11

The 3 Ps of Perinatal Depression: The 3 Ps of Perinatal Depression:

Perinatal Health, Provider Perinatal Health, Provider Education and Public AwarenessEducation and Public Awareness

Mary Zoller, MPAPolicy Analyst, Program Manager

Joan Corder-Mabe, RNC, M.S., WHNPDirector

Division of Women’s and Infants’ HealthOffice of Family Health Services

22

VDH Project TeamVDH Project TeamDivision of Women’s and Infants’ Division of Women’s and Infants’

HealthHealthOffice of Family Health ServicesOffice of Family Health Services

Joan Corder-Mabe, RNC, M.S., WHNP, DirectorJoan Corder-Mabe, RNC, M.S., WHNP, Director

Catherine Bodkin, LCSW, MSHA, Program Manager for Catherine Bodkin, LCSW, MSHA, Program Manager for

Resource Mothers Resource Mothers

Linda Foster, RD, Project Director, Linda Foster, RD, Project Director, Loving Steps,Loving Steps,

Virginia Healthy Start InitiativeVirginia Healthy Start Initiative

Theresa Taylor, RN, MPH, Perinatal Nurse ConsultantTheresa Taylor, RN, MPH, Perinatal Nurse Consultant

Mary Zoller, MPA, Policy Analyst, Program ManagerMary Zoller, MPA, Policy Analyst, Program Manager

33

Contractors:Contractors:

Jenn A. Leiferman, Assistant Professor, Project EvaluatorJenn A. Leiferman, Assistant Professor, Project Evaluator

Department of PediatricsDepartment of Pediatrics

Eastern Virginia Medical SchoolEastern Virginia Medical School

Priscilla MendenhallPriscilla MendenhallNorthern Virginia Area Health Education Center (NVAHEC)Northern Virginia Area Health Education Center (NVAHEC)

Jann T. Balmer, RN, Ph.D., Developer, Web-based curriculumJann T. Balmer, RN, Ph.D., Developer, Web-based curriculum

Director, Continuing Medical EducationDirector, Continuing Medical Education

University of Virginia School of MedicineUniversity of Virginia School of Medicine

Deb McMahon, CEO, Scitent IncDeb McMahon, CEO, Scitent Inc

Medical Education Course DevelopersMedical Education Course Developers

AcknowledgementsAcknowledgements

44

Goals and ObjectivesGoals and Objectives

1. 1. To increase the number of health and To increase the number of health and community-based providers who can community-based providers who can recognize, screen and refer pregnant and recognize, screen and refer pregnant and postpartum women suffering from postpartum women suffering from depression to treatment.depression to treatment.

- Increase ability of providers to recognize the signs and Increase ability of providers to recognize the signs and symptoms of perinatal depression through symptoms of perinatal depression through development of a Web-based curriculum.development of a Web-based curriculum.

- Market the curriculum and provide continuing Market the curriculum and provide continuing education credits for completing it.education credits for completing it.

55

Goals and Objectives Goals and Objectives

2. 2. To reduce the negative stigma of To reduce the negative stigma of mental illness and barriers to care mental illness and barriers to care facing women with perinatal facing women with perinatal depressiondepression

- Identify ethnic/cultural beliefs and practices Identify ethnic/cultural beliefs and practices affecting women’s choices in seeking mental affecting women’s choices in seeking mental health carehealth care

- Integrate recurrent themes and/or priority Integrate recurrent themes and/or priority findings from the focus groups into the curriculumfindings from the focus groups into the curriculum

66

Goals and ObjectivesGoals and Objectives

3. Enhance the efficiency and 3. Enhance the efficiency and effectiveness of the system of care to effectiveness of the system of care to provide comprehensive, culturally provide comprehensive, culturally competent, and family-based care for competent, and family-based care for those with perinatal depressionthose with perinatal depression

- Develop an action plan to reduce barriers to care Develop an action plan to reduce barriers to care and improve the system of careand improve the system of care

77

Approach to Achieving Approach to Achieving GoalsGoals

Conduct baseline survey of perinatal Conduct baseline survey of perinatal providers to assess their knowledge, providers to assess their knowledge, attitudes and practices on screening, attitudes and practices on screening, identifying and referring depressed identifying and referring depressed women to treatmentwomen to treatment

