Dr. Kendra Flores-Carter DSW, ACSW La Tanya Matthews, …hs.sbcounty.gov/CN/SiteAssets/Pages/Conference/E-4...Dr. Kendra Flores-Carter DSW, ACSW La Tanya Matthews, MSW Ricardo Cruz,

Children’s Network Conference 2017

Dr. Kendra Flores-Carter DSW, ACSW

La Tanya Matthews, MSW

Ricardo Cruz, BA

www.arrowheadmedcenter.org

The Heart of a

Healthy Community

Presentation Overview

www.arrowheadmedcenter.org The Heart of a

Healthy Community

Prevalence and Barriers

• Latina and Black Women

• Barriers/Concerns

NICU and Maternal Depression

• Bonding concerns after birth

• NICU impact on moms health

Enhancing Hospital MMH Care

• Relevance of Education in Hospital

• Multi-disciplinary Roles in Treatment

• ARMC Maternal Mental Health

Program

Questions and Discussions

POSTPARTUM DEPRESSION with

LATINO and BLACK WOMEN

By: Ricardo A. Cruz, CCS, BS


The Heart of a

Healthy Community

Is Postpartum Depression (PPD) prevalent amongst Latino and

Black Women?


Healthy Community

• Yes, however, little research available.

• Most studies have focused on non Hispanic whites and Asian

women.

• 46.7% rate of mild to moderate PPD and 8.4% had severe

depression.

• Black women have a prevalence rate of 38%.

• Little to no studies on Black women and PPD

RESEARCH DISPARITY


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• “...Little is known about the rates of postpartum depression among

minority women, particularly Black, Hispanic and Native American

women, and in women of low socioeconomic status, and even less data is

available about ethnic differences in rates of all health diagnoses (Seplowitz

et al.)”.

• The onset and presentation of symptoms often vary among mothers

regardless of their race and ethnicity. Many mothers emphasized loving

their children despite experiences with depression (Gaynes et al., 2005) .

• The Centers for Disease Control and Prevention estimates that African

American and Hispanic mothers have the highest rates of postpartum

depression among all racial and ethnic groups (2008).

IMPORTANCE OF RESEARCH


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• “Largest and fastest growing ethnic minority group and will

become the predominant ethnic group by the year 2020. The U.S.

Census Bureau (2004) reported an increase in the Latino

population by more than 50% since 1990, from 22.4 million to 40.4

million. Of these, 19.7 million are Latinas, about half of whom are

of childbearing age (Le et al.).”

HOME HEALTH PERSPECTIVE


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• Medical vs. Behavior • More emphasis on Medical.

POST DISCHARGE FOLLOW UP


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• Studies suggest that “Newborn Behavioral Observations

conducted in hospital and home settings may be an efficient,

cost-effective, relationship-based method for reducing the

likelihood of PPD (Nugent et al.).”

• Nurse home visits improve maternal and infant interaction

and decrease severity of postpartum depression.

BREASTFEEDING: AN EXAMPLE


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• “Data indicate that women experiencing postpartum

depression are less likely than non-depressed women to

breastfeed (Leis et al.).”

• ”The highest risk was found among women who had planned

to breastfeed and had not gone on to breastfeed (Borra et al.).”

• Nurse home visits improve maternal and infant interaction and

decrease severity of postpartum depression.

REFERENCES


Healthy Community

Borra, C., Iacovou, M., & Sevilla, A. (2015). New Evidence on Breastfeeding and Postpartum Depression: The Importance of

Understanding Women's Intentions. Maternal & Child Health Journal, 19(4), 897-907. doi:10.1007/s10995-014-1591-z

Gress-Smith, J., Luecken, L., Lemery-Chalfant, K., & Howe, R. (2012). Postpartum Depression Prevalence and Impact on Infant

Health, Weight, and Sleep in Low-Income and Ethnic Minority Women and Infants. Maternal & Child Health Journal, 16(4), 887-893.

doi:10.1007/s10995-011-0812-y

Horowitz, J. A., Murphy, C. A., Gregory, K., Wojcik, J., Pulcini, J., & Solon, L. (2013). Nurse home visits improve maternal/infant

interaction and decrease severity of postpartum depression. Journal Of Obstetric, Gynecologic, And Neonatal Nursing: JOGNN,

