More Than the Baby Blues

Effects of Depression on Pregnant and Post-Partum

Women and the Mother-Infant-

Child Relationship

CORE Group Panel

Shannon Senefeld, Psy.D. Director of Health and HIV, CRS

Kathryn Reider, MS, Sr. Nutrition Advisor, World Vision US

Janine Schooley, MPH, Sr Vice President for Programs, PCI

Panel Facilitator: Carolyn Kruger, PH.D.

Sr. Advisor for MCHN, PCI

Maternal Depression: Introduction

The combination of women’s vulnerability to depression, their responsibility

for child care, and the high prevalence in developing countries means that maternal mental health has a substantial influence on growth (underweight and stunting) and development during infancy and childhood (WHO 2010)

The global need for mental health care is large- up to 25% of population requiring it at some point and global spending is less than $0.25 per person per year in low-income countries. (Mental Health Atlas 2011, WHO).

Depression in women in developing countries has a complex etiology, is heavily stigmatized within many cultures and women may be reluctant to seek help

Health care providers in developing countries are not trained to recognize, assess and treat maternal depression

Maternal Depression: Current Status

PPD remains under-diagnosed and under-treated with limited assessment in current health and nutrition programs

We have the tools---

It is possible to identify women with increased risk factors- early screening and treatment is associated with a better prognosis for the mother and less impact on the infant/child

Available antenatal and post-partum screening tools are available but not tested with multi-cultural populations

There are studies of interventions that can prevent or mitigate the impact, i.e., home visiting, telephone counseling, interactive coaching, group interventions and message therapy.

But we are slow to implement The potential adverse effect of PPD on the maternal/infant relationship and

child growth and development reinforces the need for early identification and effective treatment models (Stewart, 2003)

Understanding Post-partum Depression (PPD)

Shannon Senefeld, Psy.D.

Director of Health and HIV, CRS

Prevalence

More than 150 million people suffer from depression globally.

Depression and anxiety disorders are most prevalent amongst women when they are in their childbearing years.

WHO estimates that 1 in 3 to 1 in 5 women in developing countries and 1 in 10 in developed countries experience a significant mental health problem during pregnancy or after childbirth.

While nearly 80% of women experience the ‘baby blues’, 10% to 20% actually go on to meet the criteria for a major depressive episode as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV).

Etiology

The etiology of mental health problems is as diverse as the mental health problems themselves.

Physiological changes that occur during pregnancy may be linked with a change in mood.

Other risk factors include being single, being in an unsupportive relationship, a previous history of stillbirth or repeated miscarriages, poverty and economic hardship, and a lack of practical support.

Biological vulnerability: family history, previous history of PPD

Etiology- Relationship of Abuse

One significant predictor of mental health problems during the perinatal period is a history of abuse. Studies estimate that women who have been exposed to intimate

partner violence are 3 to 5 times more likely to experience a mental health problem than those who have not experienced such violence. Violence against women (intimate partner and childhood) are associated with depressive symptoms

Women exposed to GBV have a higher incidence of depressive and anxiety symptoms, PTSD and thoughts of suicide.

When violence is experienced during pregnancy, this has a negative effect on the infant’s health and mother-to-child bonding- leading to low birth weight, attachment disorders and behavioral disorders later in life.

Women exposed to psychological/sexual violence have a higher severity of depressive symptoms.

Assessment

Loads of assessment tools and techniques, choice often determined by population (cultural considerations)

National Institute of Health and Clinical Excellence (NICE) recommends that two main questions are asked of women during prenatal visits to identify possible peri-natal depression.

During the last month, have you often been bothered by feeling down, depressed or hopeless?

During the last month have you often been bothered by having little interest or pleasure in doing things?

If a woman responds that she has been bothered by such feelings, NICE recommends that she is then asked a third question:

Is this something you feel you need or want help with?

Clinical Presentation

Signs and symptoms of postpartum depression are clinically indistinguishable from major depression that occurs in women at other times. 

