Moving towards a understanding of
psychosocial factors in practice
beyondblue NHMRC Guidelines
Jennifer Ericksen
Manager Perinatal Mental Health and Training
Parent Infant Research Institute
Austin Health
Parent-Infant Research Institute
Investing in the earliest years to build a brighter future
www.piri.org.au
The Parent-Infant Research Institute (PIRI)
innovative Australian research institute
developing and applying interventions to
improve parent/infant mental health
Parent Infant Research Institute © Ericksen
2013
Parent Infant Research Institute ©
Ericksen 2013
IMPACT OF PERINATAL MENTAL
HEALTH
Perinatal mental health
• These problems are common
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1 in 7 women get postnatal depression
1 in 10 get depression during pregnancy
Anxiety is even more common
Some are more vulnerable than others
• These conditions are serious
– Perinatal mental health conditions are the leading
cause of maternal death
– Leading cause of disability
– Economic and social cost
Parent Infant Research Institute © Ericksen
2013
Impact of maternal mental health
• Important for the woman herself
• Impact on relationship with partner
• Depression during pregnancy can change
mother physiologically
– Affects foetal development
• Postnatal depression can impair mothering
– Affect the child psychologically
Parent Infant Research Institute ©
Ericksen 2013
Postnatal depression
• PND symptoms of lowered mood, loss of interest,
fatigue, guilt, shame….can interfere with the
mother’s ability to provide care in a consistent way
• Detrimental effects on infant development
• Infants develop optimally when they feel secure,
nurtured and have their needs met quickly and
predictably
• If this persists there may be short and long term
effects on cognitive, emotional, social and
behavioural domains of development.
• Resilience
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2013
PND & interaction
• Mothers with depression show less
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responsiveness
stimulation
attunement Murray et al., 2003; Reck et al., 2004
synchrony of affect and behavior Righetti-Veltema, Conne-Perreard, Bousqet, Manzano, 2002
focus on the infant Murray et al, 1993
• Mothers with depression show more
– negative speech to infant Murray et al, 1993
– Intrusive or withdrawn interactions Field, Diego, Hernandez-Reif, Schanberg, & Kunhn, 2003)
PND interferes with the emotional and behavioural interchanges
between mother and infant
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2013
Disrupted mother infant interaction
• Poorer social and cognitive outcomes to school age Bernier et al 2010,
Murray et al 1996, Stams et al 2002
• Poor psychological adaptation as adolescents Feldman 2010, Korhonen et al 2012
• Later anxiety Mount et al 2010 and depression Murray et al 2011
• Poorer self regulation capacities Feldman et al 1999
• Increased insecure attachment Coyl et al 2002
leading to relationship Berlin et al 2007 and
behavioral problems Fearon et al 2010
Parent Infant Research Institute © Ericksen
2013
Parent Infant Research Institute © Ericksen
2013
Postnatal distress a dilemma
• Up to 30% of women experience mild depressive symptoms,
adjustment problems and anxiety in the postnatal period
• Women rarely recognize the symptoms of depression in
themselves
• Justify them as normal, lack of sleep
• Continue to try to cope
• Beyondblue National Postnatal Depression Program 36% of
women compared to 80% of GPs recognized depressive
symptoms
• Difficulties managing baby commonly lead to feelings of not
coping
• Even when identified women are reluctant to accept a
diagnosis of depression.
Parent Infant Research Institute ©
Ericksen 2013
HOW CAN WE BETTER UNDERSTAND
THE ATTITUDES AND BELIEFS OF
POSTNATAL WOMEN?
Pathways to care
• Current research directly asking women about
barriers and facilitators to accessing help are
sparse. (Sword et al 2008)
• How do women’s beliefs and attitudes about
depression influence their choice to seek
help?
• Can family, friends and health professionals
facilitate or deter help seeking?
• Australian women’s experience Bilszta, Ericksen,Buist,
Milgrom 2008
Parent Infant Research Institute ©
Ericksen 2013
Main themes for barriers to care
• Expectations of motherhood “I should be happy, I have
a wonderful baby” “loss of life as it used to be”
• Not coping & fear of failure “Keeping up appearances”
“What will other people think of me”
• Stigma & denial “Its just a bad day” “I’m just a bit run
down” “When I get more sleep I’ll be OK”
• Poor mental health awareness “Isn’t this normal?”
