The integration of behavioral health consultants within a state-wide psychiatry consultation program: a community case study.

This paper describes the integration and role of masters-prepared behavioral health consultants (BHCs) within a state-wide psychiatry consultation program for children, adolescents, and perinatal women. Data from the Michigan Clinical Consultation and Care (MC3) program are reviewed, with attention to the role that BHCs play in the consultation process, integrated care, screening, and their dual roles with Community Mental Health Services Programs (CMHSPs) in Michigan. Approximately 82% of MC3 services are provided by the BHCs and involve resources or integrated care. BHCs play a role in managing provider consultations and connecting patients and providers to resources in the MC3 program.

A Review of Telepsychiatry for Pediatric Patients in the Emergency Setting.

PURPOSE OF REVIEW: The purpose of this review is to summarize factors contributing to the current state of pediatric mental health access in ED settings and synthesize the existing literature on the use of telepsychiatry to extend access to care, with particular focus on feasibility and sustainability. RECENT FINDINGS: Children are presenting to emergency departments (EDs) with mental health concerns at an increasing rate, while ED capacity to treat psychiatric needs in children remains insufficient. This growing problem is compounded by decreased access to outpatient care and inpatient psychiatric beds, resulting in exorbitantly long waiting times, or "boarding," of children in crisis. Telepsychiatry has emerged as a strategy to decrease boarding of pediatric patients in ED settings by utilizing remote psychiatric professionals to provide consultation and assessment. Telepsychiatry in ED settings is an effective strategy to increase access to care and decrease length of stay for pediatric patients.

The Michigan Child Collaborative Care Program: Building a Telepsychiatry Consultation Service.

This column describes the establishment of the Michigan Child Collaborative Care (MC3), a statewide telepsychiatry consultation program that provides support to primary care providers (PCPs) in meeting the mental health needs of youths and perinatal women. The MC3 program provides cost-effective, timely, remote consultation to primary care providers in an effort to address the lack of access and scarcity of resources in child, adolescent, and perinatal psychiatry. Data from 10,445 service requests are summarized. Common diagnoses included attention-deficit hyperactivity disorder, mood disorders, anxiety disorders, and autistic spectrum disorders, with many cases (58%) deemed moderate to severe. Co-occurring psychological trauma was suspected in 9% of service requests. Partnerships, stakeholder roles, PCP engagement, and workflow integration are highlighted as keys to the program's success.

Exploring the Telepsychiatry Experience: Primary Care Provider Perception of the Michigan Child Collaborative Care (MC3) Program.

BACKGROUND: Pediatric mental healthcare is a growing component of primary care practice. However, there is a lack of access to mental health services, particularly those provided by Child and Adolescent Psychiatrists. The Michigan Child Collaborative Care (MC3) Program is a telepsychiatry service that offers embedded behavioral health consultants within primary care practices, telephonic consultation, video consultation and embedded care. Primary care provider (PCP) utilization of telepsychiatry services is predicated on perceiving the consultation service as user-friendly, helpful, and feasible in their practice. OBJECTIVE: A survey of PCPs was conducted over a 5-year period to assess PCP attitudes and perceptions regarding MC3 consultation, including measures of efficiency, user-friendliness, and confidence in providing mental healthcare. The survey contained 4 items, (2 quantitative and 2 qualitative), and took less than 2 minutes to complete. RESULTS: 649 responses were received out of 1475 possible responses (44% response rate). Common themes elicited from the qualitative items included perception of improved patient care for youth with mental illness (45.3%), improved comfort and confidence in caring for youth with mental illness (30.9%), greater comfort with the prescribing and monitoring of psychotropics (25.9%) and improved access to mental healthcare for youth (23.1%). PCPs strongly agreed that MC3 was user-friendly, efficient, and enhanced their confidence in managing pediatric mental health concerns. CONCLUSIONS: This study demonstrates that the MC3 Telepsychiatry Program is well accepted by PCPs with self-reported improvements in providing mental healthcare to patients. Future research should explore how PCP perception impacts PCP practice, knowledge, as well as outcomes for patients and families longitudinally.

Partnerships with Primary Care for the Treatment of Preschoolers.

