Opportunities to break barriers & build bridges postpartum depression needs assessment 2014

Opportunities to Break Barriers & Build Bridges: Results of the 2014 Postpartum Depression Needs Assessment Houston, Texas

A publication by

October 2014 Bethanie Van Horne, DrPH Nancy Correa, MPH Saralyn McIver, PhD Hannah Vardy

Opportunities to Break Barriers & Build Bridges

This assessment was made possible through the generous support of the Ed Rachal Foundation.

The Ed Rachal Foundation is committed to providing funds for the exclusive benefit of charitable, scientific, literary or educational purposes within the State of Texas.

On behalf of the Houston community and CHILDREN AT RISK, a heartfelt thank you to the Ed Rachal Foundation for its continued support and efforts to improve the lives of families in Houston and across Texas.

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Opportunities to Break Barriers & Build Bridges

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Table of Contents Executive Summary

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Introduction

7

Background

7

Methods

8

Literature Review

12

Definition of Postpartum Depression

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The Spectrum of Postpartum Mood and Anxiety Disorders

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Prevalence

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Risk Factors

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Consequences

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Prevention

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Screening

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Treatment

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Results

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What is the Need in Houston?

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What are the Barriers to Addressing the Need?

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Are Local Services for PPD Available and Accessible?

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Pathways to Success: Innovation within the Houston Community

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Recommendations

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References

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Appendix A: Separate Focus Group and Interview Analyses

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Appendix B: Map and List of Organizations and Providers of PPD Services

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Executive Summary Postpartum depression (PPD) is a form of depression that occurs in women during pregnancy and up to a year after birth. It is estimated that 10-25% of mothers suffer from PPD. If left untreated, PPD can have a lasting negative impact on not only the mothers themselves, but also their children, families, and the community. PPD is treatable, but too often goes undetected and untreated. Given the negative impact PPD has on children and families, the Center for Parenting and Family Well-Being (CPFWB) at CHILDREN AT RISK conducted a year-long assessment on the state of PPD in the greater Houston area in order to develop recommendations on how to better support mothers and families in our community. The assessment incorporated input from more than 40 organizations; a review of the literature on the prevention, screening, and treatment of PPD; an assessment of local practices; and analysis and synthesis of local data related to PPD. Scope of the Problem Mental disorders are the second leading cause of hospitalization of women of childbearing age (15-44 years) in Harris County and across Texas. In 2012 alone, nearly 100,000 Texas women were hospitalized with a mental disorder, with mood disorders accounting for nearly 60% of the diagnoses. Based on conservative prevalence rates, we estimate that 69-79,000 Texas women experience PPD each year, with 12-15,000 of those living in Harris County.

Current Landscape PPD is treatable, and there are a variety of well-established effective treatment options for PPD including social support programs, behavioral therapies, counseling, and medications. However, in order for a woman to receive appropriate care, she must: be identified as having PPD, seek treatment, and find a practitioner that she can afford, has access to, and who is available to provide treatment.

Inconsistent Screening: Several short screening tools are available for health providers to screen mothers for PPD. Many experts agree that obstetricians and pediatricians are ideal candidates to conduct the screenings, given the frequency of contact during pregnancy and the first year of life of the infant. Both our assessment and local survey data from 2010 and 2012 of obstetricians and pediatricians revealed that screening practices vary across and within organizations, and many practitioners are not using validated screening tools.

Inadequate Health Coverage: In 2011, 291,839 pregnant Texas women were covered under Medicaid, and in Houston, nearly half of all women hospitalized with a perinatal mental disorder diagnosis were covered by Medicaid. Because Medicaid coverage ends 60 days after delivery for the vast majority of these women, there is an inadequate amount of time to identify and treat PPD. Consequently, many mothers in Houston and across Texas who are suffering from PPD lack the necessary health coverage for treatment.

Lack of Knowledge and Availability of PPD treatment Services: Currently in Houston there is a shortage of mental health workers, and not enough providers are available to meet the mental

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Opportunities to Break Barriers & Build Bridges health needs of the community. During this assessment, we were able to more than 20 organizations and private providers offering PPD treatment services at 50 locations across the city. However, many of these organizations have eligibility restrictions and limited capacity.

Despite the availability of a PPD specific resource guide distributed regularly by Mental Health America of Greater Houston, knowledge of available services by providers, family members and the community was found to be a major barrier to care.

Action Steps to Increase and Improve Support for Women and Families Impacted by PPD Through the input of more than 40 organizations, the CPFWB has developed the following six recommendations to better support women and families impacted by PPD. 1. Increase awareness and decrease the stigma associated with PPD and maternal mental health.

The assessment revealed that stigma and lack of knowledge prevent many women from seeking help when they are experiencing depressive symptoms. Many providers reported that moms feel embarrassed and ashamed that they are experiencing depressive symptoms during a time that is generally perceived as a joyful time in a mother’s life. As a result, more awareness is needed to inform the public on signs and symptoms of PPD, where to get help, and to inform families that PPD is common and treatable. Awareness campaigns should not only target new mothers but also fathers, friends, and extended family members who play a huge role in providing social support to the new mom and undoubtedly influence whether or not the mother seeks treatment.

To increase awareness of PPD, during the 84th Legislative Session, CHILDREN AT RISK is advocating for the establishment of a Postpartum Depression Awareness Month. CHILDREN AT RISK will also utilize its extensive partnerships with TV, radio, and print media to educate Houstonians on PPD and maternal mental health.

2. Increase educational opportunities for medical providers that interact with women, children, and families.

The assessment discovered a lack of consistency in the education that healthcare providers receive in regards to PPD. Key stakeholder interviews revealed that while some medical professionals receive adequate training and information on PPD while in school, others were not exposed to any information on PPD during their formal training. Education of medical professionals is needed to ensure that providers are aware of the signs and symptoms of PPD, how to screen patients for PPD, and where to refer patients that screen positive. Education is needed for all types of medical providers who interact with women, children, and families including obstetricians, pediatricians, family medicine doctors, nurses, social workers, and community health workers.

To increase educational opportunities for medical providers, CHILDREN AT RISK supports the inclusion of PPD education in the curricula and licensing exams for medical professionals. If the licensing boards include PPD in their exams, medical schools would be more likely to cover this material in their courses. CHILDREN AT RISK is also supportive of Mental Health America of

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Opportunities to Break Barriers & Build Bridges Greater Houston’s (MHA) extensive efforts to educate professionals in the greater Houston area on PPD. MHA has trained over 6,000 professionals on PPD through a 90 minute training which includes information on signs and symptoms, screening protocols, treatment options, and where to refer patients.

3. Increase PPD screening and identification.

The assessment revealed that lack of screening was a major barrier to women receiving appropriate treatment for PPD. Many providers did not screen patients due to lack of time, lack of resources, and lack of information on where to refer a patient who screened positive.

Furthermore, many providers who do screen do so through informal interviews and do not use validated survey instruments.

Because there are local services available in the Houston community and Mental Health America of Greater Houston is committed to providing resource guides highlighting these local services, CHILDREN AT RISK recommends screening mothers at both the obstetrician’s office during preand postnatal visits and the pediatrician’s office during well-child check-ups with the use of a validated screening tool. CHILDREN AT RISK also supports the screening of PPD through organizations such as WIC that have regular interactions with pregnant women and mothers of children under the age of one.

4. Increase the number of mental health service providers.

Although we were able to find providers in the Houston community able to support women and families impacted by PPD, there is an overall shortage of mental health providers in our community and across Texas. To increase the amount of mental health service providers, reimbursement rates for services need to be raised and the types of billable services need to be expanded so as not to prohibit providers from delivering services in ways that will increase participation and acceptability among families. Mental health providers are one of the lowest paid professions when compared to others in the health field. In order to increase the number of providers willing to train and continue to work in the mental health field, CHILDREN AT RISK recommends increasing the reimbursement rates and billable services for all professionals providing mental health services as well as the overall compensation for mental health providers specifically. In addition, we support loan forgiveness programs for mental health providers, including: social workers, counselors and therapists, psychologists, and psychiatrists.

5. Address barriers that prevent mothers/families from accessing PPD services.

The assessment revealed that too often once a mother is screened positive for PPD, she does not seek treatment due to a range of factors including difficulty in scheduling an appointment, transportation issues, language barriers, and lack of health coverage. CHILDREN AT RISK supports innovative models that address these barriers and help mothers access to services, including local programs such as Legacy Community Health Center and Texas Children’s Hospital’s Center for Children and Women that offer integrated health services. Other innovative models include telehealth, in which patients receive services over the phone or computer, and home visitation programs that include PPD screening and treatment.

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Opportunities to Break Barriers & Build Bridges 6. Ensure women have access to health coverage to adequately cover PPD treatment.

While the United States has made great strides in the past decade to include behavioral health in health coverage, there are still many mothers with PPD who lack the necessary health coverage for treatment. Specifically, Medicaid currently covers over 35,000 births in Harris County each year, yet these mothers lose coverage 60 days after delivery. Because the onset of PPD can occur anytime in the first year and wait times to be seen by a mental health provider can take up to four months in Texas, many mothers are left without the necessary health coverage to treat PPD. To eliminate this health coverage gap, CHILDREN AT RISK is advocating to change Medicaid coverage eligibility, and allow mothers to have access to full coverage for one year after delivery. CHILDREN AT RISK is currently exploring different avenues to extend coverage including: a Medicaid 1115 waiver, legislation in the 84th Legislative Session, a state amendment plan, and a pilot project through a Medicaid provider.

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Introduction Postpartum depression (PPD) impacts approximately 69-79,000 women and families each year in the state of Texas and is more common than breast cancer, gestational diabetes, and low birth weight. In addition to negatively impacting the health and well-being of the mother, when left untreated it can have a detrimental impact on the health and well-being of children living with affected parents, ranging from short-term developmental delays to lifelong mental illness.

As a result, the Center for Parenting and Family Well-Being conducted a needs assessment to better understand the state of PPD in the Houston community and to make recommendations on how to better address the issue in order to support mothers, families, and children in our community.

Background In 2011, CHILDREN AT RISK opened the Center for Parenting and Family Well-being (CPFWB) to specifically focus on supporting parents and finding ways to increase the well-being of families, and consequently children, in Texas. Through the use of research, community engagement, collaboration, and advocacy, the CPFWB is systematically addressing risk and protective factors impacting families to prevent childhood adversities. The CPFWB is working both at the state and local levels to build momentum and ensure all families are able to receive the help they need, at the level they need it.

Because children do not come with an instruction manual and every parent needs the skills to effectively raise their child(ren), the first issue the CPFWB tackled was parent education.

Through a needs assessment in 2012 and subsequent pilot program providing evidenced-based parent education training to community agencies in Houston (2013-2014), it became apparent that even with strong parenting skills and confidence, there were other reasons parents had difficulty using their skills and families continued to struggle. Parental mental illness, in particular PPD, was highlighted by both direct service providers and the local community assessments as an issue needing attention in the Houston area.

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Opportunities to Break Barriers & Build Bridges In late 2013, the CPFWB was funded by the Ed Rachal Foundation to conduct a needs assessment around postpartum depression in the Houston area. The purpose of this assessment was to determine the needs of Houston families impacted by postpartum depression, identify the barriers that exist in meeting those needs, and develop recommendations to better support mothers and families in our community. The following assessment incorporated input from more than 40 organizations; a review of the literature on the prevention, screening, and treatment of PPD; an assessment of current local practices; and analysis and synthesis of local data related to PPD. Note: There are multiple terms used to describe depression that occurs during pregnancy and through the first year after childbirth including: pregnancy-related, maternal, postpartum, perinatal, and peripartum depression. For the purposes of this report and in keeping with others in the field 1 we will refer to depression occurring during pregnancy and up to 1 year post childbirth as postpartum depression (PPD).

Methods Primary and secondary data were used to estimate the prevalence of PPD in the Houston community, identify barriers, and develop recommendations of actions needed to overcome the barriers and meet the needs of the community. Primary data sources included focus groups, interviews with key stakeholders, and secret shopper calls to organizations identified as providing treatment for PPD. Secondary data were used to describe inpatient hospitalizations with mental disorders and perinatal mental disorders in women of child bearing age.

