Screening expectant and postpartum moms for perinatal mood disorders is a topic that is coming up more and more these days, as well it should. Why? The more it’s brought up, the more the public will realize the prevalence of postpartum depression (PPD) and need for early detection and social support to help prevent and/or minimize its occurrence. And perhaps one day in the not-too-distant future the standard for care of expectant and postpartum moms will see an improvement in both areas, not to mention banishing the stigma of perinatal mood disorders once and for all!
Over at Amber Koter’s blog Beyond Postpartum, two of her recent posts address the importance of screening mothers. One was on how Australia may pave the way for screening, and the other on how screening can be performed by pediatricians at infant visits (this is because currently the only postpartum follow-up there is today is at 6 weeks…beyond that there would have to be a problem before insurance would cover an additional visit(s) to the OB/GYN). We’re not the only country considering the implementation of screening for perinatal mood disorders (and it’s a good thing too!). Australia is considering the screening of pregnant moms for their risk of PPD. The article mentions that, though the stigma of PPD has decreased, “many women were still falling through the cracks due to a lack of prenatal and postnatal screening…..Long-term untreated [postnatal depression] can cause delayed cognitive and emotional development in the baby. The benefits of picking up [PPD] early are immense.”
Over at Lauren Hale’s blog Unexpected Blessing, a recent post brings attention to a recent article in the Journal of the American Academy of Pediatrics that starts off with this promising statement: “Screening for maternal depression is gaining acceptance as a standard component of well-child care.”
And over at Katherine Stone’s Postpartum Progress, her post on June 12th informs us of yet another example of a hospital setting up a program—having moms complete questionnaires to identify risk factors and having high-risk moms see a postpartum support specialist before discharge—to help identify moms with PPD. Way to go University Community Hospital of Tampa!
Also pulled from Postpartum Progress’ highlights on screening from the Public Briefing on Depression in Parents, Parenting, and Children: Opportunities to Improve Identification, Treatment, and Prevention that took place on June 10, 2009:
- The National Academies endorses screening and believes it’s crucial, but also emphasizes screening is not helpful unless there is effective follow up and treatment tied to it.
- Individuals need an informed choice in the treatments they choose.
- The group suggests that governors of each state convene a task force to develop and implement the strategies they recommend.
Additional highlights on screening pulled from the full report of the same title:
- Pg 5-3: “[Although] screening alone will increase recognition [of depression], the best outcomes [of studies occur] when primary care settings [implement] quality improvement programs that [support] patient education and initiation of therapy.
- Pg 5-6: “The unique triggers and social issues of [the postpartum] period have led to recommendations for pediatricians, obstetricians, and family physicians to screen postpartum women. It is particularly during this period of parenting that depression has been widely recognized as impacting the parenting and nurturance of the child. Publicity about severe cases of postpartum depression has led to increased awareness and promotion of screening and education.”
- Pg 5-6: “Some public health programs have initiated comprehensive programs to address maternal depression. Several state health departments have programs that support screening, provider training, and parental supports. New Jersey, since 2006, has had a law requiring screening, education, and referral. Illinois provides additional clinician payment for conducting postpartum screening. Screening programs can have an educational role that decreases stigma as well as providing supports to individuals in their parenting role. When screening is implemented the pressure to provide follow-up resources can stimulate treatments resources, such as depression support groups. In Washington, with the advent of depression screening in the state’s Maternal Support ‘First Steps’ Program staff report that the number of postpartum depression groups in the state have more than doubled. In Australia, over 40,000 women have been screened in a wide range of clinical and public health programs with the EPDS [Edinburgh Postnatal Depression Scale] antepartum [or during pregnancy] or postpartum.”
- Pg 5-7: “In a survey of obstetricians, 44 percent reported that they screened for depression [while 31 percent of] family physicians surveyed in one state [indicated] they always screened at postpartum visits and 13 percent always screened mothers at well-child visits. The use of written screening tools was rare, with 82 percent using an interview (Seehusen et al, 2005). Pediatricians report that observation or information inquiry is the most common method of detecting maternal depression.”
