MD Perspectives
Mental Health Matters
MENTAL HEALTH MATTERS
Screening for, and Treating, Postpartum Depression
Child Abuse Prevention
National Drug and Alcohol Facts
Mental Wellness Month
Screening for Depression
Postpartum Depression
Antidepressant Medication Regime Adherence
Patients Living With Dementia
Pride Month
Mental Well-Being Event
Prescribing for Children
Here to Help
Kelly McGuire MD, MPA
Medical Director, Psychiatry
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Screening for, and Treating, Postpartum Depression
In observance of Maternal Mental Health Week (April 29 to May 5), I would like to remind you of the importance of screening for adults who may have postpartum depression (PPD) as well as mention a new prescription medication for the treatment of adults with PPD.
The American College of Obstetricians and Gynecologists recommends screening for PPD at least once during the perinatal period and once during the comprehensive postpartum visit.
To help you diagnose PPD, see my previous blog entry where I discussed using the Edinburgh Postnatal Depression Scale (EPDS EmblemHealth screening tools) as a screening tool.
If you have a patient who is struggling with PPD, please let them know that they are not alone and that PPD is manageable with treatment. It is important that they talk to family, friends, and health care providers about their experience.
EmblemHealth and ConnectiCare provide a variety of therapy and mental health resources. Members can use Find a Doctor our online directory, or call EmblemHealth at 888-447-2526, or ConnectiCare at 888-946-4658, to start managing their depression symptoms. In the case of a life-threatening emergency, please call 911.
I would also like to mention the availability of a new oral prescription medication, Zurzuvae (zuranolone), which now may be an option that primary care providers (PCPs), OB/GYNs, and mental health providers can offer their patients.
I encourage you to review the prescriber, insurance, and clinical criteria information on Zurzuvae’s website to decide whether this is an appropriate choice for your patients and your practice.
Find additional prescribing information here.
Find patient information here.
The information on Zurzuvae, as well as the websites linked here, were accurate as of the publication date of this newsletter and are presented to our providers as a courtesy. We strongly encourage you to visit the manufacturer’s site for the latest information and updates.
Child Abuse Prevention
In observance of National Child Abuse Prevention Month in April, I would like to share the following information about child abuse identification, prevention, and intervention.
One in seven children are victims of child abuse or neglect. Conservative statistics on childhood sexual abuse indicate at least one in five girls and one in twenty boys are victims of child sexual abuse.
Exposure to child abuse and neglect negatively impacts short- and long-term mental and physical health and well-being. Children with histories of abuse and neglect are at risk of perpetrating maltreatment and other types of violence as adults, as well as suffering from multiple future victimization experiences.
Primary care providers (PCPs) are well positioned to identify and address risk factors for child abuse and neglect to help break the cycle of abuse. Treatment of children and families in which abuse has occurred may:
- Mitigate the health consequences of child abuse and neglect exposure.
- Prevent recurrence of child abuse and neglect.
- Decrease the risk for other types of violence later in life.
- Decrease the likelihood that individuals will abuse their own children later in life.
All providers are mandated to report suspected child abuse.
In New York: Call 311 in New York City or the Mandated Reporter hotline at 800-635-1522.
In Connecticut: Call the Department of Children and Families Child Abuse and Neglect Careline at 800-842-2288.
The Centers for Disease Control and Prevention (CDC) have identified several approaches to prevent abuse and neglect, its recurrence, and negative outcomes. These include:
- Safe Environment for Every Kid (SEEK) Enhanced Primary Care Program.
- Behavioral parent training programs including The Incredible Years and SafeCare.
- Parent-child interaction therapy.
Additionally, the CDC finds that the following treatment programs have a strong evidence-base of support for use with children who have been abused or neglected and have behavior problems, post-traumatic stress, anxiety, or depression:
- Trauma-focused cognitive behavioral therapy.
- Multisystemic therapy for chronic and violent juvenile offenders 12 to 17 years old.
National Drug and Alcohol Facts
In observance of National Drug and Alcohol Facts Week (March 18 – 24, 2024), I have information you can share with your patients regarding opioid overdose and the opioid antagonist, naloxone. Naloxone is a medicine approved by the Food and Drug Administration (FDA) to rapidly reverse opioid overdose.
Studies show that many individuals who die of opioid overdoses failed to receive medical attention by witnesses and that timely administration of naloxone by witnesses saves lives.
