Women and Infants Mental Health Program
Screening, Access to Care, and Clinical Outcomes
A founding research focus of the WIMH Program was to examine methods to improve screening for depression, including identification in primary care settings, and to increase women’s opportunities to receive mental health treatment when needed. Studies about women’s use of mental health treatment during the perinatal period are important since most women at-risk for depression do not receive proper care and when proper care is received, the lives of women and their children can significantly improve.
Interventions, Treatments, and Complimentary Alternative Medicine
Kate Rosenblum, Maria Muzik, Shaun Ho
Perinatal Clinical Outcomes Study
The purpose of this study is to utilize clinically relevant outcome data which is largely already being collected from women who seek treatment with the Women and Infants Mental Health Clinic, while at the same time creating a registry of women who are interested in participating in other, more specific research projects for which they may be eligible. The specific aims of this study are to 1) describe characteristics of women seeking treatment with the perinatal clinical team, 2) identify predictors of treatment adherence and treatment response, and 3) establish feasibility of conducting clinical research in the perinatal clinic in psychiatry. This feasibility phase will consist of a naturalistic descriptive study of patient characteristics and outcomes. All women who seek mental health care at the clinic are asked to complete measures in addition to those she completes on MStrides for clinical monitoring. A subset of these measures will be asked again at 3 and 6 months after the initial assessment. The patients’ health record is examined to extract relevant medical comorbidity diagnoses such as diabetes, hypertension, and thyroid irregularities. This data will be used to examine epidemiology, symptom severity, service utilization, treatment response, and medical comorbidity on a large scale. Researchers plan to examine both the direct and indirect (mediation) effects on treatment outcome measures, as well as moderators and duration of the effect on outcomes. Evaluation the effect of the treatments over time from baseline through follow up and test whether such effect varies by the baseline characteristics will provide insight into the appropriate treatments for corresponding symptoms. This study is still recruiting participants from the Women and Infants Mental Health Clinic and is currently in a data collection phase.
Heather Flynn, PhD. (PI), Kate Rosenblum, PhD., and Sheila Marcus, M.D.
Perinatal Mental Health Registry
The purpose of the Perinatal Mental Health Registry is to identify women who are eligible for and interested in participating in ongoing research studies. Additionally, this registry will be helpful in reducing redundancy in screening assessments administered to women who participate in multiple projects. This project targets the female population seeking prenatal care within the University of Michigan Health System. All women seeking prenatal care at one of the 7 clinics in the University of Michigan health system receive the Edinburgh Postnatal Depression Screen (EPDS) to complete, which is standard of care. Additionally, the medical assistants, clerks, or nurses (varies by clinic) hand out the consent form and screening questionnaire to patients during select OB visits (first or third trimester or both depending on the clinic). Women are given the choice to fill out the forms and provide informed consent to be contacted about specific research studies. A research staff member reviews the screens to determine which IRB approved research study recruiting from the registry the women may be eligible for. Contact information for those women who give informed consent are distributed to each individual study. If a woman is eligible for a study, they will be contacted by that study's research staff and asked to sign a consent form to participate in that particular study's research project.
The Women’s Mental Health Registry receives approximately 30 screening forms per week. Out of those, approximately 50% of women agree to be contacted for research. An additional 11% allows their data to be retained anonymously to ensure that those who agree are representative of the population as a whole. Of those with available EPDS scores, 17% score a 9 or higher (indicating risk for depression,) and 8% score a 12 or higher (indicating likely MDD criteria.) Approximately, 47% of women screened are in their first trimester of pregnancy and 19% are in their 3rd trimester of pregnancy.
Heather Flynn, (PI) and Kate Rosenblum,
OB Study: Does routine screening for depression in obstetrics improve treatment receipt for pregnant women?