42(3), 287-300. doi:10.1111/1552-6909.12038

Le, H., Lara, M. A., & Perry, D. F. (2008). Recruiting Latino women in the U.S. and women in Mexico in postpartum depression

prevention research. Archives Of Women's Mental Health, 11(2), 159-169. doi:10.1007/s00737-008-0009-6

Leis, J., Mendelson, T., Tandon, S., & Perry, D. (2009). A systematic review of home-based interventions to prevent and treat

postpartum depression. Archives Of Women's Mental Health, 12(1), 3-13. doi:10.1007/s00737-008-0039-0

Nugent, J. K., Bartlett, J. D., & Valim, C. (2014). Effects of an Infant-Focused Relationship-Based Hospital and Home Visiting

Intervention on Reducing Symptoms of Postpartum Maternal Depression. Infants & Young Children: An Interdisciplinary Journal Of

Early Childhood Intervention, 27(4), 292-304. doi:10.1097/IYC.0000000000000017

Seplowitz, R., Miller, H., Ostermeyer, B., Sangi-Haghpeykar, H., Silver, E., & Kunik, M. (2015). Utilization of Psychiatric Services by

Postpartum Women in a Predominantly Minority, Low-Socioeconomic-Status, Urban Population. Community Mental Health Journal,

51(3), 275-280. doi:10.1007/s10597-014-9808-6

When your child is admitted into the

Neonatal Intensive Care Unit

By: La Tanya M. Mathews, MSW


The Heart of a

Healthy Community

OBJECTIVES


Healthy Community

Understanding the barriers to bonding with your infant during

a NICU admission

How the NICU impacts your emotional health

How I can help. What is my role?

AGENDA


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1st Impression

The Long Haul

Bonding

Let’s not forget about Dad

Something is not right

Recommendations

Discharge and Beyond

THE FIRST IMPRESSION


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Pregnancy – you bond with your baby from the time. Many times, we “just

hope for a healthy baby.” Many parents have no clue what the NICU is.

Admission into the NICU – Infants can be admitted to the Neonatal Intensive

Care Unit for a number of reasons, prematurity, mommy had diabetes,

substance abuse, genetics disorders or respiratory distress, etc. Having a baby

in the NICU is traumatic experience. 1

Dreams turned into Nightmares – A variety of emotions begin to set in.

Anxiety, guilt, fear, etc. They are natural responses to traumatic evets. They are

not a sign of weakness. They are healthy part of adapting and adjusting to

being your baby’s parents. 1

Introduction to the NICU – “From the intensity of the hospitalization to the

vulnerability of bringing your baby home, parents of babies who begin life

medically fragile often think, feel, and parent differently than parents whose

babies were full-term and healthy.” 2

How long does my baby have to be here – being honest with the parents

about time frames and looking at the baby’s progress. Looking forward to the future.

When I return to work – finding a balance, exhaustion, overwhelmed.

Signs and symptoms of depression – If you notice changes in your thoughts,

feelings or behaviors during or after your NICU experience, it can be difficult to tell

whether the changes represent a typical reaction or signal the development of a perinatal

mood or anxiety disorder. 2

Trust issues – From the time a mother, walks in the NICU, there are trust issues.

‘who is this taking care of My Baby?’ Communication is key between the staff and

parents. So that Parents can trust that this nurse has the experience to take care of this

baby. A mutual relationship can develop also, where “parents can tell the nurse

that you’re unsure of yourself. The nurse can give you support and practice you

need to become skilled at taking care of your baby.” 3

THE LONG HAUL


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BONDING


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First time holding

Negative touch

Skin-to-skin

Cares for the baby

Babies need fathers to be present. Physical contact benefits the

baby and it strengthen the father-baby bond.

Mothers need fathers to be present. If mothers are not able to be

in the NICU, they rely on dads to provide information, update

and to be with the baby.

Fathers and mothers are to be a team.

Staff should also check-in with the fathers to make sure they ok.

4

LET’s NOT FORGET ABOUT DAD


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SOMETHING IS NOT RIGHT


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Poor/No visitation

Social barriers – There are physical, logistical and medical

challenges that can trigger depression while your baby is in the

NICU.

