Ninth Annual Maternal and Child Health Epidemiology Conference / December 10-12, 2003

Improving the Mental Health of Women Recognition and Treatment of Depression

PATRICIA L. RYDER:  Thank you.  First of all, I'm not Dorothy.  Dorothy is taller, thinner, and younger, and I wish she were here to do this today, but she's moved-- I’m not sure if it's upward but onward.  She's now working with the Steps to a Healthier U.S. grant that we were fortunate enough to get in Pinellas County.  At the time that she did this study, I was her supervisor, so I worked with her, and I'm fairly familiar with it.  I'm not sure I'll be able to answer all your questions, but I'll give it my best shot, and I will promise to give you Dorothy's e-mail address because she will be happy to answer all your questions.

First of all, I want to just share with you a story of a mom who actually suffered from postpartum depression.  *Shanna has a three-year-old daughter, and she suffered from postpartum depression when she was born.  She said, "My idea of what it was like to have a child and to extend our family was that it was going to be just perfect-- that she would be born, that I would love her more than anything in the world, an instant love, just fall in love at first sight, and it wasn't like that.  Things really got to a point where I couldn’t function.  I wasn't sleeping.  I wasn't eating.  I wasn't myself.  I felt like I was hollow inside, like there was no feeling there.  It was a complete numbness, and all that was replaced inside of me was with anxiety.  I didn't feel love for this baby.  I would sit there nursing and just cry for hours.  I never stopped loving my husband, but I was prepared to leave him and the baby if I would feel better.  Sounds pretty selfish, doesn't it?  It was a very painful time in my life.  I wouldn't wish postpartum depression on anyone."  So it's out there, and most of us are like her.  We think when we get pregnant, life's going to be great, and we're going to fall in love with the baby, but not always that way. 

So some background on this.  About 50 to 75 percent of all new moms experience some sorts of feelings of sadness after birth.  One in 10 new mothers experience varying degrees of postpartum depressions.  The symptoms can occur after childbirth, during pregnancy, after a miscarriage or termination, or up to a year or so after delivery.  Our objectives here were to start to use a depression screen or scale to try to determine the number of pregnant and postpartum women who screened positive, the major factors causing symptoms of depression in our population, what referral process we might be able to develop for clients who scored 12 or higher, what resources were going to be available to these clients, and what barriers we might find in mental healthcare.  And so a little background just for those of you who aren't familiar with Florida system.  In Florida, there's a statewide Healthy Start initiative, so all women are mandated by law-- all practitioners are supposed to do prenatal screens for risk factors for poor pregnancy outcomes.  So the women that are-- I'm telling you this because the women that were actually now screened for depression in our system have already been screened for high-risk pregnancy outcomes. 

So it's not surprising, I guess, that we have some maybe higher numbers of people that show depression in this group than perhaps you would in a population of all pregnant women.  Okay?  Also, you'll notice-- this is a postnatal depression scale, and we're using it for pregnant women also because that was the scale we had, and we decided to see how it would work.  So the methodology was that we used the *Edinborough Postnatal Depression Scale.  It's a short 10-question document, and that was selected as our tool.  Care coordinators in these-- in our case can be anything from what we call a family support worker, who's basically a paraprofessional, up to and including nurses, but by far, the majority of the care coordinators are paraprofessionals.  They were trying an administration and scoring the tool, and clients with a score of 12 or above were supposed to be given a mental health referral. 

So what Dorothy did was to take the first 1,270 screens completed to look at for this particular evaluation, 271 of those scored 12 or higher.  And of those, 271-- 247 still had their cases open, so in some cases, when we needed to look for more information, our sample size was 247.  So if that seems to go back and forth, it's because of those two things.  Finally, file reviews and interviews were done with caseworkers to get additional data.  Now, for our results.  Demographics in this population for us were-- pretty much mirrored our Healthy Start population in Pinellas County.  Two women were Asian, 79 African-Americans, one Native American, and 165 white.  The average age was 25, and you can see the breakdown.  Only 21 were 13 to 17; 105, 18 to 24; 110, 25 to 35; and then 11 were 35 and above.  And the overall majority of high scores were white women between the age of 18 and 35.  How we administered them?  The initial goal was to give at least one during the prenatal period and another at least one during postpartum.  For one reason or another, this is the way-- the sample that we looked at broke down.  Ninety-nine were done during the prenatal period, 81 during postpartum only, and then 67 were done at least twice.  And this is a typo; it should be 148, but its 60 percent overall were screened during the postpartum period. 