Primary Data Interviews and Focus Groups: Qualitative data were collected through two methods, focus groups and interviews. The focus groups used a Participatory Learning and Action (PLA) rapid assessment research approach. All 54 community participants were randomly assigned to one of four groups during registration, which resulted in groups comprised of 13 to 15 participants.

Participants were representative of 24 community organizations where 74% routinely interact with pregnant and/or postpartum women. Of all participants, 70% held a master’s degree or higher. The aims of the focus groups were: 1. To describe the challenges and barriers women in need of postpartum mental health care, specifically for PPD, experience in Houston, Texas.

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Opportunities to Break Barriers & Build Bridges 2. To describe the underlying root causes of identified challenges and prioritize which challenges and root causes should be addressed first.

3. To describe the actions needed to be taken in order to address the underlying causes.

These aims were completed through participation in five activities. The activities were: Activity 1: As a large group, all participants were asked to brainstorm the needs of a woman and her family if she was experiencing PPD. The group was presented with a list of the signs and symptoms of PPD. This activity was included to ensure all participants began with the same information and that all aspects of the illness were considered.

Activity 2: Participants were separated into the four randomly assigned groups. The groups were asked to list all of the challenges and barriers women and families face when trying to address the needs listed during the first activity. Participants listed each challenge on a piece of paper with an individual group facilitator reading each challenge aloud to the group. The participants then grouped the challenges into categories and named each category. All categories were given to the main facilitator and read aloud for all groups to hear and use during the following activity.

Activity 3: The groups were asked to prioritize the challenge categories presented by all groups. Each participant was given ten dots to place on the category(ies) they felt should be prioritized. The participants could place all ten dots on a single category or disperse them among several categories. The votes were then tallied.

Activity 4: The groups were then asked to brainstorm the root causes for their top three to five challenge categories. Participants were asked to consider root causes based on knowledge/skills, attitudes, home environment, and external environment.

Activity 5: Lastly, the groups were asked to list potential solutions to resolve the root causes that were identified. The groups listed solutions based on a variety of settings, including homes, communities, medical/clinical settings, and other settings. Each group reported their results to all participants.

The PLA method incorporates within group analysis; subsequent analysis was completed to examine the variance between or across the four groups. The categories developed in the second activity and prioritized in activity three were later organized into broader, more inclusive categories to assist in identifying patterns and relationships between focus groups. The

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Opportunities to Break Barriers & Build Bridges proposed measures to overcome the root causes of the barriers discussed in the final group activity were also integrated across all groups by setting and into categories for action.

Interviews were the second method of qualitative data collection. The majority of the semistructured interviews were conducted face-to-face, however a few were completed over the telephone. Interviews were conducted between November 2013 and September 2014. In total 22 interviews were conducted with a primary focus on professionals working with pregnant and/or postpartum women in varied settings (e.g. psychiatry, obstetrics, pediatrics, WIC staff, integrated health clinics and hospitals). Several researchers were also interviewed. Questions for direct service providers focused on the services offered, screening for PPD, how positive screens were handled, and the challenges and barriers to servicing this population. Interviews with participants that were involved in research focused on their findings, as well as their view on screening and treatment barriers. The resulting interview notes were analyzed line-by-line.

In the first round of analysis, the interviews were coded with pre-set categories. The preset categories were the top four challenges determined by the focus groups (education, stigma, access to care, money/insurance). In the second round of analysis, open coding was used for emergent category formation. The codes were then sorted into categories.

The findings of the qualitative analysis were then integrated to provide a picture of the current barriers affecting women at risk for or currently suffering from PPD and their families and are included in this report. Separate analysis of the focus groups and interviews are presented in Appendix A. Secret shopper phone calls: In order to determine what women and families experienced when trying to find services for PPD in Houston, “secret shopper� calls were made to agencies around Houston. The caller posed as a concerned friend of a new mother who was suspected of having postpartum depression. The caller asked the agencies if they provided services for PPD, what insurance or payment types they accepted (the caller did not know if her friend had insurance), and how long her friend would have to wait to be seen (time to appointment). In many instances, wait times could not be established because eligibility needed to be established before an appointment could be scheduled.

The list of organizations to be contacted was compiled from information gathered during interviews and outreach meetings as well as local general depression and postpartum depression brochures. A total of 46 organizations were included on the list. Callers made an

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Opportunities to Break Barriers & Build Bridges effort to call organizations three times during normal business hours (9am to 5pm, Monday to Friday). If there was no response after three attempts, they were categorized as “could not be reached”. An organization was determined to offer PPD services if they offered support or treatment services (psychiatry, therapy, counseling, support groups, etc.) for those with general depression, including those with PPD. Secondary Data Secondary Data Sources and Analysis: The Texas Inpatient Public Use Data Files from 2008-2012 were used to identify the number and frequency of inpatient hospitalizations that included a discharge diagnosis of a mental health disorder and specifically, a perinatal mental health disorder. This dataset contains discharge data on inpatient hospitalizations from Texas hospitals and is housed at the Texas Department of State Health Services (DSHS). Data used in this report were limited by age, patient state of residence, and HIV/substance use discharge status. Only women ages 15-44 years of age at the time of discharge were included. Age for those with a HIV/substance use discharge status cannot be determined due to restrictions and therefore were excluded in these analyses. Data were analyzed for all women residing in Texas and those residing in Harris County at the time of discharge. A total of 3,016,683 hospitalizations over the 5-year period were included. The coding for the presence of mental health illness in discharge data (as indicated by the presence of specific ICD-9 codes, 291-319 in any of the 25 diagnosis code fields) was developed by researchers at the University of Texas Health Science Center at Houston. The presence of perinatal mental health illness was identified by specific ICD-9 codes 648.40-648.44 (“Mental health disorder of mother”). It should be noted that the unit of analysis for these data is inpatient hospitalization (not person) as the public use files do not include a unique patient identifier that would allow us to analyze the data using individual women as the unit. Although the data are considered public, the files used for this report came through a data agreement between DSHS and the University of Texas School of Public Health.

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Literature Review In the wake of the 2001 deaths of the 5 Yates children at the hands of their mother who was suffering from postpartum psychosis, there has been a flurry of research and awareness efforts across the US on postpartum mental health, particularly postpartum depression. The following section will summarize what is currently known around the prevalence, risk factors, and consequences of PPD as well as best practices for PPD prevention, identification, and treatment.

Definition of Postpartum Depression There has been much debate over the definition and temporal boundaries of PPD as defined by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM-5 does not have a specific category for PPD but instead define PPD as a nonpsychotic, major depressive disorder with an onset of symptoms during pregnancy or within 4 weeks of the birth of a child. However, in practice and in the literature, experts define PPD as major or minor depressive disorder with an episode occurring during pregnancy or within 12 months after the birth of a child.1-3 To meet the criteria for a major depressive episode, one must have five or more of the following symptoms for the same 2-week period, for minor depression, two to four symptoms must be present: 

Depressed mood

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Diminished interest or pleasure in all or almost all activities

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Significant weight loss when not dieting, weight gain, or decrease or increase in appetite

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Insomnia or hypersomnia

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Psychomotor agitation or retardation

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Fatigue or loss of energy

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Feelings of worthlessness or excessive or inappropriate guilt

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Diminished ability to think or concentrate, or indecisiveness

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Recurrent thoughts of death or recurrent suicidal ideation

Some of these symptoms are considered somewhat normal after the birth of a baby. Most mothers of newborns feel fatigue and have erratic sleeping patterns since they must wake up to feed their newborn every few hours. The inability to sleep when the baby is sleeping may

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Opportunities to Break Barriers & Build Bridges perhaps be a better indicator of depression for mothers with young infants. Weight-loss after childbirth is also common, and this symptom can easily go unnoticed.

The Spectrum of Postpartum Mood and Anxiety Disorders The addition of a new child is a major life event, and changes in maternal mood and behaviors are normal in the weeks and months after giving birth. Depending on the severity and duration, a mother may experience a range of symptoms from brief periods of tearfulness to hallucinations and psychotic thoughts. Although this literature review will focus on postpartum depression specifically, it is important to first differentiate between normal postpartum emotions and mood disorders that may require treatment.

Baby blues typically occur within 10 days after the birth of a child.4 During this time, the mother may experience a few hours, or days, of mild depressive symptoms like moodiness, anxiety, tearfulness, or sleep disruption.5 Baby blues are considered a normal postpartum response, not a mood disorder, and affect up to 85% of mothers.6,7 Women who experience baby blues notice that their symptoms clear up in as little as a few hours, and within two weeks, after onset.

Treatment for baby blues is generally neither required nor prescribed.4,5 Postpartum depression can occur anytime in the first year after the birth of a new baby.1 Early symptoms of postpartum depression are similar to those of baby blues, but gradually worsen and persist for longer than two weeks, often described as a minor or major depressive episode.

Exacerbating symptoms of postpartum depression may include a mother's thoughts of harming herself or her baby, and a general lack of interest in caring for the infant. Multiple treatment options are available (as discussed later in this review).

Anxiety disorders such as postpartum obsessive compulsive disorder (OCD) often accompany PPD.1 It is estimated that between 10-30% of all mothers experience postpartum OCD.8 OCD is characterized by intrusive, often disturbing, thoughts and compulsive behaviors that are often used to relieve the discomfort caused by the thoughts.9 In postpartum mothers, intrusive thoughts may involve harm coming to the baby, which can lead to fear to be alone with the baby or perform normal infant care activities (e.g. changing a diaper because the mother fears she will pass a deadly infection to the baby).8 The disturbing, intrusive thoughts experienced by women with OCD should be differentiated from the hallucinations and delusional thoughts experienced by women with psychosis. Women with OCD are aware the thoughts are irrational

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and they are distressed by them, whereas, aggressive thoughts experienced during psychosis do not typically cause distress or fear.8 Postpartum psychosis is the most severe and rare of all postpartum mood disorders.

Approximately 1-2 of every 1,000 mothers are affected.5 Symptoms arise soon after childbirth, and in addition to the typical symptoms of postpartum depression, mothers may also experience severe depression, manic symptoms, hallucinations, disorganized thinking, and serious thoughts of harming her infant. Hospitalization is often the most appropriate treatment option for postpartum psychosis.1

Prevalence PPD is the most common complication of pregnancy and childbirth.

However, the prevalence rate of PPD has been difficult to establish, and numerous studies have been conducted with results ranging widely depending on the criteria used to identify PPD, the length and timing of the observation/assessment, and population under

Postpartum depression affects more women than breast cancer, preterm labor, gestational diabetes, low birth weight, and pre-eclampsia.

study. However, most experts agree that the prevalence of PPD in the general population is 10-15%.5,10 There is evidence to suggest that the prevalence of PPD may vary throughout the pregnancy and postpartum period. A rigorous 2005 meta-analysis commissioned by the Agency for Healthcare Research and Quality and Safe Motherhood Group estimated that as many as 18.4% of pregnant women suffer from PPD, though there were differences in rate by trimester, and as many as 19.2% of new mothers experience PPD in the first 3 months after delivery.3 Additionally, several studies have found the prevalence of PPD to be closer to 25% in low-income women.11,12

Risk factors Identifying risk factors for PPD has been the subject of much inquiry and a wide array of biological, social, and environmental factors have been identified. Risk factors that have been found repeatedly across numerous studies and have been deemed moderate to strong risk factors include: history of depression, depression or anxiety during pregnancy, low self-esteem, stressful life events, poor marital relationships, poor social support, and neuroticism (Table 1).13 Also included in this table are risk factors that have some supportive evidence, but the strength of the effect remains unclear. Because many of these risk factors are identifiable during routine medical appointments, health professionals (both pediatric and obstetric) can increase

Opportunities to Break Barriers & Build Bridges monitoring and screening of women with one or more risk factors to ensure timely recognition and early treatment.

