Demystifying and Destigmatizing Mood Disorders of Pregnancy · Destmystifying and Destigmatizing...

Demystifying and DestigmatizingMood Disorders of Pregnancy

April 19, 2019

Janice Tinsley and Alicia Pollak

“

Destmystifying and Destigmatizing Mood Disorders of Pregnancy

African Americans often feel we are being judged by outsiders, particularly people in authority like doctors. A doctor can’t know us unless they talk to us about life, and express a genuine interest. If they are just paper pushing, asking required questions it will never happen.” –Jessica, mother of 7

Joy Burkard, MBA Presentation at AWHONN 2019Founder & Executive Director, 2020 MOM


Intersectionality- A change in FrameworkKimerberlé Crenshaw “The urgency of intersectionality” TED Women 2016 https://www.ted.com/talks/kimberle_crenshaw_the_urgency_of_intersectionality.Fusion/discussion#t-1117287

“When facts do not fit with available frames, people have a difficult

time incorporating facts into their way of thinking about a problem”

Why do frames matter? Women are left to “fall through the cracks of

a movement, left to suffer in isolation”

Intersectionality- is a framework issue, frames used are partial and

distorting, is there an alternative narrative

Classism, sexism, racism, ableism, homophobia, heterosexism,

transphobia

https://www.ted.com/talks/kimberle_crenshaw_the_urgency_of_intersectionality.Fusion/discussion%23t-1117287

“


“Becoming “trauma-informed” means recognizing that people often have many different types of trauma in their lives. People who have been traumatized need support and understanding from those around them. Often, trauma survivors can be re-traumatized by well-meaning caregivers and community service providers.”

The Trauma Informed Care Projecthttp://www.traumainformedcareproject.org/index.php

Trauma Informed Care


Assess, avoid, and respond to

triggers, triggers can CHANGE

care

Starting care involvement with

clients means starting over in

gaining report and their trust

- Go slow, sit down, be genuine

and a good listener

- Continuity in care of clients

smart and best care

Use of Trauma Informed Care


Stokely CarmichaelMetzl JM, Hansen, H. (2014). “Structural competency: theorizing a new medical engagement with stigma and inequality”. Soc Sci Med Feb; 103: 126-133

“In 1968, the civil-rights activist Stokely Carmichael famously assailed forms of

racial bias embedded, not in actions or beliefs of individuals, but in the functions of

social structures and institutions. “I don’t deal with the individual,” he said. “I think

it’s a cop out when people talk about the individual.” Instead, speaking to a group

of mental-health practitioners, Carmichael protested the silent racism of

“established and respected forces in the society” that functioned above the level of

individual perceptions or intentions, and that worked to maintain the status quo

through such structures as zoning laws, economics, schools, and courts.

Institutionalized racism, he argued, “is less overt, far more subtle, less identifiable

in terms of specific individuals committing the acts, but is no less destructive of

human life” (Carmichael, 2003: 151).


Cultural Competency vs Structural CompetencyVirtual Mentor. 2014;16(9):674-690. doi: 10.1001/virtualmentor.2014.16.9.spec1-1409

Training to help communicate with persons of different ethnic background vs

“’Structural competency’, contends that many health-related factors previously

attributed to culture or ethnicity also represent the downstream consequences of

decisions about larger structural contexts, including health care and food delivery

systems, zoning laws, local politics, urban and rural infrastructures, structural

racisms, or even the very definitions of illness and health”


“…attempt to survive”Metzl JM, Hansen, H. (2014). “Structural competency: theorizing a new medical engagement with stigma and inequality”. Soc Sci Med Feb; 103: 126-133

“These are but a few examples of the types of research that doctors can

now access—at a level of microscopic and macroscopic precision

unimaginable in Carmichael’s time—to understand how diseased or

impoverished economic infrastructures can lead to diseased or

impoverished, or imbalanced bodies or minds. And, how locating race-

based symptoms on the bodies of marginalized or mainstream persons

risks turning a blind eye to the racialized, stratified economies in which

marginalized and mainstreamed bodies live, work, and attempt to survive”


• Stigma around mental

health and pregnancy

rises and women can feel

conflicted in their choices

to care for themselves and

for their growing baby

Stigma, Boundaries, Empathy


The Joint Commission. (2018). Revisions to the National Patient Safety

Goal on Reducing the Risk for Suicide. Retrieved from

- https://www.jointcommission.org/assets/1/6/HAP_Suicide_NPSG_Prepub_emb.pd

f

U.S. Preventive Services Task Force (USPSTF)

- https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummary

Final/perinatal-depression-preventive-interventions

Policy Changes and Current Affairs

https://www.jointcommission.org/assets/1/6/HAP_Suicide_NPSG_Prepub_emb.pdf

https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/perinatal-depression-preventive-interventions


