AAP QuIIN PreSIP:
A Pediatrician’s Perspective on
Postpartum Depression Screening
June 2011
Kellie Haworth, MD, FAAP
Major, Medical Corps, United States Army
Postpartum Support International Military Coordinator
Overview
 IACH Program
 Screening Tools






EPDS
PDSS
CES-D
PHQ-2
PHQ-9
BDI
 Coding


ICD-9
CPT
 IACH study results
 Screening Suggestions
 Response to screening




What
What
What
What
to do
to document
not to say
to say
 Patient Resources





Suggested list
Professional organizations
For moms
For families
Miscellaneous
 Provider Resources





Education and training
Toolkits
Model Programs
References
Medication references
IACH Program
 Prevention


Education during pregnancy /
childbirth classes by OB
Education in newborn nursery
prior to discharge by nursing
 Outpatient screening







Newborn, 2 week,
2
month, 4 month,
6
month, and 9 month well
child visits
6 week postpartum visit
Screened prn by lactation
consultant






EPDS handed to mom by nurse
during initial screening and
vitals
Mom completes screen while
waiting for provider in privacy
of exam room
Provider reviews screen while in
exam room
EPDS scores compared to those
from last visit
Refers to PCM or OB (makes
appt for mom)
Refers for therapy (makes appt
for mom)
Refers for home nurse visit
Refers to Support Group
Telephone follow-up
 Addressing Emergencies

How

Provides handouts, information,
resources list
Clinic Social Worker / Case
Manager notified

OB Clinic
•
Provider addresses concerns
Trained RN offers education

When / where

Pediatric Clinic
•

 Positive screens in Peds

Behavioral Health contact paged and
will consult / assume care of mom in
Pediatric Clinic
Developing hospital perinatal mood
disorders team
•
2 PNP’s, 2 Psych techs
•
Immediate access to Behavioral
Health and Social Work
Services
•
Consultation with Pediatrician
/ PSI coordinator
Screening Tools
Source
Center for Epidemiologic
Patient Health
Patient Health
Edinburgh Postnatal
Postpartum Depression
Studies Depression Scale
Questionnaire
Questionnaire
Beck Depression
Depression Scale (EPDS)
Screening Scale (PDSS)
(CES-D)
(PHQ-2)
(PHQ-9)
Inventory (BDI)
Cox, JL, et al. Detection of postnatal
Beck, C. A checklist to identify women at
Kroehnke K, Spitzer RL,
Kroehnke K, Spitzer RL,
Beck AT, Ward CH, Mendelson
depression: development of the 10-item
risk for developing postpartum depression.
Williams JBW. The PHQ-2:
Williams JBW. The PHQ-9:
M, Mock J, Erbaugh J. "An
Edinburgh Postnatal Depression Scale. Br J Obstet Gynecol Neonatal Nurs Jan-Feb
NIMH
Validity of a 2-Item Depression Validity of a Brief Depression
inventory for measuring
Screener. Medical Care .
Severity Measure. J Gen
depression". Arch Gen
2003;41:1284-94
Intern Med . 2001;16:606-613
Psychiatry. June 1961;4:561–71
J Psychiatry . 1987;150:782-6
1998;27(1):39-46
# items
10
35
20
2
9
7
Timeframe
1 week
2 weeks
1 week
2 weeks
2 weeks
2 weeks
Deliberately does not contain
7 domains (sleep / appetite
Developed to cover most
First 2 items from
Derives scoring from 9
2nd version reflects
items related to somatic
disturbances, anxiety / insecurity,
diagnostic criteria for
PHQ-9
symptoms
Description
emotional lability, cognitive
impairment, loss of self, guilt / shame,
depression
DSM-IV-TR diagnostic DSM-IV-TR revisions
criteria
contemplating self-harm)
self-report
self-report
self-report
self-report
self-report
self-report
Developed to measure
Developed for postpartum
Developed for use in
women in outpatient setting
postpartum women
Primary care cutoff = 10 / 30
Minor depression = 60
Not validated for use
depression intensity,
and USPSTF
in postpartum women
severity, and depth
Positive screen needs
Mild = 0 - 9
Sum indicates severity
Specialty care cutoff = 13 / 30
Major depression = 80
further evaluation
Moderate = 15 - 19
Depression = 21 for
#10 indicates suicidal ideation
1st 7 items indicate suicidal
cutoff = 3 / 6
Severe = 20 - 27
general population
59 - 100%
91 - 94%
60%
62%
88%
cutoff-dependent
Specificity
49 - 100%
72 - 98%
92%
95%
88%
cutoff-dependent
PPV
19 - 92%
33 - 88%
53%
75%
31 - 51%
cutoff-dependent
Time
5 min
5 - 10 min
5 - 10 min
5 min
5 - 10 min
5 min
Cost
Free
$65
Free
Free
Free
Free
Scoring
Accuracy
Sensitivity
Little published data on use in Endorsed by ACOG
postpartum women
Depressive symptoms = 16 / 60
EPDS
PDSS
CES-D
PHQ-2
PHQ-9
BDI
Coding
 Diagnosis (ICD-9)
codes








