Transcript In-Home CBT for Postpartum Depression in First

Addressing Maternal Depression and
Trauma in Home Visiting
Robert T. Ammerman, Ph.D, ABPP
Every Child Succeeds and
Cincinnati Children’s Hospital Medical Center
3rd Annual Strengthening Families Summit
on Parental Depression
Concord, New Hampshire
March 31, 2014
Depression in Mothers
• Determined by self-report
– Edinburgh Postnatal Depression Scale
– Center for Epidemiological Studies Depression Scale
(CES-D)
– Beck Depression Inventory-II (BDI-II)
– Patient Health Questionniare-9 (PHQ-9)
• Diagnosis of major depressive disorder (MDD)
– Postpartum onset ≤6 months
– Prenatal
Depression and CMS Claims
Symptoms of Major Depressive
Disorder (MDD)
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Sadness
Crying
Fatigue
Disinterest
Sleep problems
Appetite problems
Agitation or slowness
Poor memory
Poor concentration
Low self-esteem
Guilt
Low motivation
Hopelessness
Suicidal thoughts
Decreased libido
CONSISTENT
&
PERSISTENT
≥2 weeks
Phenomenology
• Pervasive loss
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Loss of control
Loss of self
Social disconnection
Loss of voice
• Spiraling downward
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Anxiety
Overwhelmed
Rumination
Obsessive thinking
Anger
Guilt
From C.T. Beck, 2002
Phenomenology (cont.)
• Expectations and reality
– Shattered dreams
– Failure & incompetence
– Fear of negative evaluation
• Making gains
– Surrendering
– Despair and hopelessness
– Struggle
Things have been so rough lately
I know you can feel it too
I've been through this before
But this time I have you
Sometimes I feel so down
I just want to run away
But then I see you my angel
& that's what makes me stay
From growing in my tummy
To practicing to stand
Time is going by so fast
This was definitely never the plan
I've been so tough on myself
Because I believe you deserve the best
I try to be the perfect mom
But on the inside I'm just a mess
So bare with me baby girl
I'm fighting this depression for you
I'm still a little broken
But I know I'll make it through
Your my strength my pride
Everything that's good in me
Someday I hope I'll be able
To see just what you see
But until then I'll continue trying
To make all your dreams come true
& no matter what happens
I'll always love you.
Epidemiology of MDD
• Lifetime prevalence for the general population is as high
as 1 in 3, often begins in childhood or adolescence
• Lifetime prevalence in women postpartum: 13-26%
• Average length of episode: 3-6 months
• Impairment: 87% report significant role impairment
(social, home, relationships, work)
• Comorbidity: 71% (anxiety disorders, substance use
disorders)
• Risk for subsequent episodes: 80%
• Odds of relapse within 2 years: 50%
• First episodes in postpartum period: 50%
Associated Features
• Nationally, 57% receive treatment. Only 64%
get at least minimally adequate treatment.
• 20-30% of women depressed postpartum
receive treatment, less among low income.
• Failure to successfully treat the first episode
increases risk for subsequent episodes and
increases likelihood of treatment resistant
depression.
• Suicide risk: between 4-15%
Maternal Depression is Expensive
Mother
• Employment
• Education
• Health care utilization
• Lifetime earnings
Child
• Preterm birth
• Cognitive delays, special
education
• Mental health treatment
• Injury and illness
• Child abuse and neglect
Maternal depression is a multigenerational issue.
Economic Costs
• World Health Organization (2012)—Depression is the
leading cause of disability worldwide
• Depression in adults costs $83.1 billion annually,
including 31% direct medical costs, 62% workplace
costs (absenteeism, presenteeism and disability) and 7%
for suicide/mortality costs
• Depressed employees miss 27.2 days of work per year
• Maternal depression is associated with an increase in
pre-term births which average $51,600 per birth
• Family lifetime loss in income potential is $300,000 due
to childhood onset of psychological problems
• Identification and effective treatment saves money and
protects investments in other programs.
Depression 2 years Postpartum
Measure:
Edinburgh
Postnatal
Depression
Scale
Sample: 1,359 women over 2 years postpartum
From Mayberry et al., 2007
Center on the Developing Child, Harvard University, 2009
Video Example
Diagnostic Interview with a Depressed
Mother in Home Visiting
Risk Factors for Depression
• History of depression
• Cognitive and emotional vulnerability: pessimism,
anxiety, low self-esteem
• Stressful life events
• Low social support
• Poverty
• Unmarried
• Unwanted pregnancy
• Trauma history
Trauma
Traumatic events are shocking and emotionally
overwhelming situations that may involve actual or
threaten death, serious injury, or threat to physical
integrity.
