Skip to main content

Postpartum Depression Program Ups Access, Chips Away at Stigma

 |  By  
   September 17, 2015

Parkland Health and Hospital in Dallas is seeing such promising results from a mental health demonstration project, that it could be a model for other systems that care for a low-income, high-need population.

The stigma that mental health carries can often overwhelm a patient to inaction.

Couple that with a shortage of mental health workers, and you have a confluence of issues that perpetuate inattention to a pressing need that is not going away. Unfortunately, few hospital systems are investing in the mental and behavioral health needs of patients. The need is great for licensed clinical social workers, psychiatrists, and psychologists.

But one of the country's largest public hospital systems, Dallas-based Parkland Health and Hospital is seeing such promising results from a demonstration project, that it could be a model for other systems that care for a low-income, high-need population.

Parkland's program is aimed at identifying and treating women with postpartum depression. Instead of waiting for a patient to self-identify as possibly having PPD, each woman is screened for PPD at her two-week postpartum checkup. If the mother's PPD screening scores indicate a need for further mental health services, the patient is referred to a mental health counselor who is onsite at the clinic.

Mietra Doty, MD

Parkland has 10 women's health clinics, and there are counselors at five Parkland clinics now. By September 2016, officials say nine of the clinics will have an onsite counselor.

PPD is an issue Parkland has been paying attention to, but its previous methods just weren't working.
"We had a system of referrals to see these patients, but it wasn't very efficient" says Mietra Doty, MD, a board-certified adult psychiatrist at Parkland who sees women with PPD. "It would take a couple of months to get in, and I noticed a high rate of no shows."

Parkland officials estimate that as many as 2,000 women in its system experience PPD, which can not only endanger the health of the mother but also the health and well-being of the child.

"Babies will feel the stress of the mom," says Jackie Juarez, MSW, LSCW, a counselor at Parkland's Oak West Women's Health Center. "There may not be much eye contact, they may be fussy, or crying a lot, but once a mom starts to engage in therapy and gets help, the baby's behavior improves."

'Curbside Consults'
Juarez is also a resource for the providers at the clinic where she is co-located. She says it's not unusual for a physician to knock on her door and ask for a quick opinion on a patient mid-appointment.

"We are a resource for providers in the moment," she says. "I call them curbside consults."

These "curbside consults" have helped providers understand the unique cultural needs of patients at Oak West where Juarez estimates about half of the patients are Hispanic and often need a Spanish speaker.

All of the counselors Parkland has hired for this program are bilingual, though it is not a requirement. Still, Juarez says, understanding the Hispanic culture and being able speak their language helps overcome one of several barriers with patients.

"There is a stigma, especially within the Hispanic population, associated with counseling and medication," says Juarez.

One of Juarez's patients, 26-year old Lupe Solis, puts a finer point on it during a follow-up appointment with Juarez. "Most of them don't believe depression exists," says Solis. She has been seeing Juarez for five months for depression and anxiety. Solis was referred to Juarez after receiving a high score on her the PPD screening at her two-week PPD checkup. Solis met Juarez initially, then after an hour-long appointment, Juarez referred Solis to Doty for medication.

This new referral process—sending a patient to a mental health counselor on-site first, then having the counselor determine if a higher level of care is needed (an appointment with Doty)—has improved Doty's no-show rates and her patients' engagement with their care.

"The no-show rate is now at 50%," says Doty. It is high, but has improved significantly with only half of the mental health counselors who are slated to be hired over the next year. "When they see me, they know what to expect and what I can do for them. They're much more open to my treatment recommendations."

Solis says she's seen Doty about once a month to evaluate her medication dosage, and sees Juarez about once every two weeks. During the appointment I was generously allowed to observe, Solis told Juarez that she feels like her depression is getting worse.

"I'm really stressed out from moving. I think the pressure is coming back," she tells Juarez. "I'm always tired. I could sleep all day long."

Juarez and Solis talk for about 30-minutes, the average length of her follow-up sessions with patients. As Solis explains the stress she feels from dealing with a family member who doesn't believe her mental health issues are real, Juarez nods her head in agreement. It's a small but important gesture that shows Juarez understands the unique family dynamic.

"There is a lot of family judgment in the Hispanic culture," says Juarez. "There is also a lot of self-judgment. The patients may think, 'I'm not normal.' "

During the appointment Juarez also administers a GAD-7 (for anxiety) and a PHQ-9 (for depression) screening. Solis scores in the normal range for anxiety, but higher for depression.

The scores prompt Juarez to call Doty's office to get Solis worked in for an appointment sooner than the one Solis has scheduled for October. Doty's number is on a well-worn bright yellow sticky note taped to the bottom right of her computer screen.

While Juarez calls Doty's office, Solis waits patiently, showing me pictures of her son Andy, and her 5-year-old daughter, Jocelyn.

"Nothing is more important to me than my son's health, my daughter's health, and my health, she tells me. "I really think this program has really helped me. When I first started coming, I couldn't even stand still. I look forward to coming here. I feel more relaxed because I said everything I needed to say."

Funding and Future Plans
The PPD program at Parkland is one of 22 funded though what's known as the Section 1115 waiver, which is federal money meant to offset the costs of uncompensated care hospitals deliver and improve access to care.

The waiver expires next September, but Christina Mintner, a vice president who oversees Parkland's 1115 Waiver program, says the state of Texas, one of more than a dozen states that didn't expand Medicaid, has asked CMS for a five-year extension of the waiver..

"It's crucial to the infrastructure of our health system for Medicaid and [the] uninsured population to have the waiver extension granted," she says.

Jacqueline Fellows is a contributing writer at HealthLeaders Media.

Tagged Under:

Get the latest on healthcare leadership in your inbox.