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Bridging the divide in perinatal mental health

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Bridging the divide in perinatal mental health

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Content PROTECTIVE FACTORS AGAINST PERINATAL MENTAL HEALTH DISORDERS Capstone Project Proposal Final Draft by Oreana Bohenek A Capstone Project Presented to the FACULTY OF THE USC SUZANNE DWORAK-PECK SCHOOL OF SOCIAL WORK UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree Doctor of Social Work December 2024 TABLE OF CONTENTS I. Abstract 3 II. Acknowledgements 5 III. Positionality Statement 6 IV. Problem of Practice and Literature Review 7 V. Theoretical and/or Conceptual Framework 12 VI. Methodology 14 VII. Project Description 18 VIII. Implementation Plan 17 IX. Evaluation Plan 19 X. Challenges/Limitations 20 XI. Conclusions/Implications 21 I. Abstract Preventing disease is more effective than treating a health condition (Barth et al., 2022). This is true for women experiencing perinatal mental health conditions—the period before birth (pregnancy) and 1 year after birth (postpartum)—when rates have remained high despite advanced medical care (Centers for Disease Control and Prevention [CDC], 2022). Although research studies have found the need for perinatal mental health services, there is a paucity of comprehensive training for clinicians of all disciplines involved in treatment of mothers with perinatal mental health disorders (CDC, 2022). Further, there has been a lack of mental health screening and consistent intervention in traditional maternal health care settings. This lack has created a gap in maternal health education and screening and treatment of peripartum mental health disorders across all populations, especially minority groups. Current best practices to treat perinatal psychological disorders have limitations and have not been universally available to new mothers. Thus, the proposed solution improves perinatal wellness by creating an approach that engages medical, mental health, and nontraditional maternal wellness care. These interventions are made accessible by virtual means to open access to different practice milieus. They target two separate beneficiaries: primary care clinicians and pregnant/postpartum women. This innovation is the first to provide brief yet informative training that can be facilitated in routine staff meetings or individual consultations for busy clinicians. This capstone provides the first proposal, to the author’s knowledge, that offers the concept of a prenatal virtual “retreat” as a preventative measure against perinatal psychological problems. Both interventions offer ways to support the health and mental wellness of mothers in the transformational life stages of pregnancy, birthing, and mothering. II. Acknowledgements I would like to thank all the faculty and staff of the USC School of Social Work who have assisted me in this doctoral journey. I am indebted to Dr. Ronald Manderscheid, PhD, who served as my capstone chair, for his attention to discipline, and for his expertise in the challenges of integrating medical and behavioral health care systems. I thank Dr. Sara Schwartz, PhD, for acting as my faculty reviewer and being a champion for women’s mental health. I thank Phiara Moore, RN, MSN for offering to be my external reviewer and her fierce advocacy of young mothers and their partners to be the best parents they can be. I thank my best mate Dr. Jenn Wersland for telling me from the time I received the USC acceptance letter and consistently throughout this process that I could complete it. I deeply appreciate my work supervisor, Dr. Russell McCann, for helping me through the IRB process and giving me latitude to create this project to serve mothers. I want to acknowledge my last conversation with my spiritual teacher, Ten Bears, in 2005 on the day before I gave birth to my baby for honoring the powerful transition I was about to experience. I am so grateful to all the moms who took time to review the retreat proposal and gave invaluable feedback. Thank you for your contribution to improving maternal mental health care. I would like to wish everyone beginning a new family a fulfilling, nurturing, and healthy rite of passage into parenthood. I extend a deep love and respect to my partner, James Barfoot, for helping me step into our expansive new life together as I transition beyond the role of being a doctoral student and the life stage of raising a child. I am profoundly grateful to my son’s father, Clayton Harless, who provided such steadfast care for our son when I could not. I am consistently in awe of my own son who gave me limitless grace as I stumbled through challenges fulfilling my role caring for him. Logan, I love being your mother and can’t imagine parenting a more boundlessly beautiful and thoughtful young adult. III. Positionality Statement I was raised in a traditional nuclear family with married Caucasian heterosexual parents in a rural area in the Pacific Northwest. Political affiliations growing up both geographically and within my own family tended to be conservative. There was a clear expectation of typical gender roles that echoed through the generations of my family: fathers earned money, mothers stayed at home and raised children. I broke these family norms when I completed a degree in social work at age 21 and started working in child protection. I remembered questioning early on in that role why there were not preventative strategies in place versus the reactive model that addressed child maltreatment. As a young social worker, I was viewing issue of maternal and family wellness through a professional lens, separate from my own life experience. When I chose to become a parent, I was very aware of societal expectations that a married cisgender woman should be a mother, so when I chose to have my own child, I had many assumptions that because of my familial forecasting and my own desire to be a parent, I would easily fulfill this role. Many factors converged during this time that caused me to overlook the crucial role of my own mental health as a mother. As I noted, my family of origin expected women to raise children as their primary life purpose. During the time I received obstetric care in the traditional medical model, I presented as an educated woman and was not screened for depression. Concurrently, I was working with a nonmedical spiritual teacher who talked with me about the importance of honoring the transition to motherhood. He tried to help me recognize that a supportive network would be crucial to my mental health as a mother. I never understood that lesson until a few weeks into parenthood and found myself alone with my own struggles with mental health. I found myself isolated and did not seek help, fearing I would be considered an incompetent mother. I underreported my symptoms for years with family, friends, and healthcare providers. This led to a profound lack of confidence in parenting my child. By the time I recognized that what I was experiencing was a treatable condition, many vital years of my son’s early development had passed. I was ultimately able to get the support I needed, and this inspired me to focus on women’s mental health in my current job at the Veterans Affairs (VA) as a primary care mental health (PCMHI) telehealth clinician. I chose “Closing the Health Gap” as my identified grand challenge with a specific focus on improving access to mental health care for mothers who are also military veterans. This is a population that is often underrepresented in the VA system. I have gone directly to veteran mothers to get their feedback on my retreat prototype because I recognize my own experience biases me and may not be realistic to new parents today. I also realize that my role as an PCMHI clinician biases me toward the expectation that primary care providers should recognize the importance of perinatal mental health issues. For this reason, I chose to query primary care clinicians about their learning needs in this area. Currently there is a strong push within my organization to focus on maternal mental wellness, so I am uniquely positioned to advocate for this inequity in our healthcare system. Please see Appendix A for timeline of 725 capstone projects. IV. Problem of Practice and Literature Review One of the fundamental challenges facing society has been a substantial lack of access to equitable health care for all, especially in communities where adequate services are sparse (Silk et al., 2021). The American Academy of Social Work Grand Challenges (Barth et al., 2022) identified closing the health gap as one of the grand challenges to improving overall population health and psychosocial environments that make up an individual’s life. Current medical care is expensive, thus making populations with less resources miss out on health care and making them more susceptible to poorer health outcomes (Barth et al., 2022; Fong et al., 2018). Regarding women’s health, rates of perinatal mental health disorders have been growing, including depression and anxiety (CDC, 2022). Perinatal mental health disorders can occur during pregnancy or postpartum (within 1-year post birth; American Psychological Association, 2023). Given the current health care system, it is important to note many of the grand challenges identified by the American Academy of Social Work Grand Challenges intersect and affect one another. For example, poor postnatal maternal mental health can impact overall child and family wellness (Abdollahi et al., 2017; Dadi et al., 2020; Takacs et al., 2020). These social determinants of health, such as poverty level and premorbid mental health diagnoses, offer a window into the specific ways health inequities play out in treatment for postpartum mental health; those who have challenging childhood experiences are at higher risk for developing mental health problems in general and specifically during the postpartum period (Espeleta et al., 2018; Narayan, 2023; Shabanova et al., 2022). Furthermore, medical care is often individualistic, symptom-specific, and reactive (Barth et al., 2022). This approach can undervalue mental health screenings that have the potential to identify perinatal mental health disorders and psychosocial inequities on the overall wellness of patients (Barth et al., 2022; Silk et al., 2021). These inequities can have devastating effects on the quality of maternal mental health care, especially in the setting of current standards of care in obstetrical medical management and care of expecting or postpartum women. Substantial peer-reviewed studies have identified maternal mood