Conduct focus groups of five different Conduct focus groups of five different multi-cultural populations in Virginia to multi-cultural populations in Virginia to identify barriers to careidentify barriers to care

88

Approach to Achieving Approach to Achieving GoalsGoals

Create an expert panel of state level Create an expert panel of state level provider representatives and consumers provider representatives and consumers to assist VDH:to assist VDH:

• Identify the major issues relative to Identify the major issues relative to perinatal depression in Virginiaperinatal depression in Virginia

• Inventory resources to alleviate perinatal Inventory resources to alleviate perinatal depressiondepression

• Advise VDH on ways to strengthen the Advise VDH on ways to strengthen the curriculumcurriculum

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AcknowledgementsAcknowledgementsExpert PanelExpert Panel

Family PhysiciansFamily Physicians OB/GYNsOB/GYNs PediatriciansPediatricians PharmacistsPharmacists Nurses including Nurse Nurses including Nurse

MidwivesMidwives HospitalsHospitals Mental Health FoundationMental Health Foundation Primary CarePrimary Care Managed CareManaged Care Home HealthHome Health Child abuse prevention Child abuse prevention Hispanic Chamber of CommerceHispanic Chamber of Commerce

Women who have Women who have experienced perinatal experienced perinatal depressiondepression

Health Planning AgenciesHealth Planning Agencies Early InterventionEarly Intervention State agencies-State agencies-

mental health, social services, mental health, social services, healthhealth

AcademiaAcademia

1010

Approach to Implementing Goals

Results of Provider Survey Results of Focus Groups Findings from Literature Review

Expert Panel

Synthesize issues, resources, findings

Curriculum Development

VDH

1111

Perinatal Health CarePerinatal Health CareProvider SurveyProvider Survey

645 health care providers645 health care providers

44% physicians44% physicians 21.4% social workers21.4% social workers 9.8% physician assistants9.8% physician assistants 9.5% registered nurses9.5% registered nurses 9.4% nurse practitioners9.4% nurse practitioners 3.9% midwives3.9% midwives

1212

Q.Q. Perinatal depression frequently Perinatal depression frequently goes goes undiagnosedundiagnosed

0

5

10

15

20

25

30

35

40

45

50

StronglyAgree

Agree SomewhatAgree

Neutral SomewhatDisagree

Disagree StronglyDisagree

Strongly Agree/Agree = 77.9%

1313

Q.Q. I am very confident in I am very confident in diagnosing diagnosing perinatal depression.perinatal depression.

0

5

10

15

20

25

30

StronglyAgree

Agree SomewhatAgree

Neutral SomewhatDisagree

Disagree StronglyDisagree

Strongly Agree/Agree = 40.9%

1414

Q. How do you typically treat perinatal depression?

MD/DO 1) Refer to Mental Health specialist

2) Prescribe Medication 3) Counseling in office by you

NP 1) Counseling in office by you2) Involve partner/family3) Refer to Mental Health

specialist

Practice Differences by Type of Health Care Provider

RN 1) Counseling in office by you2) Involve partner/family3) Provide written information

MD/DO = physician, NP = nurse practitioner, RN = registered nurse

1515

Practice Differences by Type of Practice Differences by Type of Health Care ProviderHealth Care Provider

NMWNMW 1) Prescribe medication1) Prescribe medication2) Involve partner/family2) Involve partner/family3)Counseling in office by 3)Counseling in office by

youyouSW 1) Counseling in office by you

2) Involve partner/family3) Refer to PCP

Q. How do you typically treat perinatal depression?

NMW = nurse midwife, SW = clinical social worker

1616

Perinatal Health CarePerinatal Health CareProvider SurveyProvider Survey

Barriers to treatingBarriers to treating: limited time, : limited time, inadequate knowledge and/or skills, inadequate knowledge and/or skills, inadequate mental health care available, inadequate mental health care available, reimbursement/insurance limitationsreimbursement/insurance limitations

What providers wantWhat providers want: assessment tools, : assessment tools, information on diagnosis/treatment information on diagnosis/treatment modalities, information on resources modalities, information on resources available, signs and symptomsavailable, signs and symptoms

