Implementing the MIHP
Depression Interventions
Making Best Use of this Webcast
• Print out the slides before you continue.
• Make notes as you go along.
• If you have questions after watching this webcast,
Joni Detwiler
MIHP State Consultant
517 335-6659
[email protected]
Learning Objectives
1. Review findings of MIHP Program Fidelity Study.
2. Define perinatal depression and describe its impact
on the mother and her infant.
3. Discuss role of MIHP professional staff in
addressing perinatal depression.
4. Discuss how to access mental health treatment and
support services in your community for women
suffering from perinatal depression.
Administrative Data Analysis:
Quasi-Experimental Study:
IHCS extracts administrative data (claims, encounters, maternal
electronic screening) from the Medicaid data warehouse to obtain
program aggregate and provider-specific data. These data include
screening rates, maternal risk, numbers of visits and other
indicators available from claims and electronic risk screeners. This is
not intended to be scientific but provides quantitative data and
actionable information to MDCH for effective program oversight
and administration.
IHCS will draft a quasi-experimental study design to evaluate the
impact of MIHP services. The design will adhere to DHHS criteria
for evidence-based home visit models. This study will be designed
by MSU researcher(s) with input from the IHCS QI staff, and a
proposal will be submitted to MDCH by mid-June 2011. This study
design component will be completed under the scope of MSU
Master Agreement with MDCH and will build on studies conducted
by MDCH and Michigan State University over the previous 7 years.
Michigan Maternal Infant Health
Program (MIHP) Evaluation
Provider Reviews and Oversight:
IHCS is piloting a web-based client survey for women who have
received MIHP services. This survey is to assess client satisfaction
with MIHP and the extent to which the MIHP provider helped the
client gain parenting skills, knowledge, and self-confidence. At the
conclusion of the pilot (9/1/11) IHCS will report pilot data and
response rates to determine whether a written survey option is
Certification and Recertification: MDCH has established provider
certification and recertification requirements for MIHP providers
including site visits and ongoing quality reviews.
IHCS will also develop a MIHP provider survey upon request by
Record Review (Program Fidelity): IHCS will review client records
completed by all MIHP providers to assess program fidelity (the
extent to which services are delivered consistently and according to
program policy). The initial review will be conducted in JuneAugust 2011, and IHCS will provide MDCH with a report by
September 30, 2011. Subsequent reviews will be conducted at least
every three years.
MIHP Program Fidelity Study
Record Review (Program Fidelity)
MSU review of client records completed by
MIHP providers to assess program fidelity
(extent to which services are provided
consistently and according to policy).
Plan of Care 2 (POC 2) depression domain
– Inconsistent
– Absent
QI Response to
Fidelity Study Results
1. Develop online training on implementing the MIHP
depression interventions
2. Require staff to view trainings on depression and
infant mental health at
3. Develop tools to assist staff to help women navigate
the mental health services systems
Depression Overview
• Let’s start at the beginning…
Depression is a Worldwide
Public Health Issue
• Unipolar (clinical) depression is one of the top
leading 5 causes of disability on our planet. Together
with bipolar disorder (manic depression), it is costlier
and more burdensome than any other ailment
except cardiovascular disease. (1)
• Depression affects twice as many women as men,
regardless of racial and ethnic background and
income. (2)
• One in four women will experience severe
depression at some point in life. (3)
Depression in the Perinatal Period
There are three types of depression women may
experience during the period from start of pregnancy
to 12 months after giving birth:
• The Baby Blues
• Perinatal Depression
• Postpartum Psychosis
NOTE: Prenatal Depression, Postpartum Depression, Postnatal
Depression, Maternal Depression, and Perinatal Depression
generally refer to the same mental health disorder.
Definition: Baby Blues
Common reaction the first few days after delivery.
Crying, worrying, sadness, anxiety, mood swings.
Usually lifts in about 2 or 3 weeks.
Experienced by 50 – 80% of women.
Perinatal Mood Disorder
• Major and minor episodes of clinical depression
during pregnancy or within first year after delivery.
• More than the Baby Blues:
– Lasts longer and is more severe
• Symptoms:
Sad, anxious, irritable
Trouble concentrating, making decisions
Sleeping or eating too much or too little
Frequent crying and worrying
Perinatal Mood Disorder
• Symptoms (continued)
Loss of interest in self care
Loss of interest in things that used to be pleasurable
Shows too much or two little concern for baby
Not up to doing everyday tasks
Feelings of inadequacy
Suicidal thoughts
• Symptoms last more than 2 weeks
Perinatal Mood Disorder
• Co-occurs with anxiety disorder for 2/3 of women: (4)
Generalized Anxiety Disorder
Panic Disorder
Obsessive-compulsive Disorder
• Often co-occurs with substance use disorder
Definition: Postpartum Psychosis
• A rare disorder (one or two in 1,000 women).