Table 1: Risk Factors for PPD Moderate to Strong Risk Factors History of depression Low self-esteem Stressful life events Poor marital relationship Poor social support Neuroticism Depression or anxiety during pregnancy

Weak to Moderate Risk Factors Low socioeconomic status Single parent Unwanted pregnancy Pregnancy complications Difficult infant temperament

Risk Factors with Some Supportive Evidence Younger age14 Low education15 Race/ethnicity15,16 Domestic violence17-20 Parity21

Consequences Depression causes a great amount of suffering, no matter when it is experienced, and it affects the quality of life not only of those experiencing the symptoms but also those around them. The impacts of PPD are of particular concern because the lives affected include young infants and children in need of constant care and supervision. The symptomology of depression (fatigue, lack of pleasure and interest in things, distractibility, agitation) make it difficult for a mother to attend to the needs of her child(ren) and create the supportive and engaging environment children need to grow and thrive. Many studies have been conducted to better understand the impact of PPD and parental depression. In addition to the symptoms experienced by the mother, research has shown that PPD negatively impacts parenting practices, the child’s cognitive, social and behavioral development, family relationships, and the economy (Table 2).

Age of the child, chronicity, and length of depressive episode(s) also appear to influence the severity of consequences suffered, with longer episodes and more chronic depression having a greater impact.22

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Table 2: Consequences of PPD Impacted Associated Consequences Parenting Practices Hostility, higher rates of negative interactions with infant23 Inattentiveness and nonresponsiveness24 Lower quality interactions between mother and child25,26 Missed pediatric appointments27 Reduced use of child safety precautions28,29 Child Higher risk of preterm birth and poor birth outcomes30 Higher risk of maltreatment31 Difficulty with attachment relationships32 Language and developmental delays33,34 Lower IQ33 Increased rates of psychiatric disorders such as depression, substance abuse, and conduct disorders as a child and adolescent35 Family Higher risk for paternal depression36 Decreased marital satisfaction24,36 Economy More emergency room visits for child27 Decreased productivity at work (if they return)37 Higher medical claims37 Increased usage of disability days37

Prevention There are many opportunities for medical intervention, because the onset of PPD symptoms occurs during a time when women are seeking medical care often. They have medical appointments for their pregnancy, delivery and postpartum care, as well as for their infants, so there are multiple opportunities and settings for prevention, detection, and early intervention.

Over the past few decades, a wide range of interventions including biological and psychosocial interventions have been developed and tested for efficacy including: 

Education: Verbal or written educational materials on PPD provided without behavior change activities

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Modified care: Change in timing or frequency of obstetric care

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Therapy: Use of therapeutic activities to change mood/behavior/cognition led by a clinician (e.g. cognitive behavior therapy, guided relaxation)

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Social support: Contact with mother that provides social support but not a specific therapeutic activity

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Dietary supplements: Use of non-pharmaceutical supplements (e.g. selenium38)

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Hormonal: Use of long-acting progestogen contraceptives (e.g. norethisterone enanthate39) or hormone replacement (e.g. transdermal Oestrogen40 or estradiol41)

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Medication: Use of pharmaceuticals (e.g. nortriptyline42 or sertraline43)

A 2013 comprehensive review44 evaluated 37 studies on PPD prevention programs and demonstrated that there are a wide variety of prevention interventions that effectively reduce the symptoms and prevent depressive episodes before 6-months postpartum. Although more research is needed to confirm the results, this study found that intervention type was not a significant moderator suggesting that providing general social support and contact during this period may be enough to reduce the prevalence of PPD. However, it was noted that higherlevels of depressive symptoms pre-intervention were associated with less improvement postintervention, indicating that there may be a high-risk group that does not respond to prevention activities and will need to seek treatment. Also of note, interventions starting during pregnancy as well as those begun postpartum showed significant decreases in depressive symptoms.

Screening Early detection of PPD symptoms is critical in order to get mothers the help and support they need. There is no single screening tool that is recognized to be the best tool for assessing PPD. The Edinburgh Postnatal Depression Scale (EPDS) is the screening tool most commonly used,10 but multiple screening tools (Table 3) have been validated and deemed effective in identifying women with elevated symptoms of depression.

“Postpartum depression is far more common than gestational diabetes. All women receiving prenatal care are screened for diabetes, but how many pregnant and postpartum women are screened for depression?”

-Dr. Ruta Nonacs, Massachusetts General Hospital

Because symptoms can emerge during pregnancy and up to one year post delivery, there are multiple opportunities to screen, including during regular obstetrician visits, pediatric well-child visits, and other settings where mothers and young children frequent. For example, pregnant women should be seeing an obstetrician every month of their pregnancy and infants have seven standard well-child visits during the first year of life.

In fact, the American College of Obstetricians and Gynecologists recommends psychosocial screening of pregnant women at least once per trimester using a brief 2-question interview with follow-up assessment when indicated. The American Academy of Pediatrics recommends screening during infant well-child visits and has included screening tools (PHQ-2 and EPDS) in its

Opportunities to Break Barriers & Build Bridges Bright Futures Tool and Resource Kit.2,45 Despite these recommendations, screening practices continue to be inconsistent across practices. Some states have mandated screening to increase the detection.46

Table 3: PPD screening tools Screening tool Administration

Other information

BDI: Beck Depression Inventory and BDI-II

 Self-administered  21 items  5-10 min.

 Charge: $125 for a manual +50 forms  Available in Spanish

BDI-FS (formerly BDI-PC)

 Self-administered  7 items  <5 min.

psychcorp.pearsonassessments.com/haiweb/cultures/enus/ productdetail.htm?pid=015-8019-415

CES-D: Center for Epidemiological Studies Depression Scale

 Self-administered  20 items  5-10 min.

 Free  Available in Spanish

EPDS: Edinburgh Postnatal Depression Scale

 Self-administered  10 items  5 min.

 Free  Available in 58 languages (incl. Spanish)

PDSS: Postpartum Depression Screening Scale

 Self-administered  35 items  5-10 min.

 Charge: $92 for a manual +25 forms  Avail in Spanish & Italian

PHQ-9: Patient Health Questionnaire-9

 Self-administered  9 items  5 min.

 Free  Available in 20+ languages

PHQ-2: Patient Health Questionnaire-2

 Self or clinician administered  2 items  1 min.

 Free  2 questions from the PHQ-9  Available in 20+ languages

www.pearsonclinical.com/psychology/products/100000159/beckdepression-inventoryii-bdi-ii.html?Pid=015-8018-370

cesd-r.com/

www.rikshandbokenbhv.se/Dokument/Edingburgh%20Depression%20Scale%20Translated%20G ov%20Western%20Australia%20Dept%20Health.pdf

www.wpspublish.com/store/p/2902/postpartum-depression-screeningscale-pdss#purchase-product

www.phqscreeners.com/

www.cqaimh.org/pdf/tool_phq2.pdf www.phqscreeners.com

This table was adapted from the Massachusetts Department of Public Health (2011) Postpartum Depression Screening Tool Grid

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Treatment Treating PPD can be complex due to a mother’s hormonal changes and safety concerns when the mother is receiving treatment while pregnant or breastfeeding. A number of safe and effective treatment options for PPD have been identified (for reviews see10,47-51). Similar to the aforementioned prevention interventions, pharmaceutical options (e.g. antidepressants) and psychological (e.g. interpersonal therapy, cognitive behavioral therapy) treatments can be effective options for women. Peer-support, home visitation by a health worker, and nondirective counseling have also been demonstrated to be effective in reducing symptoms of depression. Alternative options such as bright light therapy, acupuncture, massage, vitamins, and exercise have been tried, but there is limited evidence to support their effectiveness.

Although treatable, most women with PPD do not receive treatment.52 Barriers to treatment have been explored to better understand the reasons behind the lack of follow-up and help seeking behaviors.53,54 Identified barriers include: lack of knowledge about PPD and recognition of the symptoms, the inability to admit one’s feelings, previous negative experiences with mental health services, wariness of medications, stigma, lack of access to care, provider-

“As we struggle, we hate ourselves, thinking we are terrible mothers. We judge ourselves because we’re sure everyone else is too.”

-Giggles and Grimaces blog on Postpartum Depression

patient relationship, provider interest and acknowledgement of mother’s feelings, and lack of social support from family and friends.

Opportunities to Break Barriers & Build Bridges

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Results Interviews and focus groups were conducted with local direct service providers, program managers, and leaders in organizations providing services and interacting with pregnant and postpartum women. Primary and secondary data analysis were used to describe the need in Houston, identify the barriers to care, and recognize the innovation of providers and programs to address barriers and ensure women and families get the care they need.

What is the Need in Houston?

There is no surveillance system in place counting the number of women screened or diagnosed with PPD, thus determining the actual number of women affected in Houston or Texas is difficult. In order to provide reasonable estimates of the impact PPD is having on the Houston community, prevalence rates found in the literature and analysis of inpatient hospitalization records were used.

Estimates Based on Prevalence Rates As discussed previously, the prevalence rates most often reported in the literature for PPD are 10-15% for the general population and 25% for low-income populations. Based on birth information obtained from US Census American Community Survey data for 2013, we estimate that between 12,000-15,000 women living in Harris County and 69,000-79,000 women living in Texas experienced PPD in 2013 (Table 4). Because these numbers do not include all women who were pregnant, just those delivering an infant, this is likely a conservative estimate of the burden of PPD. Table 4. Estimated Range of Women Experiencing PPD in Harris County and Texas, 2013 Births Harris County Texas

70,284 387,079

Mothers living Mothers living <200% of FPL â&#x2030;Ľ200% of FPL 55% 45% 53% 47%

Mothers experiencing PPD* 12,827-14,408 69,481-78,577

* Computed using 10% as the low end and 15% as the high end for mothers living â&#x2030;Ľ200% federal poverty line (FPL), 25% was used in calculations for both regions for mothers living below 200% FPL

Inpatient Hospitalizations with Mental Health Disorders During the first year after childbirth, women are at a greater risk of psychiatric hospitalization than at any other time in their lives.55 However, research indicates that the vast majority of women with PPD are not identified or treated. Diagnosis of or treatment for a perinatal mental health disorder during an inpatient hospital stay (e.g. while in the hospital for delivery or

Opportunities to Break Barriers & Build Bridges pregnancy complication) could provide further insight into the burden of disease in our community, particularly for severe cases. Inpatient hospital records from 2008-2012 were analyzed to gain a better understanding of the number and characteristics of the women that were treated or diagnosed with a mental health disorder in an inpatient setting. A total of 3,016,683 records for femalesâ&#x20AC;&#x2122; ages 15-44 who were residents of Texas, and specifically Harris County, at the time of discharge were examined. Because the data are hospitalization and not person specific, we are unable to determine all mental health diagnoses occurring specifically in new mothers. Therefore, we analyzed the dataset looking at both the specific diagnosis codes for perinatal mental disorders (a specific set of ICD-9 codes for â&#x20AC;&#x153;Mental disorders of the motherâ&#x20AC;?) as well as for any mental health disorder to give a broader view of mental health issues in women of childbearing age. (See the methods section for more information on the data source and specific coding criteria).

Between 2008 and 2012 in Harris County and in Texas, mental health disorders were the second leading reason women ages 15-44 were hospitalized; the leading reason was pregnancy/childbirth. There was an average of 12,360 hospitalizations per year with at least 1 mental disorder present in the discharge diagnoses in Harris County and 89,110 in Texas. Over the 5-year period, the number and proportion of hospitalizations that included a diagnosis of a mental disorder increased from 10.7% to 13.2% in Harris County and from 13.6% to 16.0% in Texas.

Perinatal mental disorders were present in 1% of all female hospitalizations and 8-9% of female hospitalizations with any mental health disorder. Over the 5-year period, there was an average of 1,100 hospitalizations with a perinatal mental disorder in Harris County and 6,900 in Texas.

Mood, substance abuse, anxiety, thought, and perinatal mental disorders were the top 5 mental health diagnoses in both Harris County and Texas (Tables 5 and 6). Among women with mental health diagnoses during their hospitalization, nearly 60% had a mood disorder diagnosis (e.g. depression, bipolar), and approximately 20% had an anxiety diagnosis. Comorbidity was common (>60% had 2 or more mental health diagnoses).

