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Perinatal Mood and Anxiety Disorders: Healthy Mothers, Healthy Communities

Elizabeth M. LaRusso, MDTina Welke, LICSW

September 2019

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Objectives

• Describe the impact of perinatal mood and anxiety disorders (PMADs) on women, their families, and their communities

• Review an empathic approach to engaging women and their families in appropriate treatment

• Identify key resources in the community to help improve the care of women experiencing PMADs

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Objective #1

Describe the impact of perinatal mood and anxiety disorders (PMADs) on women, their families, and their communities

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The Mother Baby Mental Health Program

Mission: We partner with women, their families and care teams to optimize mental health throughout the transition to motherhood.

Vision: To transform the delivery of perinatal mental health care.

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What do we believe?

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How common are PMADs?

• Highest rates in childbearing women, 8-23%

• PPD is one of the most common complications of pregnancy

• Anxiety is less studied; 13-21%

• Allina Health/MBCSL is the largest pregnancy care provider in Minnesota

– >15,000 deliveries in 2017 = 3,000 pts

Bonari et al, Can J Psychiatry 2004. Marcus et al, J Women’s Health 2003. Yonkers et al, APA/ACOG report, Obstet Gynecol 2009.

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What is the impact of untreated PMADs on pregnant women?

• Poor maternal health• Higher use of alcohol & tobacco• Increased total medication exposures• Decreased weight gain/poor nutrition• Decreased compliance with prenatal care• Increased risk of postpartum depression

Bonari et al, Can J Psychiatry 2004. Wisner et al, Am J Psychiatry 2000. ACOG Practice Bulletin, Obstet Gynecol 2008.

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What is the impact of untreated depression on obstetric outcomes?

•Pre-term delivery•Low birth weight•Preeclampsia

Cripe 2011, Davis 2007, Hollins 2007, Li 2009, Ding 2014.

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What is the impact of untreated PMADs on children?

• Decreased activity level, attentiveness, facial expression in newborns

• Increased irritability/reactivity to stressors, elevated cortisol levels in newborns

• Delayed language development

• Increased risk of long-term social, emotional, & behavioral problems in children

Yonkers et al, APA/ACOG report, Obstet Gynecol 2009. Nulman et al, Am J Psychiatry 2002. Weissman et al, JAMA 2006. Pilowsky et al, Am J Psychiatry 2008. Bonari et al, Can J Psychiatry 2004. Glover et al, British J Psychiatry 2002.

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• Increased relationship discord

• Disrupted bonding between parents and children

• Financial loss from missed work

•Multigenerational trauma:

– Suicide is the leading cause of maternal death in the first postpartum year

Oates M. Suicide: the leading cause of maternal death. British J Psych 2003; 183, 279-281

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What is the impact of untreated PMADs on families?

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• Every untreated case of maternal depression in Minnesota is estimated to cost society at least $23,000 annually in increased health care costs and lost productivity

• Untreated PMADs were estimated to cost the US $14.2 billion dollars in 2017

Zero to Three Research to Policy Project: Maternal Depression and Early Childhood Summary. Children’s Defense Fund, Minnesota, May 2011. Mathematica Policy Research, Luca et al, April 2019.

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What is the financial impact of PMADs?

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Does my insurance cover mental health treatment?

Mathematica Policy Research, Luca et al, April 2019.

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What’s the good news?

• Depression is one of the most consistent, well-replicated risk factors for childhood anxiety, disruptive behavior, & depression, BUT…

• Remission of maternal depression is significantly associated with lasting reduction of childhood psychiatric symptoms, AND…

• Depression is treatable! With support and treatment, it does get better.

Weissman MM et al, JAMA 2006. Pilowsky DJ et al, AM J Psychiatry 2008.

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Objective #2

Review an empathic approach to engaging women and their families in appropriate treatment

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What do women want?

•Women often have exaggerated concerns & misinformation about mental health issues during pregnancy & the postpartum period

• Qualitative studies reveal that many women want their OB provider to address their emotional needs

•Women note many barriers to accessing mental health treatment & prefer to receive care from trusted providers

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Lisa’s story…

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• It is important to consider what feelings this evokes in you, possibly anger, sadness, disbelief, helplessness

• How could this happen in our health care system? What could have been done differently?

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What is your reaction to Lisa’s story?

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• Always lead with empathy, regardless of level of intensity and stress

• Be aware of your own emotional reaction and inadvertent negative judgements

• Lead with open-ended quesMon s

• Listen to patient concerns throughout interaction

• Ask clarifying questions and do not make assumptions

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How should you approach Lisa?

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How can you perform a therapeutic intervention?

• Take a non-judgmental, supportive stance

• Acknowledge efforts to be a good mother

• Involve partner/support system

• Provide education to patient & partner

• Encourage acceptance of meds when indicated

• Encourage modification of breastfeeding expectations when indicated, especially to protect sleep

• Provide appropriate community resources

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2020

Empathy vs Sympathy-Brene Brown

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Goal:

-Join with the patient and help them see benefits of change

-Make a positive impact

-Help with intervention/connection to treat perinatal mental health!

Practice the following:-Open ended questions, such as: tell me more about, help me understand, what I hear you saying is….

-Asking tough questions can be difficult and important, “I understand you have a history of anxiety, tell me more….”

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Motivational Interviewing

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• Never underestimate the power of your interventions

• Nurses can have an enormous impact on a patient's experience, positive and negative

• Be present and curious

• Always lead with empathy, curiosity, and the belief that almost all mothers are doing the best they can

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What is the optimal role for nurses in supporting new mothers?

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• When at a loss for what to say, it’s often best to listen attentively and empathically to patients.

