Why Screening of Postpartum Moms is Important and Who Can and Should Do the Screening

Today’s post was inspired by a March 19, 2018 NPR article by April Dembosky titled “Lawmakers Weigh Pros and Cons of Mandatory Screening for Postpartum Depression,” as well as a June 2018 Romper article by Karen Fratti titled “Moms Should be Screened for Postpartum Depression in the ER, New Study Suggests, & It Makes Perfect Sense,” a June 30, 2018 News Medical article titled “Screening mothers for PPD in emergency setting,” and a June 29, 2018 Austin360 article by Nicole Villalpando titled “Who should be screening moms for postpartum depression? More doctors now can.

Screening moms for postpartum depression (PPD) serves multiple purposes.  Screening will help ensure moms get the help they need and avoid suffering unnecessarily.  In case you weren’t aware, screening educates women on what PPD is, why it happens and just how common it is (1 in 7 new moms experience it), and helps them avoid what I and so many other mothers have gone through (PPD makes you feel alone, like you’re losing your mind and will never return to your previous self).  It will ensure fewer moms will ultimately fall through the cracks.  It will ensure fewer tragedies involving mothers and their babies.  And I’ve said this many times before, but a mother who is not well cannot care for her baby the way a healthy mother can.  This is pure logic.  Unfortunately, logic takes a back seat because our capitalist society places more priority on what benefits the pocket over what benefits the people’s well-being.

So…..question is WHO should screen new moms for PPD?

Her OB/GYN?  This should be a given, period, hands down, no questions asked!  In May 2018 the American College of Obstetricians and Gynecologists recommended that, in addition to the standard 6-week postpartum visit, OB/GYNs perform a follow-up visit within the first three weeks postpartum.  This new recommendation is due to the fact that symptoms of PPD often begin before the 6-week appointment.   See second half of my blog post on the issues many OB/GYNs are faced with in terms of screening.

Her baby’s pediatrician (but here the patient is the baby, not the mother)?  The American Academy of Pediatrics (click here and here) recommends doctors screen mothers for PPD when they bring their newborns in for wellness visits, since they occur numerous times in the baby’s first year; whereas, the mother only gets the one wellness check at postpartum week six.  Pediatricians who realize that the baby’s development can be negatively impacted when the mother is ill with PPD will try to screen the mom for PPD.  Problem is, most pediatricians as far as I’m aware are not prepared to screen and refer mothers since the mother is not a patient.

An ER physician?  While you will no doubt raise your eyebrows, doctors like Dr. Lenore Jarvis, an emergency medicine specialist with the Children’s National Emergency Department at United Medical Center in Washington, DC, have been seeing moms bring their babies to the ER, and it turns out the baby is fine but it’s the mother who is highly anxious and feeling overwhelmed.  In these cases, it’s logical to try to determine if it’s the mother who needs help.  In fact, Dr. Jarvis and several colleagues conducted a research study with several colleagues on screening moms for PPD in an ER setting.  A Eureka Alert release dated June 29, 2018 explains the results of the research study. Moms who participated were screened using the Edinburgh Postnatal Depression Scale supplemented by other questions.  The great thing about the research study is that, when moms scored positive for PPD, they received information about PPD and were offered–or if they had a strong positive score from screening, they were required to have–a consultation with a social worker.  Additionally, the researchers followed up with mothers who screened positive one month later to see how they were doing.  This is akin to case management programs we have in place when patients check out of hospitals (I explain all this in my post below). Now THIS is the way it SHOULD be!

Dr. Jarvis refers to the ER as a “safety net  for people who are not routinely accessing regular checkups for themselves and their children. If a mother is having an acute crisis in the middle of the night and feeling anxious and depressed, they often come to the emergency department for help.”  Because American policymakers have been so resistant to instituting policies that would require insurance companies to work with doctors to ensure PPD is caught early through screening and subsequent referrals–researchers/subject matter experts on PPD are left to make recommendations for what Dr. Jarvis referred to as a “safety net” approach of having emergency rooms screen for PPD when moms come in either for their babies (for colic, fevers, etc.) or even for themselves (symptoms of a postpartum mood disorder).

While I agree we need to cover all bases and try to screen a new mother wherever and whenever possible, why do we even need to resort to waiting until a mom comes into the ER to screen them?  Why do we have to have such a safety-net, fall-back, beats-nothing-at-all, better-late-than-never approach in the first place?  Answer:  our society continues to place too much priority on conception and childbirth but once the baby is born, everyone forgets the mother.  Once the baby is born, the mother’s health falls by the wayside.  I’ve blogged about this before, but the attention from that point on will be on the baby from visitors who coo at the baby and treat the mother as invisible.  Same thing with doctor visits; the mother only gets one postpartum wellness check at 6 weeks.  That’s it.  It’s like the mother ceases to exist.  Whereas, other cultures have customs to honor and mother the mother (click here and here for past posts).  The birth of the baby is synonymous in these cultures with the birth of the new mother and they are honored for bringing new life into the world.  This, my friends, is why maternal mental health advocacy is so important.  Until American policymakers institute policies to demonstrate the importance of mothers and their health, we advocates must continue to act as “squeaky wheels to get the grease.”