The Substance Abuse and Mental Health Service Administration (SAMHSA) recommends:
- Individuals using opioids (prescribed or illicit) — and their friends, family members, caregivers, and concerned community members — should consider having naloxone available to administer in case they witness an overdose.
- Friends, family members, caregivers, and concerned community members of individuals using opioids (prescribed or illicit) should be aware of how to recognize the signs of an overdose and what to do until emergency medical help arrives.
Providing naloxone and educating patients on the signs of opioid overdose and what to do if they witness an overdose can save lives.
- Naloxone is available by a pharmacist over the counter without a prescription and is also available by prescription from a doctor.
- Naloxone is covered by all EmblemHealth and ConnectiCare plans, whether or not the patient is prescribed an opioid.
Important information to share with your patients
Opioid overdoses can occur if someone:
- Accidentally or intentionally takes an extra dose of a prescribed opioid or methadone.
- Accidentally or intentionally takes a prescription opioid not prescribed to them.
- Takes an illicit opioid such as heroin or morphine.
- Mixes opioids (prescribed or illicit) with alcohol or certain other medications like benzodiazepines.
Children are particularly susceptible to overdose if they accidentally ingest an opioid not prescribed to them.
Opioid overdose is life-threatening and requires immediate emergency attention.
Signs of an opioid overdose:
- Not waking or responding to touch or voice; limp; unable to speak.
- Breathing is not normal, very slow, or has stopped.
- Pinpoint pupils.
- Bluish lips, nose, or fingernails; pale or clammy face.
- Vomiting or gurgling noises.
If you suspect someone is overdosing on opioids, immediately:
- Call 911.
- Begin CPR if breathing has stopped or is weak.
- Administer naloxone, if available.
Opioid Overdose Medication Resources
See the new resources we have added to the Programs, Classes, and Resources page on naloxone and opioid overdoses.
January is Mental Wellness Month
A new year is an opportunity to reflect on the past and make resolutions for the future. Remember that mental health is just as important as physical health, and that seeking professional help can improve mental wellness.
If your patients are feeling isolated, anxious, angry, stressed, or sad, and want to improve relationships with others, consider setting mental health goals. The following resources can help make finding the right support easier. EmblemHealth and ConnectiCare’s partners for behavioral health benefits, Carelon and Optum, respectively, have updated their websites with helpful information on finding providers and services, benefits, cost estimates, self-help programs, and educational materials.
Carelon Behavioral Health has a new member portal to help EmblemHealth members find a behavioral health provider. Using the Find A Provider search tool on the homepage, members can search by type of specialty or service, provider name, or health concern. They can then filter results by facility and practitioner type, specialties and services, provider gender and race, languages, and more.
Carelon’s behavioral health member portal also provides information on available benefits as well as cost estimates. The portal also offers a wide range of resources including a regularly updated mental well-being library with self-help tools and education materials on more than 200 topics.
Members can also use the chat/text tool in the behavioral health portal to ask about benefits and claims. The chat is available 8 a.m. to 8 p.m., Monday through Friday. For system issues or other assistance, call Carelon Member Services at 888-447-2526 (TTY: 711) any time. Language assistance services are available if needed.
For our ConnectiCare members, the Provider Directory located on Optum’s Live And Work Well website can be used to search by type of provider or service, place, condition, and estimated cost. Members can search by key word in the search bar (e.g., psychologist, therapy, anxiety, depression, medication evaluation, support). They can also choose from the lists and descriptions provided within the Find Care by Categories options at the bottom of the page.
To browse as a guest, you may use our company’s access code: ConnectiCare. Optum’s website also provides information on self-help programs and resources for substance use and/or mental health issues. If you experience system issues or would like assistance, call Optum’s Member Services at 888-946-4658 (TTY: 711) any time. Language assistance services are available, if needed.
And, as always, remember anyone, anytime, can call 988 in any state to obtain free, confidential mental health support 24/7 via the 988 Suicide & Crisis Lifeline. In the case of a life-threatening emergency, please advise your patients to call 911.
Happy New Year!
Screening for Depression
In my previous blog about postpartum depression, I shared the Edinburgh Postnatal Depression Scale (EPDS), found on page 8 of the EmblemHealth behavioral health screening tools booklet. This tool can help diagnose postpartum depression. Now I would like to share the Patient Health Questionnaire (PHQ), which you can use to screen adolescents and adults in your practice for Major Depressive Disorder (MDD).
