Improving health care systems to promote maternal mental ......you have a happy, healthy baby. What...

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Improving health care systems to promote maternal mental health: A Massachusetts statewide initiative Nancy Byatt, DO, MBA, FAPM Medical Director, MCPAP for Moms Assistant Professor of Psychiatry and Ob/Gyn UMass Medical School/UMass Memorial Health Care Kathleen Biebel, PhD Program Director, MCPAP for Moms Research Assistant Professor of Psychiatry Systems and Psychosocial Advances Research Center UMass Medical School February 5, 2015

Transcript of Improving health care systems to promote maternal mental ......you have a happy, healthy baby. What...

Page 1: Improving health care systems to promote maternal mental ......you have a happy, healthy baby. What else do you want?’ ” ).Byatt et al. 2014. General Hospital Psychiatry. Women

Improving health care systems to promote maternal mental health: A Massachusetts statewide initiative

Nancy Byatt, DO, MBA, FAPM Medical Director, MCPAP for Moms Assistant Professor of Psychiatry and Ob/Gyn UMass Medical School/UMass Memorial Health Care Kathleen Biebel, PhD Program Director, MCPAP for Moms Research Assistant Professor of Psychiatry Systems and Psychosocial Advances Research Center UMass Medical School February 5, 2015

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Disclosure Statement: Nancy Byatt, D.O., M.B.A. & Kathleen Biebel, Ph.D.

With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship between the parties listed above (and/or spouse/partner) and any for-profit company which could be considered a conflict of interest.

Funding: Meyers Primary Care Institute UMMS Faculty Scholar Award MA Department of Mental Health UMCCTS UL1TR000161 NIH KL2TR000160

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©MCPAP For Moms

http://www.google.com/url?url=http://jenhudsonmosher.blogspot.com/2013/04/obsession.html&rct=j&frm=1&q=&esrc=s&sa=U&ei=FTyRU5SQOu_QsQS0jYHwDw&ved=0CEQQ9QEwETgU&usg=AFQjCNHj-FCeyDw4njkTi9unigOMXmh3Cw
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http://www.google.com/url?url=http://jenhudsonmosher.blogspot.com/2013/04/obsession.html&rct=j&frm=1&q=&esrc=s&sa=U&ei=FTyRU5SQOu_QsQS0jYHwDw&ved=0CEQQ9QEwETgU&usg=AFQjCNHj-FCeyDw4njkTi9unigOMXmh3Cw
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http://www.google.com/url?url=http://jenhudsonmosher.blogspot.com/2013/04/obsession.html&rct=j&frm=1&q=&esrc=s&sa=U&ei=FTyRU5SQOu_QsQS0jYHwDw&ved=0CEQQ9QEwETgU&usg=AFQjCNHj-FCeyDw4njkTi9unigOMXmh3Cw
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http://www.google.com/url?url=http://jenhudsonmosher.blogspot.com/2013/04/obsession.html&rct=j&frm=1&q=&esrc=s&sa=U&ei=FTyRU5SQOu_QsQS0jYHwDw&ved=0CEQQ9QEwETgU&usg=AFQjCNHj-FCeyDw4njkTi9unigOMXmh3Cw
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1 in 8 women suffer from perinatal depression

Gavin et al. Ob Gyn 2005, Vesga-Lopez et al. Arch Gen Psychiatry 2006.

©MCPAP For Moms

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Perinatal depression is twice as common as gestational diabetes

Gavin et al. Ob Gyn 2005, Vesga-Lopez et al. Arch Gen Psychiatry 2006. ACOG Practice Bulletin 2013.

