Addressing Maternal Depression and Trauma in Home Visiting
Robert T. Ammerman, Ph.D, ABPP Every Child Succeeds and
Cincinnati Children’s Hospital Medical Center
3rd Annual Strengthening Families Summit on Parental Depression
Concord, New HampshireMarch 31, 2014
Depression in Mothers
• Determined by self-report– Edinburgh Postnatal Depression Scale– Center for Epidemiological Studies Depression
Scale (CES-D)– Beck Depression Inventory-II (BDI-II)– Patient Health Questionniare-9 (PHQ-9)
• Diagnosis of major depressive disorder (MDD)– Postpartum onset ≤6 months– Prenatal
Depression and CMS Claims
Symptoms of Major Depressive Disorder (MDD)
• Sadness• Crying• Fatigue• Disinterest• Sleep problems• Appetite problems• Agitation or slowness• Poor memory• Poor concentration• Low self-esteem• Guilt• Low motivation• Hopelessness • Suicidal thoughts• Decreased libido
CONSISTENT&
PERSISTENT≥2 weeks
Phenomenology• Pervasive loss
– Loss of control– Loss of self– Social disconnection– Loss of voice
• Spiraling downward– Anxiety– Overwhelmed– Rumination– Obsessive thinking– Anger– Guilt
From C.T. Beck, 2002
Phenomenology (cont.)
• Expectations and reality– Shattered dreams– Failure & incompetence– Fear of negative evaluation
• Making gains– Surrendering– Despair and hopelessness– Struggle
Things have been so rough latelyI know you can feel it tooI've been through this beforeBut this time I have youSometimes I feel so downI just want to run awayBut then I see you my angel& that's what makes me stayFrom growing in my tummyTo practicing to stand Time is going by so fastThis was definitely never the planI've been so tough on myselfBecause I believe you deserve the best
I try to be the perfect momBut on the inside I'm just a messSo bare with me baby girlI'm fighting this depression for youI'm still a little brokenBut I know I'll make it throughYour my strength my pride Everything that's good in meSomeday I hope I'll be ableTo see just what you seeBut until then I'll continue tryingTo make all your dreams come true& no matter what happensI'll always love you.
Epidemiology of MDD• Lifetime prevalence for the general population is
as high as 1 in 3, often begins in childhood or adolescence
• Lifetime prevalence in women postpartum: 13-26%
• Average length of episode: 3-6 months• Impairment: 87% report significant role
impairment (social, home, relationships, work)• Comorbidity: 71% (anxiety disorders, substance
use disorders)• Risk for subsequent episodes: 80%• Odds of relapse within 2 years: 50%• First episodes in postpartum period: 50%
Associated Features
• Nationally, 57% receive treatment. Only 64% get at least minimally adequate treatment.
• 20-30% of women depressed postpartum receive treatment, less among low income.
• Failure to successfully treat the first episode increases risk for subsequent episodes and increases likelihood of treatment resistant depression.
• Suicide risk: between 4-15%
Maternal Depression is Expensive
Mother• Employment• Education• Health care utilization• Lifetime earnings
Child• Preterm birth• Cognitive delays,
special education• Mental health
treatment• Injury and illness• Child abuse and
neglect
Maternal depression is a multigenerational issue.
Economic Costs• World Health Organization (2012)—Depression is
the leading cause of disability worldwide• Depression in adults costs $83.1 billion
annually, including 31% direct medical costs, 62% workplace costs (absenteeism, presenteeism and disability) and 7% for suicide/mortality costs
• Depressed employees miss 27.2 days of work per year
• Maternal depression is associated with an increase in pre-term births which average $51,600 per birth
• Family lifetime loss in income potential is $300,000 due to childhood onset of psychological problems
• Identification and effective treatment saves money and protects investments in other programs.
Depression 2 years Postpartum
Sample: 1,359 women over 2 years postpartum
Measure:Edinburgh PostnatalDepressionScale
From Mayberry et al., 2007
Center on the Developing Child, Harvard University, 2009
Video Example
Diagnostic Interview with a Depressed Mother in Home
Visiting
Risk Factors for Depression
• History of depression• Cognitive and emotional vulnerability:
pessimism, anxiety, low self-esteem• Stressful life events• Low social support• Poverty• Unmarried• Unwanted pregnancy• Trauma history
Trauma
Traumatic events are shocking and emotionally overwhelming situations that may involve actual or threaten death, serious injury, or threat to physical integrity.