Reactions to traumatic events vary considerably,
ranging from relatively mild creating minor
disruptions in the person's life to severe and
debilitating.
International Society for Traumatic Stress Studies
http://www.istss.org/WhatisTrauma/4339.htm
Types of Interpersonal
Traumatic Experiences
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Physical abuse
Sexual abuse
Emotional abuse
Witnessing violence
Physical or sexual assault
Intimate partner violence
Timing
Severity
Frequency
Duration
Trauma experiences of
mothers in home visiting
Witness IPV
Witness crime
13.4%
43.7%
31.2%
N=806
Trauma=74.1%
2+=68.9%
26.7%
32.7%
28.2%
IPV
Physical abuse
Sexual abuse or assault
Victim crime
Ammerman et al., 2009
Impacts of interpersonal trauma
Traumatic Experiences
Biological
emotional
dysregulation
Behavioral
Social
fear and
avoidance
relationship
maladjustment
Posttraumatic Stress Disorder
Complex trauma
The HPA Axis
Hyman, 2009 (Nature)
Effects of Dysregulated Cortisol
Greater or lesser sensitivity to stress cues
Greater arousal, more time needed to recover
Inattention, distractibility
Poor memory
Emotional and behavioral dysregulation
Biobehavioral Response to Trauma
-Genes contribute to how we respond to stress.
-Genes can make us more vulnerable to traumatic stress.
-Genes can be altered through exposure to traumatic stress,
and these changes can be passed on to offspring.
-Traumatic stress alters how neurons
connect with each other and how
they work.
-Traumatic stress changes brain architecture.
These changes can occur in the developing
fetus and remain for a lifetime.
Adverse Childhood Experiences
(ACE) Study
• N=17,337 men and women, varied
demographics, recruited 1995-1997
• Lifespan perspective on effects of ACEs on
health and well-being
• Identified 10 ACEs that were highly predictive of
poor outcomes
Felitti et al., 1998
Increased risk for poor health &
social outcomes
• Alcoholism and
alcohol abuse
• Chronic obstructive
pulmonary disease
(COPD)
• Depression
• Fetal death
• Health-related quality
of life
• Illicit drug use
• Ischemic heart
disease (IHD)
• Liver disease
• Risk for intimate
partner violence
• Multiple sexual
partners
Increased risk for poor health
& social outcomes (cont.)
• Sexually transmitted
diseases (STDs)
• Smoking
• Suicide attempts
• Unintended
pregnancies
• Early initiation of
smoking
• Early initiation of
sexual activity
• Adolescent pregnancy
• Early death
www.cdc.gov/ace/index.htm
ACE Score Items
1.
2.
3.
4.
5.
Emotional Abuse
Physical Abuse
Sexual Abuse
Emotional Neglect
Physical Neglect
SCORE: 0-10
6. Parents separated
or divorced
7. Mother IPV
8. Household problem
drinker or drug user
9. Household mental
illness
10.Household prison
Endorsement of ACE Items (N=94)
1-Emotional Abuse
2-Physical Abuse
3-Sexual Abuse
4- Emotional Neglect
5-Physical Neglect
100%
90%
80%
67.0%
70%
60%
50.0%
50%
39.4%
40%
10%
38.3%
30.9%
30%
20%
55.3%
21.3%
8.5%
18.1%
12.8%
0%
1
2
3
4
5
6
7
6-separate/divorce, 7-mother IPV, 8-alcohol/drugs,
9-mental illness, 10-prison
8
9
10
ACE Total Score in HV Sample and CDC 2009 Five
State Survey, Female (18-24 yrs) Sample
50%
43.6%
45%
40%
35%
35.5%
30%
25%
22.6%
20%
15%
10%
17.0%
21.0%
20.2%
13.2%
9.6%
9.6%
7.6%
5%
0%
0
1
2
3
≥4
Key Features of Infant Social
and Emotional Development
• Infants can imitate facial expressions and show
preferences for caregivers.
• Infants have a need to seek out communication
with others.
• Infants can elicit social and emotional responses
from caregivers.
Key Features of Infant Social
and Emotional Development
• Communication between mothers and infants is
organized around face, voice, gesture, and gaze--“a
dance”.
• Secure attachment is the cornerstone of early social
and emotional development.
• Communication directly influences, and is
influenced by, brain development and emerging
physiological regulation.
