What is one way PHC is addressing MMH and Perinatal Depression & Anxiety?
Partnership’s Mental Health Access team has completed a two year project aimed at increasing access to mental health services for all Partnership Members. Access to mental health services goals were met in targeted counties (Solano, Yolo, and Humboldt) but, equally important, an action plan was developed to increase mental health utilization for women of child bearing age, particularly during the perinatal period.
What did a brief review of CPSP sites reveal?
Jessica Hackwell discussed behavioral health screening and intervention practices with several Comprehensive Perinatal Service Program (CPSP) sites in our region. Their feedback indicated that although appropriate depression screening tools were being used both during pregnancy and postpartum, behavioral health care was often discontinued shortly after birth because of the multiple appointments required for baby and maternal health.
What does our PHC data on referrals to Behavioral Health care show?
We also looked at Beacon Health Options utilization data for all women of child bearing age versus those in the perinatal period (three months before and after birth).
| Penetration rate by county * | Counties ABOVE Penetration Rate of 6.0% (in order from highest to lowest) | Counties BELOW Penetration Rate of 6.0% (in order from highest to lowest) | |
| Women of Child Bearing Age (14-47) | Average: 9.8%Range: 4.9% to 13.8% | Shasta, Mendocino, Marin, Sonoma, Lake, Humboldt, Napa, Siskiyou, Trinity, Solano, Del Norte | Modoc, Yolo, Lassen |
| Women during Peinatal Period | Average: 7.5%**Range: 0% to 21.9% | Marin, Shasta, Sonoma, Mendocino, Lake, Trinity | Napa, Lassen, Humboldt, Solano, Yolo, Siskiyou, Del Norte, Modoc |
* Data summarized for Beacon claims paid through end of 2016
** 3/31/17 update perinatal only 8.2% penetration
The primary diagnoses for these claims were Mood Disorders (including Major Depression and Bipolar) followed closely by Anxiety Disorders and then Adjustment Disorders (the milder versions of depressive and anxiety disorders). We also looked at Beacon utilization broken down by PCP health center or clinic. The highest number of deliveries were FFS with a 5.7% Beacon utilization. Only one of the top ten clinics in terms of number of deliveries (67 to 193) approached the 14% or one-in-seven mark for prevalence of perinatal mental health problems (penetration rates ranged between 0.8% and 14%). In general, clinics with fewer deliveries were more likely to refer for behavioral health care.
Where do the nationwide prevalence figures originally come from?
The sentinel study was published in JAMA Psychiatry in May of 2013 and involved screenings on 10,000 mothers with follow-up home or telephone clinical interviews to determine DMS-IV diagnoses. The outcome highlights:
- 14% of the screenings were positive (Edinburgh Postnatal Depression Scale EPDS score of 10 or higher), yielding the one-in-seven statistic for incidence.
- Positive screenings were more likely among those who were younger, African-American, publicly insured, single, or less well-educated.
- 1% of episodes began postpartum, 33.4% during pregnancy, and 26.5% before pregnancy.
- 3% had self-harm ideation (#10 on the EPDS). All those with self-harm ideation had full EPDS scores above 10.
- The most common diagnoses (from clinical interview) were unipolar depression (68.5%) with two-thirds having co-morbid anxiety disorder. A striking 22.6% had bipolar disorders.
- One major conclusion: Strategies are needed to differentiate bipolar from unipolar depressive disorders.
Let’s look at detailed prevalence data in one of our PHC counties:
Nicole Bonkrude, MPH, the MCAH Coordinator for Public Health Branch of Shasta County HHS was kind enough to share results of the Shasta Co MCAH Needs Assessment Survey for FY 13-14. Although this data represents only one of our 14 counties, there is no reason to assume that it is not representative of other of our counties with similar demographics.
- In a six-month postpartum survey, respondents reported having experienced postpartum depression (20.3% in 2011) which was higher than the State average (13.5% in 2011)
- 27% of the women said they had had an episode of two weeks or longer of feeling empty, sad, or depressed sometime in their life. Lower income women were more likely to report this than higher income women. Of these women, 52% had this experience sometime before their pregnancy, 34% had it during their pregnancy, and 78% had it since their baby was born.
- 72% of women reported being asked at a healthcare visit at some point in their life about feelings of being sad, empty, depressed, or having a lack of interest in things. 42% reported being asked this before their pregnancy, 83% reported being asked during their pregnancy, and 92% reported being asked since their baby was born.
- Additionally, Shasta County was listed with the 12th highest rate of maternal depression of the 58 counties in California (California MCAH Home Visiting Assessment, 2010). In 2009, Shasta County maternal depression rate was 24.6 per 1000 discharges, or approximately 50 women per year, but only included women with documented diagnosis.
- The following chart shows the increase in rates over time based on diagnoses of anxiety or depression per 1,000 discharges from Labor & Delivery
What is the prevalence of the more serious postpartum psychosis?
According to Psychiatric Times the prevalence in the general population is 0.1% to 0.2% which is significantly lower than the prevalence of “baby blues” (50% to 75%) or postpartum depression (10% to 13%). It is one of the rarest psychiatric disorders, yet almost always is considered a psychiatric emergency because of its rapid onset and the catastrophic risk to mother and child. Because of its severity level, all such suspected cases are referred to County MHP services and/or require immediate law enforcement intervention.