This article reviews mental health access issues relevant to preschool children and data on this population obtained through the Michigan Child Collaborative Care Program (MC3). The MC3 program provides telephonic consultation to primary care physicians (PCPs) in 40 counties in Michigan and video telepsychiatric consultation to patients and families. Attention-deficit/hyperactivity disorder and disruptive behavioral disorders are frequent initial presenting diagnoses, but autism spectrum disorders, parent-child relational issues, trauma, and posttraumatic stress disorder should also be considered. Collaborative care programs provide promising ways to promote access to child psychiatric services when these services are distant to local PCP offices.

Executive Functioning at Baseline Prospectively Predicts Depression Treatment Response.

OBJECTIVE: Existing cognitive and clinical predictors of treatment response to date are not of sufficient strength to meaningfully impact treatment decision making and are not readily employed in clinical settings. This study investigated whether clinical and cognitive markers used in a tertiary care clinic could predict response to usual treatment over a period of 4 to 6 months in a sample of 75 depressed adults. METHODS: Patients (N = 384) were sequentially tested in 2 half-day clinics as part of a quality improvement project at an outpatient tertiary care center between August 2003 and September 2007; additional subjects evaluated in the clinic between 2007 and 2009 were also included. Diagnosis was according to DSM-IV-TR criteria and completed by residents and attending faculty. Test scores obtained at intake visits on a computerized neuropsychological screening battery were the Parametric Go/No-Go task and Facial Emotion Perception Task. Treatment outcome was assessed using 9-item Patient Health Questionnaire (PHQ-9) self-ratings at follow-up (n = 75). Usual treatment included psychotropic medication and psychotherapy. Decline in PHQ-9 scores was predicted on the basis of baseline PHQ-9 score and education, with neuropsychological variables entered in the second step. RESULTS: PHQ-9 scores declined by 46% at follow-up (56% responders). Using 2-step multiple regression, baseline PHQ-9 score (P ≤ .05) and education (P ≤ .01) were significant step 1 predictors of percent change in PHQ-9 follow-up scores. In step 2 of the model, faster processing speed with interference resolution (go reaction time) independently explained a significant amount of variance over and above variables in step 1 (12% of variance, P < .01), while other cognitive and affective skills did not. This 2-step model accounted for 28% of the variance in treatment change in PHQ-9 scores. Processing speed with interference resolution also accounted for 12% variance in treatment and follow-up attrition. CONCLUSIONS: Use of executive functioning assessments in clinics may help identify individuals with cognitive weaknesses at risk for not responding to standard treatments.

Vitamin D levels and perinatal depressive symptoms in women at risk: a secondary analysis of the mothers, omega-3, and mental health study.

BACKGROUND: Vitamin D insufficiency may be associated with depressive symptoms in non-pregnant adults. We performed this study to evaluate whether low maternal vitamin D levels are associated with depressive symptoms in pregnancy. METHODS: This study was a secondary analysis of a randomized trial designed to assess whether prenatal omega-3 fatty acid supplementation would prevent depressive symptoms. Pregnant women from Michigan who were at risk for depression based on Edinburgh Postnatal Depression Scale Score or history of depression were enrolled. Participants completed the Beck Depression Inventory (BDI) and Mini International Neuropsychiatric Interview at 12-20 weeks, 26-28 weeks, 34-36 weeks, and 6-8 weeks postpartum. Vitamin D levels were measured at 12-20 weeks (N = 117) and 34-36 weeks (N = 112). Complete datasets were available on 105 subjects. Using regression analyses, we evaluated the relationship between vitamin D levels with BDI scores as well as with MINI diagnoses of major depressive disorder and generalized anxiety disorder. Our primary outcome measure was the association of maternal vitamin D levels with BDI scores during early and late pregnancy and postpartum. RESULTS: We found that vitamin D levels at 12-20 weeks were inversely associated with BDI scores both at 12-20 and at 34-36 weeks' gestation (P < 0.05, both). For every one unit increase in vitamin D in early pregnancy, the average decrease in the mean BDI score was .14 units. Vitamin D levels were not associated with diagnoses of major depressive disorder or generalized anxiety disorder. CONCLUSIONS: In women at risk for depression, early pregnancy low vitamin D levels are associated with higher depressive symptom scores in early and late pregnancy. Future investigations should study whether vitamin D supplementation in early pregnancy may prevent perinatal depressive symptoms. TRIAL REGISTRATION: https://clinicaltrials.gov/ REGISTRATION NUMBER: NCT00711971.

