Kiley: Welcome everyone. I am going to give a little overview on what we did for Part 1.
Part 1 Review
Maternal Mental Health (MMH) Disorders – Definition and Prevalence
Maternal mental health disorders can happen during pregnancy and the postpartum period. This is often known as the perinatal period, and they can include such things as depression, anxiety, OCD, PTSD, and on very rare occasions psychosis. This is a very common problem during this period that is often not talked about. However, it is the highest obstetric complication at about a rate of 20 percent. This is more than pre-eclampsia and gestational diabetes combined. While both of those are tested for routinely, maternal mental health disorders are not screened during pregnancy or postpartum.
Risk Factors of MMH Disorders
There are a variety of things that come into play. Biological risk factors like your history, your family history, or a personal history of mental health need to be considered. Another could be sensitivity to hormones. It could also be a combination of those two. Looking at the social risk factors, this could be things such as inadequate social support, being in a military family, being a teen mom, or having a lot of stress in your life due to external factors. One specific example is poverty, but poverty can also cause other things as well. Other risk factors would be things such as birth trauma, pregnancy, or infant loss. Additionally, having a high risk infant with severe medical issues, like feeding difficulties, can cause a higher risk for developing a maternal mental health disorder.
Perinatal Loss and Motherhood
The role of motherhood starts at conception and during pregnancy. This is different from society's view, which is at birth. Because of this discrepancy of when the role of a mother begins, there is often role confusion, disenfranchised grief, and a deconstruction of motherhood. The mom has had a baby, but she does not now have a live baby with her. It is a confusing concept for her and for everyone. She sees herself as a mother, but society does not.
The mental health picture following loss is very complex. Typically, when somebody dies, we grieve. In this case, it is an "out of order death." It is unexpected. In addition to the grief, you have post-traumatic stress. This occurs in a lot of people. There will also be maternal mental health disorders due to the various risk factors coming into play other than loss, including hormones. They have given birth to a baby so there is a massive change in hormones. It could also be what is in their environment. Three things are coming into play, and you cannot look at any of them separately
Impact of Perinatal Mood Disorders
Now, we are going to move on looking at the impact of perinatal mood disorders. I think that you will all find Part 2 a little bit more interesting because it is applicable to your life and work. We are going to first look at the broader impact of maternal mental health.
Broader Impact of MMH Disorders
- Society
- Financial
- Families
(California Task Force on Maternal Mental Health/2020 Mom (2017); Diaz & Chase, 2010; Greenberg, Fournier, Sisitsky, Pike, & Kessler, 2005 and 2010; Sontag-Padilla, Schultz, Reynolds, & Lovejoy, 2013)
How does maternal mental health disorders affect society, finances, and families? Major depression is the number one cause of disability in the world. That is pretty amazing, and not in a good way. Depression is widely spread, and a lot of people are dealing with it. There is absenteeism from work, a loss of productivity, and direct treatment costs. It impacts the employment and household income, and if they are not employed or working enough, then they will become part of the public assistance system, which burdens society.
They approximate the cost of care for the mother and baby, for a mom who has perinatal and postpartum depression, at about $22,500 a year. This is from the Wilder research study. This is why we are stressing the importance of screening; to prevent and treat before it becomes full-blown and out-of-control.
What does it do to families? It causes strain within a marriage and within the family if there are other children. Of course, it also affects the development of the infant, into childhood and adulthood.
Paternal Postnatal Depression Impact on Baby
Dads suffer as well, and I do not think a lot of people are aware of that. The number one risk factor for dads developing depression is that the mom suffers from postpartum depression as well. Depression in dads is associated with detrimental effects on the child's well-being, whether it is emotionally, physically, or mentally (Fletcher, Feeman, Garfield, & Vimpani, 2011; Musser, Ahmen, Foil, & Coddington, 2013; Ramchandari, Stein, Evans, & O’Connor, 2005). They have seen in studies that behavior problems show up more in boys.