disorders as a serious global health problem, with postpartum depression being the health condition most prevalent in mothers (Johnson et al., 2018; Wang et al., 2021; Wisner et al., 2024; Yasuma et al., 2020; Yu & Sampson, 2016). A systematic review by Wang et al. (2021) stated, “The global prevalence of PPD [postpartum depression] was found to be approximately 17.22% in the largest meta-analysis of PPD to-date” (p. 7). Multiple studies have identified a range (10%–20%) of mothers will experience a depressive episode following childbirth (Glazer & Howell, 2021; Holopainen & Hakulinen, 2019; Tandon et al., 2021; Werner et al., 2015; Wisner et al., 2024; Yasuma et al., 2020). The percentage is likely underreported due to stigma surrounding maternal depression (Centers for Disease Control and Prevention [CDC], 2022). In the United States, the organization that has largely informed obstetric treatment is the American College of Obstetricians and Gynecologists (Payne, 2016). Perinatal mood disorders are highly treatable in a multidisciplinary reproductive health plan of care when identified early (CDC, 2022, Lindensmith, 2018; Stewart & Vigod, 2016; Werner et al., 2015; Yu & Sampson, 2016). However, although screening programs and treatment have been recommended often, as noted earlier, they have seemed disparate and difficult to incorporate into standards of care (Leboffe et al., 2020). Further, when initial maternal health screenings have been completed in a primary care setting, they have not always led to viable treatment pathways (Blackmore et al., 2021). Some promising movements have included improving access to peer- or professionally led supportive environments for new mothers along with postpartum psychoeducation (Johnson et al., 2018; O’Connor et al., 2019; Stewart & Vigod, 2016; Tandon et al., 2021). Another hopeful trend in perinatal mental health has been increased collaboration between clinicians who offer more comprehensive person-centered care (Guintivano et al., 2019; Leboffe et al., 2020; Tandon et al., 2021). Ultimately, at the macro level, a better health care system needs to be in place to advocate for these solutions that provide standard perinatal mental health in all settings (Blackmore et al., 2021; Motrico et al., 2023; Yu & Sampson, 2016). Perinatal mental health is an issue that has been studied for many years and a variety of evidence-based practices have shown to be most effective (O’Connor et al., 2 019). Interventions have been designed to prevent or treat symptoms early (Johnson et al., 2018; Tandon et al., 2021; Stein et al., 2018). Furthermore, prevention interventions have been proposed with the objective to improve maternal mental illness and reduce mortality outcomes (Glazer & Howell, 2021; Tikkanen et al., 2020; Yu & Sampson, 2016). Werner et al. (2015) offered there has not been a consistently researched best practice for prevention of maternal depression. One prevention trend that repeatedly emerged in the literature was the value of assessing mental health symptoms during pregnancy in mothers to help guide treatment (Cohen & Daw, 2021; Terrazas et al., 2018; Werner et al., 2015; Yasuma et al., 2020). This argument for prevention is promising, especially when reliable and valid assessment tools created pathways to potential intervention (Johnson et al., 2018; Yu & Sampson, 2016). The challenge is to find opportunities where these programs can be viably and routinely implemented. Another daunting problem contributing to maternal mental health issues has been the lack of quality maternity clinicians. The United States has had one of the smallest maternity care provider workforces, including obstetrical physicians and midwifery clinicians. There has also been a lack of specialized mental health training for clinicians (Tikkanen et al., 2020). In response to postnatal mental health, multiple creative approaches have been used to support women postpartum. Professional or paraprofessional health care providers have visited new mothers and their babies as a common practice in other developed countries, but this approach has been less common in the United States (Tandon et al., 2021; Tikkanen et al., 2020). Postpartum education and social support, including interventions like home visits following birth have been known to improve maternal depression rates (Woolhouse et al., 2014). Some studies have shown cognitive behavioral therapy, and interpersonal psychotherapies can also be effective for improving postpartum depression, especially when administered early (O’Connor et al., 2019; Yasuma et al., 2020). Internet-based technologies that provide support and psychoeducation to new mothers have also been discussed in the literature (Pugh et al., 2016; Zeng et al., 2023). This supports the idea that when mothers receive the resources they need, their overall maternal wellness improves. Unfortunately, although these interventions exist, they have not been made universally available as standard of practice in maternal health care. Comprehensive and wholistic wellness practices after birth can lead to improved overall maternal mental health (McCloskey & Reno, 2019). Self-care practices encourage one to parent in an endurably present and mentally healthy way; one must be open to their own inner human experience as a parent (Kabat-Zinn & Kabat-Zinn, 1997; Millwood, 2019). Nontraditional approaches have been shown to be effective in helping to treat postpartum depression, although more research is needed to substantiate these approaches (McCloskey & Reno, 2019; Wang et al., 2021). Examples include, but are not limited to, aromatherapy, mindfulness training, light therapy, and tai chi (McCloskey & Reno, 2019; Wang et al., 2021). Kolomanska et al. (2019) examined the relationship between physical movement and maternal mental health, and repeatedly found exercise influenced postpartum wellness. Another study conducted by Aguilar-Cordero et al. (2019) looked specifically at water-based activities that improved postnatal mental health through exercise, such as swimming. These practices have been routine in other countries with lower rates of perinatal mental health disorders, suggesting the adoption of alternative treatments could be beneficial in the United States to help reduce maternal outcomes. The literature identified three major national movements within the last several decades that were created or updated to improve maternal mental health treatment options. These programs include the power of prevention, healthy families, and Obama’s Affordable Care Act (CDC, 2020; Fong et al., 2018; Tikkanen et al., 2020). Each of these programs contained a component of preventative efforts to improve maternal mental health and access to care. Further, each program addressed how the wellness of parents can improve child health outcomes, thus introducing the compelling argument that improved maternal mental health care reduces the likelihood of individuals to experience other psychosocial challenges, such as encouraging youth developmental problems and violence throughout one’s life trajectory. The Grand Challenge of Close the Health Gap called attention to the lack of health care opportunities and resources for a large part of the United States population (Barth et al., 2022; Fong et al., 2018). Thus, the literature on maternal health has consistently identified a paucity of, and inaccessibility to, adequate perinatal psychological care, especially for minority populations and individuals with lower incomes who are at higher risk for perinatal mental health disorders (McCloskey & Reno, 2019). Racial and exclusionary health care disparities must be considered in any forthcoming policy and program proposals in maternal depression interventions. V. Theoretical Framework The theoretical framework guiding this proposal can best be understood through the lens of systems theory, which is theory of change focused on benefiting the social support system of the mother to help empower maternal confidence in navigating changing roles parenthood brings (Millwood, 2019; O’Connor et al., 2019). In the literature review, there was an overarching recognition that multiple current systems including the medical model and the prescriptive way in which health and mental health treatments practiced have not adequately addressed the issue of perinatal psychological disorders. For example, the American College of Obstetricians and Gynecologists has only required the Edinburgh Postpartum Depression Scale to be administered once during pregnancy, thus missing opportunities to intervene and prevent worsening symptoms (Cohen & Daw, 2021; Glazer & Howell, 2021; Smith-Nielson et al., 2018). In the spirit of systems theory, this author’s vision is multiple systems need to be targeted; there is a need for (a) increased training for clinicians who are responsible for the care of expecting and new mothers with little time for this training and (b) more creative alternatives will help bridge the current health gap. Maternal mental wellness fosters the emotional and developmental health of the child, which in turn can improve family relations (Stein et al., 2018; Takacs et al., 2020). Similarly, early attachments can affect an individual’s response in their adult relationships. Interpersonal connections are so important in parenthood; thus, strengthening relationships can have a mood stabilizing effect (Sockol, 2018). Maternal mental wellness fosters the emotional and developmental health of the child, which in turn can improve family relations. Understanding maternal mental health from a systems theory perspective can also stop the cycle of psychological challenges that can be passed down through generations; prophylactic approaches involve all areas of an individual’s life on the micro and macro levels (Isobel et al., 2019). The Grand Challenge of Close the Health Gap recognizes preventive strategies are needed to best care for an individual within their relationships, families, and communities. Thus, it is a multipronged, multisystemic approach. Using a systems theory of change in understanding maternal mental health provides context to needing multiple points of interventions, including patient–clinician interface, person-in-environment, and trainer– trainee interactions. VI. Methodology Stakeholders on the design team for this study include an external design partner—a VA colleague of the author named Phiara Moore, MSN, RN. Ms. Moore is a current telehealth education coordinator with the VA, who has an extensive background in obstetrical direct clinical practice and as a nurse educator. Further, she has her own private practice professionally mentoring expecting new