- Pg 5-11: “[Several] state programs are conducting screening programs in which home visitors administer and score a standardized depression screen and then refer mothers (or fathers) scoring above a predetermined clinical threshold to community mental health services for further evaluation and treatment as indicated.”
Not only do I feel that postpartum screening is needed, I believe OB/GYN offices should screen their patients initially (as new patients), prenatally (during pregnancy), and postpartum. OB/GYNs should screen their patients for risk of perinatal mood disorders prior to pregnancy, throughout pregnancy (more frequently if the predisposition exists), and as part of the standard 6-week postpartum check-up (they should even offer a 3-month check-up to determine if there are any PPD symptoms and/or moving the 6-week visit to the 4th week, so there is one at one month and one at two months) to increase the likelihood of successfully detecting PPD. The standard 6-week postpartum visit with the obstetrician should include blood work to check for deficiencies in iron, thyroid, etc., even if there are no outward signs of anything amiss, like PPD. The standard protocol should be to, first of all, establish a baseline of hormone levels (progesterone/estrogen) before pregnancy. Then, at 6 weeks postpartum, tests should include a thyroid panel, Adrenal Stress Index and blood work to measure hormone/neurotransmitter levels.
- Have you experienced PMS, and if so, what are the symptoms?
- Have you or an immediate family member experienced mood disorders, major depression, PPD, extreme anxiety, panic attacks, an eating disorder (e.g., anorexia), alcohol or drug addition, bipolar disorder, OCD, and/or psychosis?
- Do you experience any negative effects from taking birth control pills?
- Do you have or do you have a family history of thyroid disorder?
- Have you had a baby before? If so, have you had any previous negative experiences related to childbirth (stillbirth, miscarriage, adoption, abortion)?
- Have you had PPD before?
- Have you had infertility issues and had to have multiple IVF cycles?
OB/GYNs should be proactive instead of reactive and only treat patients that come through their door that already have symptoms of a mood disorder. Why is that, you ask? Well, the earlier they treat the patient, the faster the patient will recover, and the quicker she can return to caring for her baby. For instance, if a woman indicates in the onboarding questionnaire that they have a personal or family history of bipolar disorder, the obstetrician should follow her closely during pregnancy and postpartum. Even if a woman has never exhibited signs of bipolar disorder, if she has a family history of it, her first episode may occur after childbirth.
Once a patient becomes pregnant, the doctor should advise her on what PPD is and how the risk indicators correlate with PPD. The history of the patient (i.e., answers to all the above), in addition to any complications during childbirth, should be recorded and taken into consideration when evaluating the patient for the possibility of PPD. Regardless of whether a woman is at risk for PPD, there should still be a consultation in which the doctor will briefly go over what it is and who is at risk. If the woman is at risk, there should be an explanation of the treatment options and an emphasis on having a support network lined up to provide emotional and practical support that goes into effect as soon as they return home from the hospital. Speaking to the woman’s partner directly would be a plus for emphasis on the importance of their support. The doctor should explain to patients and their partners how first-time parenthood is not as easy a transition as they are led to believe.
Questions the doctor could ask the patient from the time she first learns she is pregnant and throughout her pregnancy, keeping in mind that preeclampsia and other complications can also cause depression to occur:
- How have you been feeling physically and emotionally?
- Have you had any pain, spotting or difficulty sleeping?
- Are you feeling particularly stressed, and if so, is it due to a major change you are experiencing, such as marital problems, death of a loved one, financial problems, a recent move, a job change?
- Is this a planned pregnancy?
- Do you have any expectations in terms of childbirth, motherhood, childcare and becoming a parent for the first time?
- Have you had any prior experience in caring for a newborn/infant?
- Aside from pregnancy books and books on baby care, have you read anything on PPD? If not, you should read Placksin’s “Mothering the New Mother” and other books listed on the Postpartum Support International website and on Katherine Stone’s Postpartum Progress.