U.S. Preventative Services Task Force (USPSTF)- https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/perinatal-depression-

preventive-interventions

“The USPSTF recommends that clinicians provide or refer pregnant

and postpartum persons who are at increased risk of perinatal

depression to counseling interventions.”

https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/perinatal-depression-preventive-interventions


AB 1893 Maternal mental health: federal funding. (2017-2018)

- Requires DPH to investigate and apply for federal funds and notify the Legislature before

1/1/2020 of efforts to secure and utilize funding

- https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180AB1893

AB 3032 Maternal mental health conditions. (2017-2018)

- Requires hospitals with perinatal services to develop and implement a maternal mental health

program and require education and information for patient, families, and hospital perinatal

employees

- https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180AB3032

CA Legislation 2018

https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180AB1893

https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201720180AB3032


AB 2193 Maternal mental Health

- Requires a provider caring for women during the perinatal period to screen at least once for

mental health

- https://leginfo.legislature.ca.gov/faces/billAnalysisClient.xhtml?bill_id=201720180AB2193

CA Legistation 2018

https://leginfo.legislature.ca.gov/faces/billAnalysisClient.xhtml?bill_id=201720180AB2193


AB 3032 Maternal Mental Health Conditions

123615.5. The Legislature hereby finds and declares all of the following:

(a) Maternal depression is a common complication of pregnancy. Maternal mental health disorders encompass

a range of mental health conditions, such as depression, anxiety, and postpartum psychosis.

(b) Maternal mental health conditions affect one in five women during or after pregnancy, but all women are at

risk of suffering from maternal mental health conditions.

(c) Untreated maternal mental health conditions significantly and negatively impact the short- and long-term

health and wellbeing of affected women and their children.

(d) Untreated maternal mental health conditions cause adverse birth outcomes, impaired maternal-infant

bonding, poor infant growth, childhood emotional and behavioral problems, and significant medical and

economic costs, estimated to be $22,500 per mother.

(e) Lack of understanding and social stigma of mental health conditions prevent women and families from

understanding the signs, symptoms, and risks involved with maternal mental health conditions and

disproportionately affect women who lack access to social support networks.

(f) It is the intent of the Legislature to raise awareness of the risk factors, signs, symptoms, and treatment

options for maternal mental health conditions among pregnant women and their families, the general public,

primary health care providers, and health care providers who care for pregnant women, postpartum women,

and newborn infants.


Case Report #1Janice’s patient


Case Report #2History

First time mom

Hx GAD, Childhood ADHD

1 episode of Major Depressive Disorder 5-8 years ago, when

she was overworked

Presents PP, “I have run out of coping strategies” and feels

she needs help

Reports anxiety in keeping baby safe

Reports insomnia


Case #2Diagnosis

Major Depressive Disorder

For our hospital, diagnosis: Gaps in care revealed!


Structural Assets:

- Legal status

- Access to care

- Educated

Structural Vulnerabilities:

- Lack of support at home

- Hospital without immediate

in-house psych care

- Partial coverage for care in

psych at UCSF


Case #2Treatment

Kept in house at BCH, infant allowed to visit. If tx to other

campus, no visits from newborn

- Very few locked facilities that allow moms with babes

- Women with episodes, especially postpartum shown to have

potential stress and issues with bonding/relationship with

newborn

- Does separating women at this crucial bonding time benefit the

dyad? No right answer here, it’s done many different ways, but

often in separation of dyad for mom’s care


Case #2Treatment

Suicide leading cause of maternal death PP. Case reviews show between 50-80% of

cases had potential to prevent if treated patient differently

Titration of Lexapro upwards, need to go slowly,

Used Klonopin as temp plan while primary med had effect

- Pt concerned for dependency/addiction-reassured not an issue in short term use

- Klonopin and breastfeeding-pregnancy it’s contraindicated, but PP low dose

acceptable, can monitor infant for drowsiness and adequate weight gain. It has a

longer half life and aware of potentiation with CNS depression psych meds

(LactMED App)


Case #2Clinical Pearls from conversation with Dr. Robertson!

Watch for red flags! Some psychiatrists will w/d clients from SSRIs at 36 weeks to avoid issues

with infant PP. If this is your patient and they need meds they are at a higher risk for incident PP

and takes time to titrate the meds back! GAP in care and exposure to risk

Watch for insomnia, as many clients need respite care to help with the mood disorders. Does

your hospital provide respite at night?

Breastfeeding can happen with most meds, it’s a question of which one…NOT to Tx or not to Tx.

These clients need the pharmacologic assistance if that is what they have been using

Screening question for PP presentation: “Is this what you thought it would like?”