• A severe form of perinatal depression that can be
• Symptoms: extreme confusion, hopelessness, can’t
sleep or eat, distrusts others, sees or hears things
that aren’t there, thoughts of harming self, baby or
• A medical emergency requiring urgent care.
Prevalence of
Perinatal Depression
• 10-20% of all women experience depression during
the perinatal period. (5)
• Prevalence in low-income and black women is
estimated at almost double that of white women. (6)
• Analysis of depression rates across 6 home visiting
(HV) programs found that the % of women exceeding
clinical cutoff for depression at enrollment ranged
from 28.5 – 61%. (7)
Prevalence in MIHP Population
July 01, 2012 – July 01, 2013
MRI Depression Scores
% of Total Screened
0 = Low
1 = Moderate
2 = High
3 = Unknown
4 = No Risk
Total Screened
Total Mod &
High Risk
Total No Risk
Total Unknown
Total Low Risk
Total Screened
Risks for Perinatal Depression
• Can affect any woman regardless of age, race,
income, culture, or education.
• Factors that increase the risk: (8)
History of depression
Use of alcohol and tobacco during pregnancy
Without a partner
Lower level of education
Few Pregnant Women Access
Depression Treatment
• U of M Depression Center study: 20% of pg women
scored hi on standard depression survey, but of
those, only 14% received any MH treatment. (9)
• Northwestern Univ. screened 10,000 PP women:
14% screened +; of those, 19% thought of harming
selves. Recurrent episodes. Vast majority of PPD
women in US not treated. (10)
• Effective treatments have been identified - Cognitive
Behavioral Therapy, Interpersonal Therapy, & meds.
• Few women access depression treatment.
Why Low-Income Women Don’t
Access Depression Treatment
The illness itself gets in the way
Shame about not being “strong”
Guilt: “You’re supposed to be happy” when you’re pregnant.
Stigma around using MH services; being seen at CMH
Fear of being labeled “crazy”; lumped in with people with
6. Partner, parent or community (e.g., faith or cultural group)
prohibits it
7. Family or friends say “it’s all in your head - snap out of it”
Why Low-Income Women Don’t
Access Depression Treatment
8. Fear that she will be judged, especially if she’s young
9. Fear of taking medications, especially during pregnancy
10. Belief that psychotherapy won’t help because trauma, loss
and stress are so prevalent in low-income community
11. Isolation
12. Hoops to jump and long wait times to get an appointment
13. Logistical barriers (e.g., transportation, child care)
14. Previous negative experience with MH treatment
15. Too overwhelmed caring for infant and working
Why Low-Income Women Don’t
Access Depression Treatment
16. Mistrust of system
17. Fear MH treatment will be used against her in custody
18. Fear that confidentiality will be violated, resulting in:
• CPS referral
• Domestic violence
Be upfront about when a CPS report is mandated, but
maintain a warm relationship so that the mother feels
understood and trusts that what she may say about her
own MH won’t be misconstrued.
Adverse Effects of
Untreated Perinatal Depression
Untreated depression
among pregnant and
postpartum women is of
concern due to its adverse
effects on the health of
the mother, the health of
the infant, and the
relationship. (11)
Adverse Effects of
Untreated Perinatal Depression
1. Depressed women are more likely to engage in risk
taking behaviors: (12)
• More likely to use substances.
• Less likely to comply with prenatal care, putting self and
baby at risk for complications and poor birth outcomes.
• Less likely to use contraception consistently.
Adverse Effects of
Untreated Perinatal Depression
2. Pregnant, depressed women are 3.4 times more
likely to deliver preterm and 4 times more likely to
deliver a baby with low birth weight than nondepressed women. (13)
3. Undiagnosed and untreated maternal depression is
associated with increased rates of maternal suicide.
Adverse Effects of
Untreated Perinatal Depression
4. Maternal depressive symptoms in early infancy
contribute to unfavorable patterns of health care
seeking for children.
– Increased use of acute care at 30-33 months, including
Emergency Department visits in past year.
– Decreased receipt of preventive services, including ageappropriate well child visits and up-to-date
immunizations. (15)
Adverse Effects of
Untreated Perinatal Depression
5. Maternal depression, alone, or in combination with
other risks can pose serious, but typically
unrecognized barriers to healthy early development
and school readiness, particularly for low-income
young children. (16)
The cumulative impact of depression in combination
with other risks to healthy parenting (e.g., low
educational achievement) is greater.