This study sought to 1) compare rates of depression and treatment notations in medical charts pre and post screening implementation, 2) examine the impact of routine screening on provider feedback and treatment receipt, and 3) examine depression severity over time as related to treatment receipt. The study implemented routine depression screening in obstetrical settings in an effort to: assess presenting rates of depression in pregnant women; the impact of screening on provider discussion of depression and appropriate referral; and patient follow-through with treatment. In two University affiliated obstetric clinics, pregnant women were administered the Edinburgh Depression Screen (EPDS) as part of routine care. Providers were notified about positive depression risk. Women who screened positive for depression (score of greater than 10) were contacted for a diagnostic interview (SCID-IV). These women were interviewed again one month later.
Over a 12 month period, 1684 women completed an EPDS depression screening at their OB clinic. 16% (n = 269) scored positive for depressive symptoms. Of these women, 35% (n = 94) met criteria for current Major Depressive Disorder, and 28% (n = 75) met criteria for past Major Depressive Disorder (MDD). More than half of the women with current MDD were not receiving any form of treatment (55%), compared to 44% of depressed women reporting current treatment. However, at one month follow-up, only 23% of women overall were receiving treatment suggesting that physician notification did not impact mental health treatment. Routine screening feasibly identifies depressive risk in obstetrics. Screen notification increases physician discussion of depression, but follow-up mental health care by patients is poor. More efforts may be needed to encourage rapid receipt of mental health services for high-risk women.
Heather Flynn (PI) and Shelia Marcus.
Barriers Study: Understanding treatment use in pregnancy
Existing research indicates that practical barriers interfere with women’s ability to receive treatment, such as insurance, available treatment, transportation, and ability to pay. New data from recent research projects suggests that even women who don’t have practical barriers still don’t seek treatment; women’s beliefs about themselves impact whether they will seek treatment; and some women seek help from religious persons, friends, and family before or rather than health professionals. This study was designed to further explore the kinds of barriers women might experience in seeking mental health treatment. We are particularly interested in gaining information about women’s expectations for treatment, issues related to stigma; the support they have from others to seek treatment; and other concerns about treatment. In this study, women were screened at University affiliated outpatient OB clinics for depression symptoms using the Edinburgh Postnatal Depression Scale (EPDS). Those women who screened positive for depression (score of >=10), where then mailed a consent form and survey. The survey inquired about asked about recent formal and informal treatment use in prenatal care settings, confidence in the helpfulness of treatment, providers, and settings, and perceived barriers to treatment.
Pregnant women overall reported low rates of formal treatment use but frequently sought help from informal sources, such as friends, family, and printed materials. All women expressed greatest confidence in psychosocial treatments and lowest confidence in antidepressants. African American women reported less confidence in advice from family and friends and in antidepressants than did white women. Women expressed greatest confidence in treatments delivered by mental health professionals and religious leaders. African American women sought help more frequently and had significantly more confidence in religious leaders as treatment deliverers than white women. Women had greatest confidence in treatments delivered in professional and home settings, with African American women expressing greater confidence in religious settings than white women. All women reported greatest concern with structural barriers, compared with attitudinal and knowledge barriers.
Heather Flynn (PI), Heather O'Mahen
Flynn, H., O'Mahen, H. (2008). Preferences and Perceived Barriers to Treatment for Depression during the Perinatal Period. Journal of Women's Health, 17(8), 1301-1309.
OB CARES: The Obstetric Clinics and Resources National Provider Survey: Practice Patterns in the Treatment of Depression during Pregnancy
The American College of Obstetricians and Gynecologists has issued recommendations for routine depression screening during each trimester as well as treatment algorithms for depression during pregnancy. Yet, little research exists as to optimal strategies for the delivery of depression care in everyday obstetric practice. In addition, we know little of provider decision-making in the treatment of depression during pregnancy. In order to implement these evidence-based recommendations in everyday prenatal care we need to understand how to influence provider behavior in addressing depression. Therefore, we propose a national survey of prenatal care providers to evaluate the determinants of provider decisions regarding the provision of depression care during pregnancy. Specifically, our project aims to: (1) To describe prenatal care providers’ practice patterns in managing depression during pregnancy; (2) To understand the role of contextual factors in provider decisions to treat depression during pregnancy and to evaluate the relative importance of internally versus externally-derived factors upon these treatment decisions; and (3) To determine whether perceived control over these factors affects provider decisions in addressing depression during pregnancy.