UCSF past OB psychiatrist, Dr. Anna Glezer’s website www.mindbodypregnancy.com

- “One study found that women who discontinue medications and are postpartum have three times the risk of relapse compared to

non-postpartum women.”

http://www.mindbodypregnancy.com


DepressionPerinatal period and up to one year postpartum

Up to 1 in 5, 20% incidence in perinatal period

Depression is the most common pregnancy complication

Postpartum is period of highest risk

Up to 50% of women are those in poverty

Vulnerable populations: teens, single moms, military women,

low income, socially isolated, recent immigrants, women with

high risk pregnancies, infertility, NICU moms


S/Sx:

- Big 3: depressed mood,

anhedonia and low energy (and

SI)

- hopelessness

- persistent sadness

- lack of pleasure or no joy

- change in appetite

- issues sleeping and/or extreme

fatigue not due to the changes of

new care of baby

- Recurrent thoughts of harm or

death

- Feeling agitated or possibly

slowed

Depression


Preterm birth

Low birth weight infants

Fetal growth restrictions

Substance use

Depression effects


DepressionTreatment

SSRI antidepressants

-Often recommended as a long-term anxiety solution

-Many medications originally approved for the treatment of depression are also

prescribed for anxiety. In comparison to benzodiazepines, the risk for dependency

and abuse is smaller. Medications are:

- Prozac (Fluoxetine)

- Zoloft (Sertraline)

- Paxil (paroxetine)

- Lexapro (Escitalopram)

- Celexa (Citalopram)

https://www.helpguide.org/articles/depression/antidepressant-medication.htm


Common side effects of

SSRIs include:

- Fatigue

- Nausea

- Agitation

- Drowsiness

- Weight gain

- Diarrhea

- Sexual dysfunction

- Nervousness

- Headaches

- Dry mouth

- Increased sweating

- Insomnia

Depression Treatment


SSRI’s and Breastfeeding

SSRI’s effect on pregnancy and breastfeeding

- Women already taking antidepressants should be encouraged to continue

treatment post-natally and for at least six months after resolution of the

depression depending on the number of previous episodes of depression, as the

risk of relapse is linked to stopping treatment.

- Overall, there is a lack of safety data (particularly long-term safety) on the use of

antidepressants in pregnancy

- The SSRI of choice for depression in women who are breastfeeding is sertraline

because of its relatively shorter half-life compared with fluoxetine or citalopram,

which have the potential to accumulate in the child


Perinatal Anxiety(OCD, PTSD, Panic Disorder, Generalized Anxiety Disorder

6-15% incidence in perinatal period

About 6% of pregnant women and 10% of postpartum women

develop an anxiety disorder which may be associated with

depression


S/Sx:

Excessive worry

Restlessness

Fatigue

Irritability

Insomnia

Fear of being alone with the baby

Reexperience of traumatic event

Feeling detatched

Anxiety in the Perinatal Period


Preterm Birth

Low birth weight infants

Fetal growth restriction

Prolonged labor

Fetal distress

Anxiety Effects


Anxiety Treatment

Treatment

- Benzodiazepines (also known as tranquilizers) are the most widely prescribed

type of medication for anxiety. Because they work quickly—typically bringing relief

within 30 minutes to an hour—they’re very effective when taken during a panic

attack or another overwhelming anxiety episode.

anax (alprazolam)

Klonopin (clonazepam)

Valium (diazepam)

Ativan (lorazepam)


Anxiety Treatment

Mode of Action

- Benzodiazepines work by slowing down the nervous system, helping you relax

both physically and mentally. But it can also lead to unwanted side effects

- The higher the dose, the more intense these side effects typically are. However,

some people feel sleepy, foggy, and uncoordinated even on low doses, which can

cause problems with work, school, or everyday activities such as driving. The

medication hangover can last into the next day.


Common side effects of

benzodiazepines include:

Drowsiness

Dizziness

Poor balance or coordination

Slurred speech

Trouble concentrating

Memory problems

Confusion

Stomach upset

Headache

Blurred vision

Anxiety Treatment


Anxiety Treatment

Safety concerns

- According to the FDA, benzodiazepines can worsen cases of pre-existing

depression, and more recent studies suggest that they may potentially lead to

treatment-resistant depression. Furthermore, benzodiazepines can cause

emotional blunting or numbness and increase suicidal thoughts and feelings.

- benzodiazepines lead to physical dependence and tolerance, with increasingly

larger doses needed to get the same anxiety relief as before. This happens

quickly—usually within a couple of months, but sometimes in as little as a few

weeks.


Anxiety Treatment

If you abruptly stop taking your medication, you may experience severe withdrawal

symptoms such as:

- Increased anxiety, restlessness, shaking

- Insomnia, confusion, stomach pain

- Depression, confusion, panic attacks

- Pounding heart, sweating, and in severe cases, seizure

Many people mistake withdrawal symptoms for a return of their original anxiety

condition, making them think they need to restart the medication. Gradually tapering

off the drug will help minimize the withdrawal reaction.