Adverse Effects of
Untreated Perinatal Depression
6. Postpartum depression can impair early
relationships: (17)
• Secure attachment, or healthy emotional bond,
between an infant and primary caregiver is key to the
future emotional development of the infant.
• Depression threatens the mother’s emotional and
physical ability to care for her child and to foster a
healthy relationship with her child.
Still Face Experiment Video
Still Face Experiment: Dr. Edward Tronick –
YouTube (2:49)
A phenomenon in which an infant, after 3 minutes of
“interaction” with a non-responsive expressionless mother,
“rapidly sobers and grows wary. He makes repeated attempts to
get the interaction into its usual reciprocal pattern. When these
attempts fail, the infant withdraws [and] orients his face and
body away from his mother with a withdrawn, hopeless facial
expression.” (18)
Adverse Effects of
Untreated Perinatal Depression
7. Children born to a women who suffers from
postpartum depression are: (19)
• More likely to lack secure attachment and are therefore
at increased risk for delayed or impaired cognitive,
emotional and linguistic development.
• More likely to have behavioral problems.
• More likely to experience worse long-term mental
health problems.
Adverse Effects of
Untreated Perinatal Depression
8. A study of WIC mothers found that postpartum
depression resulted in: (20)
Poor nutrition
Poor infant weight gain
Childhood obesity and adiposity
Poor mother-child interactions
Maternal MH Problems:
A Challenge to HV Programs
• Three challenges to HV programs have been
consistently identified: maternal mental health,
substance abuse, and intimate partner violence. (21)
• Qualitative research finds that HVs identify maternal
MH problems as a significant barrier to providing HV
services in a consistent, continuous manner
– More difficult to engage and serve
– Harder to work with parents who:
• Are perceived as “uncommitted” or “unmotivated”
• Threaten to commit suicide
HVs Feel Inadequately Trained to
Address MH Problems
• In one study, 44% of HVs felt they were inadequately
trained the help families with MH problems. (22)
• HVs often say they are uncomfortable discussing
depression with a mother because:
– They don’t have the right training and are afraid they’ll say
the wrong thing.
– When they do bring it up and the women refuses MH
services, they feel responsible.
– They feel overwhelmed to be the only lifeline for a
depressed and perhaps abused woman.
Becoming More Comfortable
Discussing Depression
• If you don’t feel prepared, it’s perfectly
understandable you would be uncomfortable talking
about depression.
• You are not going to make it worse for the mother by
discussing her depression.
• We’ll give you some concrete ways to frame your
discussion later in this presentation.
What Can MIHP Do?
• Care coordination
• Education
• Support and
• Not therapy
– Exception: Infant Mental
Health Specialist can
provide brief mental
health interventions
History of Trauma
Is Related to Depression
• Trauma is very common among women in MIHP.
• Trauma is the personal experience of interpersonal
violence including: (23)
sexual abuse
physical abuse
severe neglect
and/or the witnessing of violence, terrorism and disasters.
What is Trauma-Informed Care?
• An appreciation for the high prevalence of traumatic
experiences among persons we serve.
• A thorough understanding of the profound
neurological, biological, psychological and social
effects of trauma and violence on the individual,
including adoption of health-risk behaviors as coping
mechanisms (smoking, substance abuse [SA], self
harm, sexual promiscuity, violence).
• Care that addresses these effects, is collaborative,
supportive and skill–based. (24)
Learn More about
Trauma-Informed Care
• Trauma-informed organizations and programs are
based on an understanding of the vulnerabilities or
triggers of trauma survivors that traditional service
delivery approaches may exacerbate, so providers
can be more supportive and avoid re-traumatization.
• Trauma-informed care is spreading across health and
human services: MH, child welfare, health care, DV,
foster care, homelessness, SA, criminal justice,
military families, refugee services, and others.
• for learning resources.
Diversity-Informed Practice:
Community Context
Community context affects perception of depression:
 Many women who live in poverty or experience
institutional racism may assume they’ll be depressed (or
get diabetes, or be physically abused, or be sexually
assaulted, etc.) because “that’s just the way it is for the
women in this neighborhood/housing project/tribal
community/town.” They feel powerless to reduce their
depression (low sense of self-determination).
 Or, they may deny their depression. “It’s not me, it’s my
life circumstances.”
We met with a team of diverse MIHP providers
to discuss cultural implications of depression
and stress
Diversity-Informed Practice:
Language and Cultural Perceptions
• Be mindful of potential language barriers in approaching MH
issues (e.g., some Spanish-speakers may use the word
“nervous” or “under pressure” instead of “depression”).