Guidelines for Screening Adolescents and Adults
The U.S. Preventive Services Task Force (USPSTF) recommends using a depression-focused tool like the PHQ when screening for MDD in adolescents aged 12 to 18 years. The PHQ can also be used with adults. The PHQ-2 is used for the initial depression screen. It consists of two questions and can be done before the visit. If the PHQ-2 score is positive, it is followed by an in-person administration of the PHQ-9 at the visit.
You can find the PHQ-2, PHQ-9, and all relevant information on scoring and action steps on pages 2-7 in the EmblemHealth screening tools booklet linked above.
Follow-up Care and Treatment
Ensure that patients who screen positive receive follow-up care within 30 days of the positive screen.
If you have a patient who is struggling with depression, encourage them to talk to a mental health professional.
EmblemHealth and ConnectiCare provide a variety of therapy and mental health resources.
Postpartum Depression
It is not uncommon for women to experience “baby blues” of possible sadness, crying, mood swings, anxiety, and/or irritability for a few days to weeks after pregnancy. For some women these symptoms can last longer, be more severe, and interfere in their ability to care for themselves and/or their baby, meeting the criteria for postpartum depression (PPD). Untreated, PPD can be long-lasting and harmful. Thus, it is important to screen for and assist in the treatment of PPD.
Symptoms
PPD symptoms may begin during pregnancy or up to a year after and can include:
- Depressed mood.
- Severe mood swings.
- Severe anxiety.
- Panic attacks.
- Severe anger or irritability.
- Loss of interest in activities that used to be pleasurable.
- Feelings of hopelessness, worthlessness, shame, or guilt.
- Overwhelming fatigue.
- Appetite changes.
- Trouble sleeping.
- Difficulty concentrating.
- Difficulty bonding with your baby.
- Recurring thoughts of death.
- Thoughts of hurting yourself, your baby, or others.
Risk Factors
PPD can happen to any woman, but risk factors include:
- A personal history of depression, either during pregnancy or at other times.
- Family history of depression.
- A difficult pregnancy or birth experience.
- Giving birth to twins or multiples.
- Experiencing relationship or financial problems.
- Receiving little or no support from family or friends to help with caring for the baby.
- Unplanned pregnancy.
- Loss of pregnancy.
Screening
The American College of Obstetricians and Gynecologists recommends screening for PPD at least once during the perinatal period and once during the comprehensive postpartum visit.
A screening tool to aid in the diagnosis of PPD is the ten question Edinburgh Postnatal Depression Scale (EPDS). The EPDS, it’s scoring, and action steps are on pages 8-9 of EmblemHealth screening tools.
Treatment
If you have a patient who is struggling with PPD, please let them know that they are not alone and that PPD is manageable with treatment. It is important that they talk to family, friends, and health care providers about their experience.
EmblemHealth and ConnectiCare provide a variety of therapy and mental health resources. Members can use Find a Doctor our online directory, or call EmblemHealth at 888-447-2526, or ConnectiCare at 888-946-4658, to start managing their depression symptoms.
In the case of a life-threatening emergency, please call 911.
NYCWell provides free, confidential, mental health support 24/7.
- Call 888-NYC-WELL (888-692-9355).
- Text WELL to 65173.
- Chat nyc.gov/nycwell.
For those in Connecticut, mental health services and support can be reached via 211.
You may also call 988 from any state to obtain free, confidential mental health support 24/7 via the 988 Suicide & Crisis Lifeline.
Thank you to Allison Goldring and Rachel Wagers for their contributions to this post.
Help Improve Your Patient’s Antidepressant Medication Regime Adherence
When prescribing antidepressant medication, it is important to understand that most people do not see immediate, noticeable results as they would when taking aspirin for a headache. It is important to manage your patient’s expectations and provide support and coping strategies to help them deal with the symptoms while the medicine does its work.
Antidepressants may be slow to take effect, but when they do, they can make a big difference in the patient’s quality of life. To help improve your patients’ adherence to their antidepressant medication regimen, I recommend the following:
- Assure your patients that relief from symptoms takes time. Although they may begin feeling better in as little as four weeks, it may be at least six months before they see long-lasting results.
- Alert patients to side effects and let them know side effects are often short-lived. Remind them to contact you if they have side effects before discontinuing the medication, as it could make symptoms worse.