Anxiety TreatmentClinical Pearls

Don’t drink on benzodiazepines. When mixed with alcohol, benzodiazepines can

lead to fatal overdose.

Don’t mix with painkillers or sleeping pills. Taking benzodiazepines with

prescription pain or sleeping pills can also lead to fatal overdose.

Antihistamines amplify their effects. Antihistamines—found in many over-the-

counter sleep, cold, and allergy medicines—are sedating on their own. Be cautious

when mixing with benzodiazepines to avoid over-sedation.

Be cautious when combining with antidepressants. SSRIs such as Prozac and

Zoloft can heighten benzodiazepine toxicity. You may need to adjust your dose

accordingly.


Anxiety Treatment

SSRIs have been used to treat:

- SSRIs have been used to treat generalized anxiety disorder

(GAD)

- obsessive-compulsive disorder (OCD)

- panic disorder

- social anxiety disorder

- and post-traumatic stress disorder


Posttraumatic Stress Syndrome

PTSD 7.7% in socioeconomically disadvantaged patients

Approximately 18% of women experience a traumatic birth

and 5-9 % of these women will develop PTSD


Obsessive/Compulsive Disorder


Panic DisorderFaruk Uguz (2016) A pharmacological approach to panic disorder during pregnancy. The Journal of Maternal-Fetal & Neonatal Medicine, 29(9), 1468-1475

Characterized by repeated panic attacks

Women twice likely as me and mean age for presentation is

childbearing years

Prevalence during pregnancy 0.2-5.2% (same as general

population) but pregnancy may exacerbate up to 33%


Panic Disorder EffectsFaruk Uguz (2016) A pharmacological approach to panic disorder during pregnancy. The Journal of Maternal-Fetal & Neonatal Medicine, 29(9), 1468-1475

Preterm birth

SGA

Anemia

Polyhydramnios

More negative effects on birth weight then depression or GAD

Increase in congenital abnormalities and increase in cleft lip with or without cleft

palate


Bipolar

1-3% in general population, typical diagnosis 18-30 years

Sometimes misdiagnosed as depression, which delays

proper treatment, increases risks for poor outcomes

Highest risk for adverse outcomes, imperative these women

have collaborative plan in place for pregnancy, especially

going into the postpartum period


Periods of severely depressed mood and

irritability

Mood much better than normal

Rapid speech

Little need for sleep

Racing thoughts, trouble concentrating

Continuous high energy

Overconfidence

Delusions (often grandiose, but including

paranoid)

Impulsiveness, poor judgment,

distractibility

Grandiose thoughts, inflated sense of self-

importance

In the most severe cases, delusions and

hallucinations

Bipolar Type IS/Sx (https://www.postpartum.net/learn-more/bipolar-mood-disorders/)

https://www.postpartum.net/learn-more/bipolar-mood-disorders/


Periods of severe depression

Periods when mood much better than

normal

Rapid speech

Little need for sleep

Racing thoughts, trouble concentrating

Anxiety

Irritability

Continuous high energy

Overconfidence

Bipolar Type IIS/Sx (https://www.postpartum.net/learn-more/bipolar-mood-disorders/)



Bipolar Effects

Conflict of decision making/stigma of whether to continue with medications during

and/or after pregnancy

Increased rate of GHTN

Increased rates of hemorrhage

Increase in IOL

Increase rate of c/s

Increase in mood disorders post-natally

Increase severe SGA

Increase in risk of infants with congenital abnormalites if on mood stabilizers


Bipolar Treatment

Scrandis, D. (2017). Bipolar disorder in pregnancy: A review of pregnancy outcomes. J Midwifery Women’s Health, 62, 673-683.


Perinatal Psychosiswww.postpartum.net

1 in 1000-3000 incidence

Increased incidence have personal or family history of bipolar

disease or Hx of psychotic episode (260/1000, 570/1000 fam

hx with psychosis)

Sudden onset, usually first 2 weeks

5% rate of suicide, 4% rate of infanticide

Treat as an emergency

http://www.postpartum.net


S/Sx:

- Delusions

- Hallucinations

- Irritability

- Hyperactivity

- Decrease need for sleep or unable to

sleep

- Paranoia

- Rapid mood swings

- Difficulty communicating

Perinatal Psychosis


Increased rate of c/s

PROM

AP hemorrhage

Abruption

Preterm delivery

Stillbirth

Perinatal Psychosis Effects


Psychosis Treatment

Treatment

- Postpartum psychosis constitutes a medical emergency, generally requiring rapid

identification and intervention

- Postpartum psychosis is typically treated with a combination of antipsychotic

medication and a mood stabilizer

- Benzodiazepines and antidepressants are used to treat insomnia or depression

- Treatments for postpartum psychosis, a relatively rare syndrome, have not been

tested in randomized clinical trials

- Women with mild to moderate illness may be able to breastfeed.


