Maternal Depression: Causes, Consequences, and Intervention

Robert T. Ammerman, Ph.D, ABPP

Every Child Succeeds and Cincinnati Children’s Hospital Medical Center Delaware Healthy Mother and Infant Consortium Annual Summit April 9, 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

Symptoms of Major Depressive Disorder (MDD)

• 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 – Loss of control – Loss of self – Social disconnection – Loss of voice • Spiraling downward – 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

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 • Trauma history • Low social support • Poverty • Unmarried • Unwanted pregnancy

Causes of Depression

• Genetics • Disruptions in HPA axis and stress response • Sensitivity to hormonal changes • Social disconnection • Cognitive distortions

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

• 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.

time

Course of Depression & Development (illustrative)

1 st episode 4 months 2 nd episode 9 months 3rd episode 4th episode 2 months 3 months 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

110

Exposure to Maternal Depression in Infancy & IQ

BOYS AT AGE 11 100 15 points 90 80 70 FSIQ VIQ PIQ 60 50 No Dep at 3 mo

Hay et al., 2001

Dep at 3 mo

Video Example

Mother-Child Interaction Using Still-Face Paradigm

Treatment Options

• Antidepressant medications • Interpersonal Psychotherapy • Cognitive Behavioral Therapy • Non-traditional and emerging: Listening Visits, yoga, mindfullness therapy, lay counselors

Treatment Challenges

• 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.

74.8% with trauma history Course of Depression (BDI > 13 @ enrollment and/or 9 months) in home visitation (N = 806) 55.8% Non-Dep Dep 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 IH CBT 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

34.8% received community treatment

Post-treatment Assessment

N=93 Retained: 86.8% ≥ 2 points: 95.6%

3 Month Follow-Up Assessment

Demographics of Sample (N=93)

Mother Age: 22.0 (4.6) years Mother Race: Caucasian African American Asian American 62.6% 34.1% 1.1% Hawaiian/Pacific Islander 1.1% Native American 1.1% Mother Ethnicity: Appalachian Hispanic 3.3% 7.7% Mother Marital Status: Married Separated Single, never married 13.2% 1.1% 85.7%

Demographics of Sample (cont.)

Mother Education: 11.4 (1.9) years Number of Children 1 92.3% 2 - 3 7.7% Family Income: $ 0- 9,999 $10,000-19,999 $20,000-29,999 $30,000-39,999 $40,000-49,999 54.8% 21.1% 16.4% 3.3% 2.2% $50,000-59,999 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% • Postpartum onset: 29.2% • Recurrent: 75.3% • # Episodes: 2.66 (1.59) • Suicide attempts: 43.9% • Age of 1 st episode: 15.1 (5.2) years

Current and Lifetime Comorbid Psychiatric Disorders 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Current Past P TS D S oc . P h ob G .

A D O C D A lc . A bu se P an ic D is .

D ru g D ep A .

lc . D ep .

S pe c. P ho b .

D ru g A b u se B ul im ia A no re xia

25 20 15 10 5 35 BDI-II Scores at Pre-Treatment, Post-Treatment, & Follow-Up 30 IHCBT THV Pre Post Assessment Time Point FU F=7.9, p<.01

Not affected by therapist or home visiting model

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

MDD Diagnosis at Pre- & Post Treatment & Follow-Up

29,3% 69,8% 20,1% 52,6% IHCBT THV Pre Post FU Χ 2 =19.0, p<.001

MDD Diagnosis at Pre-treatment, Post-treatment, & Follow-Up for Completers, Partial Completers, & THV

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 21,7% 40,0% 69,8% 9,5% 44,4% 52,6% Comp <15 sess THV Pre Post FU

90 85 80 75 70 65 60 55 50 45 40

Social Support Using ISEL Scale (Total)

IH-CBT THV Pre Post FU F=5.1, p<.01

IH-CBT Client Feedback at Post-Treatment I feel more confident as a parent Happy with level of confidentiality Sessions in home were convenient 0% Therapist and Home Visitor worked together to help me 20% 40% 60% 80% 100%

IH-CBT Home Visitor Feedback at Post Treatment Happy with level of confidentiality Therapist and I collaborated on case 0% Therapist was available 20% 40% 60% 80% 100%

Predictors of symptom status at post-treatment

14 12 10 8 6 4 2 0 Symptomatic Asymptomatic

BDI-II at post txt: ≥9 ≤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.

IH-CBT sessions Home visits

Dissemination

Kentucky (6 sites) Massachusetts (4 sites)

www.movingbeyonddepression.org

Kansas (1 site) Connecticut (4 sites)

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