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Table 5. Top 5 Mental Health Disorder Discharge Diagnoses, Females ages 15-44 years, Harris County 2008-2012 2008 2009 2010 2011 2012 Total All Hospitalizations 107,826 110,474 99,465 104,147 106,131 528,043 No Mental Disorder Discharge Diagnosis 96,309 98,254 88,211 91,376 92,100 466,250 â&#x2030;Ľ 1 Mental Disorder Discharge Diagnosis 11,517 12,220 11,254 12,771 14,031 61,793 Mood Disorders 6,575 7,026 6,682 7,489 8,356 36,128 Substance abuse 2,958 2,886 2,528 2,847 2,715 13,934 Anxiety Disorders 1,691 1,893 1,865 2,349 3,006 10,804 Thought Disorders 1,347 1,490 1,307 1,521 1,671 7,336 Perinatal Mental Disorder 931 996 1,006 1,210 1,368 5,511

Table 6. Top 5 Mental Health Disorder Discharge Diagnoses, Females ages 15-44 years, Texas 2008-2012 2008 2009 2010 2011 2012 All Hospitalizations 620,670 631,512 567,984 598,203 598,314 No Mental Disorder Discharge Diagnosis 535,985 542,506 484,702 505,476 502,470 â&#x2030;Ľ 1 Mental Disorder Discharge Diagnosis 84,685 89,006 83,282 92,727 95,844 Mood Disorders 49,431 51,872 48,684 54,946 57,003 Substance abuse 26,268 27,902 25,140 27,359 26,761 Anxiety Disorders 14,513 16,486 16,519 20,361 25,814 Thought Disorders 7,316 7,449 6,930 8,000 8,484 Perinatal Mental Disorder 6,173 6,784 6,586 7,492 7,438

Demographic information on all female hospitalizations, those including any mental health diagnosis, and those including a perinatal mental disorder diagnosis are presented in Table 7.

Mental disorders, including perinatal mental disorders, impact women in every age, race-ethnic, and payment group. Within inpatient hospital stays, nearly half of all perinatal mental disorders are diagnosed in white non-Hispanic women and women paying with private insurance.

Medicaid covers 46.3% of hospitalizations with a perinatal mental disorder in Harris County and 47.5% in Texas. Because the vast majority of women covered by Medicaid are eligible due to pregnancy and will lose coverage 60 days after delivery, many mothers needing mental health services are without medical coverage to pay for those services.

Total 3,016,683 2,571,139 445,544 261,936 133,430 93,693 38,179 34,473

Opportunities to Break Barriers & Build Bridges

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Table 7. Demographic Characteristics of Female Hospitalizations, ages 15-44 years, Texas 2008-2012 Texas Harris County All Female Any Mental Perinatal All Female Any Mental Perinatal Mental hospitalizations Disorder Mental hospitalizations Disorder Disorder n (%) n (%) n (%) n (%) n (%) n (%) Total 3,016,683 386,548 31,135 468,936 53,096 5,070 Age 15-19 367,749 (12.2) 58,996 (13.2) 3,338 (9.7) 59,207 (11.2) 8,697 (14.1) 441 (8.0) 20-24 634,035 (21.0) 54,153 (12.2) 8,267 (24.0) 107,137 (20.3) 7,780 (12.6) 1,107 (20.1) 25-29 683,325 (22.7) 67,187 (15.1) 9,318 (27.0) 122,201 (23.1) 9,832 (15.9) 1,479 (26.8) 30-34 595,515 (19.7) 76,193 (17.1) 8,036 (23.3) 111,330 (21.1) 10,704 (17.3) 1,404 (25.5) 35-39 419,863 (13.9) 85,892 (19.3) 4,394 (12.8) 76,108 (14.4) 11,451 (18.5) 827 (15.0) 40-44 316,196 (10.5) 103,123 (23.2) 1,120 (3.3) 52,060 (9.9) 13,329 (21.6) 253 (4.6) Race Ethnicity White non-Hispanic 1,104,320 (36.6) 235,772 (52.9) 18,080 (52.5) 150,209 (28.5) 26,672 (43.2) 2,595 (47.1) Black non-Hispanic 394,776 (13.1) 66,405 (14.9) 4,188 (12.2) 113,590 (21.5) 16,466 (26.7) 1,134 (20.6) Hispanic 1,089,506 (36.1) 86,127 (19.3) 7,862 (22.8) 186,073 (35.2) 9,898 (16.0) 1,163 (21.1) Other/Unknown 428,081 (14.2) 57,240 (12.9) 4,343 (12.6) 78,171 (14.8) 8,757 (14.2) 619 (11.2) Payment Method Private Insurance 1,361,769 (45.1) 203,784 (45.7) 15,344 (44.5) 215,890 (40.9) 26,838 (43.4) 2,536 (46.0) Medicaid 1,175,154 (39.0) 97,084 (21.8) 16,382 (47.5) 226,789 (43.0) 14,060 (22.8) 2,554 (46.3) Medicare/Public Funds 134,007 (4.4) 57,861 (13.0) 1251 (3.6) 20,816 (3.9) 7,235 (11.7) 180 (3.3) Self-pay/Unknown 345,753 (11.5) 86,815 (19.5) 1,496 (4.3) 64,548 (12.2) 13,660 (22.1) 241 (4.4)

In an examination of the top 5 hospitals where the perinatal mental disorders were present in the discharge diagnosis codes in Harris County (accounting for over 50% of the hospitalizations with perinatal mental disorders), only 1 of the hospitals, Ben Taub, has a psychiatric unit and follow-up services within the hospital. Women’s Hospital of Texas, which accounted for 22% of all perinatal mental diagnoses, hosts support groups for women with PPD. This suggests that many women are being referred to other facilities or physicians for follow-up care and on-going treatment for their mental illness. (Though not in the top 5 diagnosing hospitals during the 2008-2012 study period, it should be noted that Texas Children’s Hospital opened the Women’s Pavilion in November 2011 and has psychiatric and support group services available for women with postpartum depression and other perinatal mental disorders).

What are the Barriers to Addressing the Need?

One of the main objectives of both the interviews and focus groups was to identify barriers standing in the way of affected women and families receiving the help and support they need.

Interviews and focus group results were analyzed separately (see Appendix A for full analysis) and then integrated to provide a comprehensive assessment of these challenges (Figure 1).

Significant consistencies were found across all qualitative data. Four major themes around barriers were found: 

education and awareness amongst providers, women/families, and the community;

Opportunities to Break Barriers & Build Bridges 

service delivery, access to care, and utilization;



individualized characteristics of each woman/family; and



policy and macro-level systems

Figure 1: Conceptual Model of Barriers

Education and Awareness Inadequate education and awareness was the most frequent barrier that was shared by both focus groups and interviewees. The lack of education and awareness was cited as a barrier amongst professionals, the community, and women at risk for PPD and their families. The need for education and awareness across the community was pervasive, impacting the other elements in the model. Specifically, participants linked lack of education/awareness to: 

Professionals not recognizing PPD. Professional training gaps present challenges to the use of evidence-based interventions and best practices while working with women experiencing PPD.



Stigma. Participants felt that if the community was better educated on mental health and PPD specifically, the stigma associated with PPD would decrease and more women and families would seek services.

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Opportunities to Break Barriers & Build Bridges 

Family support. Participants believed women at risk of PPD and their families may have difficulty recognizing the signs and symptoms of PPD because they do not have proper education and awareness of the illness. The lack of education and awareness by family members (partners, siblings/parents of the mother, close friends) was also discussed during interviews, as it has been observed by providers that family members/support networks are not always supplied education on how to support their loved one experiencing PPD.



Participation in services. Participants felt that women and families do not always know where to find help or even who to ask for help.

Service Delivery The theme of service delivery was the most recurrent topic in the interviews. Participants described practicing in highly varied service delivery models. Those working within models that have a level of integration between medical and behavioral health care expressed more ease in access to mental health care. For example one interviewee reported obstetricians treating mothers for mental health stabilization, or “crisis management,” in a non-integrated setting; while an interviewee in an integrated setting reported patients were able to flow easily from obstetrics to behavioral health.

Participant concerns with service delivery, including concerns pertaining to access to treatment due to barriers on the provider side, were broken down into subcategories of screening, referral, treatment/intervention, and utilization.

Screening: The most prominent challenge for screening uncovered during the assessment was the lack of standardized procedures. Because PPD screening is not a required element in obstetric or pediatric care, and formal guidelines have not been issued standardizing the specific times when it is best to screen or the instruments by which to screen, there is much variation within and across practices in regards to the instruments and time of screen. During our assessment, we found organizations servicing pregnancy and postpartum women that did not screen for PPD at all, screened outside recommended timeframes (e.g. within several days of delivery), or screened multiple times beginning in pregnancy and throughout one year postpartum. Both validated survey instruments, most commonly the Edinburgh Postpartum Depression Scale (EPDS), and informal, non-validated interviews were used to screen, sometimes within the same organization. For example, one organization used the EPDS to screen during pregnancy and an informal interview to screen during well-child check-ups. Cut-

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Opportunities to Break Barriers & Build Bridges

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off scores, signifying high risk for PPD, also varied across organizations. For the EPDS, scores ranging from 9-13 out of a possible 30 were used to indicate the need for further treatment.

Referrals: Because pregnant and postpartum women are often seeking medical care in obstetric and pediatric offices, off-site mental health treatment referrals are frequently provided; however it is less clear if the referrals result in a mother engaged in care. The resource knowledge of the individual making the referral was identified as a potential barrier. Also of concern was the likelihood of referrals chains when referrals are made to agencies providing referral services, not direct services, or inappropriate referrals because the mother will not meet criteria for treatment. For example, because Mental Health America of Greater Houston (MHA) provides educational material on PPD, many providers refer at risk mothers to them for treatment ; however MHA does not provide direct treatment and must refer mothers elsewhere in the community.

Treatment/Intervention: After a woman is identified and decides to seek treatment, there are often challenges of access and availability of services. Through analysis, barriers to care were found when providers do not or are unable to overcome challenges women and their families experience to improve access to care. These concerns include lacking transportation assistance, “care in her language,” availability of navigators to provide support, as well as “having women leave house for services.” It was identified that women with PPD have difficulty accessing care in private practice due to provider shortages, from local mental health authorities if their symptoms are not

Further insight into screening practices and barriers across Texas Two recent studies56, 57 provide further insight on screening practices and barriers to screening through obstetric and pediatric practices in Texas. In 2010 Texas Children’s Hospital distributed a questionnaire electronically to all (n=252) pediatric providers in the Texas Children’s Pediatric network to assess the current screening practices of pediatricians. 96 providers completed the survey for a 38% response rate. Less than half of the respondents reported screening for PPD (43%).

Of the providers who reported routinely screening for PPD, the majority did not use validated screening instruments (56%). Pediatric providers who do not routinely screen for PPD reported the following reasons for not screening: lack of time (58%), inadequate training (54%), and inadequate resources to screen (44%).

Researchers at Baylor College of Medicine distributed a similar questionnaire in 2010 to 2,028 obstetrician-gynecologists across Texas to assess screening practices of obstetricians and to identify barriers to screening. 189 providers completed the survey for a 9% response rate. The vast majority of the respondents reported screening for PPD (85%). Similar to the pediatric providers, of the obstetric providers who reported routinely screening for PPD, the majority did not use validated screening instruments (72%). Obstetric providers who do not routinely screen for PPD reported the following reasons for not screening: inadequate training (56%) and inadequate resources to screen (46%).

Opportunities to Break Barriers & Build Bridges severe enough to meet treatment criteria, and have limited to no local options of supportive, intensive treatment. Participants expressed concerns with the difficulty women with PPD have in accessing prompt, appropriate treatment options at varied levels of care. This barrier was persistent across service delivery components (i.e. screening, referral, and treatment).

