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 HampshireMarch 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)

• 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

Things have been so rough latelyI know you can feel it tooI've been through this beforeBut this time I have youSometimes I feel so downI just want to run awayBut then I see you my angel& that's what makes me stayFrom growing in my tummyTo practicing to stand Time is going by so fastThis was definitely never the planI've been so tough on myselfBecause I believe you deserve the best

I try to be the perfect momBut on the inside I'm just a messSo bare with me baby girlI'm fighting this depression for youI'm still a little brokenBut I know I'll make it throughYour my strength my pride Everything that's good in meSomeday I hope I'll be ableTo see just what you seeBut until then I'll continue tryingTo make all your dreams come true& no matter what happensI'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

Sample: 1,359 women over 2 years postpartum

Measure:Edinburgh PostnatalDepressionScale

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 Studieshttp://www.istss.org/WhatisTrauma/4339.htm

Types of Interpersonal Traumatic Experiences

• Physical abuse• Sexual abuse• Emotional abuse• Witnessing violence• Physical or sexual assault• Intimate partner violence

TimingSeverityFrequencyDuration

Trauma experiences of mothers in home visiting

43.7%

32.7%

28.2%

26.7%

31.2%

13.4%

Percent

Ammerman et al., 2009

N=806Trauma=74.1%

2+=68.9%

Impacts of interpersonal trauma

Traumatic Experiences

Biological Behavioral Social

emotional dysregulation

fear and avoidance

relationship maladjustment

Posttraumatic Stress DisorderComplex trauma

The HPA Axis

Hyman, 2009 (Nature)

Effects of Dysregulated Cortisol

Greater or lesser sensitivity to stress cuesGreater arousal, more time needed to recoverInattention, distractibilityPoor memoryEmotional 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. Emotional Abuse2. Physical Abuse3. Sexual Abuse4. Emotional

Neglect5. Physical Neglect

6. Parents separated or divorced7. Mother IPV8. Household problem

drinker or drug user

9. Household mental illness

10.Household prison

SCORE: 0-10

Endorsement of ACE Items (N=94)

1 2 3 4 5 6 7 8 9 100%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

8.5%12.8%

21.3%

50.0%

30.9%

67.0%

39.4%

55.3%

38.3%

18.1%

1-Emotional Abuse 2-Physical Abuse 3-Sexual Abuse 4- Emotional Neglect 5-Physical Neglect

6-separate/divorce, 7-mother IPV, 8-alcohol/drugs, 9-mental illness, 10-prison

ACE Total Score in HV Sample and CDC 2009 Five State Survey, Female (18-24 yrs)

Sample

0 1 2 3 ≥40%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

9.6%

17.0%20.2%

9.6%

43.6%

35.5%

22.6%

13.2%

7.6%

21.0%

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.

Course of Depression & Development (illustrative)

1st episode4 months

2nd episode 9 months

3rd episode 2 months

Age 16 Baby born(age 20)

child 1 year old

= depressive episode = normal mood

4th episode 3 months

child 3 years old

time

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

• 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)

44.2%

55.8%Non-DepDep

12% receive mental health treatment

Ammerman et al., 2009

74.8%withtraumahistory

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 mothersObserve mothers in natural environment

Observe important features that would not be evident in officeMaximize learning and application of new skills

Logistical challenges: privacy, other family, distractionsUnexpected challenges and crises

IH-CBT: Adaptations to Population

New mothers with limited parenting experienceYoung mothers with few social supports

Emerging adulthoodEducational underachievement & lower IQ

Cultural sensitivityPoverty and hardship

Trauma history & intimate partner violencePsychiatric comorbidity

IH-CBT: Adaptations to Service

Collaborative relationship with home visitorLogistical coordination of multiple services

Frequent contacts with home visitorCoordination of careAvoid triangulation

Conceptual representation of IH-CBT collaboration

MOM

THERAPIST HOME VISITOR

primarilyHV domains

primarilydepressiondomains

MIDIS DesignScreening: EPDS ≥11

Eligibility/Pre-treatment AssessmentSCID Diagnosis of MDD

IH-CBT15 sessions + booster

Ongoing home visitation

Typical Home VisitationCommunity resources

Ongoing home visitation

Post-treatment Assessment

3 Month Follow-Up Assessment

Inclusionary:ECS participant≥16 years oldBaby 2<10 monthsEPDS ≥11MDD using SCID

Exclusionary:Substance depend.PsychosisCurrent suicidalityMeds or therapy

randomization

N=93Retained: 86.8%≥ 2 points: 95.6%

34.8%receivedcommunitytreatment

Demographics of Sample (N=93)

Mother Age: 22.0 (4.6) years

Mother Race: Caucasian 62.6% African American 34.1% Asian American 1.1% Hawaiian/Pacific Islander 1.1% Native American 1.1%

Mother Ethnicity: Appalachian 3.3% Hispanic 7.7%

Mother Marital Status: Married 13.2% Separated 1.1% Single, never married 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 54.8% $10,000-19,999 21.1% $20,000-29,999 16.4% $30,000-39,999 3.3% $40,000-49,999 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 1st episode: 15.1 (5.2) years

0%5%

10%15%20%25%30%35%40%45%50%

Current

Past

Current and Lifetime Comorbid Psychiatric Disorders

BDI-II Scores at Pre-Treatment, Post-Treatment, & Follow-Up

5

10

15

20

25

30

35

Pre Post FU

Assessment Time Point

BD

I-II

Sco

re

IHCBT

THV

F=7.9, p<.01 Not affected by therapist or home visiting model

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

Pre Post FU0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%100.0%

29.3%

20.1%

100.0%

69.8%

52.6%

IHCBTTHV

Χ2=19.0, p<.001

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

Completers, & THV

Pre Post FU0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%100.0%

21.7%

9.5%

100.0%

40.0%44.4%

100.0%

69.8%

52.6%

Comp<15 sessTHV

Social Support Using ISEL Scale (Total)

40

45

50

55

60

65

70

75

80

85

90

Pre Post FU

IH-CBT

THV

F=5.1, p<.01

0% 20% 40% 60% 80% 100%

IH-CBT Client Feedback at Post-Treatment

Therapist and Home Visitor worked together to help me

Sessions in home were convenient

Happy with level of confidentiality

I feel more confident as a parent

0% 20% 40% 60% 80% 100%

IH-CBT Home Visitor Feedback at Post-Treatment

Therapist was available

Therapist and I collaborated on case

Happy with level of confidentiality

Predictors of symptom status at post-treatment

Symptomatic Asymptomatic0

2

4

6

8

10

12

14IH-CBT sessionsHome visitsSeries3

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.

Recovery and HOME

RR DR RD DD25

27

29

31

33

35

37

39

PostFU

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