Depression 10-15 in 100

Diabetes 3-7 in 100

©MCPAP For Moms

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Two-thirds of perinatal depression begins before birth

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Pregnancy 33%

Postpartum 40%

Before pregnancy

27%

Wisner et al. JAMA Psychiatry 2013

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Poor health care Substance abuse Preeclampsia Maternal suicide

Bodnar et al. (2009). The Journal of clinical psychiatry. Cripe et al. (2011). Paediatric and perinatal epidemiology, Flynn, H. A., & Chermack, S. T. (2008). Journal of Studies on Alcohol and Drugs; Forman et al. (2007). Development and psychopathology, Grote et al. (2010). Archives of general psychiatry; Sohr-Preston, S. L., & Scaramella, L. V. (2006). Clinical child and family psychology review,; Wisner et al. (2009). The American Journal of Psychiatry,

Perinatal depression effects mom, child & family

Low birth weight Preterm delivery Cognitive delays Behavioral problems

©MCPAP For Moms

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Generation 0 Childhood impact

Maternal depression

Generation 1 Childhood impact

Maternal depression

Generation 2 Childhood impact Maternal depression

Generation 3 Childhood impact Maternal depression Generation 4

Childhood impact Maternal depression

Optimizing perinatal mental health could break the transgenerational impact of maternal depression

Adapted from slide created by Allain Gregoire, DRCOG, MRCPsych

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Perinatal depression is under-diagnosed and under-treated

Carter et al. (2005). Australian and New Zealand Journal of Psychiatry, 39(4), 255–261; Marcus et al. (2003). Journal of womens health 2002, 13(1), 373–380. Smith et al. (2009). General hospital psychiatry, 31(2), 155–62.

©MCPAP For Moms

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The perinatal period is ideal for the detection and treatment of depression

Regular opportunities to screen and engage women in treatment

80% of depression is treated by

primary care providers

Front line providers have a pivotal role

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Transforming obstetrical practice to include depression care could provide a solution

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Goals

Goals

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We conducted qualitative studies to understand how depression could be addressed in Ob/Gyn settings

Study 1: Perspectives of

women

Study 2: Perspectives of Ob/Gyn providers

1. Better understand how to engage perinatal women in depression treatment

2. Inform development of interventions to integrate depression treatment into Ob/Gyn settings

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Women with perinatal depression experience multiple barriers to receiving mental health care

Byatt et al. 2014 General Hospital Psychiatry.

Fear, stigma and shame Lack of resources and supports Negative interactions with providers Providers lack of knowledge about mental health care

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“I’m telling you the god’s honest truth, the person who screened me said, ‘Well, you have a happy, healthy baby. What else do you want?’ ”

). Byatt et al. 2014. General Hospital Psychiatry.

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Women with perinatal depression are clear on what would be helpful

Byatt et al. 2014 General Hospital Psychiatry.

Ob/Gyn providers to integrate depression into obstetric care Authentic and validating conversation Access to resources and supports in Ob/Gyn settings

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Obstetric providers have numerous challenges when considering maternal mental health

Limited resources and time constraints Mental health beyond scope of services Discomfort with mental health issues

Byatt et al. 2012 Journal of Reproductive and Infant Psychology

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“There [are] patients that come in and say, ‘I’m depressed. I have PTSD. I’ve been raped.’ … the basics of how to kind of approach that, how to respond…. I would like to talk about it more, but I do not know where to start. Oh crap, that really sucks, I don’t know.”

Byatt et al. 2012 Journal of Reproductive and Infant Psychology

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Training, integrated systems, and access to mental health providers can support obstetric providers

Targeted provider training Learning engagement techniques Structured screening and referral Integrated OB and depression care Immediate back up from mental health providers

Byatt et al. 2012 Journal of Reproductive and Infant Psychology

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Women do not

disclose symptoms or seek care

Unprepared providers, With limited resources

Poor Outcomes

Underutilization of Treatment

www.chroniccare.org

Patient Provider Systems Lack of detection Lack of training Lack of integrated care Fear/stigma Discomfort Screening not routine Limited access Few resources Isolated providers

Barriers to Treatment

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Obstetric provider and staff training, toolkit

Improve access to and engagement in depression treatment

Improve depression outcomes

Implementation assistance: clinic procedures, prompts, environment changes, feedback

Immediate psychiatric guidance via telephone consultation

In response, we developed the Rapid Access to Perinatal Psychiatric Care in Depression Program (RAPPID)