parents. Dr. Sara Schwartz, associate teaching professor with the University of Southern California Dworak-Peck School of Social Work, agreed to provide internal review support. The author of this capstone completed the University of Southern California Department of Social Work Research series (790A and B) taught by Dr. Schwartz, who provided insight on the state of maternal mental health and wellness and attention to methods employed in the prototyping. Within the VA setting, funding and staffing opportunities were considered and noted throughout the capstone project. It was estimated that 20 hours of licensed mental health professional staff time would be needed to review all materials and prepare to facilitate the innovation. An additional 27 hours of administration of the retreat and between 20-30 hours to provide and evaluate clinician training. A rough estimate of a VA licensed mental health independent provider hourly salary is $50 per hour, not including benefits associated with full time employment. The current allotment of staff time as a licensed mental health clinician to devote to women’s mental health treatment is .2 FTE. The requirement for primary care mental health providers within the studied telehealth program is 28 hours of clinical time which can include both individual and group treatment that can be administered to patients per week; this allows for ample time to facilitate retreats as therapeutic services. There is no allotted administrative time to provide training, so the facilitator of the training would need to get buy-in from administration to conduct that portion of the project during regular staff or one on one meetings. Multiple design thinking tools and principles were included in the creation of both prototypes utilizing Liedtka and Ogilvie’s material Designing for growth toolkit (2011). Initial napkin pitches included the needs for preventative postpartum depression treatment. Social change included existing evidence-based resources as well as disrupting the norm of the medical model and incorporating more innovative wholistic approaches. The overall return on investment was identified as improved maternity care and supportive maternal and other primary caretaker support. Opportunities for interventions were completed in the solution landscape as well as brainstorming with learning pod during 793A class. In 725B, low-fidelity and mid-fidelity prototypes and feedback was solicited from stakeholders and were amended. In 725C, high fidelity prototypes are in the process of being tested. As noted in the logic model (see Appendix B), research was initially conducted in multiple settings. Creation of the current solution landscape was initiated and can be referenced in Appendix C. The VA Office of Women’s Health (2021) identified that perinatal health-centric care is a responsibility that the VA must provide for its patients and has created programming, allowed staff time, and created funding sources to expand such programs across the nation. Telehealth is one way to more widely expand both supportive and training opportunities to VA patients and clinicians who provide these services. The author’s manager of the local primary care mental health telehealth program allowed latitude to create, implement, and expand this project. Other geographic, departmental and funding determinants may influence future expansion of this proposed programming, so although encouraged in the VA system opportunities may be limited. VII. Project Description Because primary care is an optimal time to detect, diagnose, and treat perinatal mood and affective disorders, this author created a 15-minute brief virtual maternal mental health clinical training. The mid-fidelity prototype was created to assess knowledge base and consisted of two questions, using a mixed-methods approach. Providers from telehealth primary care clinic were administered the anonymous survey using Microsoft Forms. The first question employed a Likert scale that first asked providers, “How prepared do you feel to address pregnancy-related mental health conditions?” Possible answers consisted of (0) Not at all prepared, (1) Slightly prepared, (2) Mostly prepared, or (3) Fully prepared. The second question was an open-ended question and asked, “If not prepared, what information would be helpful to raise your preparedness/education”? The survey resulted in 22 total responses to the Likert-scale question and 18 narrative responses to the second question. Themes of responses included more training, medication information, and referral pathways. The author created a high-fidelity prototype for a 15-minute training that was informed by these responses. The prototype was sent via email to individual clinicians. Three telehealth primary care clinical pharmacists and three primary care clinicians (i.e., nurse practitioners) from VA facilities across the country reviewed the final prototype, and their changes were incorporated into the iteration submitted with this document. The pilot training was administered to telehealth nursing and primary care mental health colleagues and pre- and posttest measures were completed. The data stated that preparedness had increased, showing proof of concept that the training increased skills. I am scheduled to present on 24 November 2024 to an audience of telehealth primary care professionals at a mandatory all-staff meeting. Then, the author created a 1-day virtual supportive and psychoeducational prenatal retreat with optional monthly follow up groups by querying new mothers to obtain feedback from them about how the health care system can better address their perinatal mental health. A focus group was set during a virtual postpartum wellness support group and facilitated by author, resulting in valuable feedback from mothers; this focus group led the author to create a mid-fidelity prototype of a mother’s retreat topic agenda that was presented to a mom’s group (n = 5) in the following format: “How prepared did you feel for birth and parenting experience? (0) Not prepared at all, (1) Slightly prepared, (2) Mostly prepared, or (3) Fully prepared. If not 3, what information do you wish your health care providers would have given you to support your mental health? Themes included reduced stigma to talk about the real struggles of parenting and not being able to be transparent with troubling mental health symptoms with providers for fear of being questioned about their competence to parent. Information from this focus group was used to create a high-fidelity prototype retreat agenda and curriculum that was reviewed separately by three maternal mental health clinician colleagues of the author and subject matter expertise in their field: a reproductive psychiatrist, a licensed professional counselor, and a maternity care coordinator, all within the VA system from different parts of the country. The copy that is attached with this assignment was amended and tested in two final focus groups (n = 4 and n = 2, respectively). Overall feedback themes from the mothers from those last focus groups included concerns that 5 hours was too long for the retreat and suggestions to abbreviate the content to 2–3 hours. All mothers felt the retreat curriculum would increase their preparedness From this point, the author developed and held a pilot retreat virtually for 2 hours with three participants. The time was adjusted to assure that the retreat could be billable and sustainable within the context of the telehealth program. Participants left the event with the feedback that they received information and community they had not found elsewhere. The Likert-scale question was taken out in later prototyping testing for both primary care provider training and the retreat because different clinicians and moms responded to the first prototype than in the final draft. To better test pre- and post-retreat measures, more emphasis and development was added to the open-ended questions before start of retreat and after the conclusion of the retreat and anecdotal feedback was used to inform further iterations of the retreat curriculum to better serve future participants. In addition, further post retreat assessment will be done via an email script to be sent following the retreat, which will include a link to ongoing monthly support group meeting. The email will contain open-ended questions asking participants to voluntarily reply about their retreat experience in order to elicit additional qualitative measures. The overarching goal of this initiative is to improve maternal emotional wellness. This will be achieved by educating clinicians serving mothers, expanding peripartum mental health care beyond the traditional medical model, assessing preparedness to address pregnancy-related mental health condition. Long term goals include creating a new paradigm in society that recognizes pregnancy as a rite of passage rather than simply a medical event. In future iterations, another long term plan is to amend both the training and retreats to an in-person setting. Measurable objectives are outlined in the following section. In summary, the proposed solution will include 15-minute education sessions with primary care clinicians currently treating or who may treat pregnant or postpartum people in existing telehealth settings in VA clinics. Brevity is instrumental to assure buy in from clinicians with an already short bandwidth for education that is not recognized as standard for licensing. Given the fee-for-service nature of the medical model, clinicians may not be able to be reimbursed for a retreat curriculum that is nontraditional in nature and does not have a diagnostic or billing code. In that case, leveraging grants from funders whose objective focuses on maternal, child, and family well-being of Veterans could support this initiative. An additional funding source for retreats in the private setting for hybrid virtual and in-person events could be a partnership with insurance companies, so one could offer the service as part of a preventive maternal health package. In terms of scope of this program, it would initially start in the facilitator’s local telehealth catchment area and then increase to other geographical need areas as availability and need allow. This information will likely need to be informed by data and feedback from the initial mother’s retreat. See appendices C, D and E for breakdown of specific activities throughout the 725 series of courses. Ethical considerations were vetted by presenting the capstone project to the local VA Institutional Review Board. The project was identified and allowed to proceed as a quality improvement project and not research. Further scrutiny