Health / 2013

Speak Up When Youre Down: Maternal Mental Health Improvement Project

Idea submitted in the My LA2050 Maker Challenge by Los Angeles County Perinatal Mental Health Task Force

The mission of the Los Angeles County Perinatal Mental Health Task Force is to remove barriers to the prevention, screening and treatment of prenatal and postpartum depression in Los Angeles County. Common barriers include lack of screening, inaccessibility of informed treatment, stigma and lack of reimbursement from payors. In order to address these barriers and increase access to depression screening and treatment services for medically underserved pregnant and postpartum women, the Task Force has been working in partnership with USC-Eisner Family Medicine Clinic on the Maternal Mental Health Improvement project - a pilot project that embeds maternal mental health care in a primary care setting. USC-Eisner FMC is a federally qualified nonprofit community health center dedicated to improving the physical, social, and emotional well-being of people in Metro, South and South Central Los Angeles, regardless of their ability to pay. Its patient population includes high-risk, uninsured, under-insured and otherwise medically underserved women and their infants. According to the 2008 LAMB survey, 23.1% percent of new mothers in the catchment area served by USC-Eisner FMC reported depression during pregnancy and 58.2% reported some level of depression postpartum - a rate roughly twice that of pregnant women nationwide. In addition, many struggle with financial stress, poor social support and chronic illnesses such as diabetes, hypertension and thyroid disease. Additional risks include linguistic barriers, immigration status, lack of health insurance, obstacles to care such as transportation and childcare, and lack of access to mental health services. As part of the Maternal Mental Health Improvement project, which is based on the IMPACT model, all prenatal and postpartum patients are screened for perinatal mood and anxiety disorders at each visit. Patients who screen positively (10 or more on the PHQ-9 or 4 or more on the Edinburgh 3) are connected with an onsite social worker, social work intern and/or occupational therapist, who conducts a full assessment of the patient. These cases are referred to the New Family Care Team, which consists of primary care physicians, social workers, occupational therapists, psychologists and case managers at USC-Eisner FMC, as well as a consulting perinatal mental health psychiatrist, psychologist, licensed marriage family therapist and a social worker. Members of the New Family Care Team meet on a weekly basis to discuss patients who have presented as high or medium risk for perinatal depression, provide expertise from members' respective disciplines and construct an optimal treatment plan for each case. Treatment options may include individual or group therapy, psychiatric care, medication, cognitive behavioral therapy, interpersonal psychotherapy and/or psycho-dynamic psychotherapy, social support and intensive case management with warm referrals to community resources. Since January 2012, 420 pregnant and postpartum women have been screened for perinatal depression at USC-Eisner FMC. Positive screens, which account for approximately 33% of all women, are given an extensive intake assessment using a tool developed by the Task Force. The intake/assessment tool includes a comprehensive psychosocial history, including risk factors such as past trauma and loss, domestic violence, substance abuse, immigration status and social support, as well as a complete psychiatric differential diagnosis. Thus far, the intervention appears to be creating a medical home for women and their children, potentially lowering rates of fragmented medical and mental health care and addressing the physical and mental health needs of women and children. The most important observation thus far has been that time and time again, women express reluctance to being given a referral outside of the clinic, but are willing to connect with an "emotional support person" who is on the premises. In this way, women are far less likely to fall through the cracks. The Task Force is currently actively fundraising for the Maternal Mental Health Improvement project so that it can design a data dashboard that will track the project's outcomes. Data sets that will be collected through the dashboard will be used to inform conclusions about the efficiency and cost-effectiveness of the IMPACT model of collaborative mental health care as applied to maternal depression.

What are some of your organization’s most important achievements to date?

The Los Angeles County Perinatal Mental Health Task Force was founded in February 2007 by Special Counsel/Legislative Analyst, Kimberly Wong, following her personal experience with severe postpartum depression. The Task Force is a coalition composed of over 35 public and private non-profit agencies as well community leaders, research partners, advocates for mothers, infants, and families, survivors of maternal depression and affected family members. Through its programs and initiatives, the Task Force aims to: (1) Raise public awareness of the disorder so that women who are suffering are not ashamed or embarrassed to seek help; (2) Increase perinatal depression screening and referral rates among community and health care providers; and (3) Advocate for legislation that supports the identification and treatment of perinatal depression.

Since its inception, the Task Force has:

*Obtained the dedication of May of every year as Perinatal Depression Awareness Month throughout Los Angeles County and the state of California. *Distributed over 800,000 Speak Up When You’re Down: Six Things Every New Mom and Mom-to-Be Should Know About Maternal Depression posters and brochures (available in 7 languages). *Developed a Training & Technical Assistance program that has delivered tailored perinatal mood disorder trainings to over 1,500 health care and community-based providers. *Published a Community Providers Perinatal Mental Health Toolkit, which includes information and handouts on the signs, symptoms, risk factors, effects, screening, assessment, prevention, and intervention for perinatal depression and related mood and anxiety disorders for providers. *Launched an innovative, first of its kind, pilot project with USC-Eisner Family Medicine to implement an IMPACT model in which perinatal mental health is embedded in primary care visits both for screening and intervention. *Co-sponsored ACR 53 (Hernandez), the Kelly Abraham Martinez Act, which urges hospital providers, mental health care providers, health plans, and insurers to invest resources to educate women about perinatal depression risk factors and triggers.