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RAPPID Intervention Development Established multidisciplinary working group and developed

timeline

Developed RAPPID program components via iterative process

Prepared for beta implementation

Beta-tested RAPPID in one clinic site

Elicited feedback on beta version

Finalized RAPPID components and products for pilot implementation study

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We established and obtained iterative feedback from a multidisciplinary working group

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We recruited psychiatric and perinatal health care professionals from one Ob/Gyn clinic site

Obtained iterative feedback on the core program components and uncovered barriers and facilitators to implementation of RAPPID over a period of 8 months

Iterative feedback from advisory group and MCPAP leadership

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We trained Ob/Gyn providers and staff and Beta tested RAPPID

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Recruited working group members and

clinic providers and staff to

participate in Beta testing

Two 1.5 hour trainings for

OB/GYN residents,

attendings and clinic staff

Implemented RAPPID at 1

clinic site for 5 Mondays over

5 weeks

Chart review and

focus group

Coded focus group data and

identified themes

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In 2010, Massachusetts passed a Postpartum Depression Act

PPD Commission MCPAP for Moms Funding

©MCPAP For Moms

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©MCPAP For Moms

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Education

Care Coordination

855-Mom-MCPAP

©MCPAP For Moms

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Telephone Consultation

Obstetric providers/ Midwives

Family Medicine

Psychiatric providers Primary

care providers

Pediatric providers

Providers can call for patient consultations

©MCPAP For Moms

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1-855-Mom-MCPAP

Telephone Consultation

©MCPAP For Moms

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1-855-Mom-MCPAP

Telephone Consultation

©MCPAP For Moms

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Edinburgh Postnatal Depression Scale (EPDS)

Validated in pregnancy and postpartum 10 items Asks about self-harm

©MCPAP For Moms

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26-28 weeks Birth

2 wks post-

partum

Administer Edinburgh Postnatal Depression Scale

1st pre-natal visit

6 wks post-

partum

Administer EPDS for high-risk patients

©MCPAP For Moms

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Screening - Algorithm for Obstetric Providers

©MCPAP For Moms

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Treatment - Recommended Steps Before Beginning Antidepressant Treatment

©MCPAP For Moms

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Treatment - Antidepressant Treatment Algorithm

©MCPAP For Moms

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Education about various treatment and support options is imperative

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Ask women what type of treatment they prefer

There are effective options for treatment during pregnancy and breastfeeding. Depression is very common during pregnancy and the postpartum period. There is no risk free decision. Women need to take medication during pregnancy for all sort of things.

©MCPAP For Moms

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Linkages with support groups and community resources

Support the wellness and mental health of perinatal women

©MCPAP For Moms

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Can refer moms to www.mcpapformoms.org

http://www.mcpapformoms.org/
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MCPAP for Moms has served many providers and parents in our first five months (July-Nov, 2014)

OB Practices Enrolled 26

Trainings (including 7 community trainings) 57

Women Served 194

Doc-doc Telephone Encounters 172

Face to Face Evaluations 21

Care Coordination Encounters 142

Telephone Encounters with Ob/Gyns and Midwives 122

Telephone Encounters with Psychiatric Providers 26

Telephone Encounters with Other Providers 25

PPD Coalition Started 6

Support Groups Available 139

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Provider and parent feedback has been overwhelmingly positive

“Your program is awesome.” –Perinatal woman

“I love this service! I am going to call every day.” –Obstetric provider

“It’s kind of amazing that I can just call you guys and you’re

there.” –Obstetric provider

“It was perfect! I plan to have them come here and train us so we can all use it.” –Family Medicine provider

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In summary, our aim is to promote maternal and child health by building the capacity of front line providers to address perinatal depression

©MCPAP For Moms

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Please contact us for more information

Thank you!

Nancy Byatt, DO, MBA, Medical Director, MCPAP for Moms [email protected] Kathleen Biebel, PhD, Program Director, MCPAP for Moms [email protected]

mailto:[email protected]
mailto:[email protected]

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