acknowledges that during the prototyping and facilitation of the retreat, sensitive information about a patient’s mental health status. To mitigate this, a clear process is presented about how to refer patients to individual mental health care if they are not already established, or to collaborate care with patient’s current mental health provider. Another means of mitigating ethical concerns is addressed in the mother’s retreat when Risks/Consequences of the retreat are reviewed at the beginning of the event and time is allowed for participant questions and concerns. VIII. Implementation Plan As noted, the mother’s retreat pilot is set for November 13, 2024, and VA maternal health colleagues from multiple disciplines (RN, primary care and mental health telehealth clinicians) are currently providing referrals. The information gathered from the pilot retreat will offer valuable feedback and guidance for the next project. Using the exploration, preparation, implementation, sustainment (EPIS) framework, the action plan includes: ● The exploration stage, which consisted of ongoing literature review, meetings held with nonprofit leaders to explore ideas for retreat, information-gathering from VA national reproductive mental health team, involvement in Postpartum Support International monthly consult calls, creating alliances with multidisciplinary providers, and searching national databases for potential grant funding. ● The preparation stage included review of draft of PCP training with author’s external reviewer. Further preparation has included drafting and refinement of the PCP training curriculum. Preparation has and will continue to include reviewing and creating the schedule of events for the retreat. ● The implementation stage included holding initial and ongoing one hour weekly prenatal and postnatal wellness support virtual groups in the VA PCMHI telehealth program. Piloting is underway for the brief clinician education meeting and mother’s virtual retreat. Dates have been set for the initial retreat: 13 November 2024. PCP training is set for 24 November 2024. Measures will be administered at both events. ● The sustainment stage will include using pre- and post-event measures from the virtual formats to inform these programs going forward. A report to telehealth administrators and national mental health clinicians within the VA will be scheduled in January 2025. It will be important at this stage to continue to solicit funding to expand iterations of in-personal maternal wellness retreat format within VA and beyond. IX. Evaluation Plan Initially, the evaluation for mother’s retreat was going to be done via administering the EPDS before and after the retreat. However, throughout the prototyping iterative process, it became clear that the most efficient way to measure impact is to inquire into participants’ self-assessment of readiness to parent before and after retreat is held. From the single measurement question, participants will be asked open-ended responses as to what content was most effective and impactful, as well as suggested areas for change. Measure of success will be based on mother’s self-report of feeling more prepared and supported in their agency as a new parent. As the project evolves, continued iterations and improvement will be made based on participant’s oral and written feedback. For the evaluation of the primary care provider training that will be administered on 24 November 2024 all staff meeting, the pre-screening question identified in the methods section will be given before dissemination of the training. The prototype training will then be delivered via videoconference. The same question will be given to the same group after the training in order to measure learning. Clinician trainees will be asked to participate in a telephone or video call to give further open-ended feedback within the week following the training. The training will also be presented in a staff meeting of clinicians in a telehealth primary care mental health clinicians with a prospective audience of ten and pre and post measures will also be collected on 14 November. Based on the ongoing nature of the iteration process and integration of updated research, the training prototype will remain a working document based on trainee response and suggestions. Within the telehealth program where this information is being collected, data from both measures will be gathered by the facilitator of both the mother’s retreat and PCP trainings in a summary and presented to the section chief’s meeting of the author’s telehealth program at a date to be determined by author/facilitator and acting manager. To measure impact of the retreat and training pilots, the author is scheduled to present findings in a monthly maternal mental health collaborative that includes national clinicians on 14 January 2025. The project’s success will be determined as noted by pre- and post-test measures of self-assessed improvement in preparedness of mothers for parenthood and clinician’s preparedness to address pregnancy-related mental health issues. Success on a larger scale will be evidenced by implementation of the retreat in telehealth programs across the VA with completed launches of the interventions, resulting in larger quality improvement of maternal mental health in the VA system. X Challenges/Limitations A limitation of this capstone is the small sample size of mothers (N=6) and (N=6) in focus groups. Further iterations in the pilot and follow-up retreats are crucial to improvement of the initial innovation. Another issue that arose during testing was the need to eliminate the Likert-scale from the prototyping due to pre-training/pre-testing sample populations not being the same thus the original quantitative measure could not be assessed. Ongoing pre- and post-testing measures during the scheduled pilot retreat and primary care clinician training from the same participant will better assess impact and add a quantitative measure. An additional limitation was that due to sample population availability, the retreat and training had to be curtailed to VA patients and staff only. This reduced the demographic considerably and likely created a more homogenous population in the overall population sample. Future planning includes cultivating a population for both prototypes in the private sector and at Federally Qualified Health Centers and other agencies designed to serve disenfranchised populations which will expand to be more inclusive to all populations. With more time and additional resources, a viable replication could be conducted of both prototypes via in-person retreats and trainings. Another limitation is that the terminology “maternal” and “mother” minimized emphasis on the experience of the father/partner or non-primary parent. Emerging literature is revealing a postpartum mental health experience by nonbirthing parents is separate but crucial to understanding the larger issue of parental mental health5 but was not included in this study due to time and sample size limitations. XI. Conclusions/Implications Perinatal mental health issues remain one of the most common complications of pregnancy (American Psychiatric Association, 2023 & Center for Disease Control and Prevention, 2022). Maternal mental health support and primary care contain many areas for improvement (Cohen & Daw, 2021). The implications of this capstone are two-fold: Ideally, parents can pass benefits of the retreat experience on to their children; clinicians can provide more informed primary care, which will by extension help to grand challenge of social work: closing the health gap, promoting healthy development of youth and families and beyond to have an impact on the other wicked grand social challenges. Lessons learned during this capstone process and throughout the author’s experience at the University of Southern California Doctor of Social work program curriculum include the need for solid literature review, design thinking and ongoing prototyping to create a polished pilot maternal mental health virtual retreat and primary care provider brief training on perinatal mental health issues. Measures needed to be shifted from a postpartum depression inventory to a qualitative open-ended question in the iterative process to better capture the impact of the retreat and training on individual participants. The project required the author to consider many areas for quality improvement in the VA telehealth primary care and maternal mental health settings in which the testing took place. Further considerations of outcomes measures are multiphasal and need to be adjusted given sample size variability in forthcoming retreats and trainings. An audience of stakeholders (mothers and clinicians) at other VA telehealth sites is scheduled in January of 2025 to determine replication opportunities across the nation and impact on VA maternal mental health practice. This will give a bigger picture vision of macro programmatic changes to improve maternal mental health supportive care and clinician training. This capstone proposal will be expanded to an in-person retreat and training at private and community primary care clinics and other possible venues. Action planning to further this innovation includes: a review of post-retreat feedback questions, follow up phone calls to participant volunteers, report to section chiefs of primary care with initial findings and action plan for further retreats and trainings, and report to national stakeholders for consideration of larger-scale changes to policy that addresses maternal health care. Appendix A: 726 Series Timeline Activity Timeline Progress notes Complete first iteration of clinician education curriculum and mother’s retreat June 2024 Completed mid-level prototype Field-tested low-level prototype with group of mothers and primary care clinicians January 2024 Defaulted to VA virtual version to increase accessibility. Complete first draft of retreat curriculum/learning objectives August 2024 Currently working on draft Finalize topics for retreat October 2024 Date set for primary care all staff training (24 Nov 2024) Date set for virtual mother’s retreat (13 Nov 2024) Develop and hold mother’s retreat per curriculum Preparedness question (preand post-retreat to attendees) and query retreat attendees if they would be interested in post retreat phone call November 2024 See prototypes for primary care all staff training curriculum See prototypes for mother’s retreat Complete post retreat and post training review calls Present findings to VA administration December 2025 Initiate monthly postpartum support groups January – March 2025 Strategic planning for second mother’s retreat (informed by survey question and mother/clinician feedback) Target month for second mother’s retreat March 2025 Amend curriculum for mother’s retreat and clinician training (informed by survey question and mother/clinician feedback) Strategic planning for inperson retreat First in-person retreat Continue monthly virtual support groups Summer 2025 Target: by December 2025 Review ongoing grant opportunities Identify site for retreat and date Identify date and hold retreat and complete preparedness question and open-ended feedback calls Appendix C: Intervention Phases (Mothers) Prenatal Postpartum Prescreening call (1-3 months preretreat) Once monthly postpartum support groups (beginning at 1 month and up to one year after baby is born accessible virtually via current group’s link) Administer pre-retreat questions (day of retreat) Individual psychotherapy/resources (as already established with patient or referral to primary care mental health on call clinician) as needed for first year postpartum) Mother’s retreat Crisis intervention resource availability (ongoing) Post retreat questions and survey (day of retreat) Optional: follow up call (within 1-month post retreat for patient volunteers) Appendix D: Intervention Phases (Clinicians) 1. Contact primary care section chief to request to speak at routine monthly required staff meeting a. Optional for future in person trainings: Outreach call to OB and/or primary care clinics (speak with office manager, chief nurse or clinician) 2. Schedule fifteen-minute meeting to deliver presentation covering ● sequela of postpartum mood disorders ● current solutions ● pilot retreat justification/details 3. Clinician follow up calls/feedback Appendix E: Survey Data Pregnancy-Related Mental Health Care Inquiry N=22 Responses 03:18, Average time to complete 1. How prepared do you feel to address pregnancy-related mental health conditions? (0 point) not prepared at all 2 somewhat prepared 15 mostly prepared 4 fully prepared 1 2. If not prepared, what information would be helpful to raise your preparedness/education? 18 Responses ID Name Responses 1 anonymous Re-review of information I have collected over the years just prior to entering a visit 2 anonymous additional training (preferably live and interactive) along with a compilation of resources 3 anonymous what meds are safe to use, what resources are available at every site we cover and what is the process to getting those resources b/c half the time we don't know how to order what and it's different at every site 4 anonymous It's rare I have pregnant patients, so I don't really need education on the topic that I may forget, I need resources to be able to go to when these patients do show up 5 anonymous Having good "go -to" phrases to use to discuss difficult topics (termination of pregnancy, elevated health risks to mother, PPD). 6 anonymous What are some specific pregnancy MH conditions that I could anticipate? 7 anonymous More frequent contact with the information. 8 anonymous List of available appropriate contacts that are site -specific and details on what patients are appropriate for referral to these contacts 9 anonymous recommended treatment options for pregnant individuals 10 anonymous not sure...not sure what the biggest MH problems are? 11 anonymous more education about hormones, birth control. 12 anonymous more education regarding safety in pregnancy for psychiatric medications 13 anonymous training 14 anonymous I would appreciate taking a TMS module or live seminar on how to approach pregnancy -related mental health conditions. 15 anonymous list of medications that are pregnancy safe, information on Postpartum resources for mothers 16 anonymous Everything, do not recall every being trained on this! 17 anonymous more education 18 anonymous Specific medications . Mother’s Retreat Virtual Version • • • • • • Note to facilitators: • • -It is recommended for this virtual retreat to be facilitated by two by 2 individuals, one licensed mental health professional and a second licensed professional or paraprofessional • Facilitators (licensed and non-licensed) must take two-hour course to have access to the material and facilitate their own ROSE course available through VA Mental Health and Suicide Prevention Program available through womenandinfants.org • Additional training is recommended for licensed staff: 12-hour VA Reproductive Mental Health series available on Women’s Mental Health SharePoint on demand {ADD BIO OF FACILITATORS HERE} PRIMARY FACILITATOR NAME(s) Photo(s) EDUCATION AND/OR EXPERIENCE BACKGROUND SPECIAL INTERESTS CO-FACILITATOR NAME(s) Photo(s) EDUCATION AND/OR EXPERIENCE BACKGROUND SPECIAL INTERESTS Pre-retreat Survey WELCOME! Please answer the two questions below and submit How prepared did you feel for birth and parenting experience? 0) Not at all prepared 1) Slightly prepared 2) Mostly prepared or 4) Fully prepared. If not a four, what information do you wish your health care providers would have given you to support your mental health? Note to ponder while awaiting start of retreat: According to Postpartum Support International: “You are not alone, and you are not to blame. Help is available. You will get better”. “Adjusting to parenthood is a massive life change. And it is okay to say you’re not okay. You don’t have to fake being happy” Mother of two who recovered from postpartum depression Plan of Events 0830-1530 (specify time zone) 0830 Check in and take pre-test 0900 Welcome Sharing Circle 1030 Meditation 1100 Your fourth trimester & self-care as a parent Take bio breaks as needed throughout the day 1200 Lunch and interaction with others 1300 Movement: nature walk 1330 Guest speaker segment 1330 Maternal Mental Health 101 Take bio breaks as needed throughout the day 1430 Closing gratitude circle 1500 Mother connections Closing notes: please consider our monthly postpartum wellness support group. You are cordially invited throughout the first year of your baby’s life on an ongoing basis or if you just need to come for support. These groups are available in person and video hybrid via zoom. We will be sending out all material discussed in the different classes as well as a link to the postpartum virtual groups via email. If you have children in the home, they are welcome to be in the virtual room. Please mute yourself when you are not talking to decrease background noise. If you need to turn off camera to attend to them, please feel free to do so and come back on camera when you can. I. Introduction to Talking Circle & Guidelines for the retreat Proposed time: 1- 1.5 hours utilizing the following format. Objective of talking circles: This is a forum that includes equal sharing of all participants. The shape of the circle indicates that everyone contributes a part of the circle to make it complete. In this way, the sharing circle for the Peripartum Wellness Retreat encourages parents to support one another through the course of the day. Important Reminders: Participants have a unique journey that has led them to this stage of parenthood. It is vital that the facilitator hold space for each viewpoint, recognize the need for emotional processing and encourage others to practice a judgment free space. It is also acceptable for any participant to pass when it is their turn to share. Introduction Script: “Welcome to this sacred space where we will share challenges, fears, hopes for our experience of parenthood and will pay tribute to you individually. The circle represents a complete shape that every one of you fulfills a space to preserve this completeness. In this circle you have the opportunity to explore your own experiences of being parents, your visions for yourself as a parent, and your hopes and fears as you embark on this journey. Guidelines are below; these are developed to foster a respectful and seamless experience for you within the limitations of a virtual format.” References http://firstnationspedagogy.ca/circletalks.html Group Telehealth Agreement (*adapted from group agreement currently used in perinatal wellness support groups facilitated by author) 1.Confidentiality: I understand the laws that protect the confidentiality of my medical information also apply to telehealth, including group treatment conducted over video telehealth. I understand that the VA has instituted procedures and policies to protect my privacy and confidentiality. The provider will lock the virtual medical room to ensure no unauthorized person will enter the session or listen. I understand that everything said and done in group is confidential. I agree to protect the group confidentiality, by not revealing the names of other members of the group, nor what is said and done in the group. I understand that if I violate this confidentiality, I will be removed from the group. I understand that there is an exception to this confidentiality that applies to the group provider. The one exception to confidentiality is when the provider believes that I may be a threat to myself or others. 2.Risks and Consequences: The VA does not record telehealth sessions, including group telehealth sessions, without prior approval. I understand that I will not audio or video record any portion of the treatment session. I acknowledge that while this session will not be audio or video recorded by the VA, there is a risk that the session could be audio or video recorded and disseminated by a group member without knowledge or approval from VA or other group members. The consequence for any member audio or video recording any portion of the treatment session will be the removal from the group for violating confidentiality, as well as referral for prosecution to the full extent of federal and local laws. Applicable local laws may include the location of the provider and all members. 3.Privacy: Participation in this group is voluntary, and I have the right to withdraw from the group at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I am otherwise entitled. No group member is ever required to answer any question, to participate in any activity, or to say anything. If I am asked questions or asked to participate in an activity that makes me feel uncomfortable, I understand that I have the right to decline, and I agree not to pressure any other group members to participate if they are uncomfortable. I agree to be in a quiet, private location during my session. Please turn off any other electronic devices for the duration of the circle. 4.Dignity: I agree that I will be tolerant, respectful, and supportive of other group members. I will avoid language that stereotypes or is derogatory to others and will provide only helpful feedback. I will be considerate of others who are talking, will give others a chance to talk, and will not engage in side conversations. 