The cost of services and insurance acceptance was also discussed as a challenge for entry into or continuation of treatment. The most frequent concern cited by participants in this area was the limited 60 days of postpartum care covered by Medicaid (for women being covered by Medicaid due to pregnancy). It appears that in such situations the focus shifts from treatment to transitioning the woman to another system such as a Federally Qualified Health Center (FQHC) or the county’s safety net system, Harris Health. Often though, this transition was described as “problematic” with providers confessing that “we could do more to follow-up with patients to make sure they are enrolled and able to be seen.”

Utilization: The issues with access and availability of services were reported to often lead to problems with utilization and participation in services. Participants expressed concerns with low attendance in support group sessions, psychiatric care that is underutilized, and, most often, referrals that go unused. Participants pointed to difficulties with scheduling, lack of prompt psychiatric care, lack of integration at one location, and prior experience with poor quality mental health care as the main reasons they felt mothers and families did not participate in services after identification and referral. Access and utilization of services appears to improve when mental health services are expanded and/or integrated in the community setting with other support services. However, the data indicated utilization continues to be lower than anticipated in these settings as well.

Characteristics of Woman/Family Individual characteristics of the woman/family emerged as a barrier to care from focus groups during their consideration of barriers and root causes. These characteristics appeared as factors that are unique to each woman/family that could influence her likelihood to engage in care.

These characteristics include barriers that stem from socioeconomic status, insurance status (ability to pay for care), transportation, geographic location, childcare, work situation, social support, life stressors, culture or language barriers, and mental status (advancement of PPD).

Participants shared additional characteristics that are likely to influence a woman’s participation in care, such as lack of sleep, motivation, perceived urgency or priority of seeking treatment, family relationships (e.g. partner power struggles), and expectations that nothing will change.

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Opportunities to Break Barriers & Build Bridges Barriers that stem from individual characteristics indicate the importance of client assessments, which should aid in the development of plans to accommodate or bridge these challenges in accessing services.

Policy and Macro-level Systems The majority of data supporting systemic barriers were identified in the focus groups; however, these concerns occurred in participant interviews as well. The most frequent policy concerns involved insurance, specifically Medicaid, which was consistent with participant insurance coverage concerns that fell under the Access to Care and Characteristics of Woman/Family categories. Participants discussed other barriers stemming from policy, including work/leave policy, transportation, and immigration. In addition, participants addressed the impact of the media. Media was identified as a root cause of misinformation, such as focusing on extreme cases, and establishing unrealistic expectations of motherhood.

Action Recommendations from Focus Groups In the last activity of the focus groups, participants were asked to list actions to address the root causes of the top barriers to care by the setting (e.g.: homes, community, medical/clinical setting, or other). Not all groups were able to complete this activity due to time. However, the results are telling and greatly informed the development of recommendations.

It is no surprise that education was included in all settings. All groups agreed in-home services are an area for improvement. Participant suggestions included home visitations by professionals and education in the home. Early intervention was discussed in three of the four groups, suggesting support system development and education provision during pregnancy with the family. In the community setting there was agreement that resources need to be further developed and that media should be engaged to promote awareness.

The largest quantity of suggestions for action was directed towards the medical/clinical setting.

Within education, training for professionals on PPD, screening, and referrals was recommended. Three of the four groups discussed action that would cause a shift in attitude.

The action suggestions were, “accountability, shared burden,” “creating the medical need,” “prioritization of PPD as a mental health issue,” and “destigmatize medication use while breastfeeding.” Participants also recommended actions for service delivery, including standardization of protocol; integration, coordination, and extension of care; and improvements to screening (e.g.: mandate, proper timing).

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Opportunities to Break Barriers & Build Bridges

Are Local Services for PPD Available and Accessible?

Interviews, focus groups, and the literature identified lack of knowledge and accessibility of services as major barriers for families to find and participate in services. As a result, CHILDREN AT RISK attempted to contact all Houston organizations used as a referral source by providers (including organizations listed in brochures and those disclosed during interviews). To get a sense of what a concerned family member or friend would encounter when trying to find and access services, callers posed as a friend of a new mother who was suspected of suffering from PPD. Overall, we attempted to contact a total of 46 organizations (several with multiple locations).

Two of those organizations are now closed. Of the remaining 44 organizations, 19 offered one or more treatment options (e.g. psychiatry, therapy, counseling, support groups) for those with depression, including but not necessarily specific to PPD; 19 organizations do not provide services for depression or PPD; and 6 organizations could not be reached. Four of the organizations that did not provide treatment made referrals to a different organization offering services.

In general, callers found it somewhat difficult and frustrating to make contact with organizations. Approximately 40% of the time more than one call was needed to make contact with the organization and hold times could be as long as two hours. An additional level of confusion was added when the person answering the phone at the organization was not aware of whether or not they offered services for PPD and thus was not able to respond accurately.

Once contact was made, we found that many of the organizations offering services were flexible about the payment types accepted (e.g. Medicaid, private insurance, Harris Healthâ&#x20AC;&#x2122;s Gold Card), and/or offered services on a sliding fee scale. Several organizations had eligibility restrictions based on insurance/payment method (e.g. Medicaid or uninsured only), residency (clients need to live within certain zip codes to receive services or in the case of Harris Health, clients must be Harris County residents), and severity (e.g. MHMRA only has the capacity to treat very severe cases). There was not enough information about wait times available to assess the average wait times for services. This was because many of the organizations required more information regarding insurance, or wanted the depressed mother to call herself and make an appointment.

Based on the contact made with the organization during the secret shopper calls as well as interviews with service providers in organizations providing services, below is a map (Figure 2)

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Opportunities to Break Barriers & Build Bridges of Houston area services for depression, including PPD. Overall, we were able to identify more than 20 organizations and private providers offering PPD treatment at 50 locations across the city. Because there were several organizations that we were unable to reach to verify the availability of PPD services, there may be more options available than identified during this assessment. See Appendix B for the full list of organizations and private providers.

Figure 2: Map of Organizations Providing Depression and PPD Services

Pathways to Success: Innovation within the Houston Community Though many challenges to getting and keeping women in care were identified during this assessment, many Houston organizations have stepped up to address those challenges and found ways to provide the education, screening, and treatment services so needed in the community. Below we have highlighted 7 programs/organizations for their efforts to help Houston families impacted by PPD. Education and Training Mental Health America of Greater Houston Mental Health America of Greater Houston (MHA) has coordinated the Yates Children Memorial Fund (YCMF) since 2002, a Womenâ&#x20AC;&#x2122;s Mental Health collaborative group working to significantly improve the mental health outcomes of mothers with new babies in Greater Houston. Through

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Opportunities to Break Barriers & Build Bridges this program, MHA is making great strides increasing awareness of postpartum depression and educating professionals on postpartum depression, screening, and treatment. In total, they have trained over 3,000 professionals on PPD and distributed almost 600,000 brochures. Just this year (as of October 2014), 434 professionals have been trained on PPD and nearly 6,000 PPD brochures in English and Spanish have been distributed to the community, along with over 11,000 mental health guides.

The Center for Postpartum Family Health The Center for Postpartum Family Health is a private mental health counseling center opened in 2014 to provide services for families during the perinatal period including PPD screening, mental health assessments, individual, couples and family counseling, psychotherapy and free and lowcost support groups. Sherry Duson, a long-time Houston therapist specializing in maternal mental health, established the Center in response to seeing the growing need in Houston for more perinatal mental health services. She supervises the therapists working at the center, as they train to also become specialists in working with new mothers, while providing counseling services on a sliding scale. The Center for Postpartum Family Health strives to provide new parents with the information and support they need to thrive during this important life transition.

Integrated Healthcare The Center for Children and Women The Center for Children and Women through Texas Children’s Health Plan is a new medical facility designed to make receiving medical care easy by offering comprehensive services in one place and by being open 7 days a week with day and evening hours. The Center offers pediatric primary care, vision and dental care, comprehensive obstetric services, and a pharmacy to Medicaid and CHIP recipients. Knowing that access to behavioral health services was an issue for many of their patients, the Center was designed to have integrated behavioral health services including case management, social work, counseling, and psychiatric care. Pregnant women are screened for PPD regularly throughout the pregnancy and during the 3 and 6 week postpartum visits using the EPDS. Approximately 15% of their pregnant and postpartum mother’s access behavioral health service and many more are being seen by a Center social worker, who addresses a multitude of individual and family needs. One of their lead psychologists noted, “It is our goal to catch mental illness early and do counseling, coaching, etc. so that PPD doesn’t happen and moms are stable before their Medicaid coverage runs out.”

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Opportunities to Break Barriers & Build Bridges Legacy Community Health Center Legacy Community Health Center is a federally qualified health center (FQHC) with 8 locations in the greater Houston area. Legacy Community Health Center provides comprehensive health services for adults and children including primary care, dental and vision services, behavioral health, family planning, community outreach, and wellness and nutrition. Legacy Community Health Center is reducing barriers to PPD treatment through an integrated care model. Mothers are screened for PPD at their 3- and 6-week postpartum visits with their obstetrician using the EPDS screening tool. Mothers are also screened at every well-child visit from birth to two months through an informal interview. If a mother screens positive, they are immediately referred to Legacy’s behavioral health department, and mothers with potentially severe cases of PPD are prioritized and seen as quickly as possible. Through offering multiple screenings and referring to behavioral health specialists that are in the same location as the pediatrician and obstetrician, it is Legacy’s goal that they will eliminate barriers to treatment and more moms will receive the appropriate services if they have a positive screen. Psychiatrists report that the services are so well integrated and presented to the patient in such a way that “they sometimes don’t even know they are seeing a psychiatrist. They just know that someone here is going to provide them the services and help they need and want.”

Attention to Language and Cultural Diversity HOPE Clinic HOPE Clinic is a federally qualified health center (FQHC) servicing 27 square miles in West Houston, in particular the large Asian-American population located in this area. The clinic provides healthcare to all ages through preventive and primary care services, including: behavioral health, pediatric, OB/GYN, family practice, internal medicine, pediatric psychiatric consultation, cancer screening, lab work, and mammography services. With extended hours and providers that speak over 14 languages and dialects including Mandarin, Cantonese, Vietnamese, Korean, Hindi, Arabic, Burmese and Spanish, HOPE’s mission is to ensure that all Houstonians are able to receive culturally sensitive care regardless of their ability to pay or communicate in English. Clinicians at HOPE screen for PPD using the EPDS during pregnancy and in the postpartum period. Counselors and behavioral health specialists meet with at-risk mothers at the same location to determine the best treatment plan for the mother and her family.

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Opportunities to Break Barriers & Build Bridges Demonstration Projects through Delivery System Reform Incentive Payments (DSRIP): Projects focusing on expanding access to healthcare Texas Children’s Hospital To address the need for earlier screening and treatment of maternal depression, the Texas Children’s Pavilion for Women launched a pilot program in May 2014 to screen patients multiple times throughout their pregnancy and postpartum period. “Our goal is to identify women with maternal depression as soon as possible and get them into care because maternal depression is treatable,” says Lucy Puryear, M.D., who oversees the program. As part of the program, women are screened for maternal depression using the EPDS multiple times throughout their pregnancy and postpartum and those requiring follow-up mental health services are referred to an inhouse psychiatrist for care. Referrals are processed quickly and most patients are seen within seven days of being screened. Currently, two Texas Children’s Pediatrics practices and four obstetric practices are serving as pilot sites for the project. Future plans focus on educating and training staff at additional pediatric clinics to implement standardized screening and referral; adding additional providers, including a psychiatrist, therapist and social worker; and expanding to additional sites with the intent of integrating maternal mental health services where women are already seeking treatment.

