or led at the programmatic level

• Staff training • Universal screening • Triage protocols • Referral system

• Cross–system intervention and coordination • Policy Development • Universal protocols • Organizational change Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved

•Medical Model •Clinical •Community Mental Health Theory •Program-level •System-level •Social Justice Theory •Life Course Theory •Survivor Movement

To achieve optimal mental health outcomes for mothers and families through effective integrated care.

• Personal Empower mothers • Clinical Train and support providers • System Implement effective protocols • Org Change Integrate systems • Policy Impact policy to support interventions

Engagement 1. Build the case 2. Understand the community 3. Identify key stakeholders Action 1. Assessment 2. Develop goals 3. Design and implement action plan Refinement 1. Evaluate impact 2. Evaluate process 3. Identify next steps

1. Build the case 2. Understand the community 3. Identify key stakeholders

•Recruit allies •Engage media for public education •Review research •Understand how policy impacts outcomes •Utilize national best practices •Provide training for professionals Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved

• Demographics of mothers • Risk factors for PMD • Geographic impact

1. How many births per year in your community? 2. Poverty level in your community? 3. Anticipated % of PMDs 10 – 20% of moms; up to 50% of moms below poverty level 4. Demographics of mothers: ethnicity, language, etc. 5. Geographic factors: rural, urban, climate 6. Protective factors

Stakeholders

Backbone organizations

Champions

Mental Health Community Services Health Center Crisis Services

Family Practice

Early Intervention

Perinatal Pediatric Practice Support Coalition DPH

Community Obstetrical Care Advocacy Organizations Psych Hospital Inpatient Prenatal Women’s Shelter NICU Education Social Obstetrics DCF Pediatric Work Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved CASE STUDY: Franklin County Perinatal Support Coalition

• Multiple professional trainings • Best practice in nursing • Meetings with Key stakeholders • Media coverage/ Legislative initiatives • Meetings with key stakeholders

• Population 71,372 • Birth rate: 500 births per year • Poverty level: 50 % Medicaid population • Ethnicity & race: 91% White, 5% Hispanic • Teen birth rate: 7 % • Single mothers: 50% • Education: 8% < 12th grade • Estimated % of PMD: 10 – 25% = 50 – 125 • Impact of poverty on % of PMD: 50% up to 250

Clinical and Community Service Net Support Options Health Center

Crisis Services Valley Medical Group

Franklin County Perinatal Support Greenfield Coalition Community Action Pediatrics

Pioneer Women’s Baystate Franklin MotherWoman Health Medical Center MHU

Perform a SWOT Analysis with community • Strengths • Weaknesses • Opportunities • Threats

Identify key questions for the community • Medical providers trained? • Status of screening? • Appropriate crisis services?

Perform a SWOT Analysis for your community

• Strengths: What supports are in place for mothers?

• Weaknesses: What challenges are there to helping mothers in crisis?

• Opportunities: What next steps are apparent?

• Threats: What factors will make it difficult to proceed?

Identify 3 key questions for your community

1. Medical providers trained? 2. Status of screening? 3. Appropriate crisis services?

• What are the goals for building a comprehensive safety net for mothers in your community? • What is the gap between strengths and weaknesses? • What are the top 5 priorities? Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved

• Training • Public education • Specialized support groups • Resource and referral system • Emergency protocols • Universal screening • Policy Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved

• Establish committees and leadership

• Ongoing meetings of leadership team

• Offer templates for actions

• Support initiative and innovation

Hospital • No screening, resources

Pediatricians • No screening, training, time, resources

OB/Gyns and CNMs • No screening, training, resources

Crisis Services • No triage protocols, no training

Mental Health Providers • No screening, training, protected time

• No support group, no mentor program, no home Community Services support

Early intervention • No screening, training, protocols Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved CASE STUDY: Franklin County Perinatal Support Coalition