The Task Force is a project of 501(c)3 fiscal sponsor, Community Partners.

Please identify any partners or collaborators who will work with you on this project.

The Task Force will work with the following partners on its Speak Up When You’re Down: Maternal Mental Health Improvement project:

*USC-Eisner Family Medical Center, a federally qualified nonprofit community health center dedicated to improving the physical, social, and emotional well-being of people in Metro, South and South Central Los Angeles, regardless of their ability to pay.

*The Magnolia Place Community Initiative (MPCI), a ground-breaking model for large scale community mobilization and transformation where children, living in the most vulnerable neighborhoods, break all records of success in their education, health milestones, the nurturing they receive from their family, and the economic stability of their family.

Please explain how you will evaluate your project. How will you measure success?

The Task Force will contract with an external evaluator to conduct a comprehensive evaluation of the Speak Up When You’re Down: Maternal Mental Health Improvement project, including qualitative and quantitative indicators of project success. Qualitative measures may include feasibility and implementation challenges and successes within the participating clinic and program, as well as program milestone achievements. Quantitative measures may include descriptive baseline measures of outcomes related to screening and access to care, implementation of screening and intervention protocols and demographic, clinical and psycho-social variables of the patients seen during the research project. Data elements will include date of birth; marital status; ethnicity; family income; insurance status; age of first prenatal visit; history of mental health; immigration status; evidence of substance abuse, domestic violence, etc. Other data will include maternal and birth outcomes.

Benchmarks that will be tracked over the project’s life include:

*Number of prenatal and postpartum women at USC-Eisner FMC to be screened for perinatal mood and anxiety disorders; *Percentage of screened patients to be provided warm referrals to treatment; *A cost per patient for embedded maternal mental health care at USC-Eisner FMC is established; *A cost per patient for maternal mental health care at comparison site is established; *Quality outcomes of embedded maternal mental health care at USC-Eisner FMC are identified; *Quality outcomes of maternal mental health care at comparison site are identified.

A summative evaluation of progress towards achieving the project’s intended objectives will be measured annually through a data dashboard consisting of tracking outputs of participation, attendance, as well as practice outcomes of screening, referring and access to care in representative clinical settings. The Task Force will utilize these evaluations to regularly revisit the project’s goals and strategies and to revise them, if necessary.

How will your project benefit Los Angeles?

Perinatal or maternal depression encompasses a range of mood disorders that can affect a woman during pregnancy and around the time of birth. Mothers who suffer from perinatal depression are at-risk of delivering a pre-term baby, a low-birth weight baby and/or a baby with elevated stress hormones. They are also less likely breastfeed, use car seats, electrical outlet covers or smoke detectors, place her baby on his/her back to sleep, or talk, play or show books to her baby on a daily basis. A mother suffering from postpartum depression is also more likely to abuse drugs and/or alcohol, display anger and disengagement with her baby and use corporal punishment. Children of women who are suffering from perinatal depression may display poor weight gain, low self-esteem and behavioral problems. Most importantly, depression in the postpartum period interrupts healthy bonding between mother and child, leading to impaired cognitive, behavioral, and emotional development in early childhood and beyond.

Of the approximately 150,000 live births occurring in Los Angeles County each year, over 22,000 women experience clinical perinatal depression. Women who live in disadvantaged populations are particularly susceptible. Recent studies have demonstrated that in households below the federal poverty threshold, as many as one in four mothers of infants is experiencing moderate to severe levels of depressive symptoms. The most recent Los Angeles Mother Baby (LAMB) Survey results identified close to 40% of Hispanic and African-American women as experiencing some degree of perinatal depression.

Highly treatable and often preventable, perinatal depression and related mood disorders are often not diagnosed and/or treated due to lack of screening and inaccessibility of informed treatment. In fact, 19 percent of women in Los Angeles rate their mental health as fair or poor during their pregnancy, yet 42 percent of new mothers were not asked about feeling depressed during their hospital stays, well baby appointments or 6 weeks postpartum check ups.

Through its Speak Up When You’re Down: Maternal Mental Health Improvement Project, the Los Angeles County Perinatal Mental Health Task Force will increase awareness of maternal depression and its impact on the mother, child, family and community at large amongst pregnant and postpartum women, health care and community providers and county policy makers. As a result, by 2050 all pregnant and postpartum women will be screened for maternal depression during their prenatal visits and postpartum check up and all women who are high-risk for maternal depression will receive treatment.

What would success look like in the year 2050 regarding your indicator?

Success will that all pregnant and postpartum women are screened for perinatal mood and anxiety disorders during prenatald and postpartum visits by health care and other community providers, and that 100% of high risk patients are provided with a warm referral to an organization or agency that can help them.