Transportation

Distance

Poor support

Anxiety, anger, depression – “Understandably, the stress and

exhaustion of life in the NICU takes a very real toll on parents’

mental health. Parents of children who have a stay in the NICU are

at a greater risk for anxiety, depression, and post-traumatic stress

disorder, for month or even years to come.” 5

RECOMMENDATIONS


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Checking-in – Communication! Communication! Communication. Multi-disciplines involved

with parents during infant’s length of stay.

Counseling – When should you seek professional counseling…

You think it may help.

Your ability to cope with the situation is not improving and you feel stuck

You continue to find no joy in other parts of your life

You have trouble with your relationship with your partner or others close to you

You feel a parent support group isnt “quite enough”

You should talk to a professional counselor if:

You feel prolonged numbness or detachment

You continue to feel detached from your baby

You have trouble getting out or bed or starting your day

You feel unable to cope or manage your other responsibilities

You think about harming yourself or others

Your doctor or the hospital social worker can refer you to a counselor who understands the trauma

of having a baby in the NICU. Even just a couple of visits might give you the reassurance you need. 3

DISCHARGE AND BEYOND


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A study in 2013 measured risk factors and management

strategies in PPD mothers and NICU infants.

131 mothers were given the Edinburgh Postnatal

depression scale.

19.1% experienced PPD. As the infant stayed longer in

the NICU, the odds of PPD increased, then leveled off

and then decreased after being admitted 31 days or

more.

Recommendation was to screen mothers routinely and

treat aggressively. 6

DISCHARGE AND BEYOND Cont.


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Mothers with previous mental health disorder and experiencing

negative perceptions of self and infant at the NICU discharge were

at increased risk for depressive symptomatology 1 month post

discharge regardless of infant’s gestation age. Comprehensive

mental health assessment prior to discharge is essential to identify

women at risk and provide appropriate referral. 7

Screen mothers at their 6 week f/u

Also screen mother at infant’s pediatric appointments

Provide resources and insurance referrals

The Fourth Trimester & Loss


Healthy Community

Definition of the Fourth Trimester8

Stages of Grief

Grief and Loss vs. Maternal Mental Illness9

-Complicated to differentiate

-Just address it

• Grief starts at the here

-Trained staff to provide grief support9

• Walking out the hospital

-Provide parents with some tools to cope

• Time Limit?

-Reminders, triggers, hopes and dreams10

REFERENCES


Healthy Community

1. “Is this normal? How the NICU Impacts Your Emotional Health.” Hand to Hold:

Fragile Babies. Strong Support. Http://handtohold.org. March 2015.

2. Best, Sarah LCSW. “I can’t seem to shake the emotions from my baby’s time in the

NICU. What can I do?” Managing the Stress of a Baby’s NICU Stay. The Seleni

Institute.

3. March of Dimes. “Becoming a parent in the NICU.” www.marchofdimes.org

4. Fisher, Duncan. “Fathers are needed in the NICU.” https://fatherhood.global

Dec. 2016

5. MacMillian, Amanda. “The Stress of Having a Baby in the NICU.” The Seleni

institute.

6. Vasa R, Eldeirawi K, Kuriakose VG, Nair GJ, Newsome C and Bates J,

“Postpartum depression in mother’s of infants in the neonatal intensive care unit: risk

factors and management strategies.” The Journal of Pediatrics. Aug. 2013.

7. Hawes, Kathleen PHD, Elisabeth McGowan, Melissa O'Donnell, Rishard Tucker,

Betty Vohr. “Social Emotional Factors Increase Risk of Postpartum Depression in

Mothers of Preterm Infants.” The Journal of Pediatrics. December 2016.

http://handtohold.org/

http://www.marchofdimes.org/

https://fatherhood.global/

8. The Fourth Trimester: What you should know about life postpartum. Deborah

Bohn . 2012. Https://www.babble.com

9. Grief and Bereavement Education and Support. CHOC Children’s Hospital.

Http://www.choc.org

10. Wender, Esther. MD. “Supporting the Family After the Death of a Child.”

Pediatrics. December 2012, Volume 130/issue 6

REFERENCES Cont.