So for the scores, as I said, 271 of the total scored 12 or above, and 21 percent to us was quite a high number, one in five of our women giving indications of depression.  The average score was 15, and on the first screen, 14 percent scored 12, 54 percent scored 13 to 17, and 32 percent scored 18 or higher.  These were-- of the ones who had two screens, this shows how they changed.  Nineteen percent increased regardless of whether or not they got counseling, 47 percent decreased if they had counseling that included a minimum of eight visits, and 34 percent scored the same and had counseling.  So referrals and compliance, this was where we expected to have most of our insights or get much of the information we need to provide the services we wanted to provide.  Ninety-seven percent received referrals to an outside facility or to an in-house mental health advocate.  Of those, over half completed at least an eight-week set of visits with a qualified professional.  Ten percent met with a provider once but didn't comply with the plan.  And 35 percent, which is pi, refused any mental health services at all. 

They cited as reasons the stigma of mental illness; depression was situational-- they thought it would go away; their partner or parent refused to allow them to do it; or they felt like they had a conflict in their schedule or work or whatever.  So basically, the summary of that is that 35 percent refused, 10 percent were just basically noncompliant, and 55 percent complied with their recommendations.  The major areas of stress in trying to identify what were causing the problems in our population, 29 percent presented to us with having currently a mental health disorder or having a history of depression.  All of the folks that scored 12 or above chose life issues as a major problem, whether it was finances, housing, transportation, education, childcare, or lack of insurance; about 20 percent of these people had substance abuse problems; 10 percent had parenting or childbirth-related issues; 10 percent had domestic violence issues; and 5 percent had DCF or other legal involvement. 

DCF is our child protective agency for the health-- for the state.  Finally, the barriers that they identified keeping them from either accepting a referral or completing their plan of care was lack of insurance, language issues, social stigma, wait times, schedule conflicts, spousal parental refusal, and transportation.  One of the things we looked at was the insurance coverage because as we began this process, we discovered that we could get the mental health-- if we were referring to a licensed mental health counselor, Medicaid paid for it.  However-- and you can see about 67 percent had Medicaid coverage when they this screen done-- but the note along the bottom says almost 50 percent of the clients lost their Medicaid coverage during the postpartum period.  So that's probably when they needed it most and when they lost the ability to receive the care. 

So the conclusions we had were that a significant percentage, 21 percent, screened 12 or higher, which for us verified the need for more mental health services targeting this issue.  We felt the screening process should be more aggressive in capturing postpartum women, and it's important not to rely on a negative screen during pregnancy and repeat screen during the early postnatal period to rule out specific symptoms of postpartum depression.  Approximately one-third of the clients declined mental health services due to what they perceived as a social stigma against that, and just as a comment, one of-- it may be that one of the providers we had was-- had a high negative association in the minds of the clients with the-- a mental illness stigma.  There's a need for multicultural and bilingual services in the community.  And, finally, Medicaid dollars should be utilized to provide more in-house medical-- mental health services for these clients.  We felt that as far as public health implications go, this screen is just a first step towards addressing the mental health needs of pregnant and postpartum women. 

Our results certainly can't be generalized to another population but really should encourage policymakers to mandate a universal tool for providers for early detection of these symptoms in women.  As we said, one in 10 new mothers experienced some symptoms of depression.  If left untreated, tragic outcomes could occur for the babies and their moms.  Screening provides a mechanism to detect symptoms and connect women to resources to prevent these types of outcomes.  And that's about it.  Those of you who have been to this conference a lot know Dr. *Dromerageclod-- *Dromerage.  She couldn't be with us this year.  She's in France, lucky woman.  But Dorothy also wanted to thank Jane *vanBase, who's the Director of the Community Health Division, for helping with this presentation.  And, finally, all of those millions of questions you have, here's Dorothy and here's her e-mail address.  You're welcome to send them to her.  But I will take any questions you have and try to answer them for you.