“Maternal distress /
postpartum condition /
complication” 669.04
“Maternal condition
affecting newborn” 760.9
“Maternal condition
suspected, not found”
V89.09
“Family disruption, other”
V61.09
“Counseling, parent-child
problem” V61.20
“Reported family history of
psychiatric problems / mental
illness (not retardation)”
V17.0
“Psychosocial support, lack
from family” V62.4
“No household member able
to render care” V60.4
 CPT codes




“Administration
and interpretation
of health risk
assessment
instrument” 99420

Recommende
d for use
with EPDS
“Developmental
testing, limited,
with interpretation
and report” 96110

Prior code
for EPDS
“Parenting class,
non-physician, per
session” S9444
“Patient
education, NOS,
non-physician,
individual, per
session” S9445
“Incidence and Severity of Postpartum
Depression Among Military Beneficiaries”
 Who

 How
Women qualified to
receive medical care
at Ireland Army
Community Hospital
(IACH) Fort Knox



 What


Screened for PPD
 When / Where

OB/GYN Clinic

6 week postpartum visit
•

Using Edinburgh
Postnatal Depression
Scale (EPDS)
Positive screen
Infant age 2 - 8 weeks
Pediatric Clinic

Newborn, 2 week, 2
month, 4 month, 6
month, and
9 month
well child visits
Total score = 10 or
more
Positive score on
question #10 (suicidal
ideation)
 Yield



18 month period
1877 EPDS screens
1043 women
“Incidence and Severity of Postpartum
Depression Among Military Beneficiaries”
 Incidence varied between Peds and OB/GYN Clinics
Total Incidence of +EPDS and SI
40%
31.3%
29.5%
27.0%
30%
18.5%
20%
16.9%
13.0%
12.5%
8.5%
10%
0%
Peds
OB/GYN
Incidence +EPDS
IACH
Incidence SI in +EPDS
Civilian
“Incidence and Severity of Postpartum
Depression Among Military Beneficiaries”
•
Total incidence significant even 9 months postpartum
–
Should we screen throughout 1st year postpartum?
IACH EPDS Results by Infant Age
100%
100.0%
90%
80%
70%
60%
50%
40%
20%
34.8%
29.3%
30%
19.2%
13.3%
13.9%
10%
37.5%
9.9%
10.3%
36.4%
12.8%
14.3%
0%
</= 2 wks
n=392
>2 wks - 2 mo
>2 - 4 mo
>4 - 6 mo
n=710
n=232
n=156
Incidence +EPDS
>6 - 9 mo
n=86
Incidence SI in +EPDS
>9 mo
n=7
Screening Suggestions
 When to screen



Bright Futures says
1 month, 2 month, and
6 month well child visits
IACH study suggests
every well child visit
through first 9 months
postpartum
Consistency minimizes
awkwardness
 What tool to use


Most convenient for
individual practice
Educate all staff
 Confirmation of dx


Not necessary by
Pediatrician
Positive screen in
primary care setting
should have further
evaluation
 Delivery of screen




Front desk clerks upon
check-in
Nursing with screening
and vitals
With other
questionnaires / ASQ
Ready for provider when
enters exam room
 Scoring of screen


Nursing
Provider
 Addressing screen




Provider
Trained staff member
Social worker
Emergency contacts
Now what?
 Don’t screen until you know this answer!
 What should you do with an abnormal screen?







Provide reassurance and education
Ask whether mother has primary care provider and gain
permission to initiate conversation with that professional
Offer to initiate referral to mental health professional,
support group, or other therapeutic agency
Initiate immediate referral if mother shows severe
impairment, psychosis, or suicidal ideation
Refer to Early Intervention program for attachment concerns
Provide list of print and online resources
Schedule frequent office visits to follow up
 What should you document (infant’s chart)?





Maternal EPDS score, including score of question #10
Presence of maternal auditory or visual hallucinations or
suicidal or homicidal ideation
Health care professionals who were consulted or to whom
referrals were made
Follow-up plan (for both mother and child)
Current treatment (for both mother and child)
Response to Screening


Note mother-child interaction and assess attachment and bonding
Ask specific questions




Resources, stressors, history of depression, suicidal ideation
Listen!
Be prepared for her to deny her symptoms
Be prepared for her to be unwilling to seek treatment
 What NOT to say  What to say

This is a normal
reaction all new
mothers experience

Don’t worry about…

You have so much to
be happy about…

A healthy baby is
worth it…

You would never
really do…

Join ‘new mom’ group

You are not alone

You are not to blame

Not something you caused,
could have prevented, or
can control

With help, you will be well

It is okay to need help

Depression is treatable

Illness is temporary

You are not “crazy”