Healthy Community

http://www.choc.org/

Enhancing Maternal Mental Health Care in a Primary Care Setting

Children’s Network Conference 2017

Dr. Kendra Flores-Carter


The Heart of a

Healthy Community

Scope of the problem-Creates Health Concerns for Fetus/Infant


Healthy Community

Untreated Depression

Cognitive Difficulties

Poor Social Adaptations

Decreased Emotional Regulation

What to look for with our Pregnant Patients?


Healthy Community

Symptoms

Insomnia Hypersomnia

Weight loss/gain

Change in

Appetite

Poor Concentration

Worry Fear

Anxiety Mood

Swings

Sadness Crying

Helplessness Hopelessness

Guilt Suicidal Ideation

Understanding the Significance of this Public Health Concern


Healthy Community

Prevalence

PPD 1 in 7

13%-19%

Psychosis 1%-2%

Maternal Death by Suicide

10%

Infanticide 4%

Black Women

38%

Depression and Stress

Pre-eclampsia/Hypertension

Gestational Diabetes

NICU Infant

Pre-Term Birth

• High prevalence among AA

women

Pregnancy and Health Concerns


Healthy Community

Multi-disciplinary Roles in

Maternal Mental Health

Primary Care Approach


Healthy Community

NURSES


Healthy Community

• Nurses make up a large part of the primary care workforce in a primary care

setting such a hospital.

• Have a commitment to make decisions about patient care.

• A Study done by Hardy (2015) found that training nurses in mental health and well-being has the potential to improve integration of delivery of care for patients.

• Provide good quality physical health care to people with mental health problems, increase identification of patients with mental health concerns, enhance health outcomes, quality of life and patients experience of care.

Hardy, S. A., & Kingsnorth, R. (2015). Mental health nurses can increase capability and capacity in primary care by educating practice nurses: an evaluation of an education program in England. Journal of Psychiatric and

Mental Health Nursing, 22(4), 270-277.

PHYSICIANS


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• Physicians (OBGYNs, Pediatricians) act as gatekeepers.

• Monitor what happens overtime during prenatal care check-ups. • Notice if they are changes in mood document and review patient charts.

• The early discovery of potential problems allows physician to treat vulnerabilities

accordingly (Consulting Appropriate Specialist). • Doing so could potentially reduce moms symptoms of depression and other

health concerning issues. • Enables patients to have healthier and more happier pregnancy experience.

• Women with maternal mental health concerns receive extremely low levels of

preventive health care. • Are at risk of receiving inadequate and delayed prenatal care even when

controlling for known pregnancy related risk factors.

Byrd RS, Hoekelman RA, Auinger P. Adherence to AAP guidelines for well-child care under managed care. American Academy of Pediatrics. Pediatrics. 1999; 104(3 Pt 1):536–540.Salsberry PJ, Chipps E, Kennedy C.

Use of general medical services among Medicaid patients with severe and persistent mental illness. Psychiatric Services. 2005; 56(4):458–462.Howard LM. Fertility and pregnancy in women with psychotic disorders.

European Journal of Obstetrics & Gynecology and Reproductive Biology. 2005; 119(1):3–10.Kim HG, Mandell M, Crandall C, et al. Antenatal psychiatric illness and adequacy of prenatal care in an ethnically diverse

inner-city obstetric population. Archives of Women’s Mental Health. 2006; 9:103–107.

CLINICAL SOCIAL WORKERS


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• Clinical social workers perform assessments, arrange and develop services.

• Serve as gatekeepers to treatment providers (Gibelman & Schervish, 1996).

• Clinical Social Workers perform the largest portion of psychotherapeutic work done

in the United States (Hartman, 1994).

• Clinical Social Workers provide as much as 65% of all psychotherapy and mental

health services (Gibelman & Schervish, 1997).

• Assessment, Referrals/Resources, Collaboration with the MDT, Education to family.

Support network, Appointments, Home Health Care.

Gibelman, M., & Schervish, P. H. (1996). The private practice of social work: Current trends and projected scenarios in a managed care environment. Clinical Social Work Journal, 24, 323-338. Gibelman, M., &

Schervish, P. H. (1997). Who we are: A second look. Washington, DC: NASW Press. Hartman, A. (1994). The winds of change. Smith College Studies in Social Work, 64, 211-220.