• Stigma of mental illness affects all groups, but may be
heightened in some (e.g., some ethnic or faith-based groups).
• Some groups highly respect the authority of the MD and may
be more likely to accept idea of meds or a MH referral from
the MD than from you; work with a woman’s MD and MHP to
help her get what she needs.
Diversity-Informed Practice:
Cultural Affiliation Varies
That said, cultural affiliation varies. YOU MUST ASK.
• Not everyone in the same cultural group thinks the same
way. Young parents may not be connected to their group.
• The only way to really know what a particular individual
believes about depression (or anything else) is to ask her.
Be open to having a conversation about culture.
• I don’t know how you think or feel about this – help me
learn here. What do you think about people who have
depression? What does your family think? What does
your community think? These are very telling questions.
Diversity-Informed Practice: Legal
& Undocumented Immigrants
Legal and undocumented immigrants face different
realities in the United States.
 Persons living under political asylum and undocumented
persons working in migrant camps have very different
experiences here, but both may have history of trauma.
 Pregnant non-citizens qualify only for the MOMS program,
which offers fewer benefits than other Medicaid programs.
 Be willing to track down info on what a particular
immigrant is eligible for and what laws pertain to her.
Primary MIHP Activities to
Address Depression
1. Screen every pregnant and postpartum woman with
infant, using standardized, validated tools
embedded within MIHP Risk Identifier.
(RN, SW)
2. Educate all women about Perinatal Depression
utilizing POC 1.
(RN, SW, RD, IMH Spec.)
Primary MIHP Activities to
Address Depression
3. Refer women at mod or high risk to treatment
(including IMH services); provide education and
support; coordinate care, utilizing POC 2.
(RN, SW, RD, IMH Spec.) NOTE: RD must follow up
with SW or RN to engage them in addressing
4. Assess need for IMH services (depression is a
factor). If parent refuses, provide brief, direct
parent-infant intervention. (IMH Spec.)
Screen for
Depression and Stress
The standardized MIHP Maternal Risk Identifier is
administered at intake. It includes:
– Edinburg Postnatal Depression Scale (EPDS)
– Perceived Stress Scale 4 (PSS 4)
POC 1: Educate All Women on
Perinatal Depression
• POC 1 documents that beneficiary received one or
both of the following items from RN or SW at
administration of Risk Identifier:
– MIHP Maternal & Infant Education Packet: Pregnancy &
Infant Health
– Instructions on how to sign up for text4baby
• Education Packet includes basic info on all of the
MIHP domains to guide discussion with beneficiary:
– At administration of Risk Identifier (RN, SW)
– At later visit(s), depending on the beneficiary’s individual
situation (RN, SW, RD, IMH Spec.)
POC 1: Educate All Women on
Perinatal Depression
• Education Packet is a 44-page booklet posted on the
MIHP web site.
• The Stress, Depression and Mental Health domain is
covered on pages 22-23.
Stress, Depression and MH
Pregnancy & Infant Health
What is perinatal depression?
It’s depression that occurs during pregnancy or
postpartum. Postpartum means within a year after
giving birth.
It is VERY common.
It can be mild, moderate or severe.
Stress, Depression and MH
Pregnancy & Infant Health
How do I know if I might be depressed?
Women with perinatal depression usually sense that
“something’s not right.”
Stress, Depression and MH
Pregnancy & Infant Health
Would you answer “yes” to any following statements?
– I feel very sad and hopeless more days than not.
– I’m not enjoying life like I used to.
– I blame myself for everything.
– I worry about everything.
– I’m afraid and I don’t know why.
– I feel overwhelmed and have a hard time coping.
Stress, Depression and MH
Pregnancy & Infant Health
– I cry a lot.
– I have trouble sleeping because I’m so unhappy.
– I want to sleep all the time.
– I’m confused and distracted.
– I get angry very easily.
– I don’t think I will be a good mother.
– I have thoughts of harming myself or others.
– I hear voices or see things that aren’t there.
Stress, Depression and MH
Pregnancy & Infant Health
If you answered “yes” to any of these statements, you
may be depressed.
You are not alone.
Many pregnant women and new moms have these
same thoughts and feelings.
Stress, Depression and MH
Pregnancy & Infant Health
How does perinatal depression affect my baby? Your
baby could:
– Be born too small or too early.
– Be fussy and jittery.
– Have feeding or sleeping problems.
– End up with learning problems.
