Next Steps in Health Policy Sharon Fickley GNUR 6056 July 27 th , 2010 Perinatal Mood and Anxiety Disorders:
Dec 24, 2015
Next Steps in Health Policy
Sharon Fickley
GNUR 6056
July 27th, 2010
Perinatal Mood and Anxiety Disorders:
Articulate the percentage of women in industrialized world who experience postpartum depression
Recognize challenges facing the U.S. healthcare system relating to screening, diagnosis, treatment, and future health policies
State potential focus areas for future research on Perinatal Mood Disorders
Objectives
Perinatal Mood and Anxiety Disorders:
Encompass a variety of psychiatric disorders that occur during or soon after pregnancy. Include several types of depression, anxiety, obsessive-compulsive disorder, and psychosis
(Gaynes, et al., 2005; Postpartum Support International, accessed on 7/1/10)
Presentation to focus primarily on what has historically been called postpartum depression.
Definitions
Postpartum or “Baby” Blues: Affects approximately 60-80 % new mothers Temporary condition characterized by emotional lability Onset usually 1-3 days after delivery, resolution within 2 weeks
Postpartum Psychosis: Affects 0.1% - 0.2% women Onset generally within 2 weeks of giving birth Characterized by hallucinations, paranoia, and mental break
from reality Medical emergency requiring aggressive treatment and
hospitalization(Baker-Ericzen, Mueggenborg, Hartigan, Howard & Wilke, 2008;
Gjerdingen, Katon, & Rich, 2008; Postpartum Support Virginia, accessed on 7/1/10; Hearings on Research on Postpartum Depression, 2007)
Definitions
Postpartum Depression: Affects 8% - 20% new mothers in industrialized countries Prevalence for adolescent mothers higher – 26%-32% Prevalence statistics vary widely Onset ranges from 2 weeks – 1 year after giving birth
Contributing factors: Difficult labor, delivery, or birth Difficult Baby Poor social support Difficulty breastfeeding Significant life stressors Unplanned pregnancy Unrealistic expectations of motherhood
(Baker-Ericzen et al., 2008; Gjerdingen, Katon, & Rich, 2008; March, 2005; Postpartum Support Virginia, accessed 7/1/10; Hearings on Research on Postpartum Depression, 2007)
Definitions
Less than a college educationLow socioeconomic statusSinglePoor health in motherHistory of intimate partner violenceHormonal changes occurring after giving birth
(Gjerdingen & Yawn, 2007; Goyal, Gay & Lee, 2010; National Survey for Child and Adolescent Well-Being, Hearings on Research on Postpartum Depression, 2007)
Early Head Start Study – high rates of depression in these at-risk families
(Early Head Start Research and Evaluation Project, 2006)
Other Contributing and Risk Factors
Difficult to identify true breadth of problem No routine screening No one tool tested and proven for sensitivity and specificity Prevalence rates vary widely – when, how, what population
assessed Lack of adequate research to demonstrate treatment outcomes(American College of Obstetricians and Gynecologists (ACOG),
2010; Baker-Ericzen, et al., 2008; Gaynes, et al., 2005 )
Exact causes not known – probably multifaceted Biochemical Hypothyroid Environmental
(Gjerdingen & Yawn, 2007; Postpartum Support Virginia, accessed 7/1/10)
Problems Surrounding the Issue
Barriers to accessing screening and treatment Care Delivery Model Financial barriers related to insurance coverage Stigma Concerns regarding medications and breastfeeding Patients’ ability and willingness to continue follow-up care
(ACOG, 2008; Baker-Ericzen, et al., 2008; Gjerdingen &Yawn, 2007; Stowe, Hostetter & Newport, 2005)
Inadequate systems to accomplish meaningful follow-up care Study published in the Journal of the American Medical
Association in 2003 (Kessler) estimated that fewer than 22% of all patients in general population who are diagnosed with depression receive what is considered to be adequate care
( Institute for Clinical Systems Improvement, 2008)
Problems Surrounding the Issue
Women May be unable to care for themselves, their family, and their
baby Increased risk of relapse & suicide Poor quality of life when depressed(Hearings on Research on Postpartum Depression, 2007)
Families Infants of depressed mothers demonstrate: more crying, poor
attachment, less social interaction Children of depressed mothers demonstrate: increased
aggressive behaviors, decrease in motor, mental, and language development, behavior problems, and increased risk for psychiatric illness