Comorbidity with Substance Use Disorders

Psychiatric incidence 29.7/1000 deliveries

Substance Use 17.1/1000 deliveries

Gross underestimate of SUD r/t stigma of substance use

Some psychiatry providers require tx of substance use first,

prior to tx of psychiatric disorders- WHY not treat at the same

time! Common practice to treat at same time in UCSF


Council on Patient Safety in Women’s Healthcarewww.safehealthcareforeverywoman.org

Postpartum Care Basics for Maternal Safety: From Birth to the Comprehensive

Postpartum Visit

- Readiness for Every Clinical Setting: Develops protocols for screening and treatment for postpartum

concerns, including depression and substance abuse disorders, and establishes relationships with local

specialists for co-management or referral.

- Recognition and Prevention for Every Clinical Setting: Screens for and treats common morbidities,

including mental health issues, smoking, and substance use, as well as concerns such as unstable housing

and food insecurity.

Response for Every Clinical Setting:

- Implements treatment protocols and either provides desired care or facilitates timely referral to an appropriate resource. Whenever

feasible, a warm hand-off is provided, via a face-to-face introduction to the specialist to whom the patient is being referred.

- Maintains an up-to-date inventory of community resources to assist with unmet needs, such as 24-hour hotlines, food banks, diaper

banks, lactation support groups, and home visiting programs.

- Develops strategies to reach women who do not attend the comprehensive postpartum visit.

http://www.safehealthcareforeverywoman.org


Maternal Mental Health Bundlehttps://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Maternal-Mental-Health-Bundle.pdf

https://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Maternal-Mental-Health-Bundle.pdf


American Academy of Pediatrics recommends screening (2010)

American College of Obstetrics and Gynecology (ACOG) recommends screening

(2015)

The USPSTF recommends screening adults for depression and specifically calls out

the importance of screening pregnant and postpartum women (2016)

- -Draft recommendation related to screening to determine who is at risk to refer counseling.

(Pending, 2018)

CMS recommends states reimburse pediatricians for Medicaid screening by

pediatricians and notes coverage for mother-baby treatment (2016)

AMA recommends screening (2017)

Screening RecommendationsJ. Burkhard. “Maternal mental health”. AWHONN 2019


• No standard of care, other

then should be screened

• First visit and every

trimester

• PP visit

• Well child visit throughout

first year

When should we be screening?


• The greater the score, the increase

potential for depression

• Highly studied for use in population,

Cox et al states >12 for screening,

others lower threshold to capture

more potential

• If pt score >0 on #10, need

immediate intervention

Screening ToolsCox, J.L. Holden J.M. and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburg Postnatal Depression Scale. British Journal of Psychiatry 150:782-786.


• “our study demonstrated that the PRIME-MD

PHQ is a useful instrument for assessment of

mental disorders, functional impairment, and

recent psychosocial stressors in the busy

obstetrics-gynecology setting”

• 8 diagnoses- “major depressive disorder, panic

disorder, other anxiety disorder, and bulimia

nervosa) and subthreshold disorders (disorders

for which criteria encompass fewer symptoms

than are required for any specific diagnoses in

Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition, specifically other

depressive disorder, probable alcohol abuse or

dependence, and somatoform and binge eating

disorders).

Screening ToolsSpitzer, R.L., et al. (2000). Volume 183, Issue 3, pags 759-769. “Validity and utility of the PRIME-MD Patient Health Questionnaire in assessment of 3000 obstetric-gynecologic patients: The PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study”.


UCSF New Screening in the worksPHQ-9 (www.uspreventiveservicestaskforce.org/Home/GetFileByID/218)

http://www.uspreventiveservicestaskforce.org/Home/GetFileByID/218


UCSF New Screening in the worksGAD-7 (http://www.tbh.org/sites/default/files/Generalized_Anxiety_Disorder_Screener_GAD7.pdf)

http://www.tbh.org/sites/default/files/Generalized_Anxiety_Disorder_Screener_GAD7.pdf


Mental Health Resources for Providers and Patientshttps://safehealthcareforeverywoman.org/wp-content/uploads/2016/09/Other-Maternal-Mental-Health-Resources-2-10-16.pdf

https://safehealthcareforeverywoman.org/wp-content/uploads/2016/09/Other-Maternal-Mental-Health-Resources-2-10-16.pdf


Inpatient Care of Women with Mood Dx


Tx of care to UC for fetal treatment

Hx:

- active violence in home with current partner, hx violence with past partner

- recent immigrant, limited family support, 11yo daughter from prior relationship staying with her

in house

- Hx suicide attempt in the year prior to pregnancy

Case Report #3M.S. 34yo G3P0111 32+0, monolingual Spanish speaker


Bright, always cheerful when you entered room

Great hygiene, showered daily

Participated in care and eager to listen to monitoring of FHR

Daughter at BS helping mom with everything, “nurse-like” at age 11

Assumed care of patient, used translator phone and asked for daughter to leave during

assessment, pt hesitant, but arranged for our resource RN to hang out with daughter and take a

walk on unit. Asked patient about hospital stay, needs being met, how her daughter was coping.