• Establish a specialized, local support group

• Develop a resource and referral guide

• Develop and implement a comprehensive screening program

• Develop triage protocols

• Offer ongoing professional training

• Establish roles and contributions

• Ongoing meetings of leadership team

• Communication and planning

• Create timelines, evaluate priorities

• Support initiative and innovation

Barriers:

• Support group referrals and attendance

• Resistance to screening

• State of health care

• Computerized Medical Record

1. Evaluate impact 2. Evaluate process 3. Define next steps

Individual • mothers empowered

Clinical • providers trained

Programmatic • universal screening, triage protocols

Organizational • resource and referral mechanism, crisis Change protocols

Assessment

• Re-examine goals • Build on successes • Expand reach

Individual • More mothers seek care/treatment

• 8 trainings, over 200 providers trained, support Clinical group

• Universal screening, triage protocols, First 100 Programmatic Days Plan

Organizational • Resource and referral mechanism, crisis Change protocols

• Hospital and mental health policies across Policy practices Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved Edinburgh Postpartum Depression Scale

1. I have been able to laugh and see the funny side of things. 1. I have looked forward with enjoyment to things.  As much as I always could  As much as I ever did  Not quite so much now  Rather less than I used to  Definitely not so much now  Definitely less than I used to  Not at all  Hardly at all

1. I have blamed myself unnecessarily when 4. I have been anxious or worried for no good reason. things went wrong.  No, not at all  Yes, most of the time  Hardly ever  Yes, some of the time  Yes, sometimes  Not very often  Yes, very often  No, never 4. I have felt scared or panicky for no very good 6. I have been feeling overwhelmed. reason.  Yes, most of the time I haven’t been able to cope at all  Yes, quite a lot  Yes, sometimes I haven’t been coping as well as usual  Yes, sometimes  No, most of the time I have coped quite well  No, not much  No, I have been coping as well as ever  No, not at all

7. I have been so unhappy that I have had difficulty 8. I have felt sad or miserable. sleeping.  Yes, most of the time  Yes, most of the time  Yes, quite often  Yes, sometimes  Not very often  Not very often  No, not at all  No, not at all 9. I have been so unhappy that I have been crying. 9. The thought of harming myself has occurred  Yes, most of the time to me.  Yes, quite often  Yes, quite often  Only occasionally  Sometimes  No, never  Hardly ever  Never

•Source: Cox, J.L, Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10- item Edinbugh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786. Source: K.L. Wisner, B.L. Parry, C.M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002. Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title and the source of the paper in all reproduced copies. Edinburgh Postnatal Depression Scale (EPDS). Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved Triage Protocols