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Focus GroupsFocus Groups

Conducted with 51 participants - African Conducted with 51 participants - African American, Somali, Cambodian, Caucasian, and American, Somali, Cambodian, Caucasian, and Hispanic/Latina groupsHispanic/Latina groups

Questionnaire avoided words “depression” and Questionnaire avoided words “depression” and “mental health care” – lack of “mental health care” – lack of conceptual/linguistic equivalent and stigmaconceptual/linguistic equivalent and stigma

Used “feelings, experiences, seeking help”Used “feelings, experiences, seeking help”

Used 10 depersonalized questions that were Used 10 depersonalized questions that were asked by women known to communityasked by women known to community

1818

Key Findings from Focus Key Findings from Focus GroupsGroups

Lack of supportLack of support Experience of loss, trauma, anxiety, or Experience of loss, trauma, anxiety, or

depressiondepression Poor health of the mother and/or babyPoor health of the mother and/or baby Cultural values/stigma of mental health careCultural values/stigma of mental health care Lack of insuranceLack of insurance Lack of informationLack of information Lack of language accessLack of language access Stereotyping, racism and mistrustStereotyping, racism and mistrust Poor quality health carePoor quality health care

1919

Findings:Findings:

The women:The women:

Want community-based support from others Want community-based support from others who know the system and groups where they who know the system and groups where they can share feelings with one anothercan share feelings with one another

Need to be aware of services available in Need to be aware of services available in communitycommunity

Had no recommendations for help or support Had no recommendations for help or support involving mainstream mental health servicesinvolving mainstream mental health services

2020

Findings (continued):Findings (continued):

Restructure the postpartum period:Restructure the postpartum period: Schedule follow-up visits within two Schedule follow-up visits within two

week postpartumweek postpartum Prevent social seclusionPrevent social seclusion Promote rest for prescribed length of Promote rest for prescribed length of

timetime Offer assistance with tasks of Offer assistance with tasks of

motherhoodmotherhood Provide social recognition of new statusProvide social recognition of new status

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Findings (continued):Findings (continued): Educate providers of services for perinatal Educate providers of services for perinatal

women in the cultural, historical and socio-women in the cultural, historical and socio-economic factors influencing their liveseconomic factors influencing their lives

Assess all women for physical, mental, Assess all women for physical, mental, spiritual and social well-being several spiritual and social well-being several times in the first year after deliverytimes in the first year after delivery

Interpret findings from screening tools for Interpret findings from screening tools for depression within the lens of patient’s depression within the lens of patient’s cultural and socio-economic contextcultural and socio-economic context

Allocate funds to support perinatal women Allocate funds to support perinatal women “where they are”“where they are”

2222

Comparison of Provider Comparison of Provider Survey and Focus Group Survey and Focus Group

FindingsFindingsBarriers to CareBarriers to Care

Lack of insurance or Lack of insurance or limited insurancelimited insurance

Difficulty communicatingDifficulty communicating

-stigma, language-stigma, language Inadequate Inadequate

knowledge/skillsknowledge/skills Inadequate mental health Inadequate mental health

care availablecare available Lack of knowledge about Lack of knowledge about

servicesservices

Lack of insuranceLack of insurance Difficulty communicatingDifficulty communicating

-stigma, language, -stigma, language, stereotyping, racism, stereotyping, racism, mistrustmistrust

Poor quality health carePoor quality health care Lack of supportLack of support Do not want mainstream Do not want mainstream

mental health services but mental health services but support groupssupport groups

Lack of knowledge about Lack of knowledge about servicesservices

Providers said: Consumers said:

2323

Web Site DevelopmentWeb Site Development

Focused on four areas:Focused on four areas:

Developing curriculum learning objectives, Developing curriculum learning objectives,

content and an evaluationcontent and an evaluation Continuing education credit for health care Continuing education credit for health care

professionalsprofessionals Web site formatWeb site format Marketing Marketing

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MarketingMarketing

Worked with Regional Perinatal Councils and Worked with Regional Perinatal Councils and Expert Panel members to market curriculum to Expert Panel members to market curriculum to target audiencetarget audience