At the end of our sit down talk with translator, asked about feelings about harming herself. +SI,

+forming plan

Case #3 Assessment


Structural Assets:

- Enganged in care

- Great mother

- Honest about her diagnosis and

history

Structural Vulnerabilities:

- New immigrant

- Limited support system

- Monolingual

- Hx violence

- Financial security

Case #3


Case #3

Intervention:

- Remained with patient 1:1

- Notified charge RN and resident/attending who notified nursing supervisor and we

got a sitter ordered asap, our PCA filled in until next shift

- Room turned into “safe room”

- Psychiatry notified and to patient that day, in house, medication started

- Got an in person hospital interpreter to the BS


If patient is screened to be at risk for suicide/self-harm:

- Notify provider

- Notify charge RN

- Initiate 1:1 observation using safety attendant or unit staff

- Develop safety plan of care with provide and charge RN (see safety huddle)

- Initiate risk mitigation interventions, as appropriate (see risk mitigation

interventions)

- Initiate Suicide/Self-Harm nursing care plan

UCSF Patient at Risk for Suicide of Self-harm


SAFETY HUDDLE

1. A safety huddle is a meeting of multidisciplinary clinicians and support staff for developing a plan of care for the

patient who is at risk for injury to self or others. It can be used for patients displaying behaviors posing safety concerns

or behavioral challenges (e.g., patient who is at risk for self-harm, suicide, elopement, or potential for injury to others).

• Responsibilities of the safety huddle group are to develop short-term plans for care and contingencies, ensure

appropriate orders are written and implemented, and achieve consensus and understanding of care priorities.

• The makeup of a safety huddle group will depend on the specifics of the patient’s situation and location. Members

include the primary RN, charge RN, and a primary care provider. Other members, such as the Risk Manager, Social

Worker, or Security officer, may be needed participants.

2. A safety huddle can be initiated by any member of the care team but is usually initiated by an RN. The huddle time is

coordinated between clinicians.

3. Huddle discussion details and outputs may include:

a. Current safety risks

• Hold status

• Harm to self or others

b. History of behavioral or safety concerns

c. Priorities of care and patient care needs

d. Appropriate risk mitigation strategies and plan for maintaining safety.

4. The safety plan is communicated through the APEX care plan, provider orders, and an FYI alert. In addition to the

elements in the safety checklists (Appendix A) the plan may include:

a. Known triggers for escalation

b. De-escalation interventions

c. Provisions for safety during transport to, from, and during off-unit procedures/activities or transfers.


CONVERTING AN INPATIENT ROOM FOR SAFETY1. Converting a room for safety may be done in conjunction with other interventions to prevent self-harm or harm to others. Room conversion is

not a stand-alone safety measure.

• Other preventive interventions used prior to conversion of a room for safety or after room conversion may include: assigning a safety attendant,

removing patient belongings that may be used to cause self-harm, providing meal trays with disposable items, conducting periodic safety room

checks, and placing the patient in hospital clothing.

2. The decision to convert a room for increased safety entails:

a. Considering the risks versus benefits of removing routine equipment and supplies used for patient care.

b. Collaborative input from RNs, the primary provider, and as needed, staff from supporting services/ departments (e.g., Psychiatry, Social Work,

Security).

3. Conversion of a room for safety and back to a regular room is accomplished by coordinating resources from Nursing,

Clinical Technologies (Engineering), Information Technologies, Facilities Maintenance, and Hospitality.

4. Locate the patient in a room that maximizes safety such as near a nursing station when appropriate.

5. Remove items that may be used by the patient to inflict self-harm or harm to others (See Appendix B and Appendix C). Additional items to

remove (or reconfigure) include:

a. Alcohol based hand rub container from within its dispenser.

b. Computer and tablet arm

i. Call IT 415-514-4100. Do not enter an IT ticket. (IT will initiate a work order to Facilities Maintenance for assistance in removing large monitors

from the wall.)

ii. Indicate STAT need for Safe Room.

c. Physiologic monitor, lift equipment, ophthalmoscope/otoscope

i. Call Clinical T echnologies (Engineering) 415-514-3570

ii. Place service request ticket and mark “STAT” (Priority 1). iii. State need to remove specific equipment for Safe Room.

d. Pillow speaker cord (shorten and zip tie to bed frame)

i. Call and submit a Medical Center Support Services (MCSS) ticket requesting Facilities Maintenance support for the safe room.

6. Review how to open a patient room bathroom door if lockable.

7. When patient is no longer a risk of harm to self, or is discharged, call the same numbers to have the room converted back to a regular room.