• Interpersonal support “Come home now I’m not
coping”
• Baby management “Feeling inadequate that baby
doesn’t sleep like others do”
• Help seeking & treatment experiences “I had to get
over that I really did need help”
Parent Infant Research Institute ©
Ericksen 2013
Barriers to clinic treatment
• Barriers that limit women’s access to clinic treatment
– Majority undetected (Cox and Holden 2003)
– When detected uptake of treatment is poor around 3040% (Austin et al 2007)
– Fear of stigma and reluctance of health professionals to
ask about it (Barney et al 2006)
– A need to keep up the appearance of coping (Bilszta et al 2010)
– Denial of problem
– Lack of mental health awareness
– Access barriers, cost, availability, child care, organization
– Options that fit with a mother’s health beliefs
– Breast feeding women are hesitant to take medication
(Gentile 2007)
Parent Infant Research Institute © Ericksen
2013
Relationship with health professionals
• MCHN the most helpful of all health
professionals, play a vital role in identifying
and managing PND
• ‘should see it coming, recognize it and take
control’
• Women seek support from ‘the right person,
at the right time with the right options’
Parent Infant Research Institute ©
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Ideal Health Professional
• Key attributes women list
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empathy
kindness
knowledge of what is available
good listening skills
availability
able to actively assist the mother, calls, home visit
nurturing
ongoing relationship once referred
• Key responses
– Help mothers recognize it is not a sign of failure
– A broad range of psychosocial factors contribute
– Listen and do not attempt to normalize feelings
Parent Infant Research Institute ©
Ericksen 2013
PERINATAL MENTAL HEALTH FOCUS
Parent Infant Research Institute © Ericksen
2013
The context & current focus
National Postnatal Depression Program (2001-2005)
• 40,000 women screened in pregnancy and 12,000 postnatally, 200,000 reached
with publicity & resource materials
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National Action Plan (2006)
The National Perinatal Depression Initiative (2008-13)
• The Australian Government committed $55 million over five years with
States and Territory contributing $30 million for a total of $85 million.
• beyondblue works in close collaboration with key experts, the Australian
Government and each State and Territory government.
• The aim of the initiative is to improve the early detection and prevention
of antenatal and postnatal depression, and to provide better care, support
and treatment for expectant and new mothers.
Parent Infant Research Institute © Ericksen
2013
Parent Infant Research Institute © Ericksen
2013
The National Perinatal Depression Initiative
2008-2013
• Routine and universal screening of all women for perinatal depression and
anxiety in the perinatal period
• Follow-up support and care for women assessed as being at risk of or
experiencing perinatal depression
• Workforce training and development for health professionals
• Research and data collection
• National guidelines for screening for perinatal depression
• Increase community awareness
Parent Infant Research Institute © Ericksen
2013
Clinical Practice Guidelines
• Expert advisory committee
• Reviewed literature for best
available evidence
• Developed to assist health
professionals
– Identify
– Treat
• Levels of confidence
– 8 Recommendations
– 44 Good practice points
• Developing document
Parent Infant Research Institute © Ericksen
2013
Guideline Expert Advisory
Committee (GEAC)
Representatives from:
Australian Association of Maternal and Child Family Health Nurses
(AAMCFHN)
Australian College of Midwives (ACM)
Australian General Practice Network (AGPN)
Australian Indigenous Doctors Association (AIDA)
Australian Psychological Society (APS)
beyondblue
blueVoices – consumers & carers
Independent GP and Psychiatrist representatives
Royal Australian and New Zealand College of Obstetricians and
Gynaecologists (RANZCOG)
Royal Australian College of General Practitioners (RACGP)
Rural and Remote populations representative
© Beyond Blue Ltd
Parent Infant Research Institute © Ericksen
2013
www.beyondbabyblues.org.au
Recommendations
• All health professionals should receive training in
woman-centred communication skills and
psychosocial assessment (R1)
• Practice that is women centred involves
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Using effective communication skills to understand the woman’s experience
Allowing the woman to be active in decision making about her care
Understanding the woman’s broader context
Culturally competent practice