– End up with behavior problems, such as
Stress, Depression and MH
Pregnancy & Infant Health
It’s harder for you and your baby to form a strong
emotional attachment to each other. Attachment is
important to your baby’s development.
Stress, Depression and MH
Pregnancy & Infant Health
• Where can I get more information about perinatal
Your doctor.
Your MIHP worker
Your Medicaid Health Plan.
Online at
text4baby: Alternative to
Education Packet
Free text message service to promote MCH.
Includes intermittent messages on depression
similar to those in Education Packet.
• Resource info is linked to mother’s zip code.
• Bring Education Packet to visits for discussion
purposes, even if beneficiary chose the text4baby
• Education Packet and text4baby both good tools.
POC 1 Documentation
1. POC 1:
Check off box (Education Packet or text4baby)
Signature of RN and SW within 10 business days
2. Professional Visit Progress Note:
• Depression/stress written on line after education
packet box checked
• Other visit information
POC 2: Supporting Women at
Mod-Hi Risk of Dep/Stress
Next we’ll look at:
– How to implement the standardized POC 2
– How to document POC 2 interventions effectively
POC 2 Services
Determined in Two Ways
1. Results of the Risk Identifier
2. Woman’s situation matches risk criteria in the Risk
Information column (#2) of the POC 2
POC 2 Intervention Levels in
Stress/Depression/MH Domain
• Services stratified by anticipated intervention level
• Domain intervention levels:
– Moderate (scores 9 - 12 on EPDS or scores 9 - 16 on PSS 4
or is in treatment)
– High (scores 13 or above on EPDS or is in treatment)
– Emergency (risk of imminent harm to self or others)
Developing the POC 2
Stress/Depression/MH Domain
1. Once Risk Identifier is completed:
– Enter data into SSO data base
– Print out Score Sheet
2. Pull Stress/Depression/Mental Health POC 2 if
Risk Identifier Score Sheet indicates a risk.
Developing the POC 2
Stress/Depression/MH Domain
3. SW and RN must sign POC 3 within 10 business days
of each other.
4. No visits may be completed or billed until #2 and #3
above are done, unless an emergency arises.
Implementing the Stress/
Depression/ MH Interventions
• Follow the numbered interventions based on risk
level (low, mod, high, emergency).
• MIHP Certification Tool Cycle 4 requires you to
address any risk domain that scores out high within
the first three visits.
• All of the numbered interventions will not apply to
every beneficiary.
We’re Not in this Alone
Medicaid Health Plans and medical care providers are
active partners in MIHP services delivery.
Foundations of
Intervention Delivery
Motivational Interviewing
Coaching for Self Sufficiency
Perinatal Periods of Risk
Life Course Theory
(See Motivational Interviewing and the Theory Behind
MIHP Interventions webcast at MIHP web site)
Be Prepared to Talk with a Woman
about her Depression
• Learn as much as you can about depression, its
effects, and treatment.
• Be extremely familiar with the HRSA booklet.
Depression During & After Pregnancy: A Resource for
Women, Their Families, & Friends.
• Watch the MIHP online training: Depression, Mental
Health, Stress (Kothari and Ludtke).
• Remind yourself that talking about depression can
only help – it can’t hurt.
Talking with a Woman about
Mod/Hi EPDS or Hi PSS4 Score
Before discussing her score:
1. Focus on her symptoms
– She may shut down if you begin by using MH labels (names
of disorders) and reject idea of having a MH problem,
which she equates with “being crazy”
2. Focus on her experience with depression (self and
3. Focus on her understanding of depression
Talking with a Woman about
Mod/Hi EPDS or Hi PSS4 Score
1. Ask her about her symptoms by following up on
some of her EPDS responses. Remember when we
asked you all those questions when you first signed
up for MIHP? Fourteen of those questions asked
about how you recently felt (enjoying life, anxious,
sad, able to control important things in life, etc.).
Can we talk about some of your answers to the
questions? Can you tell more a little more about
Talking with a Woman about
Mod/Hi EPDS or Hi PSS4 Score
2. Have you ever known anyone with depression or who
was very stressed out?
Was it a family member?
What do you think it was like for that person?
What was it like for you to be with that person?
How did other people treat that person?
3. What is your understanding of depression?
Did you ever feel that you might have had depression at
any time in your life?
If so, what was that time like for you?
Low Risk Intervention 1
Review written material on stress, baby blues, and/or
perinatal depression/anxiety.
– Maternal/Infant Education Packet (POC 1).
– HRSA booklet or other comparable booklet. (Free HRSA
booklet Depression During & After Pregnancy: A Resource
for Women, Their Families, & Friends, English and Spanish)
Emphasize that depression is common & treatable.