Presentation Title69

What To Do When You Don’t Know What To Do

A practical guide to managing the complex patient

The medically and socially complex patient that presents to

labor and delivery

- Patients that have substance abuse issues

- Patients that have diagnosed and undiagnosed psychological

problems

- Patients that have homelessness


Definition

- Over the last decade, the concept of the “complex patient” has not only

been more widely used in multidisciplinary healthcare teams and across

various healthcare disciplines, but it has also become more empty in

meaning

- The concept of the “complex patient” spans across disciplines, such as

medicine, nursing, and social work, with no consistent definition

- surrogate terms, namely “comorbidity,” “multimorbidity,” “polypathology,”

“dual diagnosis,” and “multiple chronic conditions

- This has implications on how we practice, theory and how we research

What To Do When You Don’t Know What To Do

A practical guide to managing the complex patient


What do health providers mean when they talk about a complex patient?

What makes this patient complex?

When does this “label” apply and in what context?

Concept clarification is important because healthcare providers need to

understand each other when they work with so‐called complex patients

This concept can act as a needed bridge to assist clear communication in

multidisciplinary care

Does this mean a patient that abuses drugs, has mental health issues, or

several social issues i.e homeless, domestic violence


Patients who have complex health needs require both medical

and social services and support from a wide variety of providers

and caregivers, and the patient-centered medical home (PCMH)

offers a promising model for providing comprehensive,

coordinated care.


Nurses are positioned to contribute to and lead the transformative changes

that are occurring in healthcare by being a fully contributing member of the

interprofessional team as we shift from episodic, provider-based, fee-for-

service care to team-based, patient-centered care across the continuum

that provides seamless, affordable, and quality care

These shifts require a new or an enhanced set of knowledge, skills, and

attitudes around wellness and population care with a renewed focus on

patient-centered care, care coordination, data analytics, and quality

improvement.


Practical Guide to Patient ManagementDe-escalation of the patient with a psyche or violent history credit to Dr. James Hardy

Recognition of agitation- look for warning signs

- Is the patient angry?

- Ae they pacing?

- Do they have a clenched fist?

- Are they talking loud, louder than others in that environment?

- Is there a history of violence?

- Are other staff members telling you that the patient is agitated?


Caring for patient who is psychotic or under the influence of drugs

- Keep 2 arm lengths distance if they are agitated

- Wake patients carefully- never go to the head of the bed many of these

patients live in dangerous situations and wake up protecting themselves,

shake their feet

- Do not get trapped in the room with the patient

- Do not block the doorway

- Don’t try to stop a patient if they run


Verbal de-escalation

- Body language – knees bent hands at your side or namestate stance

- Tone of voice- try not to be condensending,

- Stay calm.

- Manage your own response.

- Set limits.

- Handle challenging questions.

- Prevent a physical confrontation.


Verbal de-escalation

- One person talks

- Introduce yourself

- Ask questions

- Listen and reflect back

- Keep it simple

- Don’t argue

- Offerf choices


California Senate Bill 1152

Background and Purpose

• In order to standardize the level of discharge planning service hospitals provide, California Legislature passed, and the Governor signed SB 1152.

• The law took effect, January 1, 2019

• Purpose is to help prepare the homeless patient for return to the community by connecting him or her with available community resources, treatment, shelter and other supportive services

• The law does not require hospitals to find or create service that do not exist in the community.

• Documented compliance with elements of this legislation are required by 1/1/2019.

California Senate Bill 1152

Services that Must be Offered to Homeless Patients Before Discharge

• Physician Examination and determination of stability for discharge

• Referral for follow up care

• Referral for behavioral health care if it’s determined that the patient requires behavioral health care

• Food

• Weather appropriate clothing

• Discharge medications (prescriptions)

• Infectious disease screening

• Vaccinations appropriate to the presenting medical condition

• Transportation within 30 minutes or 30 miles of the hospital

• Screening for and assistance to enroll in affordable health insurance coverage


UCSFBEHAVIORAL HEALTH COLLABORATIVE

Formed in the fall of 2018 in response to approximately 5-6 patients with

complex medical and social histories

These patients were seen in triage several times a week or month

Some seen with substance abuse, homelessness, violence on the street or

psyche issues

Triage staff very frustrated with the behavior of the patients

Residents and attendings upset with no formalized plan of care for patient’s

being discharged at night


Pharmacologic (preference to history of use)

Psychotherapy (CBT treatment most affective and/or

interpersonal therapy, preference to history of use)

Community Referrals

Case management

Supplemental- Rest, exercise, change in diet, assistance with

childcare

Outpatient Care of Women with Mood DxInterventions


Impact Model of CareUnützer J, Katon W, Callahan CM, et al. Collaborative Care Management of Late-Life Depression in the Primary Care Setting: A

Randomized Controlled Trial. JAMA. 2002;288(22):2836–2845. doi:10.1001/jama.288.22.2836

