Perinatal Mood and Anxiety Disorders:

Next Steps in Health PolicySharon Fickley

GNUR 6056July 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 undercriminal law. William Mitchell Law Review, 32, 243-263. Retrieved from

http://www.wmitchell.edu/lawreview/volume32/issue1/7march.pdfMelanie 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