PDD develops over the first 3 postpartum months, is more persistent and debilitating than postpartum blues, often interfering with the mother's ability to care for herself or her child. 

Symptoms may include depressed mood, tearfulness, anhedonia, insomnia, fatigue, appetite disturbance, suicidal thoughts, and recurrent thoughts of death. 

PPD is often characterized as intense sadness, anxiety, or despair. These interfere with the mother’s ability to function with risk of harm to mother or infant.

Anxiety is often prominent, including worries or obsessions about the infant's health and well-being. The mother may have ambivalent or negative feelings toward the infant. She may also have intrusive and unpleasant fears or thoughts about harming the infant.

Treatment

The World Health Organization (WHO) offers hopeful statistics related to maternal mental health, estimating that 70% to 80% of women with maternal mental disorders can be treated successfully and recover.

Earlier initiation of treatment is associated with a better prognosis. The woman and her partner should be involved in the full continuum of care,

including education and treatment options. Screening can occur at primary healthcare facilities and oftentimes be

integrated into ongoing, standardized care. Antidepressants have been shown to be effective in treating perinatal

depression. Non-pharmacologic treatment strategies are useful for women with mild to

moderate depressive symptoms. Individual or group psychotherapy (cognitive-behavioral and interpersonal

therapy) are effective. Psycho-educational or support groups may also be helpful. These modalities may be especially attractive to mothers who are nursing and

who wish to avoid taking medications.

Effect on the Mother-Infant-Child Relationship and Impact on Growth and Development

Kathryn Reider, MS.

Sr. Nutrition Advisor, World Vision US

Effect of Depression on the Mother

Maternal depression is associated with: Compromised parenting behavior,

nonresponsive care giving practices Less able to give maternal stimulation to infant Less positive in interaction and less affective

behavior More variable behavior, i.e., anxiety, fatigue,

insomnia, decreased appetite, substance abuse Lower likelihood or shorter duration of

breastfeeding and problems with complementary feeding practices

Effect of Depression on the Infant

Infant affect changes and insecure attachment (5.4% times greater in PPD mothers

Less interest in exploring environment

Sleep problems

Increase in crying –frequency and duration

GBV and depression during pregnancy is associated with low birth weight

Effect of Maternal Depression on the Young Child Greater cognitive, behavioral and interpersonal problems

Impaired concentration

Irritability, aggressiveness

Social withdrawal

Neurobiological changes

Affects cognitive development: perceptual, motor and verbal skills

Effect of Maternal Depression on Child Nutrition

Depression in women may be a risk factor for poor growth (underweight and stunting) in young children (WHO, 2011)

PPD leads to problems with breastfeeding, early cessation, and association with underweight at six months

Less interactive infant feeding

Association between maternal MD and child undernutrition

** p<0.05; *p<0.01 Maternal mental distress is associated with child feeding practices and anthropometry in VietnamPhuong H. Nguyen1, Purnima Menon2, Rawat Rahul3 and Marie T. Ruel3

1International Food Policy Research Institute (IFPRI), Hanoi, Viet Nam; 2IFPRI, New Delhi, India; 3IFPRI, Washington, DC. Poster presentation at the Experimental Biology conference in 2011

Association between maternal MD and IYCF practices

Maternal mental distress is associated with child feeding practices and anthropometry in VietnamPhuong H. Nguyen1, Purnima Menon2, Rawat Rahul3 and Marie T. Ruel3

1International Food Policy Research Institute (IFPRI), Hanoi, Viet Nam; 2IFPRI, New Delhi, India; 3IFPRI, Washington, DC. Poster presentation at the Experimental Biology conference in 2011

Coefficients for associations between high maternal MD and child undernutrition (multivariate

regression analysis)

Maternal mental distress is associated with child feeding practices and anthropometry in VietnamPhuong H. Nguyen1, Purnima Menon2, Rawat Rahul3 and Marie T. Ruel3

1International Food Policy Research Institute (IFPRI), Hanoi, Viet Nam; 2IFPRI, New Delhi, India; 3IFPRI, Washington, DC. Poster presentation at the Experimental Biology conference in 2011

MD Research Conclusions

Maternal distress is associated with poor anthropometric outcomes among children <5 years of age in a Vietnamese population, where food insecurity, poverty and overall undernutrition rates are low.