Development of a screening and recruitment registry to facilitate perinatal depression research in obstetrics settings in the USA.

OBJECTIVE: To create a multi-site registry to enable future large-scale studies of perinatal depression among women attending obstetrics clinics in the USA. METHODS: A screening and recruitment registry was developed that included women aged at least 18 years who attended seven obstetric clinics in the University of Michigan Health System (Ann Arbor, MI, USA) for prenatal care between September 8, 2008, and June 9, 2011. Participants completed depression screening and research recruitment materials. RESULTS: Of 4745 women who returned a screening form, 2983 had completed it, giving an overall agreement rate of 62.9%. A total of 630 participants were enrolled into ten research studies via the registry. Among the 2982 women for whom scores on the Edinburgh Postnatal Depression Scale were available, 494 (16.6%) fell within the at-risk range or had scores suggestive of clinical depression. CONCLUSION: The present registry could improve detection of perinatal depression symptoms and potentially serve as a model for dissemination and implementation at other sites with an interest in studying factors linked to perinatal depression.

Contraception and mental health: a commentary on the evidence and principles for practice.

Among the most prevalent and disabling chronic diseases affecting reproductive-aged women worldwide, depression and anxiety can contribute to adverse reproductive health outcomes, including an increased risk of unintended pregnancy and its health and social consequences. For women with these common mental health conditions who want to avoid an unintended pregnancy, effective contraception can be an important strategy to maintain and even improve health and well-being. Reproductive health clinicians play a critical role in providing and managing contraception to help women with mental health considerations achieve their desired fertility. In this commentary, we review the literature on relationships between mental health and contraception and describe considerations for the clinical management of contraception among women with depression and anxiety. We discuss issues related to contraceptive method effectiveness and adherence concerns, mental health-specific contraceptive method safety and drug interaction considerations, and clinical counseling and management strategies. Given important gaps in current scientific knowledge of mental health and contraception, we highlight areas for future research.

Parenting stress and depressive symptoms in postpartum mothers: bidirectional or unidirectional effects?

Despite the consistent link between parenting stress and postpartum depressive symptoms, few studies have explored the relationships longitudinally. The purpose of this study was to test bidirectional and unidirectional models of depressive symptoms and parenting stress. Uniquely, three specific domains of parenting stress were examined: parental distress, difficult child stress, and parent-child dysfunctional interaction (PCDI). One hundred and five women completed the Beck Depression Inventory and the Parenting Stress Index - Short Form at 3, 7, and 14 months after giving birth. Structural equation modeling revealed that total parenting stress predicted later depressive symptoms, however, there were different patterns between postpartum depressive symptoms and different types of parenting stress. A unidirectional model of parental distress predicting depressive symptoms best fit the data, with significant stability paths but non-significant cross-lagged paths. A unidirectional model of depressive symptoms predicted significant later difficult child stress. No model fit well with PCDI. Future research should continue to explore the specific nature of the associations of postpartum depression and different types of parenting stress on infant development and the infant-mother relationship.

Hazardous drinking and family functioning in National Guard veterans and spouses postdeployment.

The current study examined rates of alcohol misuse among National Guard (NG) service members and their spouses/partners, concordance of drinking behaviors among couples, and the effects of alcohol misuse, depression, and posttraumatic stress disorder (PTSD) on three measures of family functioning. This study is important because it addresses the topics of heavy drinking and family functioning in an at-risk population-NG service members returning from a combat zone deployment. We surveyed NG service members (1,143) and their partners (674) 45-90 days after returning from a military deployment. Service member rates of hazardous drinking were 29.2% and spouses/partners 10.7%. Of the 661 linked couples, 26.2% were discrepant where only one member met the criteria for hazardous drinking and 5.4% were congruent for alcohol misuse where both members met hazardous drinking criteria. Service members belonging to either congruent or discrepant drinking groups were more distressed in their marriages/relationships than those in the nonhazardous group. In dyadic analyses, an unexpected partner effect was found for parenting outcomes; that is, when service members drink more, their spouses/partners are less stressed when it comes to parenting. Importantly, both service member and spouse/partner depression was significantly associated with negative family outcomes. Results from this study suggest that when working with these families, it is important to understand the drinking status of both soldier and spouse and to treat depression in addition to alcohol misuse.

