Slide 1

Moving towards a understanding of psychosocial factors in practice beyondblue NHMRC Guidelines Jennifer Ericksen Manager Perinatal Mental Health and Training Parent Infant Research Institute Austin Health Slide 2 Parent-Infant Research Institute Investing in the earliest years to build a brighter future www.piri.org.au Slide 3 Parent Infant Research Institute Ericksen 2013 The Parent-Infant Research Institute (PIRI) innovative Australian research institute developing and applying interventions to improve parent/infant mental health Slide 4 Slide 5 Slide 6 Parent Infant Research Institute Ericksen 2013 Slide 7 IMPACT OF PERINATAL MENTAL HEALTH Slide 8 Perinatal mental health These problems are common 1 in 7 women get postnatal depression 1 in 10 get depression during pregnancy Anxiety is even more common Some are more vulnerable than others These conditions are serious Perinatal mental health conditions are the leading cause of maternal death Leading cause of disability Economic and social cost Parent Infant Research Institute Ericksen 2013 Slide 9 Impact of maternal mental health Important for the woman herself Impact on relationship with partner Depression during pregnancy can change mother physiologically Affects foetal development Postnatal depression can impair mothering Affect the child psychologically Parent Infant Research Institute Ericksen 2013 Slide 10 Postnatal depression PND symptoms of lowered mood, loss of interest, fatigue, guilt, shame.can interfere with the mothers ability to provide care in a consistent way Detrimental effects on infant development Infants develop optimally when they feel secure, nurtured and have their needs met quickly and predictably If this persists there may be short and long term effects on cognitive, emotional, social and behavioural domains of development. Resilience Parent Infant Research Institute Ericksen 2013 Slide 11 PND & interaction Mothers with depression show less responsiveness stimulation attunement Murray et al., 2003; Reck et al., 2004 synchrony of affect and behavior Righetti-Veltema, Conne-Perreard, Bousqet, Manzano, 2002 focus on the infant Murray et al, 1993 Mothers with depression show more negative speech to infant Murray et al, 1993 Intrusive or withdrawn interactions Field, Diego, Hernandez-Reif, Schanberg, & Kunhn, 2003) PND interferes with the emotional and behavioural interchanges between mother and infant Parent Infant Research Institute Ericksen 2013 Slide 12 Disrupted mother infant interaction Poorer social and cognitive outcomes to school age Bernier et al 2010, Murray et al 1996, Stams et al 2002 Poor psychological adaptation as adolescents Feldman 2010, Korhonen et al 2012 Later anxiety Mount et al 2010 and depression Murray et al 2011 Poorer self regulation capacities Feldman et al 1999 Increased insecure attachment Coyl et al 2002 leading to relationship Berlin et al 2007 and behavioral problems Fearon et al 2010 Parent Infant Research Institute Ericksen 2013 Slide 13 Slide 14 Postnatal distress a dilemma Up to 30% of women experience mild depressive symptoms, adjustment problems and anxiety in the postnatal period Women rarely recognize the symptoms of depression in themselves Justify them as normal, lack of sleep Continue to try to cope Beyondblue National Postnatal Depression Program 36% of women compared to 80% of GPs recognized depressive symptoms Difficulties managing baby commonly lead to feelings of not coping Even when identified women are reluctant to accept a diagnosis of depression. Slide 15 HOW CAN WE BETTER UNDERSTAND THE ATTITUDES AND BELIEFS OF POSTNATAL WOMEN? Slide 16 Parent Infant Research Institute Ericksen 2013 Pathways to care Current research directly asking women about barriers and facilitators to accessing help are sparse. (Sword et al 2008) How do womens beliefs and attitudes about depression influence their choice to seek help? Can family, friends and health professionals facilitate or deter help seeking? Australian womens experience Bilszta, Ericksen,Buist, Milgrom 2008 Slide 17 Parent Infant Research Institute Ericksen 2013 Main themes for barriers to care Expectations of motherhood I should be happy, I have a wonderful baby loss of life as it used to be Not coping & fear of failure Keeping up appearances What will other people think of me Stigma & denial Its just a bad day Im just a bit run down When I get more sleep Ill be OK Poor mental health awareness Isnt this normal? Interpersonal support Come home now Im not coping Baby management Feeling inadequate that baby doesnt sleep like others do Help seeking & treatment experiences I had to get over that I really did need help Slide 18 Barriers to clinic treatment Barriers that limit womens access to clinic treatment Majority undetected (Cox and Holden 2003) When detected uptake of treatment is poor around 30- 40% (Austin et al 2007) Fear of stigma and reluctance of health professionals to ask about it (Barney et al 2006 ) A need to keep up the appearance of coping (Bilszta et al 2010) Denial of problem Lack of mental health awareness Access barriers, cost, availability, child care, organization Options that fit with a mothers health beliefs Breast feeding women are hesitant to take medication (Gentile 2007) Parent Infant Research Institute Ericksen 2013 Slide 19 Relationship with health professionals MCHN the most helpful of all health professionals, play a vital role in identifying and managing PND should see it coming, recognize it and take control Women seek support from the right person, at the right time with the right options Slide 20 Parent Infant Research Institute Ericksen 2013 Ideal Health Professional Key attributes women list empathy kindness knowledge of what is available good listening skills availability able to actively assist the mother, calls, home visit nurturing ongoing relationship once referred Key responses Help mothers recognize it is not a sign of failure A broad range of psychosocial factors contribute Listen and do not attempt to normalize feelings Slide 21 PERINATAL MENTAL HEALTH FOCUS Parent Infant Research Institute Ericksen 2013 Slide 22 The context & current focus National Postnatal Depression Program (2001-2005) 40,000 women screened in pregnancy and 12,000 postnatally, 