Sensitive to differences in women’s backgrounds health perceptions and
knowledge
Psychosocial assessment
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To identify psychosocial factors known to be associated with
increased likelihood of mental health disorders
To identify current symptoms of depression/anxiety
Parent Infant Research Institute © Ericksen
2013
Recommendations
screening for depression and anxiety
• The EPDS should be used as a component of the
assessment of all antenatal women (R2) and again in
the postnatal period (R3) for symptoms of
depression/anxiety
• A score of 13 or more can be used for detecting
symptoms of depression in the antenatal period (GPP
8) and the postnatal period (R4)
• Early in pregnancy and 6-12 weeks post delivery
women should be asked questions about their
psychosocial situation (GPP 7)
Parent Infant Research Institute © Ericksen
2013
Recommendations about treatment
• In mild to moderate postnatal depression
– Cognitive Behavioural Therapy should be
considered (R6)
– Non directive counselling in the context of home
visits can be considered (R5)
– Interpersonal psychotherapy can be considered
(R7)
– Psychodynamic therapy can be considered (R8)
Parent Infant Research Institute © Ericksen
2013
Companion documents (HP)
© Beyond Blue Ltd
Parent Infant Research Institute © Ericksen
2013
www.beyondbabyblues.org.au
Psychosocial risk factors
• Past mental health problems particularly
antenatal depression/anxiety or depression Hx
• Current Mental health problems
• Previous or current abuse/violence
• Drug and alcohol usage
• Major life stressors
• Low social support practical and emotional
especially from her partner
• Low self esteem
Parent Infant Research Institute © Ericksen
2013
Refugee, asylum-seeking and immigrant women
at particular risk Collins, Zimmerman & Howard 2011
• Recent article reviewed 8 studies
5 Canada, 2 Australia 1 Taiwan
• PND may affect up to 24 - 42% of these women
compared to native born women with an incidence
of 10-15%
• Immigrants in Canada from UK, USA, Aust & NZ had
8.3% incidence but minority groups had 24.7%
incidence
• Risk factors commonly include stressful life events
prior to or during pregnancy, lack of social support
and cultural factors
Parent Infant Research Institute ©
Ericksen 2013
Psychosocial assessment
• Better understand a woman’s circumstances
• Provide a holistic integrated approach to emotional
health
• Look at social and psychological factors
• Look for those that are most commonly associated
with greater likelihood of mood disorders
• Weave symptoms of depression with physical,
emotional and social pressures on the woman into
conversation
• Give a psychosocial assessment form
Parent Infant Research Institute ©
Ericksen 2013
WORKFORCE CAPACITY BUILDING
Parent Infant Research Institute © Ericksen
2013
Capacity building for MCHN
• DEECD has arranged for access to professional
development workshops for all MCHN
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Guideline recommendations
Women-centred communication
Psychosocial Q including depression/anxiety screening
Decision making about treatment
Pathways to care
May to December
CBD and 2 in each of the 4 regions
Manual is being developed to support training
Utilizing beyondblue materials and NEW handouts
Parent Infant Research Institute © Ericksen
2013
PATHWAYS TO CARE
Parent Infant Research Institute © Ericksen
2013
Brian Danaher1 Jeannette Milgrom2&3 Charlene Schembri3
John Seeley1 Jennifer Ericksen3 Milagra Tyler1 Alan Gemmill3 Peter Lewinsohn1 &
Scott Stuart4
1. Oregon Research Institute
2. Psychological Sciences, University of Melbourne
3. Parent-Infant Research Institute
4. Deparment of Psychiatry & Psychology, University of Iowa
Benefits of Web Based Intervention
• Web based interventions may overcome
barriers that limit women’s uptake of clinic
treatment as it is perceived as
– Accessible to isolated, rural and remote
– Reduce fear of stigma by being anonymous
– Affordable
– Convenient ‘on demand’ at home
– May reach many who otherwise would not enter
into treatment for their depression
Parent Infant Research Institute © Ericksen
2013
Parent Infant Research Institute © Ericksen
2013
Recruitment for RCT
• Eligibility
– Baby 12 months or under
– Mother over 18, EPDS 12-20 , not receiving any other
treatment, can read and write English
– Has broadband internet access and used email
– Not suicidal, bipolar or psychotic, no substance use
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Phone intake, consent forms sent & returned
SCID phone assessment (1 hour)
Questionnaires reimbursed
Contact us
– PIRI 03 9496 4496 Jessica Ross
– piri@austin.org.au
Parent Infant Research Institute © Ericksen
2013