The Mothers, Omega-3, and Mental Health Study: a double-blind, randomized controlled trial.

OBJECTIVES: Maternal deficiency of the omega-3 fatty acid, docosahexaenoic acid (DHA), has been associated with perinatal depression, but there is evidence that supplementation with eicosapentaenoic acid (EPA) may be more effective than DHA in treating depressive symptoms. This trial tested the relative effects of EPA- and DHA-rich fish oils on prevention of depressive symptoms among pregnant women at an increased risk of depression. STUDY DESIGN: We enrolled 126 pregnant women at risk for depression (Edinburgh Postnatal Depression Scale score 9-19 or a history of depression) in early pregnancy and randomly assigned them to receive EPA-rich fish oil (1060 mg EPA plus 274 mg DHA), DHA-rich fish oil (900 mg DHA plus 180 mg EPA), or soy oil placebo. Subjects completed the Beck Depression Inventory (BDI) and Mini-International Neuropsychiatric Interview at enrollment, 26-28 weeks, 34-36 weeks, and at 6-8 weeks' postpartum. Serum fatty acids were analyzed at entry and at 34-36 weeks' gestation. RESULTS: One hundred eighteen women completed the trial. There were no differences between groups in BDI scores or other depression endpoints at any of the 3 time points after supplementation. The EPA- and DHA-rich fish oil groups exhibited significantly increased postsupplementation concentrations of serum EPA and serum DHA respectively. Serum DHA- concentrations at 34-36 weeks were inversely related to BDI scores in late pregnancy. CONCLUSION: EPA-rich fish oil and DHA-rich fish oil supplementation did not prevent depressive symptoms during pregnancy or postpartum.

Predictors of recovery from prenatal depressive symptoms from pregnancy through postpartum.

BACKGROUND: Identifying predictors of the course of depressive symptoms from pregnancy through postpartum is important to inform clinical interventions. METHODS: This longitudinal study investigated predictors of recovery from prenatal elevated depressive symptoms in the postpartum period. Forty-one pregnant women completed demographic, interpersonal, and psychosocial self-report assessment measures at 32 weeks of gestation and again 12 weeks postpartum. RESULTS: Of those with elevated depressive symptoms, defined as a Beck Depression Inventory-II (BDI-II) score ≥10, at the prenatal baseline, 39% (n=16) recovered to nonelevated symptom levels postpartum, whereas 61% (n=25) experienced sustained elevated symptoms. Women who recovered evidenced significantly lower baseline depression severity and more frequent engagement in physical activity and cohabitated with a romantic partner. In multiparous women (n=25), history of past postpartum depression (PPD) differentiated between those with transient and those with persisting symptoms, although history of lifetime depression did not. None of the additional demographic, interpersonal, or psychosocial variables investigated differentiated between groups. Logistic regression analysis showed prenatal depression severity and exercise frequency as predictors of recovery postpartum. CONCLUSIONS: Results suggest most women will not experience spontaneous recovery. Women with prenatal heightened symptom severity and previous experiences with PPD are acutely vulnerable to experience sustained symptoms. In contrast, having a cohabitating partner and engagement in prenatal exercise predicted symptom improvement. Physical exercise may be an important clinical recommendation, as it may improve mood. Given the small sample size, these results are preliminary. Implications and future research recommendations are discussed.

Mental health, substance use and intimate partner problems among pregnant and postpartum suicide victims in the National Violent Death Reporting System.