- Tell your patients that the dosage or medication may need to be adjusted to find what is most effective for them.
- Strongly encourage patients taking antidepressants to attend an office visit at least once a month during the first three months. This will give them an opportunity to discuss any issues they are having with the medication.
- Also, encourage your patients to combine depression medication with talk therapy. In talking to a trained professional, your patient may learn strategies to manage their condition until they feel the medication’s therapeutic effect.
- Remember, if a patient has been stable on an antidepressant for at least a year, consider a trial of tapering off the medication to see if it is still needed.
Communicating With Patients Living With Dementia
In honor of Alzheimer’s and Brain Awareness Month, I would like to offer some strategies for communicating with someone living with dementia.
In the early stages of dementia, individuals are often able to participate in discussions with providers and caregivers about their needs and preferences. As the dementia progresses, communication can become more difficult. Individuals may have difficulties with:
- Finding their words.
- Understanding words.
- Following a conversation.
- Paying attention.
- Losing their train of thought.
- Remembering how to do something.
- Frustration with impaired communication.
If communication becomes significantly impaired, the individual may rely on nonverbal communication or caregivers to communicate for them. Providers should always try to engage patients in direct communication, alongside caregivers as needed, in order to understand their needs and preferences.
Here are helpful tips to keep in mind when communicating with a patient with dementia:
- Make eye contact while talking to each other.
- Express calmness in your tone, volume, and body language.
- Talk about one thing at a time.
- Be direct and specific.
- Use short and simple sentences.
- Slow down if they are having difficulty following you.
- Kindly repeat what you are saying, as needed.
- If you are not understood, try using different words or a visual prompt.
- Give choices if there is difficulty with an open-ended question.
- Allow plenty of time for the patient to process what you are saying and develop a response.
- Be patient. Try not to interrupt or complete their sentences.
- Display active listening and watch their body language.
- If they are having difficulty finding a word, ask them to describe it.
- Let them express their feelings. Do not dismiss their worries.
- Rephrase their responses to check your understanding if needed.
- Supplement the conversation with written information or step-by-step instructions when applicable.
Pride Month
In honor of Pride Month, I would like to take this opportunity to bring awareness to mental health disparities among students who identify as LGBTQ+.
The Centers for Disease Control’s Youth Risk Behavior Survey found that of LGBTQ+ students:
- Almost 70% experienced persistent feelings of sadness or hopelessness during the past year.
- More than 50% had poor mental health during the past 30 days.
- Almost 25% attempted suicide during the past year.
- Those who have any same-sex partners were:
- Significantly more likely to experience all forms of violence.
- More likely than their peers to have used or misused substances.
- Least likely to feel connected at school* indicating less protection for these groups.
*Along with female students and students of color.
The Substance Abuse and Mental Health Services Administration (SAMHSA), which is part of the U.S. Department of Health & Human Services (HHS), states research has shown that:
- Gender identity is expressed most often by age three.
- Families of LGBTQ+ youth contribute significantly to that youth’s health and well-being.
- Family reactions experienced as rejection by their LGBTQ+ child can contribute to serious health concerns and inhibit their child’s development and well-being.
SAMHSA has a useful Practitioner’s Resource Guide: Helping Families to Support Their LGBT Children. This resource helps practitioners guide family support of the health and well-being of adolescents who identify as lesbian, gay, bisexual, and transgender.
It calls for practitioners to:
- Proactively engage and work with families with LGBTQ+ children and adolescents.
- Provide caregivers’ education on sexual orientation and gender identity and how to support their LGBTQ+ children early in their child’s development.
- Help caregivers who react negatively or ambivalently to their LGBTQ+ children.
- Make referrals for support, if needed.
If you have an EmblemHealth or ConnectiCare LGBTQ+ member who is struggling with mental health issues, see We Are Here To Help.
Special Event May 18: Mental Well-Being for New Yorkers
On May 18, 2023, we held an educational webinar for the public on mental well-being for New Yorkers. The event was hosted by Sarah Downs, director of health programming and delivery for WellSpark Health*. Downs interviewed me, Matt Kudish (CEO of the National Alliance on Mental Illness New York City (NAMI-NYC)), and Terri Rhymes-Lowery (regional manager of EmblemHealth Neighborhood Care). The webinar included a clinical overview of common mental health conditions, a discussion on coping and supporting loved ones, actionable tips for improving mental well-being, and a question-and-answer session with the panelists. New York City Council Member Linda Lee (chair of the Committee on Mental Health, Disabilities, and Addiction) and Dr. Dara Kass (regional director of the U.S. Department of Health and Human Services) provided opening remarks.