Key Features of Infant Social
and Emotional Development
• In normal mothers’ interactions with babies, 42%
of time is spent exhibiting positive affect. For
babies, 15% of time.
• Mothers “guide” the quality of the interaction and
the direction of development. They provide the
scaffolding needed for successful development.
Characteristics of Depressed Mothers
• Withdrawn: disengaged, flat, unresponsive, little
support.
• Intrusive: rough, angry, interrupt
• Unable to read cues.
• Rejecting.
• Imbalanced, discordant.
Characteristics of Depressed Mothers
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Don’t enjoy parenting.
View themselves as less competent and ineffective.
View children as more difficult.
Less tolerant.
More likely to attribute inappropriate intent in children.
See their behavior as caused by outside influences.
Preoccupied, less attentive, don’t anticipate.
Slower and less effective problem-solvers.
Course of Depression &
Development (illustrative)
1st episode
4 months
2nd episode
9 months
3rd episode
2 months
4th episode
3 months
time
Age 16
Baby born
(age 20)
= depressive episode
child 1
year old
= normal mood
child 3
years old
Impact on Infants and Development
• Avoid mom, look away (for intrusive moms),
docile, typically following maternal rejection.
• Fussy, cries, focus on self-regulation (for
withdrawn moms).
• Crystallizing of communication patterns.
• Delays in emotional regulation, and
physiological organization.
• Attentional problems.
IMPORTANT: timing, length, severity, frequency,
inter-episode functioning, partner support, other adults
Video Example
Mother-Child Interaction Using
Still-Face Paradigm
Treatment Challenges
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Treatment capacity
Availability of evidence-based treatment
Access and disparities
Choice and engagement
Antidepressant medications: adherence, effect
on developing fetus, cost, trauma issues
Moving Beyond Depression™
Overcoming barriers, fostering
collaboration, and engaging depressed
mothers in a non-traditional setting
www.movingbeyonddepression.org
Unique Opportunity in Home Visiting
• Reach mothers who might not otherwise receive
treatment.
• Appeal to mothers’ interest in their baby’s
development.
• Lower barriers to treatment.
• Identify mothers early in the MDD episode.
• Leverage relationship between mother and home
visitor.
• Leverage ongoing and lengthy home visitation
services to optimize outcomes.
Course of Depression (BDI > 13 @
enrollment and/or 9 months) in home
visitation (N = 806)
74.8%
with
trauma
history
Non-Dep
Dep
55.8%
44.2%
Ammerman et al., 2009
12% receive
mental health
treatment
Essential Intervention Elements
Ameliorate depressive symptoms
Help mother and home visitor/service
Collaborate with home visitor, no burden
Implement in home to remove barriers
Use evidence-based treatment
Fit with population, setting, & service
IH-CBT: Adaptations to Setting
Overcome barriers to treatment to reach mothers
Observe mothers in natural environment
Observe important features that would not be evident in office
Maximize learning and application of new skills
Logistical challenges: privacy, other family, distractions
Unexpected challenges and crises
IH-CBT: Adaptations to Population
New mothers with limited parenting experience
Young mothers with few social supports
Emerging adulthood
Educational underachievement & lower IQ
Cultural sensitivity
Poverty and hardship
Trauma history & intimate partner violence
Psychiatric comorbidity
IH-CBT: Adaptations to Service
Collaborative relationship with home visitor
Logistical coordination of multiple services
Frequent contacts with home visitor
Coordination of care
Avoid triangulation
Conceptual representation of IHCBT collaboration
THERAPIST
HOME VISITOR
primarily
depression
domains
primarily
HV domains
MOM
Inclusionary:
ECS participant
≥16 years old
Baby 2<10 months
EPDS ≥11
MDD using SCID
MIDIS Design
Screening: EPDS ≥11
Exclusionary:
Substance depend.
Psychosis
Current suicidality
Meds or therapy
Eligibility/Pre-treatment Assessment
SCID Diagnosis of MDD
randomization
IH-CBT
15 sessions + booster
Ongoing home visitation
Typical Home Visitation
Community resources
Ongoing home visitation
Post-treatment Assessment
3 Month Follow-Up Assessment
34.8%
received
community
treatment
N=93
Retained: 86.8%
≥ 2 points: 95.6%
Demographics of Sample (N=93)
Mother Age:
22.0 (4.6) years
Mother Race:
Caucasian
African American
Asian American
Hawaiian/Pacific Islander
Native American
62.6%
34.1%
1.1%
1.1%
1.1%
Mother Ethnicity:
Appalachian
Hispanic
Mother Marital Status:
Married
Separated
Single, never married
3.3%
7.7%
13.2%
1.1%
85.7%
Demographics of Sample (cont.)
