Download maternal depression

Maternal Mental Health What Every
Hospital Should Know
Joy Burkhard, MBA
Founder & Director 2020 Mom
Chair, National Coalition for Maternal Mental Health
Katie Monarch, MSW, LCSW
Coordinator/Postpartum Depression Program
St. Joseph Hospital, Orange
March, 2016
MARCH OF DIMES CONFERENCE
Did you know?
Women in their childbearing years account for the largest
group of Americans with Depression.
Postpartum depression is the most common complication of
childbirth.
There are more new cases of mothers suffering from
Maternal Depression each year than women diagnosed with
breast cancer.
American Academy of Pediatrics has noted that Maternal
Depression is the most under diagnosed obstetric
complication in America.
What is in a Name?
Postpartum Depression (PPD):
Often incorrectly used to refer to the umbrella of disorders.
Perinatal/Peripartum Mood and Anxiety Disorders (PMADs):
The clinical term often used. Not well understood by the public.
Because of concern by the larger Mental Health Community, over
“MAD” many don’t use this term any longer.
Maternal Mental Health (MMH) Disorders:
This term is being more widely adopted as it refers to the range of
disorders and is
Men can experience mental health challenges during this time too.
Maternal Mental Health Facts
WHO
•Up to 80% of moms will experience the ‘baby blues’ which resolve untreated within 2 wks
•Up to 20% of women will experience maternal depression (MP) during pregnancy or
postpartum. Anxiety often present.
•Psychosis is extremely rare but serious (effecting less than .2% of women)
WHAT
• Maternal Depression is a mood disorder with symptoms similar to the ‘blues’ that persist
beyond 2 weeks. Symptoms can be mild to severe. MD is treatable.
•Irritability, Significant changes in appetite, Poor concentration, Fatigue, Feeling
SYMPTOMS
WHY
WHEN
overwhelmed, Persistent sadness, Anxiety, Insomnia or in some cases hyperinsomnia,
Obsessive thoughts and fears such as thoughts of harm to the baby, Recurrent thoughts of
death or suicide. Women generally also feel confusion and shame and consequently may
not share their feelings.
Evidence suggests that women who experience maternal depression are more vulnerable
to changing hormones levels including increase stress response. Additionally genetics,
psychosocial factors and life stressors play a role.
•Risk factors include prior depression or family history, substance abuse problems, lack of
social support or absence of community network, relationship stress, unwanted pregnancy,
fertility challenges & financial instability. African Americans are 35% likely to suffer from
MD & adolescents also face higher risk.
MD onset generally occurs within the first 6 weeks postpartum though can be diagnosed
within a year.
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What are the “Baby Blues”?
 Occurs 3-5 days after birth and lasts up to 2 weeks
 50% of 80% of women experience symptoms
 Symptoms may include:
Crying
Irritability
Lack of energy
Restlessness
Feeling overwhelmed
Anxiety
Self-doubt and feelings of
inadequacies
May act frantic about
breastfeeding & other newborn
care issues
Symptoms of Maternal Depression
 Depressed mood
 Inability to experience
pleasure
 Sleep disturbance
 Change in appetite
 Exhaustion
 Feelings of worthlessness
and/or guilt
“ I want to cry all the time…”
“The color is gone from
everything…”
“People are only interested in
the baby and not me…”
“The baby is crying but I can’t
do anything about it…”
Symptoms (continued)
 Lack of concentration or
indecisiveness
“I have trouble
 Frequent thought of death or
deciding on
suicide
anything…”
 Symptoms may be confused with
some of the normal feelings
associated with childbirth
 Symptoms persist most of the time “Sometimes I think
everyone would be
 Strongly associated with high
better off without me…”
anxiety, panic attacks, and
obsessive-compulsive thinking
Untreated Mothers
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Increase risk of Pre-term/Low Birth Weight Babies (x4)
Increase risk of Preeclampsia
Increase her risk of substance abuse & smoking
Increase her risk of ER visits & psychiatric hospitalizations
Interfere with her relationship stability
Impact a mom and partner’s ability to work (+presenteeism) or
return to work from disability
Increase the risk of abortion or adoption
Impact her long-term well-being and
sense of worthiness
Increase her risk of suicide
Increase risk of neglecting her children
Increased risk of committing Infanticide
(caused by psychosis not depression)
Impact on Children
• Can cause emotional & social problems in children:
• Lower self esteem
• Increased Anxiety and fearfulness
• Increased risk for depression
• Problems forming secure relationships
• Can cause developmental delays in infants/children:
• Late walking/talking
• Delayed readiness for school
• Learning difficulties and problems w/ school
• Attention/Focus impairment
Maternal Anxiety
Anxiety is common, even normal, as the mother begins to
understand how vulnerable the newborn is.