UT Physicians The UT Physicians THRIVE program is a comprehensive maternal health program being offered

by UTHealth at their Texas Medical Center OB/GYN clinics. One component of the program is project HOPE (Home Outreach for Parent Encouragement), a brief home visitation program for pregnant and postpartum women at risk for PPD. Women are screened multiple times during pregnancy and the postpartum period using the EPDS. Those with EPDS scores indicating the woman is at risk for PPD are seen by a licensed social worker to help her determine if the program is a good fit for her and her family. Once enrolled, social workers will visit the mother in her home 4-5 times within the first 6-months after delivery. The key purpose of these home visits is to complete a curriculum based intervention with women that will help them to identify and work through personal problems in order to alleviate stress and reduce symptoms of depression and to develop good self-care routines. Home visits may also be used to provide resource information and breast feeding support. “By screening often and providing in-home support services to women, our goal is to increase the number of women receiving treatment for PPD by eliminating several of the main barriers to care.”

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Opportunities to Break Barriers & Build Bridges

Recommendations 1. Increase awareness and decrease the stigma associated with PPD and maternal mental health.

The assessment revealed that stigma and lack of knowledge prevent many women from seeking help when they are experiencing depressive symptoms. Many providers reported that moms feel embarrassed that they are experiencing depressive symptoms during a time that is generally perceived as a joyful time in a mother’s life. As a result, more awareness is needed to inform the public on signs and symptoms of PPD, where to get help, and to inform families that PPD is common and treatable. Awareness campaigns should not only target new mothers but also fathers, friends, and extended family members who play a huge role in providing social support to the new mom and undoubtedly influence whether or not the mother seeks treatment.

To increase awareness of PPD, during the 84th Legislative Session, CHILDREN AT RISK is advocating for the establishment of a Postpartum Depression Awareness Month. CHILDREN AT RISK will also utilize its extensive partnerships with television, radio, and print media to educate Houstonians on PPD and maternal mental health.

Initiatives across the Country Washington, California, and New Jersey have implemented the public awareness campaign Speak Up When You’re Down to educate mothers and their families about PPD. The campaign is the result of 2005 legislation in Washington State to increase awareness and educate the community. It is available in 5 languages and is state funded.

In 2002, the Perinatal Foundation in Wisconsin made a multi-year commitment of programmatic and financial resources to address the issue of perinatal mood disorders. The Perinatal Mood Disorders Initiative included the public awareness campaign “You can’t tell by looking”, conferences, action guides, research and collaborative projects to build awareness, promote screening and effective interventions, and support research.

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2. Increase educational opportunities for medical providers that interact with women, children, and families.

The assessment discovered a lack of consistency in the education that healthcare providers receive in regards to PPD. Key stakeholder interviews revealed that while some medical professionals receive adequate training and information on PPD while in school, others were not exposed to any information on PPD during their formal training. Education of medical professionals is needed to ensure that providers are aware of the signs and symptoms of PPD, how to screen patients for PPD, and where to refer patients that screen positive. Education is needed for all types of medical providers who interact with women, children, and families including obstetricians, pediatricians, family medicine doctors, nurses, social workers, and community health workers.

To increase educational opportunities for medical providers, CHILDREN AT RISK supports the inclusion of PPD education in the curricula and licensing exams for medical professionals. If the licensing boards include PPD in their exams, medical schools would be more likely to cover this material in their courses. CHILDREN AT RISK is also supportive of MHAâ&#x20AC;&#x2122;s extensive efforts to educate professionals in the greater Houston area on PPD. MHA has trained over 6,000 professionals on PPD through a 90 minute training which includes information on signs and symptoms, screening protocols, treatment options, and where to refer patients.

Initiatives across the Country Through the Bureau of Family Health within the Iowa Department of Public Health, Iowa has launched the Iowa Perinatal Depression Project, which provides educational opportunities on PPD to medical providers.

The initiative includes a web-based training for physicians to increase the stateâ&#x20AC;&#x2122;s capacity to identify and treat PPD through primary care providers. The state also created and distributed a pocket guide for health care professionals that provides information on PPD treatment, billing, and coding.

Opportunities to Break Barriers & Build Bridges 3. Increase PPD screening and identification The assessment revealed that lack of screening was a major barrier to women receiving appropriate treatment for PPD. Many providers did not screen patients due to lack of time, lack of resources, and lack of information on where to refer a patient who screened positive.

Furthermore, many providers who do screen do so through informal interviews and do not use validated survey instruments.

Because there are some local services available in the Houston community and Mental Health America of Greater Houston is committed to providing resource guides highlighting these local services , CHILDREN AT RISK recommends screening mothers at both the obstetricianâ&#x20AC;&#x2122;s office during pre- and postnatal visits and the pediatricianâ&#x20AC;&#x2122;s office during well-child check-ups with the use of a validated screening tool. CHILDREN AT RISK also supports the screening of PPD through organizations such as WIC that have regular interactions with pregnant women and mothers of children under the age of one.

Initiatives across the Country Both New Jersey and Illinois have enacted legislation that requires physicians, nurse midwives, and other licensed health care professionals to screen new mothers and educate them about PPD. Rhode Island is working to increase screening through the child care and primary care setting. As part of this initiative, child care and primary care professional are trained on how and where to refer parents who screen positive for PPD. For Medicaid recipients in Colorado, PPD screening at well-child visits can be billed under the Medicaid ID of the infant.

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Opportunities to Break Barriers & Build Bridges 4. Increase the number of service providers that are able to care for PPD Although we were able to find providers in the Houston community able to support women and families impacted by PPD, there is an overall shortage of mental health providers in our community and across Texas. To increase the amount of mental health service providers, reimbursement rates for services need to be raised and the types of billable services need to be expanded so as not to prohibit providers from delivering services in ways that will increase participation and acceptability among families. Mental health providers are one of the lowest paid professions when compared to others in the health field.

CHILDREN AT RISK recommends increasing the reimbursement rates and billable services for all professionals providing mental health services as well as the overall compensation for mental health providers specifically. In addition, we support loan forgiveness programs for mental health providers, including: social workers, counselors and therapists, psychologists, and psychiatrists.

Initiatives across the Country In the 83rd legislative session, the state of Texas recognized the mental health shortage through the passage of House Bill 1023 and commissioned a report to solicit policy recommendations to address the mental health shortage in Texas. The report was released in February 2014 and recommends the following strategies to address the mental health shortage: incentivization for workers, expansion of medical education, reconsideration of scope of practice, targeted recruitment of providers, telemedicine, curriculum changes to higher education programs, and expanded training in clinical settings.

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Opportunities to Break Barriers & Build Bridges 5. Address barriers that prevent mothers/families from accessing services.

The assessment revealed that too often once a mother is screened positive for PPD, she does not seek treatment due to a range of factors including difficulty in scheduling an appointment, transportation issues, language barriers, and lack of health coverage.

CHILDREN AT RISK supports innovative models that address these barriers and help mothers access to services, including local programs such as Legacy Community Health Center and Texas Childrenâ&#x20AC;&#x2122;s Hospitalâ&#x20AC;&#x2122;s Center for Children and

Initiatives across the Country Through the Kentucky Department of Public Health, Kentucky is working to bring PPD services to the homes of new mothers through home visiting programs.

The Kentucky Health Access Nurturing Development Services (H.A.N.D.S.) Reach Out project has developed a stepped-care protocol for referral and treatment of women.

Depending on their scores on a selfadministered perinatal depression screening, patients receive targeted care.

Women that offer integrated health services. Other innovative models include telehealth, in which patients receive services over the phone or computer when it is too difficult to get to access services in person, and home visitation programs that include PPD screening and treatment.

Louisiana is using an integrated care model to care for women with PPD in New Orleans. The initiative provides mental health treatment and case management to women, infants, and fathers.

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Opportunities to Break Barriers & Build Bridges

6. Ensure women have access to health coverage to adequately cover PPD treatment.

While the United States has made great strides in the past decade to include behavioral health in health coverage, there are still many mothers with PPD who lack the necessary health coverage for treatment. Specifically, Medicaid currently covers over 35,000 births in Harris County each year, yet these mothers lose coverage 60 days after delivery. Because the onset of PPD can occur anytime in the first year and wait times to be seen by a mental health provider can take up to four months in Texas, many mothers are left without the necessary health coverage to treat PPD. To eliminate this health coverage gap, CHILDREN AT RISK is advocating to change Medicaid coverage eligibility by allow mothers to have access to full coverage for one year after delivery.

CHILDREN AT RISK is currently exploring different avenues to extend coverage including: a Medicaid 1115 waiver, legislation in the 84th Legislative Session, a state amendment plan, and a pilot project through a Medicaid provider.

Initiatives across the Country To increase access to care and health coverage, in North Carolina parents can be seen under their childâ&#x20AC;&#x2122;s Medicaid benefits for the first six visits.

As of 2014, 26 states and the District of Columbia have opted to provide coverage to low-income mothers and families up to 138% of the federal poverty line through Medicaid. This would allow mothers to have coverage before pregnancy and after delivery, without the automatic loss of coverage at 60 days.

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Opportunities to Break Barriers & Build Bridges

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52. Rowan P, Greisinger A, Brehm B, Smith F, McReynolds E. Outcomes from implementing systematic antepartum depression screening in obstetrics. Archives of women's mental health.

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Archives of Womenâ&#x20AC;&#x2122;s Mental Health. 2005;8(2):77-87.

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Appendix A: Separate Focus Group and Interview Analyses Focus Group Analysis: A total of fourteen challenge categories were created across the four focus groups. The groups were then asked to rank the challenge or barrier categories to determine priority in taking action. The top six categories were, in order of their ranking: Education, Stigma, Access to Care, Money/Insurance Coverage, Legislation, and Service Availability. All focus group data were then analyzed to look at the categories across all groups. The following sections detail the findings of the analysis between the groups.

Education Across all four groups education was listed as a challenge of high priority, receiving the most votes in total. In all four groups, inadequate education and awareness was cited as a barrier amongst professionals, new mothers at high risk for PPD, their families, and society at large.

Challenges that pertained to providers focused on the quality of services provided. Participants expressed that lacking education leads to problems with service coordination, timely screening, follow-up evaluations, use of evidence-based practices, resource knowledge, and specific knowledge of PPD. Education was also prominent in the discussion of the root causes of barriers to care, where provider education was seen as a barrier to women accessing services due to lacking training and awareness of resources.

All four groups also expressed barriers to care that stem from the mother and her family having inadequate education and awareness of PPD. Participants cited education/awareness as one of the main reasons for difficulties with 1) recognizing the signs of PPD; 2) knowing where to go for support (“lack of familiarity with resources to get support”), and 3) seeking early intervention/ knowing there are prevention/early intervention options. The importance of education for family members was discussed in two groups; citing education is needed so that the family can provide appropriate support. Participants also discussed the impact of education and awareness on the mother’s self-perception. Examples of participant challenges that were sorted into this sub-category include, “worry about being labeled a bad mom,” “speculation this should be a happy time,” and “mother even identifying that there truthfully is a problemanswering questions or assessments truthfully.”

Lastly, three of the four groups addressed public or community education as a main challenge to PPD awareness. Two of these groups categorized stigma within community education concerns, making a direct link between stigma and education/awareness. The relationship between education and stigma was also evident in the fourth activity where participants brainstormed the root causes of barriers for mothers at high risk or suffering from PPD. Interestingly, only two of the groups created a main category for stigma as a barrier to care; however, stigma ranked second overall as a challenge that should be addressed (behind education). Participants felt that if the community was better educated on mental health and PPD specifically, the stigma associated with PPD would decrease and more women and families would seek services.

Access to Care Access to care was also a highly prioritized barrier to care across all groups, ranking as the third most popular challenge needing attention. Within each group, access to care issues were organized differently. However, this theme was consistent between all groups and concerns of access were found across many categories. For example, “lack of financial resources to access

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Opportunities to Break Barriers & Build Bridges services” was categorized in “Money” in one group and “access to medical evaluations…wait times” was grouped under the category “Patient Centered Care” in another group.

Access to care was expanded in subsequent analysis to include availability of services, which was noted as a main category in three of the four groups. Participants cited difficulty accessing available services, lack of providers with PPD knowledge or specialization, not having facilities for psychiatric care where mother and baby can stay together, and lack of resources available in the community. Other specified challenges related to service delivery systems and the coordination of care, such as complications with follow-up, referrals being made “but doesn’t go anywhere,” and the level of integration of mental health services with obstetric and pediatric services. All groups cited issues with insurance as a challenge to accessing care, with one group addressing concern with continuation of services once Medicaid terminates.