Impact on Mother-Infant Dyad
Mental health has a big impact on the mother-infant dyad (Beck, 1999; Kingston, 2011; Kingston, Tough, & Whitfield, 2012; Knitzer, Theberge, & Johnson, 2008).
- Inability of mothers to fulfill roles
- Inability to function
- Lack of health and safety practices
- Impaired cognition
- Increased risk of early breastfeeding cessation
- Inconsistent responses to infant’s actions
- Disrupted mother-infant relationship
I am not going to read through all of these, but I will touch on a few. There is the inability of a mom to fulfill her roles, whether it is a mother, wife, employee, or friend. She is not able to do those things in life that she wants and needs to do. She cannot function and may be so overwhelmed she cannot take care of herself, her home, and the baby. This leads to things such as a lack of health and safety practices, which could risk the baby's safety. Finally, the last bullet points are how it impacts the relationship and the infants development.
Impact on the Baby
Maternal mental health is so important because it does impact the baby, not just the mom and/or dad.
May manifest in the following ways:
- Lack of stimulation
- Neglect
- Isolation
- Insecure attachment
- Impaired maternal bonding
Resulting in:
- Developmental delays
- Increased risk of emotional and physical harm
- Possible fatal abuse
- Insecure attachment have effects on emotional regulation in adulthood
- Behavioral problems
Maternal depression and anxiety is a stronger risk factor for childhood behavioral problems than smoking, drinking, or domestic violence. The other thing I want to point out here is the negative outcomes on the child's mental health and overall functioning that last well into adulthood. It moves with them throughout their lives and will affect them forever. Again, that is why it is important to treat the mom, which impacts the baby. You cannot really separate the two of them, they are a dyad. If there is a lack of regulation in the mom, then the baby will be disregulated.
How OTs Can Support Mothers and Promote Maternal Mental Health
This is what you really want to know, and why you are here. How does this affect you and your practice? Maternal health and wellness is an emerging practice field in OT. There are groups of people out there doing this. Many individuals are doing it, but there are two groups on Facebook that may be of interest to you. One of them is called Occupational Therapy in Postpartum Care, and the other is Women's Health 4OT. These are two groups that have OT's in them that are focused on women's health. I would encourage to join. It is a nice way to see who else out there is doing this type of work, and it is not only in mental health, but it spans all types of maternal wellness. I think things are growing which is really exciting. We need to be aware and support these people who are doing this work. There is my soapbox.
US Preventive Services Task Force
What are the current recommendations for screening during pregnancy and postpartum? The US Preventative Services Task Force is recommending depression screening of all adults including pregnant and postpartum women. That is interesting that they included that group of people (Siu and the US Preventive Services Task Force, 2016).
American College of Obstetrics and Gynecologists
The American College of Obstetrics and Gynecologists say that clinicians should screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool (Committee on Obstetric Practice, 2015). Many of us out there do not think that is enough. There needs to be something during pregnancy and something postpartum. I personally still do not think that is enough because you do not know when these issues will arise, but this is what they are recommending at the moment. There is room for improvement, but at least they have a recommendation for it.
California Task Force on the Status of Maternal Mental Health White Paper
Now, I am going to refer to the California Task Force on the Status of Maternal Mental Health White Paper which you can find in the reference section on both Part 1 and 2. This was a task force that met in California for one year, and they created this report. They have different core competencies for different health providers, and this is specifically health providers who are not OBs or psychiatrists.
- Understand signs and symptoms of the range of MMH disorders
- Develop knowledge about valid screening tools
- Understand how to interpret results
- Develop knowledge of menu of prevention/treatment options
- Recognize when to refer to psychiatry
- Recognize and refer to the local network of MMH services available in the community
- Understand trouble breastfeeding is a risk factor for anxiety and depression.