The following section is an excerpt from my book.

New mothers, especially the ones at high risk for PPD, should be screened during their six-week postpartum visit, 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 six-week screen doesn’t indicate PPD, she should be assessed once more at the twelve-week point—or when she weans or when her period returns, whichever comes first, 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 two 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 anxiety about the baby
  • Restlessness/irritability
  • Detachment from and inability to bond with the baby
  • Difficulty thinking, concentrating or making decisions
  • Feelings of guilt, inadequacy, failure and/or worthlessness
  • Urge to run away
  • Onset of panic attacks
  • Sense of despair and/or hopelessness leading to thoughts of death/suicide
  1. How have you been feeling physically and emotionally?
  2. 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, or a job change?
  3. How do you feel about the baby? Are your feelings in line with your expectations of how you’d feel about the baby?
  4. 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?
  5. Are you breast-feeding and, if so, how is it going?
  6. How do you feel the labor and delivery went? Do you feel you experienced any sort of trauma during the delivery?
  7. Do you feel your childbirth and motherhood experience are meeting your expectations?
  8. Do you feel particularly anxious about your baby’s health (colic, SIDS)?
  9. How is your appetite?
  10. How are you sleeping? Have you been able to get at least four, if not five, hours of sleep a night?
  11. Have you had any recurring thoughts/images that are disturbing?
  12. How have you been adapting to motherhood, in general?
  13. 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. This all theoretically sounds good and fine, but in most cases, OB/GYNs are not prepared to implement. Why not? At the very least, it would require training on perinatal mood disorders (recognition of symptoms and treatment), as well as ability to provide the right referrals as needed.

This last paragraph from my book excerpt remains true to this day.  Sad because I published my book in 2011.  Seven years later, things have not really changed.

California’s screening bill, AB 2193, has yet to pass the Senate and get signed into law.  Once passed, it would be an exciting development for mothers, as it doesn’t just require screening for PPD.  It requires health insurance companies to set up case management programs (same way my mother was assigned a case manager each time she had to stay overnight at a hospital to ensure she had a plan in place to address the issues that landed her in the hospital–i.e., physical therapy in a rehab center, visiting nurse to change her bandaging, etc.) to help connect moms who screen positive for PPD with a mental health practitioner.

Case management is set up to ensure there is a treatment/referral plan in place.  I sincerely hope that this means health insurance companies are prepared and able to carry out the new requirements.   And I sincerely hope that California will lead the way for other states to follow suit in setting up similar screening bills that will actually require health insurance companies to set up case management programs.

It goes without saying that screening moms for PPD serves no purpose if you can’t help those who test positive for PPD.  So far, as the first state that put mandatory screening in place, New Jersey has not had any reason to be excited ever since its initial groundbreaking “first-state-to-mandate-screening” announcement.  New Jersey, as well as 3 other states— Illinois, Massachusetts, and West Virginia — have tried mandated screening, and it did not result in more women getting treatment, according to a study published in Psychiatric Services in 2015.

A whopping 78% of those who screen positive don’t end up getting mental health treatment per a 2015 research review published in the journal Obstetrics & Gynecology.  Why have women in these states with mandatory screening not been getting treatment?  Well, for starters:

  1. Some obstetricians and pediatricians are afraid to screen for PPD because they are not equipped to refer.  But why is that?   Why is it hard for them to all rely on the resources available via Postpartum Support International?  Its website lists resources in every state.  And many states have already formed, or are in the process of forming, chapters to focus on state-specific efforts at advocacy, training, and other improvements.
  2. The resources to whom doctors (obstetricians, pediatricians, general practitioners, etc.) can refer mothers are limited, especially in more rural areas.  And in more rural areas, it’s harder to find mental health practitioners trained in prescribing meds to pregnant/breastfeeding women, let alone trained in treating moms with PPD.
  3. All too many mental health practitioners don’t take the woman’s insurance or there are significant limitations from an insurance coverage perspective.
  4. There’s a very long wait (several months) to see most mental health practitioners, especially for the first time….a woman in the throes of PPD can’t afford to–both literally (from a cost perspective) and figuratively (from a life & death perspective).
  5. There’s little incentive financially, thanks to insurance companies’ lack of adequate coverage for doctors who do such screening…..in my opinion, screening should be done at the standard 6-week postpartum checkup and therefore covered as part of that checkup.

