1. Perinatal Depression MCH Federal/State Partnership Meeting Alexandria, VA October 17, 2007 Diana Cheng, M.D. Medical Director, Women’s Health Maryland Department of Health and Mental Hygiene

2. Causes of Depression hormones

3. Depression Across the Female Lifespan Pregnancy/Postpartum Premenstrual Peri-menopause Birth Death Menopause Menarche

4. Postpartum Depression • Affects 1 out of every 8 postpartum women • Begins 2 weeks – 1 year postpartum • Symptoms • Depression, anhedonia • Emotional stress, helplessness, irritability, anger • Inability to do normal everyday tasks • Appetite changes, sleeping too much/ too little • Thoughts of self-harm or suicide • Overly intense worries about baby • Lack of interest or fear of harming baby

5. Depression During Pregnancy • Pregnancy is not protective against depression • Affects 10-15% of pregnant women • Begins any trimester • Symptoms

6. Percentage of Mothers Who Reported Being at Least Moderately Depressed in the Postpartum Period, Maryland PRAMS 2001-2003 Annual household income Age Marital status Race and ethnicity

7. Risk Factors for Maternal Depression • Prior depression (30%) • Prior postpartum depression (50%) or psychosis (70%) • Depression during pregnancy • Prior PMDD (premenstrual dysphoric disorder) • Family history of depression or bipolar disorder • ?Teens, not married, low income • Recent stressful events • marital/partner discord, loss of loved one, family illness, premature birth

8. Edinburgh Postnatal Depression Scale • Created for postpartum women • Can also be used during pregnancy • Less emphasis on physical symptoms • Takes < 5 minutes to complete • Self-administered • Validated screening tool • Useful in primary care settings • Rates intensity of depressive symptoms • 10 questions, each worth 0-3 points • Score >12 (out of 30) indicates likely depression

9. Treatment for Depression • Support • Support groups (facilitated), family, friends, help lines • Counseling • Cognitive behavioral / interpersonal therapy • Other treatments • light, alternative medicines • ECT • Antidepressants

10. Maternal DepressionGetting Help

11. Maternal Depression: Effects on Infant and Child • Poor pregnancy outcomes • PTL, LBW, SGA, RDS, ?PIH ?SAb • Poor mother-infant attachment • Irritable, lethargic, poor sleep • Language delays • Behavioral difficulties • Lower cognitive performance • Mental health disorders • Attention problems Kahn, et al. AJPH 2002;92:1312-1318 Bonari et al. Can J Psychiatry 2004;49:726-735 • Infant Behav Dev 2004;27:216-229 • Psychiatry 2004;67:63-80

12. Maternal Effects of Untreated Depression • Poor prenatal behaviors • Nutrition, prenatal care, substance abuse • Poor parenting behaviors • Longer persistence of symptoms • Increased risk of postpartum depression • Increased risk of relapse • Suicide

16. Maryland Program: DepressionDATA to Action

17. Data ACTION • Maternal Depression Team (multidisciplinary) • Providers (ob,ped, CNM, FP, psych, nursing, social work, public health) • Health care coverage (Insurance/medicaid) • Organizations (WIC, March of Dimes, academic/community, women’s health, daycares, churches) • Legislation – 2004 Maryland General Assembly • Grants

18. 1-800-PPD-MOMS Helpline • Website (www.healthynewmoms.org) • Media messages • Posters, Video PSAs, Radio Ads • Local partnership grants • Provider training • Information Packets • Provider CMEs, screening scale, brochure, resource list • Education

19. www.healthynewmoms.org

21. Available in English, Spanish, Chinese, Korean, Vietnamese, Russian, French

22. WELL Project“Women Enjoying Life Longer” A Women’s Health Program in 3 Title X Baltimore County Family Planning Sites Eastern Family Resource Center Dundalk Health Center Essex Health Center

23. Maternal Depression • Common Disorder • Under-diagnosed, under-treated • Adverse effects • mother, fetus, infant, family • Validated screening tools • Effective treatment • Universal Screening • Capacity, advocacy, research, education