5.Behavior: Safety is of the utmost importance. Violence or intimidation toward other group members is not tolerated. Gossip and grudges can be very destructive in a group. I agree that if I have something to say to another group member, I will say it to the member directly and in a respectful way rather than talk about him or her with others. End by telling the group: “By participating in this group, you agree to abide by these guidelines. Does anyone have any objectives or additions to the agreement to feel safe to proceed?” Potential Sharing Circle Questions: “What have been the most memorable experiences of your pregnancy?” “What is one thing you have been thinking about, but haven’t shared with anyone? “If you could identify a positive and negative, or a rose and a thorn in your pregnancy, what would they be?” II. Pregnancy Meditation: Play Link: Ultimate Pregnancy Meditation | Belleruth Naparstek (insighttimer.com) (23:34m) This is a narrated meditation that is pre-scripted and available on the internet for public use. III. Importance of Self-Care – Write your own plan Suggested aid to distribute: “Your Postpartum Plan” from Postpartum Support International 2023 (posted online for public use) (see appendix) Outline of Presentation/explore emotions (to be completed by pregnant person/expecting parent): -My biggest challenge: -Partner’s biggest challenge: Sleep/rest: -Minimum hours sleep needed by both partners -Sleep arrangements -Plan for nighttime feedings Mental Health and emotional nurturing -Current coping skills -Behavioral activation: 1-2 short activities each day for selfrejuvenation, “joy infusion” -Warning signs for intervention -List 3-5 support people Link/References: Postpartum-Planning-Class-Plan-2023_11_6.pdf LUNCH together – building community Introduce the idea of a book club that can be started today and reviewed together at first follow up postnatal group. Make sure to choose books that are simple, easy to read, engaging…not texts. Ideas include: The little blue rocket, Good moms have scary thoughts, Asking for a pregnant friend. Alternative idea: parental wellness podcast or related television programming that is pregnancy themed if book club idea is too time intensive. IV. Outdoor Mindfulness Activity Instruct attendees to walk in a place that is safe for 20-30 minutes (this is best facilitated with in-person curriculum if safe for their condition and cleared by their physician). Alternatively, attendees can choose a place outside to sit that is comfortable and safe from the elements. Encourage mindful reflection, see below for guide: Engage all five senses Consider: aromas, weather, wildlife, sounds, color, any tastes. Return to circle and have gratitude round for what they experienced. -Alternative activity: Jon Kabat-Zinn Everyday blessings: the inner work of mindful parenting (1998) V. Guest Speakers: -Seek volunteers from your current women’s health programming to help educate about available programming to support mother’s health and wellness. Availability of these resources varies site-to-site. Script idea: “I am facilitating a new mother’s retreat for our Veterans within the Women’s Mental Health program. I am inviting subject matter experts to offer their expertise to help mothers in their postpartum care. Does your schedule allow for a 15–30-minute presentation to improve education of the Veterans as they enter motherhood?” Ideas include: - Pelvic Floor Physical Therapist: explanation of physical changes to expect and how to heal oneself post-delivery - Massage Therapist: Demonstrate self-massage and partner massage - Maternity Care Coordinator – RN/case manager assigned prenatally for support to define role postpartum VI. Maternal Mental Health 101 *Adapted from Reach Out Stay Strong Essentials (ROSE evidencebased curriculum for postpartum depression prevention) -Facilitators must take two-hour course to have access to the material and facilitate their own ROSE course available through VA Mental Health and Suicide Prevention Program and recommended the 12-hour VA Reproductive Mental Health series available on Women’s Mental Health Sharepoint on demand -Topics to be discussed (to be expanded over break) -Psychoeducation about postpartum depression -Role transitions (include paternal mental health section) -Relaxation exercises -Assertiveness definition and role playing -Support people (review and expand upon from self-care portion section III) -Who are your unconditional people? -Who will be there 24/7 in the first weeks? * Rose Program: Intervention to Prevent Postpartum Depression (womenandinfants.org) **For supplemental curriculum from scholarly references in this area, see: Johnson, J. E., Wiltsey-Stirman, S., Sikorski, A., Miller, T., King, A., Blume, J. L., Pham, X., Moore Simas, T. A., Poleshuck, E., Weinberg, R. & Zlotnick, C. (2018). Protocol for the ROSE sustainment (ROSES) study, a sequential multiple assignment randomized trial to determine the minimum necessary intervention to maintain a postpartum depression prevention program in prenatal clinics serving low-income women. Implementation Science, 13(1), 115–128. https://doi.org/10.1186/s13012-018-0807-9. Kleiman, K.R., & Raskin, V.D. (2018). This isn’t what I expected: Overcoming postpartum depression, 2nd edition. Tantor Audio. Orchard, E. R., Rutherford, H. J. V., Holmes, A. J., & Jamadar, S. D. (2023). Matrescence: lifetime impact of motherhood on cognition and the brain. Trends in Cognitive Sciences, 27(3), 302–316. https://doi.org/10.1016/j.tics.2022.12.002 Sacks, A., & Birndorf, C. (2019). What no one tells you: A guide to your emotions from pregnancy to motherhood. Simon & Schuster. VII.Closing Circle Resume initial circle environment to close the day. Review basic guidelines for circle. Sample script: “What are your biggest lessons today?” “How will you approach motherhood (parenthood) going forward?” “What are your most precious support systems?” “Share about your outside mindfulness experience.” (Give emergency numbers: 911, 988 and see mom’s line in additional resources at end of document) VIII. Optional (in development): a. Expressive therapies such as journalling and art therapy b. Explore Intergenerational Review: What kind of parent do you want to be? c. Gratitude jar (to be reviewed at first postpartum support group) d. Yearly reunion IX. In case of emergency: In any therapeutic milieu, an emergency plan needs to be created. This is one reason why two facilitators are recommended. The main facilitator can continue with the group and the co-facilitator can go offline and call Veteran in crisis. The co-facilitator must consult with the facilitator after the retreat to assure coordination of care with existing mental health clinicians with whom the patient is connected or seamless referral to the established primary care mental health clinician on-call for new patients for further assessment and treatment. If the co-facilitator detects that a participant is in danger of self-harm or harm to others, a welfare check will be called using e-911. The crisis line must be provided in the beginning of the group in the chat (988) to assure access to all online. “Just to know that I am not the only one who finds role of mother difficult is a huge relief” -Mother of 6-month-old Post-retreat check: How prepared do you feel to parent successfully? 0. Not prepared at all 1. Somewhat prepared 2. Mostly prepared 3. Fully prepared If not fully prepared, what information would be helpful to further support your mental health? Provider Training Manual Perinatal Mental Health Virtual Version Considerations for facilitator(s): • If this is facilitated in a telehealth or virtual meeting, post questions in the chat • If this is done in individual consultation, give questions orally or this page in virtual document Consideration for provider(s): ‘You know, it’s OK to not be OK.’ Postpartum Support International Pre-training check: How prepared do you feel to address pregnancyrelated mental health conditions? 0. Not prepared at all 1. Somewhat prepared 2. Mostly prepared 3. Fully prepared Considerations for facilitator(s): • If this is facilitated in a telehealth or virtual meeting, post questions in the chat • If this is done in individual consultation, give questions orally or this page in virtual document Consideration for provider(s): ‘You know, it’s OK to not be OK.’ Postpartum Support International Pre-training check: How prepared do you feel to address pregnancyrelated mental health conditions? 4. Not prepared at all 5. Somewhat prepared 6. Mostly prepared 7. Fully prepared Purpose Postpartum depression is the most common condition of pregnancy. Perinatal mental health disorders, including postpartum depression, can occur during pregnancy or postpartum within one-year postbirth. Veterans are at increased risk for mental health disorders in this stage of life. Peripartum depression and anxiety disorders are underreported, which could explain the lack of maternal mental health detection. Primary care providers are uniquely positioned to detect mental health symptoms antenatally or postpartum. This manual and training script is designed to help primary care providers identify perinatal mental health disorders and connect Veterans to the appropriate level of care. This information is presented in a brief format supported by literature review and field research polling current providers’ of need areas in perinatal mental health. Objectives At the end of this short training, clinicians will be able to: • Identify diagnostic clues to perinatal mental health diagnoses in primary care clinical encounter • Describe symptoms of perinatal maternal distress • Understand screening tools • List evidence-based treatments for these conditions • Review and utilize a perinatal mental health resource list “Perinatal mental and substance abuse disorders refer to these conditions that occur before, during, and up to one year after giving birth” American Psychiatric Association, 2023 Facilitation This training is best delivered by a mental health provider (i.e., clinical social worker, psychologist) who has completed the 12- hour Reproductive Mental Health Trainings and has passed the test. It is designed to be delivered in team or staff meetings, or in one on one instruction/coaching with the provider and facilitator must be able to connect provider with referrals for psychotherapy and psychiatric consultation, as well as information about support including the mother’s retreat when developed. Training Outline (to be posted in chat during meeting or individually via email/teams instant messaging used