Barriers To Seeking Services


The Heart of a

Healthy Community

Approaches to Barriers


Healthy Community

• Services

• Some Services should be FREE

• Poor/Low Income Population

• Significant Logistical Barriers

• Lack of Support

• Working with Families to Identify Support within their Communities

• Educating Spouses and Additional Family Members on the importance of being

there for their loved one.

• Interventions

• Culturally Sensitive Interventions

• Interventions that are Brief, Effective, Easily Accessible

Treatment Options for MMH


The Heart of a

Healthy Community

Cognitive Behavior Therapy


Healthy Community

• Standard treatment of depressive, anxiety, and stress and adjustment disorders

• Often includes pharmacological treatment and/or different types of

psychotherapy.

• CBT is an effective way of treating depressive disorders.

• Reconstructing thoughts

• Motivational Interviewing

• Strengths Based

• CBT is the most studied psychotherapy for depression, and thus have the greatest

weight of evidence

Oei TP, Bullbeck K, Campbell JM. Cognitive change process during group cognitive behaviour therapy for depression. J Affect Disord 2006; 92: 231–41.

Cuijpers P, Berking M, Andersson G, Quigley L, Kleiboer A, Dobson KS. A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in comparison with other treatments. Can J Psychiatry 2013; 58: 376–85.

Mindfulness Based Interventions


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• An important advantage of mindfulness-based therapies over most other psychotherapies is that mindfulness may be

accessible to larger groups of patients.

• After introduction.

• Patients could potentially practice mindfulness on their own.

• Mindfulness-based therapies decrease depressive symptoms and anxiety and reduce psychological distress.

• Evidence Based

• Mindfulness practices have is associated with less physical illness, improved well-being, increased self-control, decreased

negative affect, better affect tolerance and improved concentration, focus attention and working memory.

• A large number of studies suggest mindfulness-based interventions (MBIs) such as Mindfulness-based stress reduction

(Kabat-Zinn 2003) and Mindfulness-based cognitive therapy (Segal et al. 2002) are effective psychological interventions to

reduce depression and anxiety in clinical and non-clinical populations (Kuyken et al. 2015).

• There is also evidence that yoga practice in pregnancy reduces perinatal anxiety and depression (Newham et al. 2014).

• Non-pharmacologic interventions in pregnancy such as MBIs share overlapping common characteristics such as

meditation and regulated breathing. Davis DM, Hayes JA. What are the benefits of mindfulness? A practice review of psychotherapy-related research. Psychotherapy 2011; 48: 198–208.Kabat-Zinn, J. (2003). Mindfulness-based interventions in context:

past,present, and future. Clinical Psychology: Science and Practice, 10(2), 144–156.Kuyken, W., Hayes, R., Barrett, B., Byng, R., Dalgleish, T., Kessler, D.,Lewis, G.,Watkins, E., Brejcha, C., Cardy, J., & Causley, A.

(2015). Effectiveness and cost-effectiveness of mindfulness-based cognitivetherapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised

controlled trial. The Lancet, 386(9988), 63–73.Newham, J. J.,Wittkowski, A., Hurley, J., Aplin, J. D., &Westwood, M.(2014). Effects of antenatal yoga on maternal anxiety and depression: a randomized controlled trial. Depression and Anxiety, 31(8), 631–640.Segal, Z. V., Teasdale, J. D., Williams, J. M. G., & Gemar, M. C. (2002).The mindfulness-based cognitive therapy adherence scale: Inter-raterreliability,

adherence to protocol and treatment distinctiveness. ClinicalPsychology & Psychotherapy, 9, 131–138. http://dx.doi.org/10.1002/cpp

.320

ARMC Maternal Mental Health

Program


The Heart of a

Healthy Community

• We recognized the need for Education

• Trained our nurses on the signs and

symptoms of depression

• Educate Patients

• We recognized the need for Support

• Developed an in-house support group

for families

• We recognized the need for Resources

• Through partnership with Children’s

Network we are able to provide

educational materials (Brochures) to

all our moms.

| 40 Needs Assessment and Implementing MMH Program


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• On average there are 300 births monthly at ARMC. Statistics note that one in seven women will experience PPD after giving birth.