Poorer IYCF among high MD mothers suggest that child feeding practices may mediate this association for infants and younger children.

Further research is needed to unpack these associations more fully and identify intervention strategies in this context.

Maternal mental distress is associated with child feeding practices and anthropometry in VietnamPhuong H. Nguyen1, Purnima Menon2, Rawat Rahul3 and Marie T. Ruel3

1International Food Policy Research Institute (IFPRI), Hanoi, Viet Nam; 2IFPRI, New Delhi, India; 3IFPRI, Washington, DC. Poster presentation at the Experimental Biology conference in 2011

Example of Program Implementation

The HEAL Project

Janine Schooley, MPHSr. Vice President for Programs

Health

Education

Action for Latinas

What is HEAL? Health Education Action for Latinas

A Guide

A Curriculum

A Discussion

What are the roles a woman plays in her life, family,

community, work, church, etc.?

HEAL’s History

Methodology originally developed and conducted by PCI from 2001-2004.

Overall goal: to improve the health and well-being of Latina women by focusing on the area of mental health, while integrating community needs & empirically-based “best practices” for Latinas.

In this model, community health workers (“promotoras”) lead a series of six small group sessions designed around the theme of “Es Dificil Ser Mujer?” (“Is it Difficult to be a Woman?)”

Group setting

Guided discussion around specific topics

Time set aside for women to reflect & dialogue

A program that builds self esteem

Educational, psychological, reflexive

Gender-specific

How does HEAL work?

Screening

All clients are screened for depression 3X by Patient Navigators (PNs)

Antenatal: Center for Epidemiological Studies Depression Scale (CES-D 10)

Postpartum: Edinburgh Postpartum Depression Scale at post-partum and 6 months

Both screening tools are designed for the initial screening of symptoms related to depression or psychological distress

A score of 10 or higher on either screening tool generates an automatic referral to the HEAL component of the program

PHQ-9 screening tool used in HEAL sessions

Center for Epidemiologic Studies Short Depression Scale (CES-D 10)

Below is a list of some of the ways you may have felt or behaved. Please indicate how often you have felt this way during the past week: (circle one number on each line)

Rarely or none of the time (less than 1 day) = 0Some or a little of the time (1-2 days) = 1Occasionally or a moderate the time (3-4 days) = 2

All of the time (5-7days) = 3

During the past week...1. I was bothered by things that usually don’t bother me 0 1 2 3 2. I had trouble keeping my mind on what I was doing 0 1 2 3 3. I felt depressed 0 1 2 3 4. I felt that everything I did was an effort 0 1 2 3 5. I felt hopeful about the future 0 1 2 3 6. I felt fearful 0 1 2 3 7. My sleep was restless 0 1 2 3 8. I was happy 0 1 2 3 9. I felt lonely 0 1 2 3 10. I could not “get going” 0 1 2 3

Scoring Items 5 & 8 3 2 1 0 All other items: 0 1 2 3

A score of 10 or greater is considered depressed.

Edinburgh Postnatal Depression Scale (EPDS)1. In the past week I have been able to laugh and see the

funny side of things:- As much as I always could

- Not quite so much now- Definitely not so much now

- Not at all

2. In the past week I have looked forward with enjoyment to things:

- As much as I ever did- Rather less than I used to

- Definitely less than I used to- Hardly at all

3. *In the past week I have blamed myself unnecessarily when things went wrong:- Yes, most of the time- Yes, some of the time