Sent out press releases on grant award and Sent out press releases on grant award and launch of Web sitelaunch of Web site

Provided articles in state association newsletters Provided articles in state association newsletters and Web sitesand Web sites

Exhibited at nurses, physician, social workers, Exhibited at nurses, physician, social workers, and dietitians state meetingsand dietitians state meetings

Distributed sticky pads and pens with Web site Distributed sticky pads and pens with Web site address and prepared a table top display to take address and prepared a table top display to take to conferencesto conferences

2525

Future PlansFuture Plans Conduct on-site training with Conduct on-site training with

providers in four regions of the stateproviders in four regions of the state Continue to update resource library Continue to update resource library Monitor Web site usage and make Monitor Web site usage and make

modifications based on evaluationsmodifications based on evaluations Distribute CDs of the curriculum to Distribute CDs of the curriculum to

those without Web accessthose without Web access Seek additional funding to maintain Seek additional funding to maintain

the Web site the Web site

2626

Who has completed the curriculum Who has completed the curriculum (launched 3/15/06 - 10/31/06)? (launched 3/15/06 - 10/31/06)?

1,699 people started the course1,699 people started the course 612 completed it612 completed it

Of those completing it, most have been in Of those completing it, most have been in practice 20 years or morepractice 20 years or more

2727

Type of Professional and Type of Professional and GenderGender

51% registered nurses and nurse 51% registered nurses and nurse practitionerspractitioners

32% other professionals32% other professionals 16% social workers16% social workers 98% are women98% are women

2828

Practice LocationPractice Location

33% were from Virginia33% were from Virginia67% all 50 states and 3 countries67% all 50 states and 3 countries

40% urban40% urban 33% rural33% rural 22% suburban22% suburban Remainder some combinationRemainder some combination

41% worked in hospital-based practices41% worked in hospital-based practices 24% worked in health departments24% worked in health departments

2929

Results of User EvaluationResults of User Evaluation

93% said the Web site was a good or 93% said the Web site was a good or perfect match for their continuing perfect match for their continuing education needs. education needs.

48% said that they visited the Web 48% said that they visited the Web site because they could complete it site because they could complete it at times convenient to them, while at times convenient to them, while 16% said they took it to earn CEUs.16% said they took it to earn CEUs.

3030

The vast majority of users said;The vast majority of users said;

The level of difficulty was appropriate; The level of difficulty was appropriate;

The content was relevant to their The content was relevant to their work;work;

They were very likely to recommend it They were very likely to recommend it to their colleagues; and to their colleagues; and

They plan to screen for perinatal They plan to screen for perinatal depression and will change their depression and will change their practice based on the course.practice based on the course.

3131

Lessons Learned Based on the Lessons Learned Based on the Virginia ExperienceVirginia Experience

Web-based training can be an effective method Web-based training can be an effective method for increasing the capacity of the health care for increasing the capacity of the health care system to identify and treat PD.system to identify and treat PD.

It should be used in concert with other It should be used in concert with other approaches for maximum impact, e.g., approaches for maximum impact, e.g., presentations at ground rounds, phone support presentations at ground rounds, phone support and technical assistance and with involvement and technical assistance and with involvement of a wide variety of providers.of a wide variety of providers.

3232

Capacity building for referral and Capacity building for referral and treatment is an important component treatment is an important component of changing practice patterns and of changing practice patterns and better serving women and their better serving women and their families.families.

Public education campaigns need to Public education campaigns need to work toward reducing the stigma of work toward reducing the stigma of depression and make it acceptable for depression and make it acceptable for women to “speak up when you are women to “speak up when you are down.”down.”

3333

A multidisciplinary community-based approach to the identification and treatment of perinatal depression will better serve the women and their families.

3434

Support groups for women and their families may decrease the morbidity associated with perinatal depression.

3535

Reimbursement for professionals to screen and treat perinatal depression may decrease morbidity and/or mortality.

3636

You are invited to visit You are invited to visit www.www.perinataldepressionperinataldepression

.org.org

For more information contact Mary Zoller, Policy Analyst

mary.zoller@vdh.virginia.gov