(ACOG, 2008; Baker-Ericzen, et al., 2008; National Survey of Child and Infant Well-Being)
Major Stakeholders
SocietyUnipolar depression is the leading condition in years
lost to disease in both the developed and underdeveloped world (World Health Organization, 2008)
As cited in the Agency for Healthcare Research and Quality’s 2005 report on Perinatal Depression, Kessler notes that depression is the #1 cause of disease-related disability in women (Gaynes, et al., 2005)
Estimates of lost productivity range from $30 - $50 billion annually in the United States (Gjerdingen & Yawn, 2007)
Major Stakeholder
U.S. Healthcare and Labor MarketsU.S. Public Health SystemAmerican College of Obstetricians and
GynecologistsHealth Care Providers – Including
Obstetricians, Pediatricians, Family Physicians, and Nurses
Insurance Companies
Other Stakeholders
Virginia – House Bill 2310 2003 - Requires hospital staff and physicians to
distribute information and statistics regarding perinatal depression
United States June 2001 - H.R. 20 – Melanie Blocker Stokes Act –
first introduced in the U.S. House of Representatives in Rep. Bobby Rush (D-IL)
2001-2009 - Reintroduced multiple times by Rep. Rush January 2009 - Introduced in Senate as S. 324,
Senator Robert Mendez (D-NJ) March 2010 - Incorporated into the Patient Protection
and Affordable Health Care Act, H.R. 3590
Health Policy Action
Succinctly stated by Gjerdingen & Yawn:
Depression screening plus ‘high-risk’ feedback to providers improves the recognition of depression. However, for screening to positively impact clinical outcomes, it needs to be combined with systems-based enhanced depression care that provides accurate diagnosis, strong collaborative relationships between primary care and mental health providers, and longitudinal case management, to assure appropriate treatment and follow-up.
(Gjerdingen &Yawn, 2007, p.280)
Systems Issues
Women, Families, Consumer Advocates, Healthcare Providers, Insurers & Employers
Current Healthcare System, Research
Health Policy Formation, Evaluation Revised Delivery System and Models of Care
Systems Theory
As a result of passage of Healthcare Reform, increased opportunities for research, pilot projects, evaluation of local and population-based, community programs
Increased access to services due to Reform Bill’s emphasis on Mental Health Services as “essential health benefits” (H.R. 3590, 2010)
Research emphasis on: Accurate and effective screening tools Most beneficial timing and method of screening – both
ante and postpartum Accurate diagnosis & effective treatment Treatment outcomes(Stowe, et al., 2005)
What the Future Holds
Redesigned models of care – primary-care focused and modeled after the Medical Home concept
Use of multi-point opportunities to assess and screen women for postpartum depression
(Gaynes, et al., 2005; Stowe, et al., 2005) July 21st, 2010 - U.S. Department of Health and
Human Services announced that it has “allocated $88 Million for home visiting programs to improve the wellbeing of children and families”
(http://www.hhs.gov/news/press/2010pres/07/20100721a.html, retrieved July 24th, 2010)
What the Future Holds
Continue to offer inconsistent screening, diagnosis, access and follow up Will not serve the best interest of any
stakeholder in the long run, due to the clear costs to individuals, families, and society
Utilize opportunity provided by H.R. 3590 to design and carry out research that addresses key questions surrounding screening, diagnosis & treatment This alternative offers the most logical &
possibly cost-effective option, as targeted efforts driven by outcomes research are likely to decrease costs to all
Policy Alternatives
Stay informed and involved Recognize the signs and symptoms Offer guidance Address legislators
Apply for grantsDesign innovative programs that work in local
community Consider racial, ethnic, cultural, and socioeconomic
factorsPublish!
What Role do Nurses Have Now?
American College of Obstetricians and Gynecologists. (February 2010). Screening for depression before and after pregnancy. Committee Opinion Number 453. Obstetrics Gynecology, 115, 394-5.
American College of Obstetricians and Gynecologists. (April 2008). Use of psychiatric medications during pregnancy and lactation. ACOG Practice Bulletin Number 92. Obstetrics Gynecology, 111, 1001-20.