• Standard expectation for perinatal loss-– Health care worker’s role is to create an empathic, caring

environment that promotes a patient’s/family’s acceptance of the reality of death

• Bereaved parents never forget the understanding, respect, and genuine warmth they receive from caregivers– The experience is lasting and important and included in their

memories of their lost pregnancy and baby

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The Power of your Role: Your Intervention Matters!

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Take a non-judgmental, supportive stance

Acknowledge pt’s efforts to be a good mother

Involve pt’s partner/support system

Provide education to patient & partner

Encourage acceptance of meds when indicated

Encourage modification of breastfeeding expectations when indicated, especially to protect sleep

Provide appropriate community resources

Optimal Role of the RN

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• What helps protect and sustain parents/families in the aftermath of such unambiguous and tragic loss?

– Essential elements of quality care include: deep respect for individuality and diversity of parents' grief and respect for deceased child

– This is not about the amount of time you spend with a patient, it’s about the quality of the intervention

• It is essential that every team member provide compassionate care that meets or exceeds patient’s expectations

– Respect for patient’s grief process– Nonjudgmental– Communicate a sense of caring– Personal Involvement

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“Efficient Empathy”

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Communicating with parents following perinatal loss

What to say and do:

Use simple, straightforward language

Be comfortable showing emotion

Listen to parents and help them with holding the baby

Answer questions honestly

“I don’t know what to say”

“I feel sad” or “I am sad for you”

“Do you have any questions?”

“We can talk again later” “I’m sorry”

“I wish things would have ended differently”

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Communicating with parents following perinatal loss

Things to Avoid saying or doing:

Do not use medical jargon

Do not argue with parents

Do not avoid questions

“It’s best this way”

“It could be worse”

“You can have more children”

“Time will heal”

“It’s good your baby died before you knew him or her well”

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• Value of nursing care and role

• Importance of nursing presence before, during and after childbirth

• RNs are constant during hospitalization

• RN can help patients feel supported, heard and validated

• Communication between patient and medical team, including family

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What is important to remember?

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• No decision is risk-free

• It is impossible to determine absolute risks

• A mother’s emotional stability is critical to the health & wellbeing of her family

•Women with mild-moderate MDD may respond to psychotherapy

•Women with moderate-severe MDD will likely need meds + psychotherapy

• The safest medication in pregnancy is the one that helps the mother get well!

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Are antidepressants safe in pregnancy?(“I don’t want to do anything that’s going to hurt my baby.”)

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What should I know about antidepressants & pregnancy?

• Women (& health care providers) perceive antidepressants to be more harmful than other types of medications

• Risks of untreated MDD frequently overlooked as focus is on risks of medication

• SSRIs (Selective Serotonin Reuptake Inhibitors) are one of the most well-studied classes of medication in pregnancy

• Majority of the data is reassuring!

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Overview of Antidepressants in Pregnancy

Thorsness, Watson, LaRusso, 2018 Am J Obstet Gyn.

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What should I know about antidepressants & lactation?

• Large amount of data supports absence of significant infant risks with most antidepressants

• Case reports of colic, fussiness, drowsiness

• It is not advisable to change antidepressants postpartum

• Overall, the benefits of breastfeeding far outweigh potential risks

TOXNET, LactMed: www.toxnet.nlm.nih.gov.

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Breastfeeding is Best (?)

• The impact of sleep deprivation of the mother is generally overlooked as the focus is on potential risks of medication

• After delivery, clinical attention is heavily weighted towards the infant, not the mother-infant pair

• Sometimes helping women modify breastfeeding expectations and routines the most helpful intervention you can offer!

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Objective #3

Identify key resources in the community to help improve the care of women experiencing PMADs

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MBMHP Web Sitehttp://akn.allina.com/csl/MotherBaby/policies/perinatalmentalhealth/index.htm

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Circle of Moms Support Group

-Open to any pregnant or post partum woman

CALM Moms Support Group

-Open to moms of NICU infants

Mindful Moms Psychotherapy Group

-Therapy group for pregnant women who have anxiety

Inpatient psychotherapy consults

-Mother Baby Center at ANW only, with goal to expand

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Groups at Allina Health

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Circle of Moms: weekly, skills-based group for pregnant & postpartum women

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CALM Moms: weekly skills-based group for mothers of babies in NICU/ICCU/CVCC/SCN at Children’s Hospital, Mpls

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Mindful Moms: Shared Medical Visits at PGIHH

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Mother Baby Day Hospital- HCMC

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Pregnancy & Post Partum Support MN

Support, education, training, awareness

https://www.ppsupportmn.org/

Help line information:

call 612-787-7776 (PPSM)

text 612-787-7776 (PPSM)email PPSMhelpline@gmail.com

Community Resources

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MN Department of Health

Education, fact sheets, maternal well being plan templates

https://www.health.state.mn.us/people/womeninfants/pmad/index.html

Nurse Home Visiting Programs

Evidenced based home visiting program to support to new moms and babies and put them on a healthy trajectory, both physically and emotionally

Contact patients Public Health program in their county of residence

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Resources, continued…

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Metro Alliance for Healthy Families

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www.familydoctor.org

Postpartum Depression Action Plan

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CBT Anxiety Workbook

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www.womensmentalhealth.org

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https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm

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Take-Home Points

• PMADs are common, undertreated, and associated with significant risks to mothers, babies, families, and communities

• Women who experience PMADs often feel guilty, ashamed, and isolated and are very sensitive to being judged

• Antidepressant medication may be one part of a comprehensive treatment plan

• Nurses play a critical role in the identification, support, and treatment of women with PMADs and make all the difference in the experience of our patients!

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Our world view…

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Thank You!

• Please contact us directly with questions or suggestions

•Mother Baby Mental Health Program: 612.863.2273

• Dr. Beth LaRusso- Elizabeth.LaRusso@allina.com

• Tina Welke- Tina.Welke@allina.com