200,000 reached with publicity & resource materials National Action Plan (2006) The National Perinatal Depression Initiative (2008-13) The Australian Government committed $55 million over five years with States and Territory contributing $30 million for a total of $85 million. beyondblue works in close collaboration with key experts, the Australian Government and each State and Territory government. The aim of the initiative is to improve the early detection and prevention of antenatal and postnatal depression, and to provide better care, support and treatment for expectant and new mothers. Parent Infant Research Institute Ericksen 2013 Slide 23 Slide 24 The National Perinatal Depression Initiative 2008-2013 Routine and universal screening of all women for perinatal depression and anxiety in the perinatal period Follow-up support and care for women assessed as being at risk of or experiencing perinatal depression Workforce training and development for health professionals Research and data collection National guidelines for screening for perinatal depression Increase community awareness Parent Infant Research Institute Ericksen 2013 Slide 25 Clinical Practice Guidelines Expert advisory committee Reviewed literature for best available evidence Developed to assist health professionals Identify Treat Levels of confidence 8 Recommendations 44 Good practice points Developing document Parent Infant Research Institute Ericksen 2013 Slide 26 Slide 27 Recommendations All health professionals should receive training in woman-centred communication skills and psychosocial assessment (R1) Practice that is women centred involves Using effective communication skills to understand the womans experience Allowing the woman to be active in decision making about her care Understanding the womans broader context Culturally competent practice Sensitive to differences in womens backgrounds health perceptions and knowledge Psychosocial assessment To identify psychosocial factors known to be associated with increased likelihood of mental health disorders To identify current symptoms of depression/anxiety Parent Infant Research Institute Ericksen 2013 Slide 28 Recommendations screening for depression and anxiety The EPDS should be used as a component of the assessment of all antenatal women (R2) and again in the postnatal period (R3) for symptoms of depression/anxiety A score of 13 or more can be used for detecting symptoms of depression in the antenatal period (GPP 8) and the postnatal period (R4) Early in pregnancy and 6-12 weeks post delivery women should be asked questions about their psychosocial situation (GPP 7) Parent Infant Research Institute Ericksen 2013 Slide 29 Recommendations about treatment In mild to moderate postnatal depression Cognitive Behavioural Therapy should be considered (R6) Non directive counselling in the context of home visits can be considered (R5) Interpersonal psychotherapy can be considered (R7) Psychodynamic therapy can be considered (R8) Parent Infant Research Institute Ericksen 2013 Slide 30 Slide 31 Psychosocial risk factors Past mental health problems particularly antenatal depression/anxiety or depression Hx Current Mental health problems Previous or current abuse/violence Drug and alcohol usage Major life stressors Low social support practical and emotional especially from her partner Low self esteem Parent Infant Research Institute Ericksen 2013 Slide 32 Refugee, asylum-seeking and immigrant women at particular risk Collins, Zimmerman & Howard 2011 Recent article reviewed 8 studies 5 Canada, 2 Australia 1 Taiwan PND may affect up to 24 - 42% of these women compared to native born women with an incidence of 10-15% Immigrants in Canada from UK, USA, Aust & NZ had 8.3% incidence but minority groups had 24.7% incidence Risk factors commonly include stressful life events prior to or during pregnancy, lack of social support and cultural factors Parent Infant Research Institute Ericksen 2013 Slide 33 Psychosocial assessment Better understand a womans circumstances Provide a holistic integrated approach to emotional health Look at social and psychological factors Look for those that are most commonly associated with greater likelihood of mood disorders Weave symptoms of depression with physical, emotional and social pressures on the woman into conversation Give a psychosocial assessment form Parent Infant Research Institute Ericksen 2013 Slide 34 WORKFORCE CAPACITY BUILDING Parent Infant Research Institute Ericksen 2013 Slide 35 Capacity building for MCHN DEECD has arranged for access to professional development workshops for all MCHN Guideline recommendations Women-centred communication Psychosocial Q including depression/anxiety screening Decision making about treatment Pathways to care May to December CBD and 2 in each of the 4 regions Manual is being developed to support training Utilizing beyondblue materials and NEW handouts Parent Infant Research Institute Ericksen 2013 Slide 36 PATHWAYS TO CARE Parent Infant Research Institute Ericksen 2013 Slide 37 Brian Danaher 1 Jeannette Milgrom 2&3 Charlene Schembri 3 John Seeley 1 Jennifer Ericksen 3 Milagra Tyler 1 Alan Gemmill 3 Peter Lewinsohn 1 & Scott Stuart 4 1. Oregon Research Institute 2. Psychological Sciences, University of Melbourne 3. Parent-Infant Research Institute 4. Deparment of Psychiatry & Psychology, University of Iowa Slide 38 Benefits of Web Based Intervention Web based interventions may overcome barriers that limit womens uptake of clinic treatment as it is perceived as Accessible to isolated, rural and remote Reduce fear of stigma by being anonymous Affordable Convenient on demand at home May reach many who otherwise would not enter into treatment for their depression Parent Infant Research Institute Ericksen 2013 Slide 39 Slide 40 Recruitment for RCT Eligibility Baby 12 months or under Mother over 18, EPDS 12-20, not receiving any other treatment, can read and write English Has broadband internet access and used email Not suicidal, bipolar or psychotic, no substance use Phone intake, consent forms sent & returned SCID phone assessment (1 hour) Questionnaires reimbursed Contact us PIRI 03 9496 4496 Jessica Ross piri@austin.org.au Parent Infant Research Institute Ericksen 2013