– Explain what intrusive thoughts are (next slide).
– Explain that physical symptoms are common in depression
(slide after next).
Asking About Intrusive Thoughts
Many women have intrusive thoughts that really bother
them. “Intrusive” thoughts seem to enter your mind
against your will and are very hard to get rid of. E.g.,
you might find yourself worrying that you’re not doing
everything right for your baby, or you might do
something wrong to your baby, or something might
happen to your baby. All moms worry, but it’s really
hard when you’re worrying so much you can’t sleep and
you just want the thoughts to stop but you can’t figure
out how. Does this ever happen to you?
PostPartum Depression
Educational Video
Post Partum Depression Educational Video -New
Jersey – YouTube (5.13)
Women of different ages, races, and economic
backgrounds, including the First Lady of New
Jersey, describe their experiences with postpartum
Low Risk Intervention 2
Discuss stress reduction/coping strategies and/or selfcare skills.
All moms need a self-care action plan, especially if they’re
at risk for depression. There are simple, everyday things
you can do to take care of yourself to feel better. Here’s a
self-care action plan form that we can fill out together. It’s
always better to write your plan down so you can look at it
whenever you want to.
Weekly Self-Care Action Plan
1. Exercise – stay active
2. Do something pleasurable every day
3. Spend time with people who make you laugh and
feel good about yourself
Weekly Self-Care Action Plan
4. Lean on your family, friends and community when
you’re very down or very stressed
Ask about emotionally supportive people in her life:
When you’re down/stressed, who can you turn to?
Which family members?
Which friends and neighbors?
Who else (e.g., godmother, unofficial “aunt,” etc.)?
Do you have a faith community? Anyone there?
Do you belong to another kind of group? Anyone there?
Do you have enough support from these people?
Weekly Self-Care Action Plan
5. Ask for help with the baby so you can sleep
6. Find a support group or class – connect with other
women experiencing the same things you are
7. Practice relaxation (e.g., slow, deep breathing)
8. Any other way to take care of yourself this week?
9. Give yourself some credit when you do one of the
steps on this self-care action plan
Low Risk Intervention 3
Educate on symptoms of depression and/or anxiety to
report to health care provider.
Physical Symptoms are Common
in Depression
Joint pain
Limb pain
Back pain
Gastrointestinal problems
Sleep disturbances
Psychomotor activity changes
Appetite changes
What Does Postpartum
Depression Feel Like?
“It feels scary.”
“It feels out of control.”
“It feels like I’m never going to feel like myself again.”
“It feels like each day is a hundred hours long.”
“It feels like no one understands.”
“It feels like my relationship cannot survive this.”
“It feels like I’m a bad mother.”
“It feels like I should never have had this baby.”
“If feels like if I could only get a good night’s sleep, everything would be better.”
“It feels like I have no patience for anything anymore.”
“It feels like I’m going crazy.”
“It feels like I will always feel like this.”
Low Risk Intervention 4
Provide support and encouragement.
Low Risk Intervention 5
Provide information/referral to community resources
for stress reduction or problem solving.
Talking with a Woman about
Mod/Hi EPDS or Hi PSS4 Score
• Those 14 questions about how you felt around the time that
you signed up for MIHP were a kind of quiz to find out if you
could have depression or stress or both. Having both is very
common. Every woman in MIHP takes this quiz. If she gets a
moderate or high score on the quiz, she may be experiencing
• Almost HALF of all women in MIHP score moderate or high.
That’s A LOT of women. This percentage is about the same
across the US for low-income women with young children.
Talking with a Woman about
Mod/Hi EPDS or Hi PSS4 Score
• It makes perfect sense when you think about it. It’s very hard
to raise a family when you don’t have enough money to make
ends meet because you can’t find a decent job, especially if
you are a single mom and you aren’t getting much support
from other people, and you’re worried about keeping your
children safe. No wonder so many women experience
depression and stress.
Talking with a Woman about
Mod/Hi EPDS or Hi PSS4 Score
• Your score tells us that you may be experiencing depression,
stress, or both, so it’s important for you (and your baby) that
we explore this further so you can decide what to do about it.
We’ll work together and figure out best way for you.
Talking with a Woman about
Mod/Hi EPDS or Hi PSS4 Score
• Depression makes people feel really weighed down or stressed
out or both. The good news: it’s very treatable. Medications
work and so does counseling. Your doctor or a mental health
person can do an assessment to see if you really do have
depression or stress or both. You can find out about your
medication and counseling options. You can feel better, so
you can be the mom you want to be.