- Do you feel particularly anxious about this pregnancy?
There are OB/GYNs who do perform such screening today, though it’s not a standard practice (but it should be). Patients identified as high risk for PPD or have had PPD before, should be referred to a psychiatrist—preferably one who has worked with pregnant women—for a consult. The OB/GYN should explain to the patient not to be troubled by or panic about being referred to a psychiatrist, particularly if they have never seen one before. The reason for the referral should be explained carefully, as should the symptoms of the baby blues versus PPD. Having these patients establish a relationship with a psychiatrist early on is important because it is the psychiatrist who would then serve as the primary contact after the baby is born and up until the six-week visit with the OB/GYN. Unless there is a medical issue with the mother, the OB/GYN will generally not see her until the six-week follow-up. Having this other healthcare professional as a contact in case PPD rears its ugly head fills the void that exists in all too many cases, like mine, where mothers have no idea where to go for help if they have PPD.
Mothers should be assessed for PPD several times in the first year after delivery, with the most critical timeframe between 4-12 weeks. The best time to initiate a screen would be at the six-week follow-up visit with the OB/GYN, provided she doesn’t complain about symptoms up to that point. If she is symptomatic before the six-week visit, she should be screened right then. If the 6-week screen doesn’t indicate PPD, she should be assessed once more at the 12-week point and also when she weans and when her period returns, since these events can trigger PPD in some women.
The following—in addition to screening tools like the Edinburgh Postnatal Depression Scale or Cheryl Beck’s Postpartum Depression Screening Scale—should be asked at the six-week follow-up visit with the OB/GYN, which can help diagnose PPD:
1. Have you been feeling any of the following for the past 2 weeks:
- Persistent and mostly inexplicable sadness/tearfulness and feeling empty inside
- Loss of interest/pleasure in hobbies/activities you once enjoyed; inability to laugh
- Overall impaired functioning
- Sleep difficulties (either insomnia or sleeping too much)
- Weight loss (usually fairly quick) associated with a decrease in appetite
- Weight gain associated with an increase in appetite
- Excessive worrying/anxiety/concern about the baby
- Detachment from/inability to bond with the baby
- Difficulty thinking, concentrating or making decisions
- Feelings of guilt/inadequacy/failure/worthlessness/of being a bad mom
- Urge to run away
- Onset of panic attacks
- Sense of despair and/or hopelessness leading to thoughts of death/suicide
2. How have you been feeling physically and emotionally?
3. Are you feeling particularly stressed, and if so, is it due to a major change you are experiencing, such as marital problems, death of a loved one, financial problems, a recent move, a job change?
4. How do you feel about the baby? Are your feelings in line with your expectations of how you’d feel about the baby?
5. Do you feel you have adequate emotional and practical support from your partner? Do you have any relatives or any other help, like a doula, to help you with the baby during the day?
6. Are you breastfeeding and, if so, how is it going?
7. How do you feel the labor and delivery went? Do you feel you experienced any sort of trauma during the delivery?
8. Do you feel your childbirth and motherhood experience are meeting your expectations?
9. Do you feel particularly anxious/concerned about your baby’s health (colic, SIDS)?
10. How is your appetite?
11. How are you sleeping? Have you been able to get at least 4, if not 5, hours of sleep a night?
12. Have you had any recurring thoughts/images that are disturbing?
13. How have you been adapting to motherhood, in general?
14. Have you returned, or will you return, to work?
I believe these types of questions should be incorporated by all OB/GYNs throughout the country. Doing so would mean fewer expectant and new mothers falling through the cracks, increased public awareness/early detection/treatment of perinatal mood disorders and subsequent reduced impact to children, and spurring on an increase in referrals to establishment of support services. This all theoretically sounds good and fine, but in most cases, OB/GYNs are not prepared to implement. Why not? It would require training on perinatal mood disorders (recognition of symptoms and treatment), as well as ability to provide the right referrals as needed. More on such barriers to progress and current dilemma in my next post.