- Not very often- No, never

4. In the past week I have been anxious or worried for no good reason:- No, not at all- Hardly ever

- Yes, sometimes- Yes, very often

5. *In the last week I have felt scared or panicky for no very good reason

- Yes, quite a lot- Yes, sometimes

- No, not much- No, not at all

6. *In the past week things have been getting on top of me:- Yes, most of the time I haven't been able to cope at all- Yes, sometimes I haven't been coping as well as usual- No, most of the time I have coped quite well- No, I have been coping as well as ever

7. *In the past week I have been so unhappy that I have difficulty sleeping:- Yes, most of the time- Yes, sometimes- Not very often- No, not at all

8. *In the past week I have felt sad or miserable:- Yes, most of the time- Yes, quite often- Not very often- No, not at all

9. *In the past week I have been so unhappy that I have been crying:- Yes, most of the time- Yes, quite often- Only occasionally- No, never

10. *In the past week the thought of harming myself has occured to me:- Yes, quite often- Sometimes- Hardly ever- Never

QUESTIONS 1, 2, & 4 (without an *)Are scored 0, 1, 2 or 3 with top box scored as 0 and the bottom box scored as 3.QUESTIONS 3, 5-10 (marked with an *)Are reverse scored with the top box scored as a 3 and the bottom box scored as 0.Maximum score: 30Possible Depression: 10 or greater Always look at item 10 (suicidal thoughts)

PRIME-MD Patient Health Questionnaire- PHQ-9

Scoring Method For Diagnosis Major Depressive Syndrome is suggested if: • Of the 9 items, 5 or more are circled as at least "More than half the days" • Either item 1a or 1b is positive, that is, at least "More than half the days"

Minor Depressive Syndrome is suggested if: • Of the 9 items, b, c, or d are circled as at least "More than half the days"

• Either item 1a or 1b is positive, that is, at least "More than half the days" For question 1:Score Action <4 The score suggests the patient may not need depression treatment. > 5-14 Physician uses clinical judgment about treatment, based on patient’s duration of symptoms and functional impairment. >15 Warrants treatment for depression, using antidepressant, psychotherapy and/or a combination of treatment

Depression screenings2007-2010

Total screened: 484•Antenatal- CESD-10 and

•* Post partum- Edinburgh

Total referred to HEAL: 162 (34%)

* PHQ-9- pre and post sessions

Support Groups

The HEAL Educator lead a series of six small group sessions designed around the theme of “Es Dificil Se Mujer?” (“Is it Difficult to be a Woman?”) to help women identify areas of their lives they wish to change or improve.

Sessions address stress, depression and provide women with the information, skills, and support necessary to deal appropriately with these issues.

Curriculum is designed to reduce stigma around mental health issues and promote communication, empowerment and expanded self-care, including proper nutrition, exercise and general well-being.

6 Weekly Sessions

What is depression?

Why do we get depressed?

Our childhood

Major life events A woman’s

upbringing What to do? &

Where to go?

What to do?

Define what is happening Re-evaluate self: how to handle mistakes and good qualities Change in beliefs: role, love, suffering Expressing fear, sadness & anger New ways to perceive environment New ways to behave: share,

communicate & ask for help

Where to Go? Discuss community resources and referrals

The HEAL Educator provide referrals for treatment and other support services, follow up to ensure client compliance

PNs coordinate mental health referrals with core partner clinics as well as private practitioners and other programs in the community

The PN and HEAL Educator screen provides for cultural and linguistic competence before making referral

Barriers

Women prefer home sessions vs. group sessions as they get more individualized attention/staff time

Missed sessions due to competing priorities

Spouses/ partners may see sessions as threat and women are afraid of their anger & disapproval

Outcomes

General Latina women:

Improved depression scores by 40%

Pregnant women:

Improved depression scores by 60%

Thanks/Gracias!

Buzz Group Sessions

Questions:

Each group prepare 2-3 bullets for each question:

1. How can we integrate Maternal Depression/PPD/mental health into our MNCH and Nutrition programs?

2. What will it take?

3. What are the concerns?

4. Any next steps?

Feedback from Buzz Groups

Thank You