Baker-Ericzen, M.J., Mueggenborg, M.G., Hartigan, P, Howard, N, & Wilke, T. (2008). Partnership for women’s health: A new-age collaborative program for addressing maternal depression in the postpartum period. Families, Systems, and Health, 26(1), 30-43. doi:10.1037/1091-7527.26.1.30
Blocker, C. Melanie’s Story. (2003). Retrieved June 8th, 2010 from
http://www.melaniesbattle.org/story.html
Gaynes, B.N., Gavin, N., Meltzer-Brody, S., Lohr, K.N., Swinson, T., Gartlehner, G., . . . Miller, W.C. (2005). Perinatal depression: Prevalence, screening accuracy, and screening outcomes. (Summary, Evidence Report/Technology Assessment No. 119). (Prepared by the RTI-University of North Carolina Evidence Based Practice Center ). Retrieved from Agency for Healthcare Research and Quality http://www.ahrq.gov/clinic/epcsums/peridepsum.pdf
References
Gjerdingen, D., Katon, W., & Rich, D. (2008). Stepped care treatment of postpartum depression: A primary care-based management model. Women’s Health Issues, 18, 44-52. doi:10.1016/j.whi.2007.09.001
Gjerdingen, D.K., & Yawn, B.P. (2007). Postpartum depression screening: Importance, methods, barriers, and recommendations for practice. Journal of the American Board of Family Medicine, 20, 280-88. doi:10.3122/jabfm.2007.03.060171
Goyal, D., Gay, C., & Lee, K. (2010). How much does low socioeconomic status increase the risk of prenatal and postpartum depressive symptoms in first-time mothers? Women’s Health Issues, 20, 96-104. doi:10.1016/j.whi.2009.11.003
H. Res. 3590, 111th Congress (2010) (enacted): Summary. Retrieved May 25th,
2010 from http://www.govtrack.us/congress/bill.xpd?bill=h111-3590&tab=summary
Institute for Clinical Systems Improvement. (2008). The DIAMOND initiative: Depression improvement across Minnesota, offering a new direction (White Paper). Retrieved from
http://www.icsi.org/diamond_white_paper_/diamond_white_paper_28676.html
References
March, C.L. (2005). The conflicted treatment of postpartum psychosis under
criminal law. William Mitchell Law Review, 32, 243-263. Retrieved from http://www.wmitchell.edu/lawreview/volume32/issue1/7march.pdf
Melanie Blocker Stokes MOTHERS Act of 2009, H.R. 20, 111th Congress. (2009). Retrieved May 25th, 2010 from
http://www.govtrack.us/congress/bill.xpd?bill=h111-20
Postpartum Support International. Get the facts: perinatal mood and anxiety disorder overview. Retrieved from http://www.postpartum.net/Get-the-Facts.aspx
Postpartum Support Virginia. About postpartum depression and pregnancy related mood disorders. Retrieved from http://www.postpartumva.org/aboutppd.html
Postpartum Support Virginia. Causes of postpartum depression and pregnancy-related mood disorders. Retrieved from http://www.postpartumva.org/causesriskfactors.html
Research on Postpartum Depression at the National Institute of Mental Health: Hearings before the Subcommittee on Health, of the House Committee on Energy and Commerce, 111th Congress (2007) (testimony of Catherine Roca, MD, Chief, Women’s Program, National Institute of Mental Health).
References
Stowe, Z.N., Hostetter, A.L., & Newport, D.J. (2005). The onset of postpartum depression: Implications for clinical screening in obstetrical and primary care. American Journal of Obstetrics and Gynecology, 192, 522-6. doi:10.1016/j.acog.2004.07.054
World Health Organization. (2008). Global burden of disease: 2004 update. Part 3: Disease incidence, prevalence and disability, 28-36. (ISBN 978 92 4 156371 0 NLM classification: W 74). Retrieved from http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_part3.pdf
U.S. Department of Health and Human Services, Administration for Children and Families.(2006). Depression in the lives of Early Head Start Families: Early Head Start Research Project. Retrieved from http://www.acf.hhs.gov/programs/opre/ehs/ehs_resrch/reports/dissemination/research_briefs/research_brief_depression.pdf
U.S. Department of Health and Human Services, Administration for Children and Families. National Survey of Child and Adolescent Well-Being. Research Brief No. 13: Depression among caregivers of young children reported for child maltreatment. Retrieved from http://www.acf.hhs.gov/programs/opre/abuse_neglect/nscaw/reports/depression_caregivers/depression_caregivers.pdf
References