• Placing roughly 42 women per month who have given birth at ARMC at risk.

• Approximately 50 percent of these women will not seek help.

• Mainly because they lack knowledge of post-partum depression.

• How to recognize the signs and symptoms.

• Stigma surrounding mental illness.

• ARMC’s Women’s Health Department developed a Maternal Wellness Education and Support Program to bring more awareness, education, support and resources to our patients. We saw a need and our goal was to meet that need.

| 41 ARMC Women’s Health Department


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• All mothers receive the Children’s Network “You Are Not Alone Brochure”

highlighting signs and symptoms of PPD in their hospital admissions packet

• A “You Are Not Alone” DVD PSA, developed by Children’s Network, is placed in

the ARMC TIGR system for mothers to watch prior to discharge as a way to

reinforce psycho-education about PPD.

• Posters are in every single women’s health clinic rooms highlighting signs and

symptoms of PPD and ways to seek help.

• Monthly PPD Support Group

• Every third Tuesday from 11 a.m. to Noon at ARMC

• Breastfeeding mothers are welcome to bring their babies.

• Both mothers and fathers.

| 42 Maternal Wellness Education and Support Program


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Intervention Research


The Heart of a

Healthy Community

H1

• Viewing the “You Are Not Alone”

video intervention will increase Black

women’s knowledge of Postpartum

Depression.

H2

• Viewing the “You Are Not Alone”

video intervention positively

influence Black women’s Attitudes

towards Seeking Mental Health

Services.

| 44 Research Hypotheses


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| 45 Intervention “You Are Not Alone”


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https://www.youtube.com/watch?v=UC5Yfa5SvAY&t=5s

Design

• Pre-test/post-test

Sample:

• Convenience sample (N = 43) at

the Inland Empire Medical

Center located in CA.

Age:

• 18 and over

Race/Gender:

• Black Pregnant and Postpartum

female

Language:

• English

| 46 Methods


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• Fliers were placed on bulletin

boards

• Consents and survey data collected

in private rooms

• All subjects were notified that study

was voluntary and they could

withdraw at any time.

• All data kept in locked file cabinet

• Consent forms mailed to Chair at

UTK and secured in locked file

cabinet to maintain confidentiality.

| 47 Data Collection


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Age: 81% ranged from 18 to 30 years of age

19% ranged from age 31-40

Marriage: 79% were single or never been

married,

Education: 49% had some college

Employment: 72% were unemployed

Welfare: Almost all participants were enrolled in

WIC program or the combination of WIC and

other welfare benefit programs (70%),

Income: 76% monthly income ranged from $0-

$1500.

Mental Illness: 5% bipolar disorder, 2%

obsessive compulsive disorder, 2% schizophrenia

and bipolar.

Depression: 12% depression, 5% had been

diagnosed with postpartum depression

| 48 Findings


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The responses to each knowledge question were grouped into two categories correct or incorrect

responses.

The participants’ pre and post-test knowledge findings are reflected in Table 2.

| 49 Findings


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• To test the hypothesis that viewing the “You

Are Not Alone” video intervention would

increase knowledge with Black women

• A paired sample t-test was conducted.

• The hypothesis was found statistically

significant (p < .001) in that the “You Are Not

Alone” video intervention increased the

knowledge of PPD among the subjects.

• Failed to reject hypothesis

| 50 Findings


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51

| 51


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Discussion/Findings

The “You Are Not Alone” video

intervention increased the knowledge of

PPD among the subjects (Feasible

Intervention).

The “You Are Not Alone” video

intervention did not influence subjects’

attitudes towards seeking mental health

services for postpartum depression.

The apparent lack of influence on

women’s attitudes may be due to

participants being emotionally salient.

Many mothers did not have a history of

mental illness and may have perceived

the questions as none relatable.

????????

?


Healthy Community

Documents

Dr. Kendra Flores-Carter DSW, ACSW La Tanya Matthews, …hs.sbcounty.gov/CN/SiteAssets/Pages/Conference/E-4...Dr. Kendra Flores-Carter DSW, ACSW La Tanya Matthews, MSW Ricardo Cruz,