Some women have intense anxiety or irrational fears after giving
birth resulting in symptoms such as:
Rapid heart rate (fight or flight)
Sense of impending doom
Dizziness
Obsessive-compulsive thoughts; especially related to concerns
about the baby
Anxiety –Intrusive Thoughts
Obsessive/Intrusive Thoughts
May involve worry about harming the baby
She may do ritualistic behaviors in an attempt to avoid
thinking these thoughts
She is NOT a harm to her baby
What is Maternal Psychosis?
 Women appear to be well temporarily but after a short
period of time they may exhibit psychotic symptoms
Occurrence in about 1 in 1,000 live births
Greater danger that mothers may harm their infants or
commit suicide (4%/5% infanticide and suicide rate)
High likelihood of having recurrent episodes
Women who experience psychosis often have
untreated/undiagnosed bi-polar disorder.
Symptoms of Psychosis
Refusal to eat
Extreme confusion
Loss of memory
Incoherence
Bizarre auditory or visual hallucinations
Suspiciousness
Irrational statements
Postpartum Post-Traumatic
Stress Disorder
9% of women (PTSD) following childbirth.
 Caused by a real or perceived trauma surrounding birth
 Birth Loss
 Prolapsed cord
 Unplanned C-section
 Use of vacuum extractor or forceps to deliver the baby
 Baby going to NICU
 Feelings of powerlessness and lack of support during delivery
Symptoms Can Include:
 Flashbacks or nightmares
 Avoidance of stimuli associated with the event
 Persistent increased arousal (irritability, difficulty sleeping, hypervigilance,
exaggerated startle response)
 Anxiety and panic attacks
 Feeling a sense of unreality and detachment
PTSD, Continued
Women who have experienced the following are at a higher risk
of PTSD
a previous trauma, such as rape or sexual abuse
a severe physical complication or injury related to pregnancy
or childbirth, such as hemorrhage, unexpected hysterectomy,
severe preeclampsia/eclampsia, perineal trauma (3rd or 4th
degree tear), or cardiac disease.
Screening Tools
Edinburg (EPDS)
Most widely used during Perinatal Period
Addresses Anxiety
10 Questions
PHQ-9
Most recommended by researchers
Most often used in primary care
9 Questions
PHQ-2 2 Questions
PASS or EPDS-3 (Perinatal Anxiety)
Sleep Screens such as The Pittsburg Sleep Quality Index
There are no screening tools for maternal psychosis
or PTSD, however anxiety is often present with PTSD.
What Do We look for?
During the Assessment Process We:
Identify the severity of the symptoms
Identify the mothers insight, strengths, and weaknesses
Identify any barriers to treatment and develop a plan to
overcome them
Assess extent of the families understanding of the illness
Assess the impact the depression is having on the mother
Assess the impact the depression is having on the family
Common Statements
I cannot sleep even when the baby is sleeping at night.
I cannot stop crying.
I cannot concentrate.
I am fearful about returning to my job.
I have no desire to bath or get dresses.
I feel like a failure.
I have tremendous guilt that my baby will not how I am
feeling.
I cannot tell anyone what I am thinking.
My family would be better off without me.
Treatment Options
 Psychotherapy, such as cognitive behavioral
therapy (CBT) (6 sessions)
 Medication
 Meditation
 Omega 3s, Folic Acid & Vitamin D3
 Yoga and/or other exercise
 Improve Sleep
EMERGING
 Transcranial Magnetic Stimulation (TMS) –FDA
Approved
 Electro Convulsive Therapy (ECT)
Treatment Preferences
 African Americans, Latinas and
Caucasians prefer psychotherapy
over antidepressants
 Asian American women are less
likely to accept a psychotherapy
referral as it is not cultural accepted
by elders
Treatment Plans
Women need to be taken seriously when these symptoms
occur. A combination of counseling and medication can
reduce these symptoms.
The treatment plan includes:
Medical evaluation to rule out physiological problems
Psychiatric evaluation for possible medication
Individual counseling
Support groups
Additional support services
See other alternative treatment options (prior slide)
The Powerful Role of the Nurse
The nurse has a unique
opportunity to observe,
educate, and encourage.
Assess
 Mood disorder
 Pregnancy complications
 Social stressors
 Physiological stressors and L&D record
 Unexpected outcomes
 Support system
 Mother-infant bonding
 Symptoms of depression, mania, and anxiety
Educate and Encourage
Mom is the best mom. Baby asks why? Because she is
the mom.
A variety of feelings are normal
Just say No to perfectionism!
Talk to others and let other help
Caring for herself and her own recovery
Open communication about feelings with family and
friends
Role of Health Care Providers in NICU
Perception of NICU nurse support has significant inverse
relationship with depressive symptoms
NICU nurses have ample opportunity to observe motherinfant interactions daily, allowing for further identification
of mothers who may need services or extra support.
Nurses should be educated about the complex nature of
maternal stress and depression symptoms in the NICU
-
PubMed Int J Womens Health. 2014.