Protocol for use of Edinburgh Postnatal Depression Scale (Birthplace – Inpatient) Score of 4 or less Score of 5-9 Score of 10 or more Positive Score on Item #10 Reveals no obvious signs of Reveals patient is at an increased risk of Reveals patient is very likely experiencing depression, May reveal patient is in crisis. postpartum depression. Retest depression, anxiety or other emotional anxiety or emotional difficulties and is in need of further ⁪ - Report score to CNM on call patient as per routine visit complication. evaluation or referral. ⁪ - Evaluate safety of leaving patient alone or with baby schedule. - Educate pt and support people about ⁪ - Report score to CNM (Consider initiating 1:1 care -Refer to Admin Policy #77 - Educate pt and support people the signs of depression, anxiety and ⁪ - CNM will make referrals or consults as needed – “ID and care of the suicidal patient”) about the signs of depression options and benefits of treatment (See ⁪ - MD/CNM to consider psych consult (See note next ⁪ - CNM to consider Social Work consult and anxiety (See Becoming a Becoming a Family pgs 11-17) column) ⁪ - CNM to consider psych consult Family pgs 11-17) - Refer patient to a Mother-Woman ⁪ - Consider social work consult if indicated ⁪ - If situation is urgent/ acute pt crisis: - Review availability of Mother- support group (Greenfield, Northampton ⁪ - Educate pt and support people about the signs of ⁪- Contact Social work dept (3-2303 or through Woman support group or Amherst) depression and anxiety, and the options for, and switchboard after hours) (Greenfield, Northampton or - Hand out and review Resource and benefits of treatment (See Becoming a Family pgs 11- ⁪- Psychiatric consultations can be placed in CIS 7 days Amherst) Referral guide for support options 17) a week. All psych consults should be entered under - Hand out and review Resource - Retest recommended – Consult w/ ⁪ - Refer patient to a Mother Woman Support Group Peter Halperin MD. They will be seen that day if and Referral guide. CNM about potential need for early ⁪ - Hand out and review Resource and Referral Guide possible, but always within 24 hours. In the case of a - Document screening tool in postpartum visit, otherwise pt will be re- for support options critical emergency requiring immediate psychiatric CIS and score on infant D/C note screened routinely at 4 week postpartum ⁪ - Instruct patient to contact Pioneer Women’s Health input, an on call psychiatrist will always be available for visit) with further concerns about anxiety or depression after phone consultation. Call the MHU (3-2595) and ask - Instruct patient to contact Pioneer discharge. them to page the psychiatrist on call. Women’s Health with further concerns ⁪ - Give patient instructions of who to contact should ⁪ - For weekend consults – enter consult in CIS AND call about anxiety or depression after crisis arise after discharge. Crisis Services 774-5411 MHU discharge. ⁪ - Document screening tool in CIS and score on infant (3-2595) and ask them to notify covering psychiatrist. - Document screening tool in CIS and D/C Note ⁪ - Implement all other steps for pts score on infant D/C note ⁪ - Initiate problem on problem list receiving a score of 10 or more. - Consider need to initiate problem on ⁪ - Document interventions in narrative nurse’s notes ⁪ - Document screening tool in CIS and score on problem list. ⁪ - Assure that written plan is in place before discharge. infant D/C note - Document interventions in narrative ⁪ - Document interventions in narrative nurse’s notes nurses notes ⁪ - Assure that written plan is in place before discharge.

Pre and post comparison • 90% of women screened prenatally

• 100% of women screened postpartum

• 13 % of women that screen above 10 on EPDS

• Increased # of referrals during pregnancy

• Early referrals w/ more opportunity for intervention

• Franklin County Coalition Assessment

• Leadership Team Assessment

• Provider Screening Survey

• Mothers’ Satisfaction Survey

• Research • Fathers/partners support group • Family practice providers – screening & referral • Professional training – clinicians & prescribers • Peer Support Model – mother to mother • Address other important perinatal issues Community-Based Perinatal Support Model MotherWoman.org | AMCHP | February 2012 © All rights reserved

To achieve optimal mental health outcomes for mothers and families through effective integrated care.

• Franklin County Champions: Amy Olson, Sarah Carlan, Holly Christensen, Linda Jablonski and all the coalition members • Linda West and the obstetrical team at Franklin Baystate Medical Center • Beth Spong, Annette Cycon, and Abby Baines at MotherWoman • UMass Medical School • Kate Biebel, PhD • Douglas Ziedonis, MD, MPH • Tiffany Moore Simas, MD, MPH, MEd • Jeroan Allison, MD, MS • Gifty Debourdes-Jackson, MA, Rebecca Lundquist, MD • Meyers Primary Care Institute • Lennox Foundation • Anonymous Donor, Clinical and Support Options

We are currently seeking partners to further develop and research this model.

Nancy Byatt, DO, MBA [email protected] Liz Friedman, MFA [email protected] Linda Jablonski, RNC, MSN [email protected]

MedEd PPD www.mededppd.org Edinburgh Postnatal Depression Scale Triage Protocols

Promoting Maternal and Infant Mental Health: The Community-Based Perinatal Support Model for Mothers

AMCHP Presentation, February 2012

Nancy Byatt, DO, MBA Liz Friedman, MFA Linda Jablonski, RNC, MSN

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