Implementing the MIHP Depression Interventions

1. Implementing the MIHP Depression Interventions

2. 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 detwilerj@michigan.gov

3. 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.

4. MIHP PROGRAM FIDELITY STUDY

5. Administrative Data Analysis: IHCS extracts administrative data (claims, encounters, maternal electronic screening) from the Medicaid data warehouse to obtain program aggregate and provider-specific data. These data include screening rates, maternal risk, numbers of visits and other indicators available from claims and electronic risk screeners. This is not intended to be scientific but provides quantitative data and actionable information to MDCH for effective program oversight and administration. Quasi-Experimental Study: IHCS will draft a quasi-experimental study design to evaluate the impact of MIHP services.  The design will adhere to DHHS criteria for evidence-based home visit models. This study will be designed by MSU researcher(s) with input from the IHCS QI staff, and a proposal will be submitted to MDCH by mid-June 2011.  This study design component will be completed under the scope of MSU Master Agreement with MDCH and will build on studies conducted by MDCH and Michigan State University over the previous 7 years. Michigan Maternal Infant Health Program (MIHP) Evaluation Surveys: IHCS is piloting a web-based client survey for women who have received MIHP services. This survey is to assess client satisfaction with MIHP and the extent to which the MIHP provider helped the client gain parenting skills, knowledge, and self-confidence. At the conclusion of the pilot (9/1/11) IHCS will report pilot data and response rates to determine whether a written survey option is needed. IHCS will also develop a MIHP provider survey upon request by MDCH. Provider Reviews and Oversight: Certification and Recertification: MDCH has established provider certification and recertification requirements for MIHP providers including site visits and ongoing quality reviews. Record Review (Program Fidelity): IHCS will review client records completed by all MIHP providers to assess program fidelity (the extent to which services are delivered consistently and according to program policy). The initial review will be conducted in June- August 2011, and IHCS will provide MDCH with a report by September 30, 2011. Subsequent reviews will be conducted at least every three years.

6. 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 documentation: • Inconsistent • Absent

7. 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 www.michigan.gov/mihp • Develop tools to assist staff to help women navigate the mental health services systems

8. PERINATAL DEPRESSION AND ITS EFFECTS ON MOTHER AND INFANT

9. Depression Overview • Let’s start at the beginning…

10. 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)

11. 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.

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

13. Definition: Perinatal Mood Disorder • Major and minor episodes of clinical depression during pregnancy or within first year after delivery. • 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

14. Definition: Perinatal Mood Disorder • Symptoms (continued) Loss of interest in self care Loss of interest in things that used to be pleasurable 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

15. Definition: Perinatal Mood Disorder • Co-occurs with anxiety disorder for 2/3 of women: (4) • Generalized Anxiety Disorder • Panic Disorder • Obsessive-compulsive Disorder • Other • Often co-occurs with substance use disorder

16. Definition: Postpartum Psychosis • A rare disorder (one or two in 1,000 women). • A severe form of perinatal depression that can be life-threatening. • Symptoms: extreme confusion, hopelessness, can’t sleep or eat, distrusts others, sees or hears things that aren’t there, thoughts of harming self, baby or others. • A medical emergency requiring urgent care.

17. 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. (6) • 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)

18. Prevalence in MIHP PopulationJuly 01, 2012 – July 01, 2013

19. 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

20. 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.

21. Why Low-Income Women Don’t Access Depression Treatment • The illness itself gets in the way • Shame about not being “strong” • Guilt: “You’re supposed to be happy” when you’re pregnant. • Stigma around using MH services; being seen at CMH • 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 “it’s all in your head- snap out of it”

22. Why Low-Income Women Don’t Access Depression Treatment 8. Fear that she will be judged, especially if she’s young 9. Fear of taking medications, especially during pregnancy 10. Belief that psychotherapy won’t 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 appointment 13. Logistical barriers (e.g., transportation, child care) 14. Previous negative experience with MH treatment 15. Too overwhelmed caring for infant and working

23. Why Low-Income Women Don’t Access Depression Treatment 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 won’t be misconstrued.

24. 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)

25. 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.

26. 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)

27. 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 year. • Decreased receipt of preventive services, including age-appropriate well child visits and up-to-date immunizations. (15)

28. 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.

29. 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 mother’s emotional and physical ability to care for her child and to foster a healthy relationship with her child.

30. Still Face Experiment Video Still Face Experiment: Dr. Edward Tronick – YouTube(2:49) 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)

31. 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 development. • More likely to have behavioral problems. • More likely to experience worse long-term mental health problems.

32. 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

33. 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. (21) • Qualitative research finds that HVs identify maternal MH problems as a significant barrier to providing HV services in a consistent, continuous manner • More difficult to engage and serve • Harder to work with parents who: • Are perceived as “uncommitted” or “unmotivated” • Threaten to commit suicide

34. HVs Feel Inadequately Trained to Address MH Problems • 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 don’t have the right training and are afraid they’ll 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.

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

36. ROLE OF MIHP IN ADDRESSING PERINATAL DEPRESSION

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

38. 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 disasters.

39. 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 skill–based. (24)

40. Learn More aboutTrauma-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 re-traumatization. • 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 others. • http://acesconnection.com/ for learning resources.

41. Diversity-Informed Practice:Community Context Community context affects perception of depression: • Many women who live in poverty or experience institutional racism may assume they’ll be depressed (or get diabetes, or be physically abused, or be sexually assaulted, etc.) because “that’s 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. “It’s not me, it’s my life circumstances.”

42. We met with a team of diverse MIHP providers to discuss cultural implications of depression and stress

43. 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 woman’s MD and MHP to help her get what she needs.

44. Diversity-Informed Practice:Cultural Affiliation Varies That said, cultural affiliation varies. YOU MUST ASK. • 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 don’t 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.

45. Diversity-Informed Practice: Legal & Undocumented Immigrants 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.

46. Primary MIHP Activities toAddress 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.)

47. Primary MIHP Activities toAddress 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.)

48. 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)

49. 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 beneficiary: • At administration of Risk Identifier (RN, SW) • At later visit(s), depending on the beneficiary’s individual situation (RN, SW, RD, IMH Spec.)

50. 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.