Attention, American policymakers….our mothers are worth it.  I mean, we make such a big stink about fetuses and unborn babies in this country, let’s start thinking bigger picture, shall we?  Without mothers, there would be no babies to conceive and bring into this world.  Let’s start treating mothers less like second-class citizens and more like human beings who deserve to be able to give birth to and care for their babies without getting sick with PPD and possibly dying in the process!

 

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You have to break through the uncomfortable…Why? Because mothers are dying from postpartum mood disorders

You have to break through the uncomfortable…..We are losing a silent battle that no one wants to talk about.

Amen!  These are the words Brian Gaydos utters when people ask what happened to his beloved wife, Shelane, and his answer “She died from a disease called postpartum depression” makes them uncomfortable.  Discomfort from stigma is what keeps suffering mothers quiet and getting the treatment they need and deserve.

When I read the August 4, 2017 article by Michael Alison Chandler in the Washington Post titled “Maternal depression is getting more attention – but still not enough” and I saw Brian’s words at the end of  the article, I decided I needed to blog about these words and about the tragic death of his wife.  Shelane Gaydos, a 35-year-old mother with 3 daughters, lost a baby in utero at 12 weeks and within 3 weeks died by suicide.  Family members did not realize until a while after her death that she had suffered from postpartum psychosis.  The article mentions, and as statistics have always indicated, women are more likely to attempt suicide during the first year after childbirth than during any other time in their lives.  It is important to note that a woman doesn’t need to give birth to experience any one of the various postpartum mood disorders, including postpartum depression (PPD), postpartum OCD and postpartum psychosis.  She can suffer from these disorders after having a miscarriage as well.

The article mentions certain things I’ve mentioned all along in my blog and in my book:

  • 1 in 7 new mothers experience a perinatal (during pregnancy and after birth) mood disorder, and yet these disorders continue to be under-diagnosed and under-treated
  • A relatively small percentage seek professional help either because they don’t know what they are experiencing deserves and needs  professional help and/or they don’t know where to go to get help and/or they are ashamed to seek help
  • More obstetricians and pediatricians lack than possess the training needed to diagnose and treat perinatal mood disorders
  • Certain risk factors are the reason why certain mothers develop PPD and others don’t: genetic predisposition to biological factors (some mothers are affected by hormonal fluctuations during/after childbirth and after weaning more than others) versus environmental factors (poverty, poor/abusive relationships, premature birth or miscarriage, inadequate support, inadequate paid leave from work)
  • It’s thanks to advocates with platforms with a broad reach to members of the government and media that there has been progress in recent years.  Brooke Shields is one of the first of the advocates to start the trend of sharing their own experiences, spreading awareness, and trying to effect change.
  • There are still stubborn societal myths (thank you to the patriarchal and quite misogynistic forces and views still in place here in the 21st century) that only serve to put unnecessary, additional stress on women, encouraging the false notion that all mothers can not only care for their babies without any sleep or support, but also be able to breastfeed without any issues and return to their pre-baby bodies and weight quickly.  Unbeknownst to many of us stateside, societies around the world (and in olden days here in the good ol’ USA) have customs in place that provide new mothers with the support they need to recover from childbirth and care for their newborn baby.  Instead, because we are a strictly capitalistic society, more and more mothers now work and have anywhere between 0-13 weeks of paid leave and are expected to recover and jump right back to their jobs before having babies, as if they’d never given birth in the first place!  If only men who think “Women have been giving birth for centuries should just up and go back to the way they were” can experience childbirth firsthand sometime!

Certain states, like Massachusetts, New Jersey, and Illinois have passed laws that mandate screening for PPD, and thanks to recommendations by the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP), healthcare providers are screening for PPD more routinely.  What I would like to know is whether these screenings are even happening (I am dubious):

  • In 2015, ACOG recommended that OB/GYNs screen women for PPD at least once during pregnancy and once after childbirth.
  • In 2010, the AAP recommended that pediatricians screen mothers for PPD at well-baby visits during the first 6 months.

Says Adrienne Griffen, founder and executive director of Postpartum Support Virginia, whom I have the honor of knowing through my affiliation with Postpartum Support International:

Postpartum depression is where breast cancer was 30 years ago.

I truly and sincerely hope and pray that it’s NOT going to be ANOTHER 30 years for us to see a significant change in the way we view PPD as a society and reduce the numbers of women suffering–and even dying–from perinatal mood disorders!

