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!

 

Advertisements

24th Annual Postpartum Support International Conference

Last week, I spent 3 days (October 27-30) at the annual Postpartum Support International conference.  This year, it was held in conjunction with the biennial (every 2 year) Marce Society conference, which is traditionally held in the city of the current President of the Marce Society.  With the current President of the Marce Society being Katherine Wisner of the Western Psychiatric Institute & Clinic, University of Pittsburgh Medical Center, this year’s conference took place in Pittsburgh.

Past PSI conferences I attended were in Jersey City, NJ and Kansas City, KS.    With this year’s conference being held in conjunction with the Marce Society, there were over 400 people in attendance, including leading researchers and experts in postpartum depression (PPD).  I was honored to be in the presence of so many individuals who have made such a huge difference on behalf of so many women who have suffered perinatal mood disorders.

Individuals like (note that there are too many to list here, but here are the ones that are most notable to me because I have read their research in the years I have been doing tons of reading on PPD):

  • John Cox, DM, FRCPsych, FRCP, who, along with colleagues J.M. Holden and R. Sagovsky, developed the Edinburgh Postnatal Depression Scale (EPDS) in the 1980s.  Dr. Cox was awarded the Louis Victor Marce Medal in 1986 for his pioneer research and clinical work in perinatal Psychiatry carried out in Uganda, Scotland and Staffordshire.  In 2002 he was elected Secretary General of the World Psychiatric Association.
  • Lee Cohen, MD, director of the Perinatal and Reproductive Psychiatry Clinical Research Program within the Clinical Psychopharmacology Unit of the Massachusetts General Hospital, as well as an associate professor of Psychiatry at Harvard Medical School.  Dr. Cohen is a national and international leader in the field of women’s mental health, and is widely published with over 200 original research articles and book chapters in the area of perinatal and reproductive psychiatry.
  • David Rubinow, MD, Chair of Psychiatry and Professor of Medicine at UNC Chapel Hill.  Dr. Rubinow is currently President of the American Neuroendocrine Society and the Society of Biological Psychiatry, has won numerous awards for his research, his clinical supervision and training, and his scientific administration, and serves on the editorial boards of six journals and has authored more than 300 scientific publications.
  • Cheryl Tatano Beck, DNSc, CNM, FAAN, is a Distinguished Professor at the University of Connecticut School of Nursing.  Dr. Beck serves on the editorial boards of 4 journals and has published over 125 scientific articles as well as 4 books.

I was one of the minority there who was not a mental, medical or public health professional, or social worker.  There were 3 other young ladies there who, like me, are simply moms who want to learn more about perinatal mood disorders and find ways to help spread awareness, as well as to advocate on behalf of and provide support to other mothers.   These young ladies were Katherine Stone, Lauren Hale and Amber Koter-Puline.  This was my 2nd time meeting Katherine and 1st time meeting both Lauren and Amber.  This was the first time all 4 of us PPD bloggers were together in one place.

Here we are:

Amber Koter-Puline, Katherine Stone, Lauren Hale, and me

Another highlight of the conference was the appearance of Former First Lady Mr. Rosalynn Carter as the keynote speaker and book signing of the book “WITHIN OUR REACH: Ending the Mental Health Crisis,”  which she co-authored along with Susan K. Golant and Kathryn E. Cade.

There was so much information provided at the conference, but I was able to take away these 2 really important points that I would like to share with you:

  1. It is critical that we integrate behavioral health with medical care that is provided by those charged with the reproductive health of women.  I learned there is a multi-disciplinary approach to treating women with perinatal depression comprised of a psychiatrist, obstetrician, obstetrical nurse practitioner, and psychiatric social worker at Kaiser Permanente Medical Center in San Francisco.  We REALLY need more of these throughout the country!  In certain other countries, it’s the midwives and early childhood nurses–in addition to GPs–that are the front line of screeners.
  2. There was a presentation about the proposed changes being made regarding the treatment and screening of PPD for the DSM-5 due to be published in May 2013.  During this presentation, the ballroom grew noticeably hotter as one by one members of the audience took to the microphone to state their questions and concerns.  Most of them centered around the announcement that 4 weeks is the cut-off date for onset.  I mean, have you heard of a more ridiculous thing than that?!   That means that any screening that may occur (as not all OB/GYNs or other health professionals screen today) would only occur in the first 4 weeks postpartum, since a postpartum mood disorder (PPMD) would’ve had to rear its ugly head by then.   Why, then, you ask would they propose such an outlandish thing?  Well, it’s because all these years the DSM-IV and all its predecessors are based purely on statistics obtained directly from research.  Not doctor’s offices or hospitals or clinics.  Not from data obtained from the EPDS given to the thousands of moms that give birth each year.   Sounds like typical political, ahem, B.S. if you ask me….