Additionally, factors impacting access to care were found in other categories, including transportation, cost of services, financial issues for families, social support, and language barriers. Within these categories, challenges were further broken down by the setting. The setting of the challenge was either specific to the woman and her family or the provider of services. Challenges that were specific to providers were sorted into access to care, while challenges in these categories that were specific to the woman and her family were put into their own category (Woman/Family Characteristics). The importance of separating the challenges based on setting is because they need to be addressed very differently. The groups’ organization of these challenges together is interpreted as the need for providers to make accommodations and help women and their families overcome challenges to improve access to care. Provider specific concerns impacting access to care cited in the focus groups include: the absence or lack of affordable services, Medicaid acceptance, transportation assistance, “care in her language,” and availability of navigators to help families find services, as well as “having women leave house for services.”

Three of the four groups addressed the causes of access to care challenges, and across those three groups lacking education/training was cited as a root cause to access issues. Specifically, education/training as a root issue was discussed in the following ways: lack of knowledge across the community, provider training, awareness of resources, and knowledge of insurance coverage.

Also related to access to care, all groups detailed root causes that pertained to service delivery, such as: the absence or lacking of prompt services, coordinated care, free resources, in home services, and consideration of logistics.

Woman/Family Characteristics The theme “Women/Family Characteristics” as a barrier was emergent from the analysis.

Within many of the main categories developed during the PLA activities, woman/family specific characteristics were found. These specific characteristics are attributes that would be unique to each individual woman or family and included: socioeconomic status, insurance status (ability to pay for care), transportation, geographic location, childcare needs, work situation, social support, life stressors, culture or language barriers, and mental status (advancement of PPD).

Woman/family characteristics were cited frequently in the data as a root cause of the major challenges impacting the ability of women to receive care. The groups included causes such as: lack of sleep, motivation, perceived urgency or priority of seeking treatment, family

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Opportunities to Break Barriers & Build Bridges relationships (e.g. partner power struggles), and expectations that nothing will change. Barriers that stem from individual characteristics point to the importance of client assessments, which should aid in developing plans to accommodate or bridge these challenges in accessing services.

Policy and Macro-Level Systems Systemic factors appeared with great frequency. Although only half of the groups carved out a category for policy or legislation, systemic challenges were cited by all groups during their discussions of barriers and the root causes. For example, one group sorted “work doesn’t allow for FMLA (family medical leave)” in their financial category.

Insurance coverage alone was ranked fourth of all challenge categories, even before legislation.

Concerns with insurance were grouped by participants under the systemic category as well as in categories of access to care and woman/family characteristics. Additionally, legislation was ranked fifth out of the 14 challenge categories overall as an issue of high priority. The most frequent legislative concerns participants listed were insurance coverage and cost of services, work/leave policy, transportation, and immigration.

Participant opinions on media causing problems for mothers needing care appeared in three of the four groups. Media was identified as a root cause of misinformation, such as focusing on extreme cases, and establishing unrealistic expectations of motherhood.

Analysis of Interview Data The main themes resulting from the interviews were a combination of pre-set categories and emergent categories. Similar to focus groups, access to care, education, insurance coverage, and stigma concerns occurred in the interviews. As many of the interviews were conducted with service providers, service delivery concerns comprised another main category. Utilization was a category that emerged from the data. These categories are further explained in the following sections.

Education Concerns regarding education and awareness were frequently cited amongst interviewees and, much like the focus groups, this need was in reference to professionals, the community, and women and their families. The subject of education occurred in 11 interviews.

While discussing education/awareness of professionals, participants expressed training gaps around resource/referral knowledge, evidence based interventions, and best practices for working with mothers with PPD. One participant offered, “The biggest barriers cited by pediatricians… was lack of knowledge about services for moms that screen positive.”

Participants expressed that they felt education for professionals should address misrepresentations of postpartum mental illness and appropriate medications, so that interventions are optimal for the mother and her family. One interviewee said that in her experience, some obstetricians remove mothers from psychotherapeutic medications while pregnant without providing an alternate treatment for depression. The mothers are then “stuck” because it is difficult to find a new obstetrician mid-pregnancy. Training for PPD has been implemented in a few settings and opportunities for training exist locally, such as Mental Health America of Greater Houston.

Community education appeared in three interviews. The three instances provided a spectrum of experience, from one interviewee noting the need for community education, to a community

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Opportunities to Break Barriers & Build Bridges educator that presents on teen sexuality where PPD is not part of the curriculum, to an agency providing PPD informational materials to the community.

Provision of education to mothers at risk of PPD and their families occurred in 5 interviews.

Although prenatal providers are mandated to provide educational materials to expectant mothers, one interviewee disclosed feeling that this practice was not impactful in the long run.

Mothers should be educated during pregnancy on appropriate expectations and with consistency. One interviewee said, “[PPD] needs to be discussed as much as breastfeeding.”

Also mentioned was the need for family members to be educated on how to support the mother with PPD. Access to Care Discussion of accessing care arose in 11 interviews. Interviewee comments were highly similar to concerns noted by the focus groups. Those interviewed were concerned with the availability of services and barriers due to transportation and language. Data suggest general psychiatrists are uncomfortable treating pregnant women, and there are a limited number of practitioners with expertise treating PPD. Two persons interviewed who have been in practice for a considerable time cited the lack of providers as the largest barrier to care. “There just aren’t enough providers doing this kind of work in Houston. There are only four to five perinatal psychiatrists in our area,” said one interviewee. Another said, “One of the biggest barriers is not having resources for treatment. We didn’t screen as much as I would have liked or as much as was needed because there was nowhere to send them. We couldn’t do anything if they screened positive.

No psychiatrist was readily available.”

Providers such as MHMRA only have the resources to treat severe, chronic cases of mental illness. An additional concern is the lacking availability of provider facilities with higher levels of care, such as supportive inpatient treatment that allows infants to stay with the mothers while in treatment or allow significant visitation. Therefore, women with PPD have difficulty accessing care in private practice due to provider shortages, from local mental health authorities if their symptoms are not severe enough to meet treatment criteria, and have limited to no local options of supportive, intensive treatment.

Additional problems in accessing care stem from transportation. Concerns that were noted include Medicaid buses not allowing other children to accompany the mother, parking costs, and traveling to an unfamiliar place. “We are most successful getting mom into care when the services come to her, which isn’t always the case,” expressed one participant. Another participant commented, “A depressed mom ain’t going nowhere. You have to bring the services to her.”

As stated previously, participants expressed how difficult it can be for a mother to access appropriate care. Language barriers further complicate service acquisition as resources become even more limited.

Insurance Coverage Discussion of insurance or payment for mental health services occurred in 10 interviews. More than half of these pertained to Medicaid. Providers not accepting Medicaid or insurance in general were cited as a barrier to care. Occurring most frequently were concerns with mothers

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Opportunities to Break Barriers & Build Bridges on Medicaid who only have a 60 day window for postpartum care. For mothers suffering from PPD the focus shifts from treatment to transitioning her to another system such as an FQHC. Stigma Stigma appeared in 6 interviews, most of whom cited stigma as a barrier to care. One participant said the following: “Stigma is a huge issue. Moms won’t share their true feelings. There is a lot of judgment and reprimanding by people; even by those who have been through birth before because they don’t remember how they felt, or didn’t feel down after, or they don’t realize what’s going on. This is especially true in the Hispanic culture where there is a lot of pressure to be the mom and care for the baby with a smile on her face.”

Offering a different perspective, another interviewee did not perceive stigma as problematic for her practice. She credited this difference to the integration of medical and behavioral health care and how services were presented to the mother, saying, “sometimes moms don’t even know they were seeing a psychiatrist; they were just seeing someone that could help…We don’t talk about mental health issues but more the symptoms and having extra support for them.”

Service Delivery Aspects of service delivery were discussed the most frequently in interviews, occurring in 19 interviews. This is expected, as individuals working in direct practice were targeted for participation. One of the most enlightening aspects within this category was the range of service delivery models in practice. Participants working within models that have a level of integration between medical and behavioral health care expressed more ease in access to mental health care. For example one interviewee reported obstetricians treating mothers for mental health stabilization, or “crisis management,” in a non-integrated setting; while another interviewee in an integrated setting reported patients are able to flow easily from obstetrics to psychiatry.

Subcategories of Screening, Referrals, and Early Intervention developed through data analysis.

These categories are detailed in the following sections.

Screening. Screening was discussed in 13 interviews. Eight participants disclosed the tool they used for screening; seven of those exclusively used the EPDS and one agency used either the EDPS or the PHQ9. With no standardization of methods the frequency and timing of screening varied. Screening use ranged from early screens in pregnancy to establish a baseline and through the first year postpartum to screening only once and not in an ideal window (e.g. within 2 weeks after delivery when baby blues are most common).

Referrals. The provision of referrals for mental health care is a common practice, as evidenced by discussion of referrals in 14 interviews. However, the effectiveness of referrals translating into a client receiving care remains less clear. Interviewees made comments such as, “leaving it up to the patient hasn’t been working well for me” and “None of them went for depression follow-up during pregnancy.” Also of concern is the likelihood of referrals chains when referrals are made to agencies providing referral services, not direct services, or inappropriate referrals because the mother will not meet criteria for treatment. For example, a mother is referred to MHMRA for psychiatric care; however the mother does not meet MHMRA’s criteria for treatment and is then referred elsewhere.

48

Opportunities to Break Barriers & Build Bridges

Early intervention. This sub-category occurred in three interviews and was expressed as a goal.

“We try to catch mental illness early and do counseling, coaching, etc., so that PPD doesn’t happen and mom is stable before Medicaid runs out,” one participant offered.

Utilization Concerns of mental health care utilization appeared in 10 of all interviews. Participants expressed concerns with low attendance in group sessions, psychiatric care that is underutilized, and, most often, referrals that go unused. Reasons cited by participants for low utilization include: new baby complicating ability to get to care, poor quality mental health care, transportation, lack of integration of care at one location, lack of availability of prompt psychiatric care, and conflicting schedules. One interviewee reported having funding for transportation assistance and while the no show rate was lower than average, it still stood at 25%.

49

Opportunities to Break Barriers & Build Bridges

Appendix B: Map and List of Organizations and Providers of PPD services

Also see www.google.com/maps/d/edit?mid=z3UtuKArDUg8.kn1IT7uT5Kuw Location on Map 1

2

3

Organization

Address

Phone Number/ Website (281) 448-6391

Acres Home Health Center (Harris Health)

818 Ringold St. Houston, TX 77088

Aldine Health Center (Harris Health)

4755 Aldine Mail Route Rd. Houston, TX 77039

(281) 985-7600

Baytown Health Center (Harris Health)

1602 Garth Rd. Baytown, TX 77520

(281) 427-6757

www.harrishealth.or g/en/services/locatio ns/pages/acreshome-healthcenter.aspx www.harrishealth.or g/en/services/locatio ns/pages/aldinehealth-center.aspx www.harrishealth.or g/en/services/locatio ns/pages/baytownhealth-center.aspx

Notes* Private insurance accepted. Based on your household income and residence, financial assistance is available.

Private insurance accepted. Based on your household income and residence, financial assistance is available.

Private insurance accepted. Based on your household income and residence, financial assistance is available.

50

Opportunities to Break Barriers & Build Bridges

Location on Map 4

5

6

7

Organization

Address

Ben Taub Hospital

1504 Taub Loop Houston, TX 77030

1615 North Main St. Houston, Texas 77009

(713) 222-2272

Center for Postpartum Family Health

3418 Mercer Suite 100 Houston, TX 77027 12340 Jones Rd. Suite 100 Houston, TX 77070

(713) 561-3884

424 Hahlo St. Houston, TX 77020 3800 Buffalo Speedway Suite 300 Houston, TX 77098 1712 1St. St. E M20 Humble, TX 77338

(713) 674-3326 www.denverharbo rclinic.org/ (713) 600-1131

412 Telephone Rd. Houston, TX 77023

(713) 660-1880

Cypress Health Center (Harris Health)

Denver Harbor Clinic

9

Depression and Bipolar Support Alliance

11

www.harrishealth.or g/en/services/locatio ns/pages/bentaub.aspx

Casa de Amigos Health Center (Harris Health)

8

10

Phone Number/ Website (713) 873-2000

E. A. “Squatty” Lyons Health Center (Harris Health) El Centro de Corazon

www.harrishealth.or g/es/services/locatio ns/pages/casa-deamigos-healthcenter.aspx www.cpfh.org

(713) 873-5240 www.harrishealth.or g/en/services/locatio ns/pages/cypresshealth-center.aspx

Notes* Private insurance accepted. Based on your household income and residence, financial assistance is available.

Private insurance accepted. Based on your household income and residence, financial assistance is available.

Sliding-scale, based on household income. By appointment only Private insurance accepted. Based on your household income and residence, financial assistance is available.

Medicaid, CHIP, CHIP Perinatal, Medicare, and other insurance accepted Support groups only

www.dbsahouston.o rg/

(281) 446-4139 www.harrishealth.or g/en/services/locatio ns/pages/ea-squattylyons-healthcenter.aspx www.elcentrodecora zon.org/

Private insurance accepted. Based on your household income and residence, financial assistance is available.

Medicare, Medicaid, Children’s Medicaid, CHIP, and CHIP Perinatal and other private Insurances are accepted.

Individuals and families may qualify for a sliding fee scale discount based on income and family size.

51

Opportunities to Break Barriers & Build Bridges

Location on Map 12

Organization

Address

El Centro de Corazon

7037 Capitol St. Houston, Texas 77011

El Franco Lee Health Center (Harris Health)

8901 Boone Rd. Houston, Texas 77099

(281) 454-0500

14

Good Neighbor Healthcare Center (Fourth Ward)

190 Heights Blvd.

Houston, TX 77007

(713) 529-3597 www.gnhc.org/ind ex.html

15

Gulfgate Health Center (Harris Health)

7550 Office City Dr. Houston, TX 77012

(713) 495-3700

16

Hope Clinic

(713) 773-0803 www.hopechc.org

17

Houston Galveston Institute

7001 Corporate Dr. Suite 120 Houston, TX 77036 3316 Mount Vernon Houston, TX 77006

10777 Stella Link Houston, TX 77025 1335 Regents Park Dr. Suite 240, Houston, TX 77058

(713) 592-9292

13

18

19

Inner Wisdom, Inc.

Innovative Alternatives

Phone Number/ Website (713) 660-1880 www.elcentrodecora zon.org/

www.harrishealth.or g/es/services/locatio ns/pages/el-francolee-healthcenter.aspx

www.harrishealth.or g/es/services/locatio ns/pages/gulfgatehealth-center.aspx

(713) 526-8390 www.talkhgi.org

www.innerwisdom.c om/

(832)864-6000 www.innovativealter natives.org/

Notes* Medicare, Medicaid, Childrenâ&#x20AC;&#x2122;s Medicaid, CHIP, and CHIP Perinatal and other private Insurances are accepted.

Individuals and families may qualify for a sliding fee scale discount based on income and family size.

Private insurance accepted. Based on your household income and residence, financial assistance is available.

CHIP, Medicaid, Medicare, and certain types of private insurance Private insurance accepted. Based on your household income and residence, financial assistance is available.

Service area includes 77036, 77072 and 77082.

Services available in 14 languages Fee is $110.00 per fifty minute session. May qualify for sliding scale which is based upon household annual income. Some insurance is accepted.

Accept Medicare and Medicaid.

Counseling services. No psychiatrist on staff

52

Opportunities to Break Barriers & Build Bridges Location on Map 20

21

22

23

24

Organization

Address

Phone Number/ Website (713) 626-7990

InterfaceSamaritan Counseling â&#x20AC;&#x201C; Central Houston (Galleria Area)

4803 San Felipe Houston, TX 77056

InterfaceSamaritan Counseling - North Houston (Spring)

6823 Cypresswood Dr. Spring, TX 77379

(281) 376-8006

InterfaceSamaritan Counseling - West Houston

10221 Ella Lee Ln. Houston, TX 77042

(713) 626-7990

InterfaceSamaritan Counseling -West Houston

1359 N. Mason Rd. Katy, TX 77449

(713) 626-7990

InterfaceSamaritan Counseling - West Houston

700 S. Westgreen Blvd. Katy, TX 77450

(713) 626-7990

interfacesamaritan.org/

interfacesamaritan.org/

interfacesamaritan.org/

interfacesamaritan.org/

interfacesamaritan.org/

Notes* Several insurance companies and employee assistance plans accepted; Adjusted fees, depending on household income and number of dependents in the household.

Several insurance companies and employee assistance plans accepted; Adjusted fees, depending on household income and number of dependents in the household.

Several insurance companies and employee assistance plans accepted; Adjusted fees, depending on household income and number of dependents in the household.

Several insurance companies and employee assistance plans accepted; Adjusted fees, depending on household income and number of dependents in the household.

Several insurance companies and employee assistance plans accepted; Adjusted fees, depending on household income and number of dependents in the household.

53

Opportunities to Break Barriers & Build Bridges Location on Map 25

26

27

28

29

30

31

32

Organization

Address

Phone Number/ Website (713) 686-8241

InterfaceSamaritan Counseling – Northwest Houston

2003 W. 43rd St. Houston, TX 77018

Jewish Family Services

4131 South Braeswood Blvd.

Houston, TX 77025

(713) 667-9336

Krist Samaritan Center

17555 El Camino Real Houston, TX 77058

(281) 480-7554

Legacy Community Health Services – Lyons

5602 Lyons Ave. Houston, TX 77020

(832) 548-5400

Legacy Community Health Services – Montrose Campus

1415 California St. Houston, TX 77006

(832) 548-5100

Legacy Community Health Services Baker Ripley

6500 Rookin St. Bldg. B Suite 200 Houston TX, 77004

(713) 351-7350

Legacy Community Health Services – Mapleridge

6550 Mapleridge St. Suite 106 Houston, TX 77081

(713) 779-7200

Legacy Community Health Services Bisssonnet

12667 Bissonnet St. Houston, TX 77099

(281) 498-6100

interfacesamaritan.org/

www.jfshouston.org/ counselingservices.p hp

www.samaritanhous ton.org/

www.legacycommun ityhealth.org/

www.legacycommun ityhealth.org/

www.legacycommun ityhealth.org/

www.legacycommun ityhealth.org/

www.legacycommun ityhealth.org/

Notes* Several insurance companies and employee assistance plans accepted; Adjusted fees, depending on household income and number of dependents in the household.

Accept private insurance, Medicaid/Medicare or self-pay on a sliding scale.

Accept private insurance and if no insurance, sliding scale fees based on income and number of people in household.

Accept Medicaid, CHIP and most private insurance plans. Sliding fee scale available for all services.

Accept Medicaid, CHIP and most private insurance plans. Sliding fee scale available for all services.

Accept Medicaid, CHIP and most private insurance plans. Sliding fee scale available for all services.

Accept Medicaid, CHIP and most private insurance plans. Sliding fee scale available for all services.

Accept Medicaid, CHIP and most private insurance plans. Sliding fee scale available for all services.

54

Opportunities to Break Barriers & Build Bridges Location on Map 33

34

35

36

37

38

39

40

Organization

Address

Phone Number/ Website (832) 548-5300

Legacy Community Health Services â&#x20AC;&#x201C; Southwest Clinic

6441 High Star Dr. Houston, TX 77074

Legacy Community Health Services Baytown

6730 Independence Blvd. Baytown, TX 77521

(281) 628-2020

Legacy Community Health Services San Jacinto

4301 Garth Rd. Suite 400 Baytown, TX 77521

(281) 420-8400

Martin Luther King Jr. Health Center (Harris Health)

3550 Swingle Rd. Houston, TX 77047

(713) 547-1000

MHMRA of Harris County

1502 Taub Loop Houston, TX 77030

(713) 970-7070

Northwest Health Center (Harris Health)

1100 West 34th St. Houston, TX 77018

(713) 514-1107

Spring Branch Community Health Center - Hillendahl Clinic

1615 Hillendahl Blvd. Suite 100 Houston, TX 77005

(713) 462-6565

Spring Branch Community Health Center - Pitner Clinic

8575 Pitner Rd. Houston, TX 77080

(713) 462-6545

www.legacycommun ityhealth.org/

www.legacycommun ityhealth.org/

www.legacycommun ityhealth.org/

www.harrishealth.or g/es/services/locatio ns/pages/martinluther-king-jr-healthcenter.aspx mhmraharris.org/

www.harrishealth.or g/en/services/locatio ns/pages/northwesthealth-center.aspx www.sbchc.net/inde x.asp

www.sbchc.net/inde x.asp

Notes* Accept Medicaid, CHIP and most private insurance plans. Sliding fee scale available for all services.

Accept Medicaid, CHIP and most private insurance plans. Sliding fee scale available for all services.

Accept Medicaid, CHIP and most private insurance plans. Sliding fee scale available for all services.

Private insurance accepted. Based on your household income and residence, financial assistance is available.

Uninsured or Medicaid only; severe cases only Multiple locations Private insurance accepted. Based on your household income and residence, financial assistance is available.

No private insurance for behavioral health, with possible exceptions. Cost per visit is $30-65 depending on income and family size.

CHIP Pre-natal accepted.

No private insurance for behavioral health, with possible exceptions.

CoSt. per visit is $30-65 depending on income and family size. CHIP Prenatal accepted.

55

Opportunities to Break Barriers & Build Bridges

Location on Map 41

42

43

44

45

Organization

Address

Strawberry Health Center (Harris Health)

927 Shaw Ave. Pasadena, TX 77506

Texas Childrenâ&#x20AC;&#x2122;s Pavilion for Women

6621 Fannin St. Houston, TX 77030

University of 2700 Bay Area Houston Clear Lake Blvd.

Houston, TX 77058

Phone Number/ Website (713) 982-5900

Notes*

www.harrishealth.or g/en/services/locatio ns/pages/strawberry -health-center.aspx

(832) 824-1000 women.texaschildre ns.org/

(281) 283-3330 www.uhcl.edu/porta l/page/portal/HSH/H OME/CENTERS_INSTI TUTES/PSYC_SC

Vallbona Health Center (Harris Health)

6630 De Moss Dr. (713) 272-2600 www.harrishealth.or Houston, TX g/en/services/locatio 77074

The Woman's Hospital of Texas

7600 Fannin St. Houston, TX 77054

ns/pages/vallbonahealth-center.aspx

(713) 790-1234

Private insurance accepted. Based on your household income and residence, financial assistance is available.

Medicaid and private insurance accepted.

Offers services on a sliding scale basis. The intake appointment is free of charge and includes an assessment and meeting with an intake specialist.

Private insurance accepted. Based on your household income and residence, financial assistance is available.

Support groups only

womanshospital.com / *Insurance acceptance and other notes were obtained from agency websites and/or by directly speaking to the organization. These are subject to change. Please check organizational websites for most up-to-date information. **This is not an exhaustive list of services. Other providers and services may exist in the Houston area.

Location on Map 46

Private Providers

Address

Phone Number/ Website

Margaret Basu, MD

(713) 533-4363

47

Nettie Jones, MS, LPC

48

Sandhya Prashad, MD

49

Lindsay Raymer, MD, PA

2211 Norfolk St Suite #628 Houston, TX 77098 4501 Cartwright Suite 705 Missouri City, TX 77459 5420 W Loop S Fwy #2100 Bellaire, TX 77401 920 Frostwood Dr Suite 6700 Houston, TX 77024 4545 Bissonnet St. #265, Bellaire, TX 77401

50

Rhoda Seplowitz, MD

(832) 462-7009

(832) 436-4055 www.sprashadmd.com

(832) 377-7792 www.lindsayraymermdpa.com

(713) 432-0200 www.rhodaseplowitzmd.com

56