This project involves a national survey of a random sample of obstetricians, family physicians, and certified nurse-midwives. Survey content will focus on factors that are perceived to facilitate or impede the delivery of depression care and treatment preferences in response to standardized patient scenarios. Data collection for this project is ongoing. However, subsamples of 20 prenatal care providers from six obstetric clinics were interviewed to understand how prenatal care providers perceive influences on their delivery of perinatal depression care. After thematic analysis, including within-case and cross-case comparisons, researchers built a conceptual model of provider decision making from the data.
Although depression screening protocols were in place at our study clinics, we found that decisions to address perinatal depression were largely made at the level of the individual provider and were undefined on a clinic level, resulting in highly variable practice patterns. In addition, while providers acknowledged externally derived influences, such as logistical resources and coordination of care, they spoke of internally derived influences, including familiarity with consultants, personal engagement styles and perceptions of role identity, as more directly relevant to their decision making. These results highlight the pivotal role of internal factors in decisions to deliver perinatal depression care. Future interventions in obstetric settings should target the intrinsic motivations of providers.
Heather Flynn (PI) and Christie Lancaster Palladino
Christie Lancaster-Palladino, C., Fedock, G., Forman, J., Davis, M., Henshaw, E., Flynn, H. (2011) OB CARES — The Obstetric Clinics and Resources Study: providers perceptions of addressing perinatal depression—a qualitative study. General Hospital Psychiatry, 33, 267-278.
Identification of Health Factors in Pregnancy
Detection and adequate treatment of antenatal depression are a critical public health issues that must be addressed. Depression in pregnancy has been associated with poor maternal functioning and birth outcomes, yet most depressed pregnant women are not detected or treated. The purpose of this study was to provide information on rates of depression treatment among pregnant women at risk for depression and among those with clinician-diagnosed current major depressive disorder (MDD) and to examine predictors of depression treatment seeking and use. Participants in this study were recruited after being screened for depression and other health behaviors while waiting for their prenatal care visit at outpatient OB/GYN clinic sites. Researchers contacted participants for a prenatal interview via telephone. The interview assessed depressive diagnostic status, depression severity, medication use, depression treatment use and health functioning. Women with current depression symptoms were then contacted for two follow-up interviews. Women reporting substance use were contacted for one follow up interview. All participants were later contacted for an additional follow up interview via mail.
Results: Of women screened, 20% (n 5 689) scored as at-risk of depression on a depression symptoms scale (CES-D) and only 13.8% of those women reported receiving any formal treatment for depression. Past history of depression, poorer overall health, greater alcohol use consequences, smoking, being unmarried, unemployment, and lower educational attainment were significantly associated with symptoms of depression during pregnancy. These data show that a substantial number of pregnant women screened in obstetrics settings have significant symptoms of depression, and most of them are not being monitored in treatment during this vulnerable time. This information may be used to justify and streamline systematic screening for depression in clinical encounters with pregnant women as a first step in determining which women may require further treatment for their mood symptoms. As elevations in depressive symptomatology have been associated with adverse maternal and infant outcomes, further study of the impact of psychiatric treatment in pregnant women is essential.
Heather Flynn (PI), Fred Blow, and Sheila Marcus
Marcus, S., Flynn, H., Blow, F., Barry, K. (2003). Depressive Symptoms among Pregnant Women Screened in Obstetrics Settings. J Women's Health, 12(4), 373-380.
Flynn, H., Marcus, S., Blow, F. (2006). Rates and predictors of depression treatment among pregnant women in hospital-affiliated obstetrics practices. General Hospital Psychiatry, 28, 289– 295.
O’Mahen, H., Henshaw, E., Jones, J., Flynn, H. (2011). Stigma and Depression During Pregnancy: Does Race Matter? Journal of Nervous and Mental Disease, 199(4), 257-262.
O’Mahen, H., Flynn, H., Marcus, S., Chermack, S. (2009) Illness perceptions associated with perinatal depression treatment use. Archives of Women's Mental Health, 12, 447-450.