Reactions to traumatic events vary considerably, ranging from relatively mild creating minor disruptions in the person's life to severe and debilitating.
International Society for Traumatic Stress Studieshttp://www.istss.org/WhatisTrauma/4339.htm
Types of Interpersonal Traumatic Experiences
• Physical abuse• Sexual abuse• Emotional abuse• Witnessing violence• Physical or sexual assault• Intimate partner violence
TimingSeverityFrequencyDuration
Trauma experiences of mothers in home visiting
43.7%
32.7%
28.2%
26.7%
31.2%
13.4%
Percent
Ammerman et al., 2009
N=806Trauma=74.1%
2+=68.9%
Impacts of interpersonal trauma
Traumatic Experiences
Biological Behavioral Social
emotional dysregulation
fear and avoidance
relationship maladjustment
Posttraumatic Stress DisorderComplex trauma
The HPA Axis
Hyman, 2009 (Nature)
Effects of Dysregulated Cortisol
Greater or lesser sensitivity to stress cuesGreater arousal, more time needed to recoverInattention, distractibilityPoor memoryEmotional and behavioral dysregulation
Biobehavioral Response to Trauma
-Genes contribute to how we respond to stress.-Genes can make us more vulnerable to traumatic stress.-Genes can be altered through exposure to traumatic stress, and these changes can be passed on to offspring.
-Traumatic stress alters how neurons connect with each other and how they work.
-Traumatic stress changes brain architecture. These changes can occur in the developing fetus and remain for a lifetime.
Adverse Childhood Experiences (ACE) Study
• N=17,337 men and women, varied demographics, recruited 1995-1997
• Lifespan perspective on effects of ACEs on health and well-being
• Identified 10 ACEs that were highly predictive of poor outcomes
Felitti et al., 1998
Increased risk for poor health & social outcomes
• Alcoholism and alcohol abuse
• Chronic obstructive pulmonary disease (COPD)
• Depression• Fetal death• Health-related
quality of life
• Illicit drug use• Ischemic heart
disease (IHD)• Liver disease• Risk for intimate
partner violence• Multiple sexual
partners
Increased risk for poor health & social outcomes
(cont.)• Sexually
transmitted diseases (STDs)
• Smoking• Suicide attempts• Unintended
pregnancies• Early initiation of
smoking
• Early initiation of sexual activity
• Adolescent pregnancy
• Early death
www.cdc.gov/ace/index.htm
ACE Score Items
1. Emotional Abuse2. Physical Abuse3. Sexual Abuse4. Emotional
Neglect5. Physical Neglect
6. Parents separated or divorced7. Mother IPV8. Household problem
drinker or drug user
9. Household mental illness
10.Household prison
SCORE: 0-10
Endorsement of ACE Items (N=94)
1 2 3 4 5 6 7 8 9 100%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
8.5%12.8%
21.3%
50.0%
30.9%
67.0%
39.4%
55.3%
38.3%
18.1%
1-Emotional Abuse 2-Physical Abuse 3-Sexual Abuse 4- Emotional Neglect 5-Physical Neglect
6-separate/divorce, 7-mother IPV, 8-alcohol/drugs, 9-mental illness, 10-prison
ACE Total Score in HV Sample and CDC 2009 Five State Survey, Female (18-24 yrs)
Sample
0 1 2 3 ≥40%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
9.6%
17.0%20.2%
9.6%
43.6%
35.5%
22.6%
13.2%
7.6%
21.0%
Key Features of Infant Social and Emotional Development
• Infants can imitate facial expressions and show preferences for caregivers.
• Infants have a need to seek out communication with others.
• Infants can elicit social and emotional responses from caregivers.
Key Features of Infant Social and Emotional Development
• Communication between mothers and infants is organized around face, voice, gesture, and gaze--“a dance”.
• Secure attachment is the cornerstone of early social and emotional development.
• Communication directly influences, and is influenced by, brain development and emerging physiological regulation.
Key Features of Infant Social and Emotional Development
• In normal mothers’ interactions with babies, 42% of time is spent exhibiting positive affect. For babies, 15% of time.