Moderate Risk Intervention 6
Discuss treatment options for treating depression
(e.g., meds, CMH, clinics, private providers, support
groups, IMH Specialist).
Primary Care Provider or OB
CMH (serious mental illness only)
Medicaid HP (20 OP visits/yr for mild-mod disorder)
Federally Qualified Health Center (FQHC)
Private counseling agencies (e.g., Child & Family Serv)
Other (e.g., hospital or university-based depression
Support Services
• Discuss support services options for dealing with
– Depression support groups (e.g., Postpartum Support
– Other support groups (e.g., anxiety, bereavement , etc.)
– Online support groups and communities
– Web sites
• See MIHP Perinatal Depression Resources for Consumers and
Health Care Providers on web site
Moderate Risk Intervention 7
Refer for evaluation and treatment:
– HP or PCP
– Support Group
– MIHP IMH Specialist
Explain that it may take a while for treatment to
If Beneficiary Has Been a CMH
Client in the Past
• Refer to CMH if beneficiary was previously served
• If she refuses to return to CMH, get a release of
information from her so you can discuss her status
with her CMH worker.
If a Woman Declines to
Seek Treatment
• If woman declines to seek treatment or a support
group, consider using some of the ideas in the next
few slides.
• If she still declines, ask if she would at least be willing
to keep her mind open and think about it some
• It’s your decision, of course, but I really hope you will
think about it because I’m concerned about you and
want the best for you and baby.
Encouraging a Woman to
Seek Treatment
Some things you could say:
• Explain that a family member or friend who says “get
over it” doesn’t understand what depression is.
• Ask her: If you had a friend who was depressed,
what would you tell her? (Low-income women in
focus groups said: “Think about the child - your kids
shouldn’t suffer because of what you’re going
• Talk about how depression can make it harder for her
to achieve her goals for herself and family.
Encouraging a Woman to
Seek Treatment
More things you could say: (26)
• “Mental illness,” “mental disorder,” and “behavioral
disorder” are outdated terms.
• New research: Depression is a brain circuit disorder.
• People with depression aren’t “mentally ill” or
“crazy” or “losing their minds” – their brains are
“wired” differently.
• A brain circuit disorder is a real physical condition.
• Early treatment is always better.
Encouraging a Woman to
Seek Treatment
More things you could say:
• Depression is a real physical problem.
– It messes with your body, not just your emotions.
– It’s like a broken arm, except it can’t be fixed with a cast.
– It’s not going to go away by itself in a few days, like a cold
• Many celebrities have had postpartum depression:
Jennifer Lopez, Halle Berry, Gwyneth Paltrow, Courtney Cox,
Bryce Dallas Howard, Brooke Shields, etc. They talk about it
publicly because they want other women to know they aren’t
alone, don’t need to suffer in silence, and treatment works.
Moderate Risk Intervention 8
Re-evaluate risk later in pregnancy or postpartum
(recommend re-administer the EPDS and PSS 4) and
encourage beneficiary to seek treatment, if indicated.
– Re-administer at any time you feel it’s appropriate.
– If applicable, change and date POC 2.
– EPDS and PSS 4 are on web site, separate from Risk
Moderate Risk Intervention 9
Provide support and encouragement in adhering to
mental health provider treatment recommendations
including psychotropic medication and/or counseling.
Moderate Risk Intervention 10
Discuss medication schedule and importance of taking
medication as prescribed.
Moderate Risk Intervention 11
Prepare postpartum support plan.
How will you address stress and depression after
your baby is born?
High Risk Intervention 12
Ask if beneficiary has suicidal ideation, plan or intent.
High Risk Intervention 13
Develop and document emergency safety plan.
– Discuss how mom, infant and other family
members will stay safe.
– Document this discussion.
Key Elements of MIHP Safety Plan
What happens:
What we will do:
Who will do it:
By when:
MIHP Safety Plan
Strengths of Individual/Family:
What Happens:
What we will do:
Who will do it?
By When
To Prevent from happening:
How will we react:
Signature of the MIHP staff :
Signature of the MIHP beneficiary :
(adapted from community partnerships)
Emergency Intervention 14
Assist in going to nearest Emergency
Emergency Intervention 15
Call 911.
Emergency Intervention 16
Inform MHP and medical care provider.