by VA. Take pre-test Definitions: Perinatal Mental Health Statistics Screening using the EPDS Evidence-based treatments & new approaches Mother’s Perspective At-a-glance resources with links for further training Questions? Post-test and suggestions for further training Training Outline Definition of Perinatal Mental Health After completing this section of the training, clinicians should be able to expand their knowledge to the larger scope of perinatal mental health beyond postpartum depression ► There is a substantial amount of peer-reviewed literature that identify maternal mood disorders as a serious global health problem with postpartum depression being the health condition most prevalent in mothers ► Symptoms can include crying spells and sadness, lack of interest in their baby, sleep and appetite changes, guilt, loss if interest and thoughts of self-harm or harming the baby ► Baby blues vs. postpartum depression: baby blues occur 2-5 days after birth and generally dissipates within two weeks, 80% of birthing people experience ► Depression is more pervasive and causes functional limitations “VA maternity care coordinators offer pregnancy resources and support to Veterans and Veterans remain eligible for VA mental healthcare”. Kroll-Derosiers, et al., 2022 ► Statistics After completing this section of the training, clinicians should be able to understand the gravity of perinatal mental health conditions in the general and Veteran populations. -10-20% of people who give birth will have clinical levels of depression -6-10% of people who will give birth will have clinical levels of anxiety -Veterans are at higher risk for perinatal mental health challenges -Veteran partners can get depressive symptoms, too: one in ten will experience paternal depression -Depression is among the most common complication of pregnancy ►Screening Tools After completing this section of the training, clinicians should be able to identify the evidence-based screening tools for perinatal mental health and where to find in patient’s chart -Standard Assessment in Primary Care nurse intake: Review Patient Health Questionaire-9 (PHQ-9) which is validated for perinatal use and is likely more feasible for busy primary care clinicians. -Optional assessment: The Edinburgh Postnatal Depression Screen (EPDS) is completed in each trimester by assigned Maternity Care Coordinators and can be used to target pregnancy-related mental health changes. This assessment can be found in the patient’s chart. Also see appendix A for more information about the tool. 1. Inquire about mood: 2. -Example script for patients: “Mood fluctuations are common during pregnancy and after birth. This questionnaire is designed to identify ways we can support you best throughout this significant life stage” 3. -see appendix for editable Edinburg Postnatal Depression Screen and patient’s chart for current PHQ9). 4. Treatments After completing this section of the training, clinicians should be able to know basic flow of patients to appropriate level of mental health care and resources Medication – you can utilize the reproductive mental health consult to answer any questions the clinician may have about teratogenic medications as well as risks/benefits profile. To refer for reproductive mental health consult national team, psychiatric medication consult, email reproMH@va.gov Psychotherapy – Interpersonal Therapy EBP is the counseling methodology with the most evidence-based therapy for perinatal mental health conditions. To refer to psychotherapy, message primary care mental health clinician with request and patient identifying information: Parent supportive environments – groups held for parents are available in virtual and live opportunities. If you have an expecting Veteran on your panel, and would like to refer for the parent retreat (message primary care mental health clinician with request for referral to upcoming retreat cohort and patient identifying information): There are ample perinatal mental health treatments available, and prognosis is better if detected early and connected with those treatments. ► Mother’s Anecdotes: (composite responses from ongoing Veteran Postpartum Wellness Support groups) After completing this section of the training, the clinician should be able to understand mothers struggling with mental health conditions postpartum in their own words “I wish [providers] had talked with me about problems that could happen during delivery and postpartum” “I felt embarrassed to ask questions, like I was supposed to know the answers” “Everyone said I’d love being a parent, like it was the most exciting time in my life. I was ashamed because I didn’t feel that way” “I felt like people didn’t want to see the way I really felt and just wanted me to say I was doing great and loving it” ► Resource page After completing this section of the training, the clinician should be able to easily connect to resources designed for use by both clinicians and to distribute to patients. ► EPDS (can be found in “scales & measures” in BHL) edinburghscale.pdf US National Maternal Mental Health Hotline: 1-833-943-5746 Home | Maternal Mental Health Alliance (*note: this is an additional resource. The Veteran’s Crisis Line [988] is the VA-preferred emergency number) Perinatal Mental Health Toolkit Psychiatry.org - Perinatal Mental Health Toolkit VA Reproductive Mental Health Consult Email reproMHconsult@va.gov ACOG patient screening recommendations Patient Screening | ACOG VA statistics about Veteran parents VA Pregnancy and Maternity Care Research Reassurance is important. Parents don’t have to love the first experiences of parenthood. According to Postpartum Support International: “You are not alone, and you are not to blame. Help is available. You will get better”. Post-training check: How prepared do you feel to address pregnancyrelated mental health conditions? 4. Not prepared at all 5. Somewhat prepared 6. Mostly prepared 7. Fully prepared If not fully prepared, what additional information would be helpful to raise your preparedness/education? 58 Appendix A (located in VA Behavioral Health Lab application in patient’s chart) Edinburgh Postnatal Depression Scale 1 (EPDS) Name: ______________________________ Address: ___________________________ Your Date of Birth: ____________________ ___________________________ Baby’s Date of Birth: ___________________ Phone: _________________________ As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today. Here is an example, already completed. I have felt happy: Yes, all the time Yes, most of the time This would mean: “I have felt happy most of the time” during the past week. No, not very often Please complete the other questions in the same way. No, not at all In the past 7 days: 1. I have been able to laugh and see the funny side of things *6. Things have been getting on top of me As much as I always could Yes, most of the time I haven’t been able Not quite so much now to cope at all Definitely not so much now Yes, sometimes I haven’t been coping as well Not at all as usual No, most of the time I have copied quite well 2. I have looked forward with enjoyment to things No, I have been coping as well as ever As much as I ever did Rather less than I used to *7 I have been so unhappy that I have had difficulty sleeping Definitely less than I used to Yes, most of the time Hardly at all Yes, sometimes Not very often *3. I have blamed myself unnecessarily when things No, not at all went wrong Yes, most of the time *8 I have felt sad or miserable Yes, some of the time Yes, most of the time Not very often Yes, quite often No, never Not very often No, not at all 4. I have been anxious or worried for no good reason 59 No, not at all *9 I have been so unhappy that I have been crying Hardly ever Yes, most of the time Yes, sometimes Yes, quite often Yes, very often Only occasionally No, never *5 I have felt scared or panicky for no very good reason Yes, quite a lot *10 The thought of harming myself has occurred to me Yes, sometimes Yes, quite often No, not much Sometimes No, not at all Hardly ever Never Administered/Reviewed by ________________________________ Date ______________________________ 1 Source: Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786. 2 Source: K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199 Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title and the source of the paper in all reproduced copies. Edinburgh Postnatal Depression Scale 1 (EPDS) Postpartum depression is the most common complication of childbearing. 2 The 10-question Edinburgh Postnatal Depression Scale (EPDS) is a valuable and efficient way of identifying patients at risk for “perinatal” depression. The EPDS is easy to administer and has proven to be an effective screening tool. Mothers who score above 13 are likely to be suffering from a depressive illness of varying severity. The EPDS score should not override clinical judgment. A careful clinical assessment should be carried out to confirm the diagnosis. The scale indicates how the mother has felt during the previous week. In doubtful cases it may be useful to repeat the tool after 2 weeks. The scale will not detect mothers with anxiety neuroses, phobias or personality disorders. Women with postpartum depression need not feel alone. They may find useful information on the web sites of the National Women’s Health Information Center <www.4women.gov> and from groups such as Postpartum Support International <www.chss.iup.edu/postpartum> and Depression after Delivery <www.depressionafterdelivery.com>. 1 Source: Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786. 2 Source: K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199 60 SCORING QUESTIONS 1, 2, & 4 (without an *) Are scored 0, 1, 2 or 3 with top box scored as 0 and the bottom box scored as 3. QUESTIONS 3, 510 (marked with an *) Are reverse scored, with the top box scored as a 3 and the bottom box scored as 0. Maximum score: 30 Possible Depression: 10 or greater Always look at item 10 (suicidal thoughts) Users may reproduce the scale without further permission, providing they respect copyright by quoting the names of the authors, the title, and the source of the paper in all reproduced copies. Instructions for using the Edinburgh Postnatal Depression Scale: 1. The mother is asked to check the response that comes closest to how she has been feeling in the previous 7 days. 2. All the items must be completed. 3. Care should be taken to avoid the possibility of the mother discussing her answers with others. (Answers come from the mother or pregnant woman.) 4. The mother should complete the scale herself, unless she has limited English or has difficulty with reading.