What is being done on the State of CA level about Maternal Mental Health?
- The California Task Force on the Status of Maternal Mental Health Care published their report in April 2017. Recognizing that MMH disorders are treatable and early detection is critical, the Task Force set goal of 80% screening at least once during pregnancy and postpartum by 2021 and 100% by 2025. The entire report is well worth reading. However, important highlights to note are:
- Prevalence Data: (Table 1 and Figure 2, pp. 7-8)
- National Recommendations on Screening (Table 3, p. 23)
- Core Competencies for Health Care Providers treating MMH: (Table 2, p. 17)
- Critical Time Frames to address MMH: (Fig. 8, p. 21)
- A Menu of Prevention and Treatment Options (Table 4, p. 27)
- The Maternal Mental Health Safety Bundle: Released February 2016. In a Webinar on the MMH Bundle presented June 7, 2017 by Anna Sutton, RN, PHN, MSN, Yolo County HHS, I found her table of factors known to be important in assessing risk of perinatal anxiety or depression particularly relevant
| Increased Risk for Perinatal Depression | Increased Risk for Perinatal Anxiety |
| Maternal anxiety | Maternal depression or anxiety |
| History of depression in mother or family | History of depression in mother or family |
| Life Stress | Stressful life events in pregnancy/early postpartum |
| Lack of social support | Traumatic birth experience (past or present) |
| Poor relationship quality | PTB/NICU baby |
| Domestic violence | Breastfeeding problems |
| Lower income/education/on Medicaid | Low levels of social support |
| Smoking |
Nicole Bonkrude, highlighted three other important findings of this MMH Safety Bundle:
- The CDC estimates that 8-19% of women will experience a depressive episode during or after pregnancy
- Maternal depression is more common than the prevalence of Gestational Diabetes (GDM) at 9.2%.
- Maternal suicide within a year of birth exceeds hemorrhage and hypertensive disorders as a cause of maternal mortality and is underreported
You can further explore the February 2016 recommendations offered by the Council on Patient Safety In Women’s Health Care for Maternal Mental Health: Depression and Anxiety including complete resource listing and a downloadable PDF of the Bundle.
What is being recommended as a best practice on an international level?
Universal depression screening is recommended by Postpartum Support International, with timing as follows:
Ob/Gyn
- First prenatal visit
- At least once in second trimester
- At least once in third trimester
- Six-week postpartum obstetrical visit (or at first postpartum visit)
- Repeated screening at 12-month annual well-woman exam
Pediatrician
- At 3, 9, and 12-month pediatric well-child visits
Primary Care
- At 6 and/or 12-months postpartum
What are the barriers we face in carrying out recommended screening and intervention?
Developing screening visit/payment mechanisms for pediatricians who are perhaps more likely to encounter the postpartum mother than either ob/gyn or primary care providers.
- Increasing access to behavioral health care for those identified through screening for depression or anxiety at any time before, during, or for a year following delivery. Making sure all PHC providers have referral information and referral materials (see final section of this blog). Please contact Beacon’s PHC Account Manager Alison French for additional information on resources.
What are the main messages we at PHC want to give mothers?
- MMH disorders happen a lot. One-in-seven mothers experience them.
- You are not alone. Counseling is readily available.
- You are NOT a bad Mom. MMH disorders are common and treatable.
What Screening Resources can be used in primary care?
The Edinburgh Postnatal Depression Scale (EPDS) is highly recommended for screening postpartum women and can be completed in less than 5 minutes. Recommendations are that screening be done both pre-term and postpartum for at least several months or up to a year. The EPDS is available in multiple languages at this website. Scores of 10 or higher or any score on item #10 warrant referral for behavioral health care.
The PHQ-9 is the most common screening tool to identify depression. It is available in Spanish as well as in a modified version for adolescents. It is available in multiple languages as this website. Most importantly, the PHQ-9 includes a question designed to screen for danger to self which the shorter PHQ-2 version does not include. Suicide prevention can arguably be regarded as the most important aspect of depression screening.
How can you as a primary care, ob-gyn or pediatric provider refer women to Beacon Health Options for depression, anxiety, or any other MMH disorder?
The newly revised Beacon PCP Referral Form can be accessed in fillable form online at: https://www.beaconhealthoptions.com/material/phpc-pcp-referral-form/
In completing the form, follow these suggested steps:
- Fill in identifying information and check Medi-Cal Eligibility
- Check your preferred method of contact (email or FAX) to receive CONFIRMATION that your referral has been received and INFORMATION of the referral outcome. This will be referral information only, not clinical treatment information. But will let you know that your referral has been processed and the outcome of the Member contact concerning that referral.
- Check which service you are requesting for this Member:
- PCP Decision Support:A phone consult with a Beacon psychiatrist for diagnostic and prescribing support
- Out Patient Behavioral Health Services:Member referred to Beacon network provider for therapy and/or medication management (including coordination with county MH services).
- Referral for Local Care Management:Beacon case managers co-located with PHC will provide health care coordination services to engage and link Members who may have difficulty making their own appointments.
- Check all request reasons at bottom of form and submit (FAX to 866-422-3413 or email tomedi-cal.referral@beaconhealthoptions.com
Note: My thanks to Jessica Hackwell, Lynn Scuri, and the entire PHC Mental Health Access team for their support and contributions.
By Karen Stephen, Ph.D., PHC Mental Health Clinical Director