Attendees were advised that information provided during the webinar is for informational purposes only. It is not medical advice and should not be substituted for a health care provider’s advice. If they have any concerns about their health, they should contact their health care provider's office. Information provided in the webinar is not intended to imply that services or treatments described are covered benefits under any member’s plan.
*WellSpark Health is part of the EmblemHealth family of companies.
Prescribing for Children and Adolescents With Depression
Hello colleagues,
I serve as the medical director of psychiatry for EmblemHealth and have specialized training in child and adolescent psychiatry. For my first MD Perspectives blog post, in honor of Mental Health Awareness Month, I would like to talk about treating childhood and adolescent depression.
Depression has been on the rise among children and adolescents even before the pandemic. Since the pandemic, the prevalence has worsened in the context of lockdowns, change of routine, missed family and community celebrations, social isolation, illness, the fear of illness, and the loss of loved ones. Today, teen suicide is a national crisis.
If you are a primary care provider (PCP), you serve a critical role in not only screening for depression, but also treating depression in children and adolescents. To help support PCPs in their treatment of depression in this population, I would like to share a resource I have found useful in my own practice — the clinical practice guidelines of the American Academy of Childhood and Adolescent Psychiatry (AACAP).*
AACAP states the following interventions have empirical support and expert consensus for the treatment of major depressive disorder in children and adolescents:
- Cognitive behavioral therapy (CBT).
- Interpersonal therapy (IPT).
- Selective serotonin reuptake inhibitors (SSRIs), except paroxetine/Paxil.
For mild presentations: AACAP recommends considering supportive interventions as a first-line treatment.
For moderate-to-severe presentations: AACAP recommends empirically validated psychotherapies (specifically CBT or IPT) and evidence-based SSRI medicines alone or in combination.
The only two SSRIs currently approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in children and adolescents are:
- Fluoxetine (for 8 years old and older).
- Escitalopram (for 12 years old and older).
The AACAP clinical practice guidelines state that SSRIs are generally well tolerated by children and adolescents. However, there is some risk for side effects** to occur. To minimize the chance of adverse effects, AACAP recommends starting a new SSRI at a subtherapeutic dose. Despite the low risk found, AACAP recommends closely monitoring for suicidality – especially in the first months of treatment and following dosage adjustments. This recommendation is also endorsed by the FDA.
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*The American Academy of Child and Adolescent Psychiatry (AACAP) 2022 Clinical Practice Guideline for Assessment and Treatment of Children and Adolescents with Major and Persistent Depressive Disorders.
**When side effects do occur, most present in the first few weeks of treatment and include, but are not limited to, dry mouth, nausea, diarrhea, heartburn, headache, somnolence, insomnia, dizziness, vivid dreams, changes in appetite, weight loss or gain, fatigue, nervousness, tremor, bruxism, and diaphoresis. Potentially serious adverse effects include, but are not limited to, suicidal thinking and behavior, behavioral activation/agitation, hypomania, mania, sexual dysfunction, seizures, abnormal bleeding, and serotonin syndrome. It is important to know that all SSRIs have a black box warning for suicidal thinking and behavior for individuals up to 24 years of age. The Clinical Practice Guidelines cites the pooled absolute rates for suicidal ideation across all antidepressant classes for youth with major depressive disorder in one analysis to be 3% for youth treated with an antidepressant and 2% for youth treated with a placebo.
We Are Here To Help
Resources to help support mental health awareness are available to you here:
EmblemHealth Behavioral Health | ConnectiCare Behavioral Health.
If a member needs help finding a behavioral health professional, please have them contact the following:
EmblemHealth members: Call Carelon (formerly Beacon Health Options) at 888-447-2526 (TTY: 711). A representative can help 24 hours a day, seven days a week.
ConnectiCare members: Call Optum at 888-946-4658 (TTY: 711). A representative can help 24 hours a day, seven days a week.
Neighborhood Care: EmblemHealth members can stop by any of our Neighborhood Care locations for community support. Visit emblemhealth.com/neighborhood.