 

 

American Academy of Pediatrics on the Importance of Screening New Moms for PPD

According to the latest American Academy of Pediatrics report published on November 1st in the journal, Pediatrics, with the over 400,000 infants born to moms with depression each year, perinatal (both antenatal and postpartum) depression is “the most underdiagnosed obstetric complication in America [which untreated and improperly treated] leads to increased costs of medical care,….child abuse and neglect,….family dysfunction and [adverse] affects [on] early brain development.” [1]

As I have said in prior posts, depression in new moms impacts the entire family.  Not only do fathers have an increased risk for developing depression themselves, but babies are at increased risk for insecure attachment, which can lead to developmental (cognitive) delays and behavioral (social, emotional) problems as they grow older.  Children exposed to maternal and/or paternal depression are at much greater risk of developing mood disorders, such as depression.  Hence, to ensure the health and wellbeing of the baby, it is important to ensure the health and wellbeing of the baby’s mother, which is why pediatricians are in a good position to screen new moms for postpartum depression (PPD), as well as help provide referrals for treatment and community resources/support services.

Between the American College of Obstetricians and Gynecologists recommending similar screening earlier this year and now the AAP, I truly hope that this will mean more new moms with perinatal depression being properly diagnosed and treated!  According to this report, although most pediatricians agree that screening for perinatal depression is something that should be included in well-child visits during baby’s first year, they also felt that they didn’t have adequate training to diagnose and treat PPD.  The report also states that the “perceived barriers to implementation [include] lack of time, incomplete training to diagnose/counsel, lack of adequate mental health referral sources, fear that screening means ownership of the problem, and lack of reimbursement.”[2]

There are indications, based on the report, that there have been efforts to move toward inclusion of women’s perinatal health in pediatric practices as demonstrated by programs like the one set up between Dartmouth Medical School and 6 pediatric practices in New Hampshire and Vermont, which show that pediatricians have the ability to effectively screen for PPD.  There is also the ABCD (Assuring Better Child Health and Development) Project, which is comprised of 28 states and their AAP chapters.  It’s wonderful that in Illinois, one of the ABCD states and one of the only states with a postpartum depression law, pediatricians who use the Edinburgh Postpartum Depression Scale to screen new moms for PMDs are actually paid (yes, paid!) by Medicaid for doing so.   Once again, Illinois is setting a positive example for the rest of the country when it comes to looking after new mothers and babies.  For more information on the initiatives going on in the various ABCD states, visit www.abcdresources.org and www.nashp.org.

What we need to do is mandate pediatrician (and OB/GYN) training to recognize PPD symptoms and provide proper referrals to medical/mental health practitioners trained in treating PPD.  The ideal goal would be the establishment of a multi-disciplinary approach (like I mentioned in my last post) wherein doctors–be it OB/GYNs whose patients are the new mom or pediatricians whose patients are the babies of the new mom suffering with PPD—would collaborate with each other and mental health providers in their communities to ensure new moms suffering from a PMD does not fall through the cracks.

I’d like to end this post by pointing out the difference between the AAP’s view of PPD timeframes of occurrence and peak prevalence versus the proposed guidelines I wrote about in my last post with respect to the DSM-5.   The AAP indicates that the peak for a PMD is 6 weeks postpartum, with another peak occurring 6 months postpartum.  It goes on to state in the report:  “Given the peak times for postpartum depression specifically, the Edinburgh scale would be appropriately integrated at the 1-, 2-, 4-, and 6-month visits.” [3]  Hey, American Psychiatric Association, the AAP gets it more than you do!  Please get with the program!

In Conclusion:

From the mere fact that it’s the primary care pediatrician that sees the new mother and her interactions with her baby within the first six weeks (before the postnatal follow-up visit with her OB/GYN at 6 weeks), the pediatrician is in the best position to detect maternal depression early and help prevent adverse outcomes for the baby and the family. “In addition, it is the [pediatrician] who has continuity with the infant and family, and by the nature of this relationship, the [pediatrician] practices with a family perspective [since a healthy functioning family means the healthy development of the child].”[4]  Screening can [and should be] be integrated into the well-child care schedule, as it “has proven successful in practice in several initiatives and locations and is a best practice for [pediatricians] caring for infants and their families.”[5]  The report further clarifies that, since the infant is the pediatrician’s patient, just because the pediatrician screens for PPD does not mean that the pediatrician must treat the mother. It just means that if a PMD is detected during the screening process, the pediatrician would provide information for family support and referrals for therapy and/or medical treatment, as needed.


[1] Earls, Marian F. and The Committee on Psychosocial Aspects of Child and Family. Incorporating Recognition and Management of Perinatal and Postpartum. Pediatrics 2010;126;1032-1039; p. 1032.

[2] Ibid., p. 1034.

[3] Ibid., p. 1035.

[4] Ibid., p. 1035.

[5] Ibid., p. 1037.