OBJECTIVES: Suicide during pregnancy and postpartum is a tragic event for the victim and profoundly impacts the baby, the family and the community. Prior efforts to study risks for pregnancy-associated suicide have been hampered by the lack of data sources which capture pregnancy and delivery status of victims. Introduction of the United States National Violent Death Reporting System (NVDRS) offers new insights into violent deaths by linking multiple data sources and allowing better examination of psychosocial risk factors. METHODS: The analysis used data from 17 states reporting to the NVDRS from 2003 to 2007 to evaluate suicide patterns among pregnant, postpartum, and nonpregnant or postpartum women. Demographic factors, mental health status, substance use, precipitating circumstances, intimate partner problems and suicide methods were compared among groups. RESULTS: The 2083 female suicide victims of reproductive age demonstrated high prevalence of existing mental health diagnosis and current depressed mood, with depressed mood significantly higher among postpartum women. Substance use and presence of other precipitating factors were high and similar among groups. Intimate partner problems were higher among pregnant and postpartum victims. Postpartum women were more likely to die via asphyxia as cause of death compared to poisoning or firearms. CONCLUSIONS: These findings describe important mental health, substance use and intimate partner problems seen with pregnancy-associated suicide. The study highlights mental health risk factors which could potentially be targeted for intervention in this vulnerable population.

Lengthened predelivery stay and antepartum complications in women with depressive symptoms during pregnancy.

UNLABELLED: Abstract Background: It is crucial to understand the timing and mechanisms behind depression's effect on peripartum stay because attempts to intervene will vary based on the time period involved. We designed this study to compare predelivery and postdelivery length of stay in women with and without elevated depressive symptoms during pregnancy. METHODS: This study involved secondary data analysis of a larger study exploring antepartum depression. Each subject completed the Center for Epidemiological Studies Depression Scale (CES-D) during pregnancy at a mean of 25.8 weeks' gestation. We used time-stamped data to compare total peripartum, predelivery, and postdelivery lengths of stay in women with and without elevated depressive symptoms during pregnancy. In addition, we used a Cox proportional hazards regression model to evaluate potential mechanisms for depression's effect on length of stay. RESULTS: The study sample included 802 pregnant women. Overall, 18% of study subjects scored ≥16 on the CES-D. Bivariate analyses demonstrated a significant association between elevated depressive symptoms and longer predelivery stays (time from admission to delivery). Interaction analyses demonstrated a significant interaction effect between depressive symptoms and parity, such that depressive symptoms were significantly associated with predelivery length of stay in multiparas but not so in primiparous subjects. In a multivariate model of multiparous subjects, depression's effect on length of stay was partially influenced by sociodemographic confounders but remained significant until antepartum complications were added to the model. CONCLUSIONS: Depressive symptoms during pregnancy are significantly associated with a subsequent increase in predelivery length of stay, and this association is mediated in part by antepartum complications, even after controlling for sociodemographic factors. These longer hospital stays can present significant burdens to the patient, her family, and the healthcare system. Future studies should evaluate whether interventions for depression during pregnancy can impact this relationship among depressive symptoms during pregnancy, antepartum complications, and extensive predelivery hospitalizations.

The mothers, Omega-3 and mental health study.

BACKGROUND: Major depressive disorder (MDD) during pregnancy and postpartum depression are associated with significant maternal and neonatal morbidity. While antidepressants are readily used in pregnancy, studies have raised concerns regarding neurobehavioral outcomes in exposed infants. Omega-3 fatty acid supplementation, most frequently from fish oil, has emerged as a possible treatment or prevention strategy for MDD in non-pregnant individuals, and may have beneficial effects in pregnant women. Although published observational studies in the psychiatric literature suggest that maternal docosahexaenoic acid (DHA) deficiency may lead to the development of MDD in pregnancy and postpartum, there are more intervention trials suggesting clinical benefit for supplementation with eicosapentaenoic acid (EPA) in MDD. METHODS/DESIGN: The Mothers, Omega-3 and Mental Health study is a double blind, placebo-controlled, randomized controlled trial to assess whether omega-3 fatty acid supplementation may prevent antenatal and postpartum depressive symptoms among pregnant women at risk for depression. We plan to recruit 126 pregnant women at less than 20 weeks gestation from prenatal clinics at two health systems in Ann Arbor, Michigan and the surrounding communities. We will follow them prospectively over the course of their pregnancies and up to 6 weeks postpartum. Enrolled participants will be randomized to one of three groups: a) EPA-rich fish oil supplement (1060 mg EPA plus 274 mg DHA) b) DHA-rich fish oil supplement (900 mg DHA plus 180 mg EPA; or c) a placebo. The primary outcome for this study is the Beck Depression Inventory (BDI) score at 6 weeks postpartum. We will need to randomize 126 women to have 80% power to detect a 50% reduction in participants' mean BDI scores with EPA or DHA supplementation compared with placebo. We will also gather information on secondary outcome measures which will include: omega-3 fatty acid concentrations in maternal plasma and cord blood, pro-inflammatory cytokine levels (IL-1ß, IL-6, and TNF-α) in maternal and cord blood, need for and dosage of antidepressant medications, and obstetrical outcomes. Analyses will be by intent to treat. DISCUSSION: This study compares the relative effectiveness of DHA and EPA at preventing depressive symptoms among pregnant women at risk. CLINICAL TRIAL REGISTRATION NUMBER: NCT00711971.