Abstract (if available)

Abstract Preventing disease is more effective than treating a health condition (Barth et al., 2022). This is true for women experiencing perinatal mental health conditions—the period before birth (pregnancy) and 1 year after birth (postpartum)—when rates have remained high despite advanced medical care (Centers for Disease Control and Prevention [CDC], 2022). Although research studies have found the need for perinatal mental health services, there is a paucity of comprehensive training for clinicians of all disciplines involved in treatment of mothers with perinatal mental health disorders (CDC, 2022). Further, there has been a lack of mental health screening and consistent intervention in traditional maternal health care settings. This lack has created a gap in maternal health education and screening and treatment of peripartum mental health disorders across all populations, especially minority groups. Current best practices to treat perinatal psychological disorders have limitations and have not been universally ava

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Asset Metadata

Creator Bohenek, Oreana Dawn (author)

Core Title Bridging the divide in perinatal mental health

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Degree Conferral Date 2024-12

Publication Date 11/19/2024

Defense Date 11/18/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag addressing perinatal mental health issues in a creative and collaborative way

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Manderscheid, Ronald (committee chair)

Creator Email oharless@usc.edu,oreanaharless@outlook.com

Unique identifier UC11399DUC1

Identifier etd-BohenekOre-13642.pdf (filename)

Legacy Identifier etd-BohenekOre-13642

Document Type Dissertation

Format theses (aat)

Rights Bohenek, Oreana Dawn

Internet Media Type application/pdf

Type texts

Source 20241122-usctheses-batch-1224 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu