Contra Costa County in California has approximately 1,049,000 residents. The target population for this project is all low-income young families enrolled in the WIC Program. The WIC Program in Contra Costa County provides breastfeeding and nutrition education as well as checks for purchasing healthy foods to 22,000 low income pregnant women, infants and children under five years old. Because of the nutrition education and the economic incentive ($60-$110 per participant for families enrolled on WIC), more than 50% of families with infants and 25% of families with children under 5 participate in WIC throughout the U.S. The high volume of low income young families enrolled in WIC makes it an ideal setting for screening, education and referrals for perinatal depression/anxiety. Depression and anxiety are common medical problems that pregnant women and new parents face. Lower income women can be especially vulnerable to depression and anxiety.
Contra Costa Health Services
WIC Perinatal and Intra-Conception Depression and Anxiety Program
Contra Costa County in California has approximately 1,049,000 residents. The target population for this project is all low-income young families enrolled in the WIC Program. The WIC Program in Contra Costa County provides breastfeeding and nutrition education as well as checks for purchasing healthy foods to 22,000 low income pregnant women, infants and children under five years old. Because of the nutrition education and the economic incentive ($60-$110 per participant for families enrolled on WIC), more than 50% of families with infants and 25% of families with children under 5 participate in WIC throughout the U.S. The high volume of low income young families enrolled in WIC makes it an ideal setting for screening, education and referrals for perinatal depression/anxiety. Depression and anxiety are common medical problems that pregnant women and new parents face. Lower income women can be especially vulnerable to depression and anxiety. In Contra Costa County, 22% of all pregnant and parenting women enrolled on WIC screened positive for mild to severe depression using the PHQ4 (Patient Health Questionnaire) screening tool.
Project Goals and Objectives:
Goal 1: Pregnant, postpartum and parenting women will be systematically screened for depression and anxiety at WIC.
During WIC enrollment or recertification appointments, 80% of pregnant or parenting WIC clients will be screened for depression and anxiety, using a validated screening tool.
Goal 2: Women who screen positive for depression or anxiety will improve their PHQ4 scores during subsequent WIC visits due to WIC provision of referrals, classes and educational materials.
Sixty percent of pregnant and parenting WIC clients that screen moderate-severe on PHQ4 screening tool will seek and/or receive help for depression or anxiety.
Sixty% will report feeling better at subsequent WIC visit)
Goal 3: Organize a coalition to build a network of sustainable mental health, public health, community and faith-based support for families experiencing depression and anxiety.
Coalition will develop a mission statement, resource guide and a county-wide plan (logic model) to address the needs and gaps in service for families experiencing depression and anxiety.
Coalition will provide expert guidance in the development of educational materials. 3. Coalition will apply for additional grant funding to address the needs and gaps in service for families experiencing depression and anxiety.
Goal 4: Train WIC Staff, Public Health Nurses, Physicians, and Social Workers to support young families experiencing depression and anxiety.
Provide live, audio and on-line education for health and community professionals working with families experiencing depression and anxiety.
The Contra Costa WIC Perinatal and Intra-Conception Depression and Anxiety Program started in April, 2009 with a Special Project Grant funded by the California State WIC Program. The $90,000 grant was leveraged by in-kind time donated by the many professionals represented in the Perinatal Depression to Wellness Network (PDWN). Physicians, social workers, therapists, nurses and community leaders participated actively in the development, testing and evaluation of the project.
Over 30,000 families (duplicated count) were screened for depression or anxiety at all WIC sites throughout the County in the first year of grant funding, approximately 2,000/month in the second year. Classes, educational materials, brochures, referral lists, and a referral system were developed and implemented. Five hundred health and social service providers and WIC staff were trained during the grant period. An additional 350 staff/providers have been trained this year (2011). All goals and objectives were met during the grant period, but continued training and quality assurance checks will be important to sustain the high quality screening and services.
Uncovering issues causing depression and anxiety can be difficult for staff. WIC staff needed training and a good referral system to feel they had the resources to help the clients. Quality assurance chart reviews and continued staff training and support are important to maintain high quality services. The WIC Program in partnership with coalition members is the strength of the program. When WIC uncovered the need for support in the area of perinatal depression, mental health, clinical services and public health nursing mobilized to meet the needs of our population. Mental Health has since received an innovation grant to expand its services to this population at one site in the county. Several counties in California and the State of Oregon have expressed interest in adopting our materials and model. Materials and training programs have been posted on our website.
Untreated depression can negatively affect not only the woman, but also the whole family. Pregnant women who experience depression or anxiety may be at risk for increased/decreased weight gain, preterm labor, and irregular access to health care. Depressed or anxious women with babies or young children may have difficulty bonding with their children. Babies and children of depressed or anxious parents are at risk of neglect and/or abuse and may have more problems in school. Depressed parents are less likely to follow guidelines for routine health check- ups, nutrition and safety. Not all depressed or anxious clients look or act depressed. Routine screening significantly improves detection of perinatal depression. Low rates of recognizing and treating perinatal depression may be attributed to the failure of systemized screening of pregnant women and new parents for depression and anxiety. Barriers to systematic screening for depression and anxiety can include lack of time, inadequate training of health professionals for screening and education as well as inadequate resources for treatment.
A literature search indicates that targeting pregnant women and mothers of young children for depression screening, especially during the postpartum period, has been a primary depression screening focus according to a recent report from the National Academy of Sciences, especially since the emergence of such depression can impact both parenting and child development. (National Research Council and Institute of Medicine of the National Academy of Sciences, Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment and Prevention, 2010, www.nap.edu/catalog/12565.html). Most adults with depression do not get treated for it. Kessler’s large epidemiological study revealed that less than 1/3 of adults with major depression have accessed general medical or specialty emotional or mental health outpatient services in the previous year (Kessler, RC, Zhao, S, Katz, SJ, Kouzis, AC, Frank RG, Edlund, M, and Leaf, P. Past-year use of outpatient services for psychiatric problems in the National Comorbidity Survey, American Journal of Psychiatry, 1999, 156: 115-123). The one-third of adults with major depression who do get treated use a variety of alternative points of contact and entry, noteworthy given the Contra Costa County WIC Perinatal Depression Project (Kessler RC, Merikangas KR, and Wang PS. Prevalence, comorbidity and service utilization for mood disorders in the United States at the beginning of the twenty-first century, Annual Review of Clinical Psychology, 2007, 3: 137-158).
This project suggests that routine screening for depression and anxiety for all WIC prenatal and postpartum clients and parents of children under five, using a validated tool, can identify clients that need further assessment. Educating/counseling clients about anxiety and depression can help them feel more comfortable and more willing to seek help, if they need it. Building a coalition and a system of referral as well as training physicians and other health and community professionals about perinatal and intra-conception depression and anxiety will support women that need treatment.
Through a literature search we attempted to determine the degree to which physicians screen for maternal or perinatal depression. It appears that the use of written depression screening tools is still fairly rare. Many doctors report that they use observation or brief inquiries instead of written tools during patient visits; this is especially true during child wellness visits (National Research Council and Institute of Medicine of the National Academy of Sciences, Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment and Prevention, 2010, www.nap.edu/catalog/12565.html). According to the experience shared by members of the Contra Costa County Perinatal Depression Coalition, some perinatal depression screening was a practice at some doctors’ offices and clinics, but it was not systemized or widespread.
Routinely screening for depression, using a validated screening tool at a WIC site is a new and innovative practice. Since the pilot project, Contra Costa County WIC routinely screens all prenatal, postpartum women and parents of WIC children. Untreated depression may not go away without support or treatment. It is important to keep screening for depression not only during the perinatal period, but also for several (intra-conceptual) years after the birth of a child to prevent missing undiagnosed depression among parenting-age women. A second innovation is the WIC partnership with public health nursing, mental health and the coalition of community health professionals to address the needs of WIC clients and parents experiencing depression/anxiety. This partnership has since been expanded in a new innovation grant. Mental health and public health nursing will be co-located at one of our WIC sites to directly serve women in need of further assessment and treatment of depression. This will circumvent the “stigma” or apprehension of some families going to mental health clinics when they need support/treatment for depression or anxiety.
The primary stakeholders in the development and implementation of this project are the Contra Costa County Departments of Public Health (WIC, Public Health Nursing, Maternal and Child Health), Mental Health, Clinic Services, the Crisis Hotline and 211 services, Early Childhood Mental Health Services, First 5 of Contra Costa, Planned Parenthood, faith-based and other community service partners.
Role of Stakeholders/Partners
The role of the stakeholders was to plan, implement, and evaluate the perinatal depression project. The stakeholders have met on small working committees to develop the logic model, the overall plan for the project, critique the educational materials, select the screening tools, create the resource lists, as well as discuss and plan the evaluation. The whole project was guided by the Perinatal Depression to Wellness Network (PDWN).
The Contra Costa County health department has been the key to spearheading interest and enthusiasm for community leaders and public health to work together to address the issue of perinatal depression. The health department has provided time, leadership and resources to identify the problem of perinatal depression in our community, develop a plan and coordinate services and to meet the needs of women suffering from perinatal depression and anxiety.
The Contra Costa County health department has been the key to spearheading interest and enthusiasm for community leaders and public health to work together to address the issue of perinatal depression. The health department has provided time, leadership and resources to identify the problem of perinatal depression in our community, develop a plan and coordinate services and to meet the needs of women suffering from perinatal depression and anxiety. The health department fosters cooperative relationships between departments by communicating the vision and a common purpose to improve the health of families in Contra Costa County.
There are many faces of depression and anxiety. Poverty, mental illness, hormonal changes, biological changes, genetic predisposition, stress in relationships are just a few factors affecting the emotional well-being of our WIC families. It takes a collaborative effort to provide support to the individual affected by depression and anxiety as well as the staff helping the individual. The coalition provides the building blocks for a multi-faceted effort to address the identification and support for perinatal and parenting depression and anxiety. Physicians, social workers, nurses, WIC staff, faith-based organizations and community organizations all need to work together to make a difference for families. At first we were only going to work with families in the “Perinatal” period—pregnancy to 1 year after the child was born. We found that 30% the women started feeling depressed and/or anxious during pregnancy, 19% after pregnancy and before the child was one year old. We found that half of the women had been depressed outside that the perinatal depression timeline. Since depression or anxiety may not improve unless treated, it is important to screen all vulnerable women with young children often, not just during the “perinatal” timeframe.
1. 2008. Maternal and Child Health in the department of health in Contra Costa County coordinated a workshop on perinatal depression that spearheaded community action to identify and address the problem. The Perinatal to Depression Coalition (comprised of health professionals and community service partners working with low income parenting women) was formed.
2. 2009. WIC received Special Grant Funding to screen, educate and refer clients for perinatal depression.
3. 2009. The Perinatal Depression to Wellness Coalition reviewed and selected a screening tool that was appropriate for the needs of the WIC clients. The PHQ9 was initially used, then after testing that instrument for several months, WIC found the PHQ4 to be more appropriate for WIC.
4. 2009-present. WIC screened all clients and parent of children at each high risk, recertification or enrollment appointment.
5. 2009. Staff protocols were developed for how handle positively screened WIC clients.
6. 2009. The Perinatal Depression to Wellness Coalition developed a resource guide for women who screened positive for depression/anxiety.
7. 2009- present. Implement a referral system with public health nursing, mental health access line, the crisis hotline and other agencies for positively screened WIC clients.
8. 2009. Educational brochures, referral lists, classes were developed, (reviewed by subject-matter experts and the coalition) then implemented at all WIC sites.
9. 2009-present. WIC teaches a mini-class on depression and anxiety at infant and prenatal classes.
10. 2009-present. WIC staff, health and community professionals were trained in perinatal depression and anxiety.
The project activities started in November, 2008 and are continuing to present.
Process & Outcome
Feedback from Outside Evaluator, Elaine Zahnd, PhD: Screening for perinatal depression using a standardized validated instrument at WIC classes and appointments is feasible and effective as shown by the pilot, however, ideally screening should be undertaken at all phases of prenatal and perinatal care, and a uniform instrument should be adopted countywide. With a move toward such adoption, all providers would have the same scoring system, the same definitions of risk, and the same protocol of how to address perinatal depression. Women with perinatal depression could be tracked and monitored throughout their pregnancies and beyond, and receive the help they need without ever slipping through the cracks due to a somewhat segmented system. Communication and coordination throughout the system continues to enhance the ability of staff to respond to perinatal depression, and assist in providing intense attention to those women with moderate to severe depression early in their pregnancies as well as early in their infant care and parenting years.
• Working closely with the county mental health department needs to be expanded to ensure that more referrals and counselors are available immediately upon identification of a woman with perinatal depression. Having a MH counselor on site at all WIC locations would be ideal, although a difficult challenge given fiscal challenges.
• Having the depression screeners handed out in a class or at specific appointments would ensure that women with high risk scores would have someone to follow-up immediately to help them reach out for needed mental health services. Having the Public Health RN available on site to handle the high risk women would also prove beneficial.
• Staff and clients both benefitted from the pilot project, and continuing to identify women at this stage (WIC) is highly recommended. When WIC staff was asked how much WIC clients benefited by the WIC Prenatal and Parenting Screening, Education and Referral Project, 77% staff indicated that the program was “Very important”. No one felt it was “Not important”; 23% thought it was “Somewhat important”. Asked to comment, one staff member stated: it is important… “because of the population we serve – it (WIC) is an ideal place (i.e., …for screening for perinatal depression. Another staff person added, “Thank you so much for starting this project. It is difficult but has been invaluable.”
• Continued training is be helpful for staff at various periods so that they can share ideas of how to resolve problems that arise. Some private space to move to when clients breakdown or are upset would also be helpful. Nutritionists are not trained as mental health counselors, so ways to help bridge this gap by more mental health trainings would increase their skills and confidence.
• Finally, continuing to use the Contra Costa Perinatal Depression to Wellness Network as a resource is beneficial as the pilot project moves into a more permanent aspect of WIC services in the future. As the Network notes in their Vision/Mission Statement: “We recognize that the incidence of perinatal mood disorders is especially high in Contra Costa communities because of inequities in health, the stressors of poverty, unequal access to health care, isolation, substance abuse, domestic violence, racism and the scarcity of effective resources to address these issues. …and through our efforts we will strengthen, link, and provide screening, prevention, intervention and referral services to promote wellness.”
Objective 1: At least 80% of Pregnant, postpartum and parenting women enrolled on WIC will be systematically screened for depression and anxiety. Monthly chart reviews indicate that in September 2011, 93% of women certified or enrolled on WIC were screened for perinatal depression/anxiety using the PHQ4. In some clinics, there was 100% compliance. Continuous monitoring and training will maintain the high quality of compliance and service. Goal 2. Women that screen moderate to severe on the PHQ4 (> 6) for depression or anxiety will seek and receive help, and improve their PHQ4 scores during subsequent WIC visits.
Objective 2: Atleast60% of women who screen positive for depression or anxiety will improve their PHQ4 scores during subsequent WIC visits due to WIC provision of referrals, classes and educational materials. Performance Measures: During the grant period,, initial screen forms collected during the month of April, 2011 were compared to a follow-up screening collected by phone approximately 3 months later for clients scoring 6 and above on the initial screening form. WIC participants who made in-person visits to the WIC Nutritionists/WNAS for certifications in Richmond, Concord, Brentwood and Pittsburg sites during the randomly selected month of April 2011 were screened by WIC staff using the Patient Health Questionnaire (PHQ-4) measure The time frame that the PHQ-4 covers is “over the past two week period” to assess if the client was experiencing symptoms of nervousness or anxiety, extreme worry, disinterest in doing things, or feeling down or depressed, and the frequency of those symptoms. Suicide ideation and interpersonal violence are addition questions included in the screener and addressed. PHQ-4 Scoring: The client can score from 0 (“not at all”) to 3 (“nearly every day”) on each of the PHQ-4 questions for a score that ranges from zero to 12 (see Exhibit 2). A total score of 3-5 indicates “mild depression/anxiety” while a score of 6-8 indicates “moderate depression/anxiety” and a score of 9 or above indicates “severe depression/anxiety”. WIC staff followed a set protocol that outlined what they should do for each WIC client depending on the client’s score on the PHQ-4. In addition to providing at-risk clients with educational materials and referrals, they recorded whether the client was in therapy or on medication. Follow-Up Screening Process and Response Rates: Three months after the April 2011 WIC sample was initially screened, and directed to services depending on their perinatal depression/anxiety risk level, WIC staff began the follow-up survey and screening process for the grant period. Only clients with scores of 6 and above were contacted for follow-up.
The protocol involved WIC staff attempting three times to reach them on the telephone to administer the follow-up screening survey during the follow-up period (July-early August 2011). WIC staff achieved a response rate of 58.3% ( 81 out of 139 clients) for those women initially screening with a score of 6 or above (moderate to severe depression/anxiety). Of the 81 women, one turned out to be a grandmother, aged 59 years, who was not a WIC client but was accompanying her daughter at the time of the interview; given that she did not fit the project protocol, her case was removed from the analysis so the total sample size of “moderate to severely depressed” group was 80. The WIC Follow-Up Questionnaire was designed jointly by senior level WIC staff and the evaluator, and went through a number of revisions until finalization. The follow-up questionnaire also went through a pilot test, after which further revisions were made. The results the overall improvement in scores for the “moderate to severe depression/anxiety” group of 80 women indicated that 81% improved their PHQ-4 scores at follow-up. The results for the 80 follow-up clients regarding whether they sought and received help for their perinatal depression/anxiety indicated that 62.5% they sought/received help. Although 30 of the women who initially had moderate to severe depression/anxiety did not seek or get any help, half of them (n=15) had better emotional health three months after their initial screening. Of note, at the initial screening, some of these women may have been receiving counseling, seeing their physician, or on medication for their depression/anxiety, and therefore may not have felt the need for further assistance at that time despite the level of their depression/anxiety. Among the 65 women with improved scores at follow-up, 39 got help (60%). Of the small number of women who had the same score at follow-up (n=7), 71.4% got help, and of those with a worse level of depression/anxiety (n=8) at the three month follow-up, 62.5% got help. Complete evaluation results can be found on our website: http://cchealth.org/services/wic/
Objective 3: Organize a coalition to build a network of sustainable mental health, public health, community and faith-based support for families experiencing depression and anxiety. The Perinatal Depression to Wellness Network (PDWN Coalition) was convened to identify and address the needs and gaps in service for families experiencing depression and anxiety. Evaluating their effectiveness over the past several years is best by summarizing their accomplishments: 1. Recruited members from health care, social, faith-based and community services to participate in identifying and addressing the needs of families experiencing depression and/or anxiety. 2. Developed a mission statement, resource guide and a county-wide plan (logic model) to address the needs and gaps in service for families experiencing depression and anxiety. 4. Provided expert guidance in the development of educational materials. 5. Applied for additional grant funding to move this innovative platform further.
Objective 4: Train WIC Staff, Public Health Nurses, Physicians, and Social Workers to support young families experiencing depression and anxiety. The goal was met during the grant period by coordinating producing live, audio and on-line education for health and community professionals working with families experiencing depression and anxiety. These trainings can be accessed on our website: http://cchealth.org/services/wic/
TRAINING RESULTS: The perinatal depression project was successful in meeting our goal by holding 10 WIC training sessions from April 30, 2010 through September 28, 2010. A total of 239 people attended the sessions led my Caroline Cribari, MD, PhD, a Stanford-trained physician specializing in reproductive mental health, and Pec Indman, EdD, MFT, PA, a psychotherapist specializing in reproductive mental health. Dr. Cribari was formerly the chief of psychiatry at El Camino Hospital. Dr. Indman is chair of the postpartum support international education/training committee. In addition, two trainings were held at the end of August and in September, specifically on August 31, 2010 a training of WIC Bay Area Staff was conducted with approximately 190 attendees, and the other was held on September 17, 2010 for 75 early childhood therapists and nurses. With the completion of those trainings, over 500 individuals were trained during this project. In April, 2011 an additional 350 people were trained in Sacramento during a Breastfeeding Peer Counselor symposium. The trainings focus on sessions covering “Perinatal depression and mother/infant/child attachment issues” as well as “How to screen and refer WIC clients for perinatal depression”. Regarding the need for more support or training for the Perinatal Depression project, the majority of the 28 staff who completed the Staff Survey reported that they were adequately trained . Approximately 2/3 of the respondents felt that they do not need more support or training (64%), while over 1/3 do feel they could benefit from additional training and support.
WIC in partnership with public health nursing and mental health is the primary stakeholder in this project. WIC has been successful at maintaining its funding in Congress due to its record on lowering the health care costs of pregnant women, infants and children by providing healthy foods, nutrition and health education and referrals to services for prenatal and parenting women. With a little extra effort, WIC has been able to screen and educate women for perinatal depression and anxiety, then refer them for additional services as needed. This is in keeping with the WIC’s mission to improve the health and well-being of pregnant and postpartum women, infants and children. Keeping the screening tool short (even making it shorter) will improve the likelihood of sustaining the screening program at WIC. Partnering with public health nursing and mental health to assess and treat the clients we screen is essential for sustainability. Finally, the Perinatal Depression to Wellness Network (Coalition) can reach higher levels of participation and support in evaluating progress and will help in offering new ideas and innovations for the project as well as building community support, all of which will improve the success and sustainability of the project.
One of the best ways to sustain the program would be to streamline the screening by adding the screening questions for depression and anxiety to the statewide program for clients enrolling and recertifying on WIC. We are collecting data and advocating for that step to happen when the WIC revises their computer program in the future.