|
Article Excerpt
For women, depression is the leading cause of disease burden worldwide, and mothering young children increases the risk. Although screening tools are available and effective treatments exist, routine screening for maternal depression is not common in the United States. Studies have suggested that successful depression care requires a collaborative approach. The Partnership for Women's Health (PWH) model was designed to address physician barriers through a collaborative approach that includes screening mothers at routine postpartum visits and proactive follow up by a mental health advisor for linkage to treatment. Seven hundred eighteen women were screened for maternal depression in the postpartum period across 6 clinics (3 obstetric and 3 pediatric). Of the 116 women (16%) who screened positive for depression, 94% received the mental health advisor services. Almost all mothers (96%) addressed their depression. The PWH program was found to be feasible in all primary care offices. Medical providers felt that the process was easy to implement and increased their ability to identify and address maternal depression in their practices. The mothers were highly satisfied with the program, placing high value on the collaboration. Implications for practice and research are discussed.
Keywords: maternal depression, postpartum depression, collaborative care, evaluation
**********
Depression and depressive symptoms are among the most prevalent and treatable mental health disorders. Epidemiological and clinical studies have suggested that 8% to 12% of women may experience postpartum depression and 24% to 47% of women with children may experience symptoms of depression (Heneghan, Silver, Bauman, & Stein, 2000; Lanzi, Pascoe, Keltner, & Ramey, 1999; McLennan & Kotelchuck, 2000; McLennan & Offord, 2002). For women ages 15 to 44, depression is the leading cause of disease burden worldwide (World Health Organization, 2001), and mothering young children increases the risk of depression (Murray & Lopez, 1996). Recognizing maternal depression is critical because early treatment is a factor in reducing the overall duration of the depression (Beck & Gable, 2000). Both the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics specifically recommend that physicians directly inquire about maternal depression during routine visits (Committee on Practice & Ambulatory Medicine, 2000; Dell, 2002; Green, 1994).
Research has indicated that depressive symptoms in mothers contribute to a host of adverse child outcomes, including physical health, language, and behavior problems (Kahn, Zuckerman, Bauchner, Homer, & Wise, 2002). More specifically, studies have shown over decades that children whose mothers experienced depression are at greater risk for developmental delay, cognitive and functional impairment, somatic symptoms, behavioral difficulties, and injury (Beck, 1998, 1999; Green, 1994; L. Murray & Cooper, 2003; Weissman et al., 1987; Zuckerman & Beardslee, 1987). Nevertheless, the U.S. Surgeon General's report on mental health points out that the impact of maternal mental health on children is underrecognized (Office of the Surgeon General, 1999). Thus, efforts at early recognition and treatment of maternal depression will benefit women, their children and families, and society at large.
Although validated screening tools are available and highly effective treatments exist, routine screening for maternal depression is not common in the United States (Georgiopoulos, Bryan, Wollan, & Yawn, 2001). Studies have shown that detection of maternal depression in the postpartum period increases with routine use of a screening tool (Evins, Theofrastous, & Galvin, 2000) and when health professionals are specifically trained in detection and management (Lumley, 2005; Seehusen, Baldwin, Runkle, & Clark, 2005). Women have also reported feeling comfortable with screening tools and have found them easy to complete (Buist et al., 2006). Yet, there remains some controversy in the type of screening that is recommended, such as "universal" (offered to all), "targeted" (offered to those at significant risk), or "indicated" (offered to high-risk individuals who have detectable symptoms), which is widely based on the cost-to-benefit ratio (Austin, 2004) and the potential for risk or harm related to false positives and being exposed to diagnostic labeling, ineffective or harmful treatments, and costs to treatment (Austin & Lumley, 2003). Nevertheless, the U.S. Preventative Services Task Force (2002) recommended routine screening for maternal depression on the basis that the potential benefits outweigh the risks.
Goldman, Nielsen, and Champion (1999) identified the barriers to successful recognition and treatment as stigma, patient denial, limited provider skills and time, differences in the health care delivery system, restrictive insurance coverage, and lack of mental health providers. Studies to address such barriers have shown that successful depression care requires a systematic approach to detection and linking to treatment. Managed care practices can implement procedures for depression care using a collaborative approach with mental health specialists (Rubenstein et al., 1999). These strategies have also been shown to improve outcomes and the value or cost effectiveness of care (Sturm & Wells, 1995). The Partnership for Women's Health (PWH) model was designed to address these barriers and provide for the necessary supports at all levels through a collaborative system approach, including screening in primary care settings and follow up with referral and linkage to treatment by a mental health provider.
DEVELOPMENT OF PWH
In 2002, the Trilateral Partnership, a union of the three large health care systems in San Diego, convened the Depression in Women Advisory Team with the overall mission of improving the health and well-being of children and families in San Diego. The advisory team included obstetricians, pediatricians, psychologists, psychiatrists, researchers, and program managers with expertise in maternal depression. The team's multidisciplinary nature was viewed as critical to establishing an innovative program that could be sustainable over time across each of the large health care systems. The members represented institutions from throughout San Diego County, including Children's Hospital and Health Center; Sharp HealthCare; Scripps; University of California, San Diego; Health and Human Services Agency; Child and Adolescent Services Research Center; Community Health Group; and Postpartum Health Alliance.
This advisory team provided oversight and guidance in the development of the PWH program model. The larger group, as well as smaller task forces, met for 1 year and contributed the following: review of current literature; recommendation of an appropriate depression screening tool; identification of existing community resources, potential research collaborators, and funding sources; input on the development of pathways for linking positive screens to resources; determination of evaluation questions; and assistance in problem-solving system-related issues.
The advisory team directed that the PWH program be built from the established and successful Partnership for Smoke-Free Families (PSF) program, a comprehensive tobacco control program to reduce tobacco smoke exposure among pregnant women and young children. PSF works directly with obstetricians, hospital postpartum staff, pediatricians, and their office staffs to implement "best-practices 4 As" as outlined in the U.S. Department of Health and Human Services' clinical practice guideline (Fiore et al., 2000). It outsources cessation treatment to substance abuse providers and provides proactive recruitment of patients. Results showed that when given a toll-free number, only 3% of the smoking women accessed treatment services on their...
|
