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Transcript
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. 4 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 • • • • • • • • • • • 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: 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. 38