Mother Education:
11.4 (1.9) years
Number of Children
1
2-3
92.3%
7.7%
Family Income:
$
0- 9,999
$10,000-19,999
$20,000-29,999
$30,000-39,999
$40,000-49,999
$50,000-59,999
54.8%
21.1%
16.4%
3.3%
2.2%
2.2%
Baby Age (days):
154.5 (74.0)
Clinical Features of MDD
• MDD: 100%
• BDI-II: 33.7 (10.1)
EPDS: 18.9 (4.0)
HDRS: 21.7 (4.6)
• Severity—
Mild: 28.9%
Moderate: 46.7%
Severe: 24.4%
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Postpartum onset: 29.2%
Recurrent: 75.3%
# Episodes: 2.66 (1.59)
Suicide attempts: 43.9%
Age of 1st episode:
15.1 (5.2) years
Current and Lifetime Comorbid Psychiatric Disorders
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
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BDI-II Scores at Pre-Treatment, Post-Treatment, &
Follow-Up
35
BDI-II Score
30
25
20
15
10
IHCBT
THV
5
Pre
Post
FU
Assessment Time Point
F=7.9, p<.01 Not affected by therapist or home visiting model
MDD Diagnosis at Pre- & PostTreatment & Follow-Up
100%
100.0%100.0%
IHCBT
90%
THV
80%
69.8%
70%
60%
52.6%
50%
40%
29.3%
30%
20.1%
20%
10%
0%
Pre
Χ2=19.0, p<.001
Post
FU
MDD Diagnosis at Pre-treatment, Post-treatment, &
Follow-Up for Completers, Partial Completers, & THV
100%
100.0%
100.0%
100.0%
Comp
90%
<15 sess
80%
THV
69.8%
70%
60%
52.6%
50%
44.4%
40.0%
40%
30%
21.7%
20%
9.5%
10%
0%
Pre
Post
FU
Social Support Using ISEL Scale (Total)
IH-CBT
THV
90
85
80
75
70
65
60
55
50
45
40
Pre
F=5.1, p<.01
Post
FU
IH-CBT Client Feedback at Post-Treatment
I feel more confident as a parent
Happy with level of confidentiality
Sessions in home were convenient
Therapist and Home Visitor worked together to help me
0%
20%
40%
60%
80%
100%
IH-CBT Home Visitor Feedback at PostTreatment
Happy with level of confidentiality
Therapist and I collaborated on case
Therapist was available
0%
20%
40%
60%
80%
100%
Predictors of symptom status at post-treatment
14
IH-CBT
sessions
12
Home visits
10
8
6
4
2
0
Symptomatic
BDI-II at post-txt:
≥9
Asymptomatic
≤8
Ammerman, R.T., Peugh, J.L., Putnam, F.W., & Van Ginkel, J.B. (2012). Predictors of treatment
response in depressed mothers receiving In-Home Cognitive Behavioral Therapy and concurrent
home visiting. Behavior Modification, 36, 462-481.
Recovery and HOME
39
37
35
33
Post
31
FU
29
27
25
RR
DR
RD
DD
Dissemination
Massachusetts
(4 sites)
Kentucky
(6 sites)
Connecticut
(4 sites)
Kansas
(1 site)
www.movingbeyonddepression.org
Upcoming Resources
Special issue, Maternal Depression
& Home Visiting, May, 2014
Coming soon from SAMHSA
Acknowledgments
• Frank W. Putnam, M.D. & Judith B. Van Ginkel, Ph.D.
• Jack Stevens, Ph.D., Mekibib Altaye, Ph.D., James Peugh, Ph.D.
• Jodie Short, Margaret J. Clark, M.P.A., Lawson Wulsin, M.D.,
Jennie Noll, Ph.D., Chad Shenk, Ph.D., Neil Richtand, M.D.,
Ph.D., Nicole Bosse, M.A., Angelique Teeters, Psy.D.
• Healthy Families America and Nurse-Family Partnership
• Grant support: National Institute of Mental Health
(R34MH073867 & R01MH087499)
• Every Child Succeeds agencies and home visitors!
• Health Foundation of Greater Cincinnati
• Kentucky H.A.N.D.S. & Ohio Help Me Grow
• United Way of Greater Cincinnati
• Xavier University, Dept. of Psychology
www.everychildsucceeds.org