Demonstrations: Discussing
Depression with Beneficiaries
SW: Rebecca Wheeler, Consultant/Trainer, MDCH
Vignette 1
Non-talkative mother (Joni) of 3-mo old boy (Tommy);
no partner; lives with mom. Joni Detwiler, MDCH
Vignette 2
Talkative mother (Brenda) of 6-mo old girl (Jasmine);
lives with partner; no family support. Brenda Jegede, MDCH
NOTE: V2 picks up where V1 leaves off; beneficiary is different
to reflect varying communication styles and family
It’s All About Relationships
• You must have strong relationships with key referral
sources in order to provide quality care coordination.
• Especially true in MH domain because beneficiaries
are reluctant to use MH services and knowing how to
access services can be difficult.
Helping Beneficiary Navigate
MHP Mental Health Services
• Call the MHP MIHP contact person (see list on web
site), who is responsible for assisting MHP members
to access services.
• If this does not work out for the beneficiary, inform
your consultant.
• If beneficiary can’t access services, explore other
Helping Beneficiary Navigate
CMH Services
• If you already have a CMH contact, work through
him or her.
• If not, see:
– CMH Contacts for Mental Health Services for Infants
and their Families (including Infant Mental Health)
– Using CMH Contacts to Navigate Mental Health
Services for MIHP Infants and Their Families
– Possible Reasons for Referral to an MIHP Infant Mental
Health Specialist or to CMH for an Assessment
Other Options if Beneficiary
Declines MHP, PCP, CMH Services
• If beneficiary does not wish to seek MH services
through her MHP, primary care provider/OB or CMH,
look for other options.
• See MIHP web site for:
MIHP Perinatal Depression Resources for
Consumers and Health Care Providers
• Connect her with groups (parent groups, faith-based
groups, etc.) that are not stigmatizing.
Findings Magazine, Fall/Winter 2005, Volume 21, Number 1, University of Michigan School of Public
2. National Institute of Mental Health
3. Ibid.
4. Wisner KL, Sit DK, McShea MC, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum
women with screen-positive depression findings. JAMA Psychiatry 2013; doi:10.1001/JAMA Psychiatry,
5. Identifying and Treating Maternal Depression: Strategies & Considerations for Health Plans, NIHCM
Foundation Issue Brief, June 2010
6. Leis JA, Mendelson T, Perry DF, Tandon D. Perceptions of mental health services among low-income,
perinatal African American women. Women’s Health Issues. 2011; 21:314-319
7. Ammerman T, Putnam F, Bosse N, Teeters A, Van Ginkel J. Maternal depression in home visitation: A
systematic review. Aggression and Violent Behavior 15:191-200.
8. Marcus SM, Flynn HA, Blow FC, Barry KL. Depressive symptoms among pregnant women screened in
obstetrics settings. Journal of Women’s Health. 2003 May; 12(4):373-380.
9. Ibid.
10. Wisner KL, Sit DK, McShea MC, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum
women with screen-positive depression findings. JAMA Psychiatry 2013; doi:1001/JAMA Psychiatry,
11. Identifying and Treating Maternal Depression: Strategies & Considerations for Health Plans, NIHCM
Foundation Issue Brief, June 2010
12. Ibid.
13. Ibid.
14. Ibid.
15. Minkovitz C, Strobino D, Scharfstein D, et al. Maternal depressive symptoms and children's receipt of
health care in the first 3 years of life. Pediatrics Vol. 115 No.2 pp 306-314 (doi: 10.1542/peds.2004-0341)
16. Knitzer J, Theberge S, Johnson K. Reducing Maternal Depression and its Impact on Young Children: Toward
a Responsive Early Childhood Policy Framework. National Center for Children and Poverty, Project Thrive,
Issue Brief 2.
17. Identifying and Treating Maternal Depression: Strategies & Considerations for Health Plans, NIHCM
Foundation Issue Brief, June 2010
18. Jason Goldman, ScienceBlogsLLC, October 18, 2010
19. Identifying and Treating Maternal Depression: Strategies & Considerations for Health Plans, NIHCM
Foundation Issue Brief, June 2010
20. Pooler J, Perry D, Ghandour R. (2013). Prevanlence and risk factors for postpartum depressive symptoms
among women enrolled in WIC. Maternal and Child Health Journal. Advance online publication. doi:
21. Tandon SD, Parillo KM, Jenkins C, Duggan AK. Formative evaluation of home visitors’ role in addressing
poor mental health, domestic violence, and substance abuse among low-income pregnant and parenting
women. Maternal and Child Health. 2005; 9:273-283.
22. Ibid.
23. National Association of State Mental Health Programs Directors, 2004.
24. Jennings, A. Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-Specific
Services. 2004.
25. Spectrum Health Women’s Services web site
26. Thomas Insel, Mental Disorders as Brain Disorders at TEDxCaltech, Feb. 8, 2013