• Mothers “guide” the quality of the interaction and the direction of development. They provide the scaffolding needed for successful development.
Characteristics of Depressed Mothers
• Withdrawn: disengaged, flat, unresponsive, little support.
• Intrusive: rough, angry, interrupt• Unable to read cues.• Rejecting.• Imbalanced, discordant.
Characteristics of Depressed Mothers
• Don’t enjoy parenting.• View themselves as less competent and
ineffective.• View children as more difficult.• Less tolerant.• More likely to attribute inappropriate intent in
children.• See their behavior as caused by outside
influences.• Preoccupied, less attentive, don’t anticipate.• Slower and less effective problem-solvers.
Course of Depression & Development (illustrative)
1st episode4 months
2nd episode 9 months
3rd episode 2 months
Age 16 Baby born(age 20)
child 1 year old
= depressive episode = normal mood
4th episode 3 months
child 3 years old
time
Impact on Infants and Development
• Avoid mom, look away (for intrusive moms), docile, typically following maternal rejection.
• Fussy, cries, focus on self-regulation (for withdrawn moms).
• Crystallizing of communication patterns.• Delays in emotional regulation, and
physiological organization.• Attentional problems.
IMPORTANT: timing, length, severity, frequency,inter-episode functioning, partner support, other adults
Video Example
Mother-Child Interaction Using Still-Face Paradigm
Treatment Challenges
• Treatment capacity• Availability of evidence-based treatment• Access and disparities• Choice and engagement• Antidepressant medications: adherence,
effect on developing fetus, cost, trauma issues
Moving Beyond Depression™
Overcoming barriers, fostering collaboration, and engaging depressed mothers in a non-
traditional setting
www.movingbeyonddepression.org
Unique Opportunity in Home Visiting
• Reach mothers who might not otherwise receive treatment.
• Appeal to mothers’ interest in their baby’s development.
• Lower barriers to treatment.• Identify mothers early in the MDD episode.• Leverage relationship between mother and
home visitor.• Leverage ongoing and lengthy home
visitation services to optimize outcomes.
Course of Depression (BDI > 13 @ enrollment and/ or 9 months) in home
visitation (N = 806)
44.2%
55.8%Non-DepDep
12% receive mental health treatment
Ammerman et al., 2009
74.8%withtraumahistory
Essential Intervention Elements
Ameliorate depressive symptoms
Help mother and home visitor/service
Collaborate with home visitor, no burden
Implement in home to remove barriers
Use evidence-based treatment
Fit with population, setting, & service
IH-CBT: Adaptations to Setting
Overcome barriers to treatment to reach mothersObserve mothers in natural environment
Observe important features that would not be evident in officeMaximize learning and application of new skills
Logistical challenges: privacy, other family, distractionsUnexpected challenges and crises
IH-CBT: Adaptations to Population
New mothers with limited parenting experienceYoung mothers with few social supports
Emerging adulthoodEducational underachievement & lower IQ
Cultural sensitivityPoverty and hardship
Trauma history & intimate partner violencePsychiatric comorbidity
IH-CBT: Adaptations to Service
Collaborative relationship with home visitorLogistical coordination of multiple services
Frequent contacts with home visitorCoordination of careAvoid triangulation
Conceptual representation of IH-CBT collaboration
MOM
THERAPIST HOME VISITOR
primarilyHV domains
primarilydepressiondomains
MIDIS DesignScreening: EPDS ≥11
Eligibility/Pre-treatment AssessmentSCID Diagnosis of MDD
IH-CBT15 sessions + booster
Ongoing home visitation
Typical Home VisitationCommunity resources
Ongoing home visitation
Post-treatment Assessment
3 Month Follow-Up Assessment
Inclusionary:ECS participant≥16 years oldBaby 2<10 monthsEPDS ≥11MDD using SCID
Exclusionary:Substance depend.PsychosisCurrent suicidalityMeds or therapy
randomization
N=93Retained: 86.8%≥ 2 points: 95.6%
34.8%receivedcommunitytreatment
Demographics of Sample (N=93)
Mother Age: 22.0 (4.6) years
Mother Race: Caucasian 62.6% African American 34.1% Asian American 1.1% Hawaiian/Pacific Islander 1.1% Native American 1.1%
Mother Ethnicity: Appalachian 3.3% Hispanic 7.7%
Mother Marital Status: Married 13.2% Separated 1.1% Single, never married 85.7%
Demographics of Sample (cont.)