Depressive symptoms during pregnancy: impact on neuroendocrine and neonatal outcomes.

OBJECTIVE: To explore the interplay of maternal depressive symptoms on the infant limbic-hypothalamic-pituitary axis (LHPA) and neurological development. DESIGN: Pregnant women were monitored for depressive symptoms using the Beck Depression Inventory (BDI) at 28, 32, and 37 weeks of gestation and at delivery. A mixture growth curve analysis divided the women into three risk groups: low/stable, intermediate, and high/increasing depression based on BDI scores. The infant neuroendocrine system was examined using cord blood for adrenocorticotrophic hormone (ACTH) and cortisol measurements. Two-week-old infants were examined using Neonatal Intensive Care Unit Neurobehavioral Scale (NNNS). RESULTS: Infants born to women of the high/increasing depression group had significant ACTH elevation at birth. On NNNS examination, these infants were more hypotonic and habituated to auditory and visual stimuli. CONCLUSION: When compared to non-depressed women, maternal depressive symptoms, even in the absence of major depressive disorder, appeared to facilitate a different developmental pathway for the infant LHPA and early neurological development.

Public-academic partnerships: working together to meet the needs of Army National Guard soldiers: an academic-military partnership.

The conflicts in Afghanistan and Iraq have greatly increased the number of veterans returning home with combat exposure, reintegration issues, and psychiatric symptoms. National Guard soldiers face additional challenges. Unlike active duty soldiers, they do not return to military installations with access to military health services or peers. The authors describe the formation and activities of a partnership among two large state universities in Michigan and the Michigan Army National Guard, established to assess and develop programming to meet the needs of returning soldiers. The process of forming the partnership and the challenges, opportunities, and benefits arising from it are described.

Buddy-to-Buddy, a citizen soldier peer support program to counteract stigma, PTSD, depression, and suicide.

Citizen soldiers (National Guard and Reserves) represent approximately 40% of the two million armed forces deployed to Afghanistan and Iraq. Twenty-five to forty percent of them develop PTSD, clinical depression, sleep disturbances, or suicidal thoughts. Upon returning home, many encounter additional stresses and hurdles to obtaining care: specifically, many civilian communities lack military medical/psychiatric facilities; financial, job, home, and relationship stresses have evolved or have been exacerbated during deployment; uncertainty has increased related to future deployment; there is loss of contact with military peers; and there is reluctance to recognize and acknowledge mental health needs that interfere with treatment entry and adherence. Approximately half of those needing help are not receiving it. To address this constellation of issues, a private-public partnership was formed under the auspices of the Welcome Back Veterans Initiative. In Michigan, the Army National Guard teamed with the University of Michigan and Michigan State University to develop innovative peer-to-peer programs for soldiers (Buddy-to-Buddy) and augmented programs for military families. Goals are to improve treatment entry, adherence, clinical outcomes, and to reduce suicides. This manuscript describes training approaches, preliminary results, and explores future national dissemination.

Maternal mood and sleep in children of women at risk for perinatal depression.

Few studies have examined relationships between perinatal depression and sleep in offspring beyond very early childhood. Eighty-five women classified as high risk for major depressive disorder during pregnancy completed measures of mood and their child's sleep 4-7 years postpartum. Mothers with Beck Depression Inventory-II (BDI-II) scores ≥20 reported more sleep problems in their child, and child sleep disruption was a reasonable predictor of maternal BDI-II. More research is needed to determine causal relationships between perinatal depression and sleep in offspring.