RCT that demonstrated collaborative care doubled the effectiveness of

treatment in primary care of older adults with depression

- 45% of intervention group had at least 50% reduction in depressive sx compared

to 19% in typical group

- greater rates of depression treatment, more satisfaction with depression care,

lower depression severity, less functional impairment, and greater quality of life

- Synonymous with collaborative care


Integration Projects

Screen all women

Partner with disciplines

Assessment of all positive screens

Risk stratification based on assessment

Interventions: education, case mgmt, OT, psychotherapy,

med consultation


Team Lily as one intervention

for our moms

LILY


• Takes a village and many resources-

BE CREATIVE

• Know where to find policies as any

other emergency

• Be alert PP for presentations

• Document and think of a care map,

especially for screening that’s

interdisciplinary

• Begin to learn community resources

and start to make those connections

“Release the creativity of

our communities”

-Dr. Monica McLemore

Clinical Pearls

“


“We have to bare witness…hold them up…sit with

them…bare witness to them…to bring them into the

light…”

Kimberlé Crenshaw“The urgency of intersectionality” TED Women 2016


References

Spitzer, R.L., Williams, J.B.W, Kroenke, K., Hornyak, R., McMurray, J. (2000). Validity and utility of the PRIME-MD Patient Health Questionnaire in

assessment of 3000 obstetric-gynecologic patients: The PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study. American Journal

of Obstetrics and Gynecology, 183(3): 759-769.

Metzl, J.M., Hansen, H. (2014)Structural Competency: Theorizing a new medical engagement with stigma and inequality. Social Science Medicine,

103; 126-133.

http://www.traumainformedcareproject.org/

https://www.2020mom.org

Committee on Obstetric Practice. (2017)ACOG committee Opinion no. 757: Screening for perinatal depression. Obstet Gynecol, 132(5): e208-e212.

Unützer, J., et al. (2002). Collborative care management of late-life depression in the primary care setting- A randomized controlled trial. Jama,

288(22): 2836-2845.

Stewart, D.E., Robertson, E., Dennis, C-L., Grace, S.L., & Wallington, T. (2003). Postpartum depression: Literature review of risk factors and

interventions. Electronic Document. https://www.who.int/mental_health/prevention/suicide/lit_review_postpartum_depression.pdf?ua=1

Julian, Z. (February, 2019). Psychiatric care of OB patients @ZSFG. UCSF Grand round presentation, San Francisco, CA.

http://www.traumainformedcareproject.org/

https://www.2020mom.org

https://www.who.int/mental_health/prevention/suicide/lit_review_postpartum_depression.pdf?ua=1


References

Council on patient safety in women’s health care. Maternal mental health: Depression and anxiety. Electronic document. 2016, February.

https://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Maternal-Mental-Health-Bundle.pdf.

Council on patient safety in women’s health care. Postpartum care basics for maternal safety from birth to the comprehensive postpartum visit

(+AIM). 2017, March. Electronic document. https://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Postpartum-Care-Basics-

Bundle.pdf.

Metzl, J, and Roberts, D.E.(2014). Structural competency meets structural racism: Race, politics, and the structure of medical knowledge. AMA

Journal of Ethics, 16(9):674-690.

Jones, I. & Craddock, N. (2001). Familiality of the puerperal trigger in bipolar disorder: results of a family study. Am J Psychiatry, 158, 913-917.

Kelly, E. and Sharma, V. (2010). Diagnosis and treatment of postpartum bipolar depression. Expert Review of Neurotherapeutics,10(7), 1045-1051.

Meltzer-Brody, S. and Jones, I. (2015). Optimizing the treatment of mood disorders in the perinatal period. Dialogues Clin Neurosci, 17(2), 207-218.

Scrandis, D. (2017). Bipolar disorder in pregnancy: A review of pregnancy outcomes. J Midwifery Women’s Health, 62, 673-683.


Rusner, M., Berg, M., and Begley, C. (2016). Bipolardisorder in pregnancy and childbirth: a systemative review of outcomes. BMC Pregnancy and

Childbirth, 16(1), 331.

https://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Maternal-Mental-Health-Bundle.pdf

https://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Postpartum-Care-Basics-Bundle.pdf



References

Maina, G. et. al. (2014). Recurrence rates of bipolar disorder during the postpartum period: a study on 276 medication-

free Italian women. Archives Womens Mental Health, 17, 367-372.

www.mindbodypregnancy.com

Faruk Uguz (2016). A pharmacological approach to panic disorder during pregnancy. The Journal of Maternal-Fetal &

Neonatal Medicine, 29(9), 1468-1475

Uguz, F., Et al. (2019). Prevalence of mood and anxiety disorders during pregnancy: A case –control study with a large

sample size. Psychiatry Research, 272, 316-8.

http://www.mindbodypregnancy.com

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