Vignette, A Mom’s Story
My daughter arrived exactly on my due date, perfect and pink
despite a rather traumatic birth (Emergency C-Section). The entire
day felt like I was watching a really good movie. Despite what I had
planned on for my delivery, I felt it took everything in stride.
Then the sun went down, I started to cry. I had intense fear and
panic about breastfeeding. Breastfeeding became my whole
obsession.
I did not feel like eating, I did not sleep even when the baby was
sleeping, my husband as well. I had a blank stares. I told my nurse I
had made a big mistake and did not want to take my baby home
with us.
As a Provider:
1. What are your thoughts about this mom?
2. What should you ask or observe in caring for this
mom?
3. Who should you contact if you had concerns?
Role of Hospital Personnel
–Who am I?
“I” am the first person that welcomes these families into
their new life.
At a time in her life when nothing is planned to go wrong
medically or emotionally; it is my words, my expressions, my
actions the families are holding onto for a very long time.
“I” play a very important role, not only in my expertise, or job
title, or whether I got my break or lunch on time.
It is my delivery each encounter with these families that
counts.
“I” have a big job. After all my education, experience, years of
service these families need me each and every-time.
When Things Don’t Go as Planned…
–Who am I?
Delivery wasn’t what she planned
* She doesn’t seem engaged with her baby
* She is anxious
* Overwhelmed
* Over tearful
* Lack of sleep
* Afraid
It is “I” who can let her know there is help.
Who Am I?
I am her OB, Labor and Delivery Nurse, MotherBaby Unit Nurse, Location Consultant, Mother
Baby Assessment Center Nurse, NA, Techs.
All of us, who have an encounter with our
families each and every time.
“EVERYTHING”
When I end my shift today “I” can leave
thinking WOW “I” made a difference today.
See you tomorrow.
2020 Mom Points Out
• Doctors can’t do this alone
• Maternal mental health (MMH) professionals are in
short supply
• 99% of women deliver in hospitals
• 86% of women have insurance
Three minute You Tube video:
http://www.youtube.com/watch?v=i0nk05y-h90
2020 Mom is….
Expanding & Creating :
- Community Action Toolkit
- Billing and payment best practices
- Legal Case Library
2020 Mom Hospital Recommendations
What if?
• Hospitals modified birth class curriculum to address risk factors,
symptoms and local treatment options?
• Hospitals provided info. at discharge, including any local
treatment programs?
• Hospitals worked to protect sleep during the times surrounding
delivery?
• Hospitals trained staff who interact with pregnant and new
moms?
Visit 2020mom.org for a self-assessment including more best practices and resources.
Referrals
Get to know your local MMH resources
Postpartum Support International
http://postpartum.net (PSI)
PSI Warm line
(know the local resources and consider referring
directly)
On-line Support Groups in Partnership with
Support Group in Spanish
Psychiatrist or Obstetrician (for medication management w/
support)
National Coalition
 Formed in 2014
 Members from non-profits addressing MMH:
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National Healthy Mother’s Healthy Babies Coalition
Postpartum Support International
MotherWoman
Postpartum Progress
State/local non-profits
 Purpose: “SEA” – Share with each other, Engage Stakeholders,
Advocate for change,
Raise Awareness (‘collective voice’)
 Bringing Postpartum Depression Out of the Shadows Act of 2015
 May = Maternal Mental Health Awareness Month,
 follow & share images via Social Media
http://www.mmhcoalition.com
National Coalition
Internet Resources
 Postpartum Depression-Information from the Mayo Clinic
- http://www.mayoclinic.com/health/ postpartum-depression/DS00546
 Postpartum Depression-Information from MedinePlus, a service of the
U.S. National Library of Medicine and the National Institues of Health
(available in English and Spanish)
- http://www.nlm.nij.gov/medineplus/postpartumdepression.html
 Postpartum Support International (PSI)
- http://postpartum.net/
- Includes the PSI Postpartum Depression Helpline: 1-800-944-4PPD
 Postpartum Depression and the Baby Blues- Information from the
American Academy of Family Physicians
- http://familydoctor.org/online/famdocen/home/women/pregnancy/ppd/
general/379.html
 Depression after Delivery, Inc. (DAD)
- http://depressionafterdelivery.com
- The Journal of Perinatal Education
References

NIHCM Foundation Issue Brief
Identifying and Treating Maternal
The Federal Affordable Care Act requires coverage for preventive treatment
Depression: depression screening at
including postpartum
Strategies &
Considerations
Health
no cost to women.
Yet
given the for
need
forPlans
additional
there
L.A.’s Best Babies Network
Screening for Postpartum Depression at Well
Child Visits
MN: Maternal Depression and Early
Childhood
are no national standard screening guidelines.
TREATMENT OPTIONS
Treatment for MD includes psychotherapy or pharmacotherapy or a combination of both.
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