Mother Education: 11.4 (1.9) years
Number of Children 1 92.3% 2 - 3 7.7%
Family Income: $ 0- 9,999 54.8% $10,000-19,999 21.1% $20,000-29,999 16.4% $30,000-39,999 3.3% $40,000-49,999 2.2% $50,000-59,999 2.2%
Baby Age (days): 154.5 (74.0)
Clinical Features of MDD
• MDD: 100%• BDI-II: 33.7 (10.1) EPDS: 18.9 (4.0) HDRS: 21.7 (4.6)• Severity— Mild: 28.9% Moderate: 46.7% Severe: 24.4%
• Postpartum onset: 29.2%
• Recurrent: 75.3%• # Episodes: 2.66
(1.59)• Suicide attempts:
43.9%• Age of 1st episode: 15.1 (5.2) years
0%5%
10%15%20%25%30%35%40%45%50%
Current
Past
Current and Lifetime Comorbid Psychiatric Disorders
BDI-II Scores at Pre-Treatment, Post-Treatment, & Follow-Up
5
10
15
20
25
30
35
Pre Post FU
Assessment Time Point
BD
I-II
Sco
re
IHCBT
THV
F=7.9, p<.01 Not affected by therapist or home visiting model
MDD Diagnosis at Pre- & Post-Treatment & Follow-Up
Pre Post FU0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%100.0%
29.3%
20.1%
100.0%
69.8%
52.6%
IHCBTTHV
Χ2=19.0, p<.001
MDD Diagnosis at Pre-treatment, Post-treatment, & Follow-Up for Completers, Partial
Completers, & THV
Pre Post FU0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%100.0%
21.7%
9.5%
100.0%
40.0%44.4%
100.0%
69.8%
52.6%
Comp<15 sessTHV
Social Support Using ISEL Scale (Total)
40
45
50
55
60
65
70
75
80
85
90
Pre Post FU
IH-CBT
THV
F=5.1, p<.01
0% 20% 40% 60% 80% 100%
IH-CBT Client Feedback at Post-Treatment
Therapist and Home Visitor worked together to help me
Sessions in home were convenient
Happy with level of confidentiality
I feel more confident as a parent
0% 20% 40% 60% 80% 100%
IH-CBT Home Visitor Feedback at Post-Treatment
Therapist was available
Therapist and I collaborated on case
Happy with level of confidentiality
Predictors of symptom status at post-treatment
Symptomatic Asymptomatic0
2
4
6
8
10
12
14IH-CBT sessionsHome visitsSeries3
BDI-II at post-txt: ≥9 ≤8
Ammerman, R.T., Peugh, J.L., Putnam, F.W., & Van Ginkel, J.B. (2012). Predictors of treatment response in depressed mothers receiving In-Home Cognitive Behavioral Therapy and concurrent home visiting. Behavior Modification, 36, 462-481.
Recovery and HOME
RR DR RD DD25
27
29
31
33
35
37
39
PostFU
Dissemination
Massachusetts(4 sites)
Kentucky(6 sites)
Connecticut(4 sites)
Kansas(1 site)
www.movingbeyonddepression.org
Upcoming Resources
Special issue, Maternal Depression& Home Visiting, May, 2014
Coming soon from SAMHSA
Acknowledgments• Frank W. Putnam, M.D. & Judith B. Van Ginkel,
Ph.D.• Jack Stevens, Ph.D., Mekibib Altaye, Ph.D., James Peugh,
Ph.D.• Jodie Short, Margaret J. Clark, M.P.A., Lawson Wulsin,
M.D., Jennie Noll, Ph.D., Chad Shenk, Ph.D., Neil Richtand, M.D., Ph.D., Nicole Bosse, M.A., Angelique Teeters, Psy.D.
• Healthy Families America and Nurse-Family Partnership• Grant support: National Institute of Mental Health
(R34MH073867 & R01MH087499)• Every Child Succeeds agencies and home visitors!• Health Foundation of Greater Cincinnati• Kentucky H.A.N.D.S. & Ohio Help Me Grow• United Way of Greater Cincinnati• Xavier University, Dept. of Psychology
www.everychildsucceeds.org
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