Okay, so what does this all mean?  This means that moms will not only continue to have their OB/GYNs dismiss their PPMD symptoms, but now in addition, there will be a specific cutoff of 4 weeks.  Anything after 4 weeks will risk being shrugged off, as doctors will be referring to the handy dandy DSM-5 as the Bible and complacently inform these moms that they couldn’t have a PPMD because they were more than 4 weeks postpartum.

There is still opportunity to improve on the DSM-5 as it is being proposed.  You can help make a positive difference.  How?  Well, starting in May 2011 and ending midnight of June 30, 2011, the public will be able to submit comments on the draft of the DSM-5 on the American Psychiatric Association’s DSM Development website.   I will be signing up to do so, and I hope you will too.   The more women who do, the better chance we have of convincing the powers that be that they need to extend the onset period to 1 year (or even 3 months would be far better than 4 weeks)!  Voice your concern.  Tell them why.  Share your story.  I know numerous women whose symptoms of PPD didn’t begin until after the 6th week.  Like me, for one.   Other countries who have had ancient social support customs in place for centuries have had 6-8 weeks as the period in which the new mom must be cared for.  There is a reason behind that….just as there is a reason behind the Swedish model of the primary care physician (or general practitioner) performing postnatal screening between 8 and 21 weeks postpartum, with 13 weeks as peak prevalence.

To think that women who are sick with PPD will continue to be shrugged off and go untreated and allowed to suffer unnecessarily angers me to no end.    We are supposed to make progress, but instead, we are more concerned about statistics obtained during very limited studies.   Folks on the DSM-5 committee, this is a blatant example of not being able to see the forest for the trees. 

April 13, 2010 is 4th Anniversary of New Jersey’s Postpartum Depression Law

Four years ago today, New Jersey became the first state in the country to pass legislation requiring healthcare professionals to educate and screen all new mothers for postpartum depression (PPD). 

Since then, New Jersey’s Dept of Health and Senior Services’ Speak Up When You’re Down campaign has:

The key to helping mothers and their families minimize the risk (or effects, if it does occur) of PPD is early identification (via screening) and education (via awareness campaigns and ensuring healthcare providers are all aware).   Through knowledge of risk factors, symptoms, and services available locally, mothers and their families will be able to recognize sumptoms of PPD early on, as well as take immediate action to ensure proper diagnosis and treatment.

I’d just like to clarify what screening is.  It sounds like poking and prodding is involved.  No, women are not treated like lab rats or anything like that.  Screening is merely a doctor proactively asking some questions to ascertain whether a new mother entrusted to his care is exhibiting any signs of PPD.   The most widely-used screening tool for PPD is The Edinburgh Postnatal Depression Scale (EPDS), which many hospitals in New Jersey have elected to use.   It’s also important to note that, though doctors are required to screen all new mothers in their care, a mother has the right to refuse to answer some or all of the questions. 

I wish this legislation were in effect back when I had my daughter!  There are many others that feel the same way as I do.  Before this legislation went into effect four years ago, some doctors were already asking all new moms fundamental questions at each visit to ascertain if there are any symptoms of PPD, since after all it does occur in as many as one in eight new mothers!  One of the reasons why this legislation was necessary is because there are still so many doctors out there who don’t go the extra mile where their patients are concerned–and worse fail to diagnose PPD properly.  The screening should currently be taking place as the new mom leaves the hospital after having her baby, plus at her 6-week follow-up with her OB/GYN.   Since so many cases of PPD develop before the six-week follow-up visit, at some point–and I fear this may never happen because it would require a huge change in health insurance and ACOG (and whatever other organization that would have anything to do with this) — a 3- or 4-week follow-up visit becomes a requirement/standard.    What a HUGE difference this would make, wouldn’t it?!   Maybe if enough people push for this, it will happen.  One can only hope…and dream.