I think this could be applied to our group as OT's in certain ways. We need to understand the signs and symptoms of the range of maternal mental health disorders. We discussed this in detail in Part 1. Secondly, we need to develop knowledge about valid screening tools and understand how to interpret results. These are tools to test for anxiety, depression, and bipolar disorder. We need to develop knowledge of the prevention and treatment options and recognize when to refer to psychiatry or the local network of maternal mental health services in the community. There are also drug and nondrug treatments available, including nonclinical alternative practices such as acupuncture, massage, and exercise. We also should know medications. We will not be prescribing, but it is important to know that there are certain medications used to treat mental health disorders that are safe to use while pregnant and breastfeeding. I always thought that all medication was not safe during pregnancy. This is not true. There have been studies done to show that untreated depression, anxiety, psychosis, or whatever it is can be as or more harmful to the mom and the baby than the medication itself. It is good to have an open-mind about medication. Then lastly, it is important to understand that trouble breastfeeding is a risk factor for anxiety and depression. This information might be more pertinent to people working in the NICU or who help with lactation. There are certain medications that can help to increase breast milk supply, but they may trigger anxiety. If this is happening, they may need a psychiatric consultant. Again, I am not saying that you need to do that, but it is important to have that information. The "breast is best" campaign may not always be best for moms who have mental health problems as it makes their anxiety so much worse. I was unaware of this, and I think it is really interesting.
Screening – Create a Wellness Questionnaire
If it is appropriate in your workplace, you may want to create a screening tool (Beeber, Perreira, & Schwartz, 2008; Cox, Holden, & Sagovsky, 1987; Olson, Dietrich, Prazar, & Hurley, 2006; Osborne, Hermann, Burt, et al., 2015; Price & Cohen-Filipic, 2013; Siu and the US Preventive Services Task Force, 2016; Somerville et al., 2014; Spitzer, Kroenke, Williams, & Lowe, 2006).
- Edinburgh Postpartum Depression Scale (EPDS) https://pesnc.org/wp-content/uploads/EPDS.pdf
- Patient Health Questionnaire – 9 (PHQ-9) and Generalized Anxiety Disorder – 7 (GAD-7) http://www.phqscreeners.com/
- Mood Disorders Questionnaire (MDQ) (Bipolar Disorder) http://www.dbsalliance.org/pdfs/MDQ.pdf
For example, you do not need to say, "This is the Edinburgh Postpartum Depression Scale." I have a friend who works at a children's hospital, and she calls it a "Mother's Wellness Questionnaire." You can use this whether you are in a pediatric setting, a NICU, primary care, or working in mental health. You can also create your own screening tool. You want to ask the mom how she is doing, and this may be an easier way to get the information out of her because it asks the right questions. With this screening tool, the rate of detection of postpartum depression was 35.4 percent. This is not a lot, but without the screening tool, it was at 6.3 percent. Screening gives us a lot more information about who is suffering and who needs help and support.
We screen because we can increase the rate of detection, and there are treatment options are available. This is not something that is a life sentence; there is treatment. And, the cost to the infant mother and family if they do not get treatment can be serious and fatal.
The Edinburgh Postpartum Depression Scale (EPDS). This is most commonly used because it includes questions for depression and anxiety. It is nice that it includes two questions for anxiety so you do not have to do two separate questionnaires.
The Patient Health Questionnaire (PHQ-9). With this, you will also need to use the Generalized Anxiety Disorder 7-Item Scale, the GAD-7, in order to get a full picture of someone's mental health.
Mood Disorders Questionnaire (MDQ). For bipolar disorder, I would recommend using this one. This is different from the other two and screens for different things.
When screening a mom, you first need to establish trust. She is not going to open up to someone she does not know or trust. Building rapport is so important. Another thing I think is important is normalizing the disorder. We need to raise awareness that this is an issue that could be happening and educating the mom on the symptoms. I think postpartum depression does not always look like how you think it is going to look. There are many symptoms like anxiety, overwhelmingness, and hypervigilance, rather than just sadness and crying. Again, it is important to inform the mom of treatment options, and that medication and/or therapy are not the only treatment options.