This is not reflection of you
as person or mother

Intrusive thoughts are
different from psychosis
Patient Resource List

National

24 hour crisis lines













Massachusetts General Hospital Center for
Women’s Mental Health, Boston, MA
•
http://www.womensmentalhealth.org/
UNC Center for Women’s Mood Disorders
•
http://www.psychiatry.unc.edu/wmd/
Women and Infants Day Hospital, Providence,
RI
•
http://www.womenandinfants.org/
landingPage4.cfm?topicID=333&
facilityID=7
Emory School of Medicine Women’s Mental
Health Program, Atlanta, GA
•
http://www.emorywomensprogram.org/







OB / GYN
Family Practitioners
Midwives
Other professionals








Mental Health Center
Psychiatrists and PNPs
Psychologists
Social Workers
Therapists
Other providers


Law enforcement
Emergency Room
Mental Health Center
Crisis line
Mental Health providers

Blogs
Online support groups
Regional

Maternal-Child Health programs

PSI coordinators

Crisis line

Support groups
Emergency

Professional Organizations
Internet

Local

National Suicide Help Line: 1.800.SUICIDE
(784.2433)
National Suicide Talk Line: 1.800.273.TALK
(8255)
Specialized treatment centers



Home Health nurses
Doulas
Lactation consultants
Case Managers
WIC office
Early Intervention Services
Head Start program
Next Door

Faith Communities

Family members


Spouses / significant others
Extended family
Professional Organizations




























Postpartum Support International (PSI)
Marcé Society
North American Society for Psychosocial Obstetrics & Gynecology (NASPOG)
National Center for Education in Maternal and Child Health (NCEMCH)
National Institute for Healthcare Management Foundation (NIHCM)
Women's Behavioral HealthCARE
Mental Health America (MHA)
Association for Postnatal Illness (APNI) (UK)
National Alliance on Mental Illness (NAMI)
National Healthy Mothers, Healthy Babies Coalition (HMHB)
Center for Postpartum Health
The Pacific Post Partum Support Society (PPPSS)
Lamaze International / Lamaze Institute for Normal Birth
Womenshealth.gov
American Society for Reproductive Medicine (ASRM)
National Institutes of Mental Health (NIMH)
National Institutes of Health (NIH)
Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN)
American Academy of Family Physicians (AAFP)
American Academy of Pediatrics (AAP)
American College of Obstetricians and Gynecologists (ACOG)
American Medical Association (AMA)
American Psychiatric Association (APA)
American Psychological Association (APA)
American Nurses Association (ANA)
National Association of Social Workers (NASW)
American Public Health Association (APHA)
National Center for Complementary and Alternative Medicine (NCCAM)
Postpartum Support
International (PSI)

Non-profit organization

Mission: “Promote awareness, prevention, and treatment of mental health issues
related to childbearing in every country worldwide through support, education,
advocacy, and research”

www.postpartum.net
•
Toll-free Help Line : 800.944.4PPD (4773) (English and Spanish)

Volunteer Area Support Coordinators
In all 50 US states, Canada, Mexico, and 36 other countries worldwide
Provide telephone and email support, information, local resources





“Healthy Mom, Happy Family: Understanding Pregnancy and Postpartum Mood and
Anxiety Disorders”
Educational DVD for families and providers
4 survivor stories accompanied by up-to-date information given by 3 experts

Free phone "Chat with the Experts“
First Mondays of each month for dads, every Wednesday for moms
Facilitated by PSI Professionals

Offer standardized training and education

Resources for women, families, students, and professionals


Professional Organizations

Marce Society





North American Society for
Psychosocial Obstetrics and
Gynecology (NASPOG)




www.marcesociety.com/
International organization dedicated
to prevention, understanding, and
treatment of psychiatric illness
related to childbearing
Promotes, facilitates, and
communicates about research into all
aspects of mental health of women,
infants, and partners around time of
childbirth
Encourages involvement from
psychiatrists, psychologists,
pediatricians, obstetricians,
midwives, nurses, early childhood
specialists, consumer advocacy, and
self-help groups
www.naspog.org/
Society of researchers, clinicians,
educators and scientists involved in
women’s mental health
Fosters scholarly scientific and
clinical study of biopsychosocial
aspects of obstetrics and gynecology
National Center for Education in Maternal and
Child Health (NCEMCH)


Maternal and Child Health Library

www.mchlibrary.info

Research center of Georgetown University

Collection of historical documents related to
US maternal and child health

PPD Knowledge Path
• http://www.mchlibrary.
info/KnowledgePaths/ kp_post
partum.html
• Offers current resources about
prevalence and incidence of postpartum
depression, identification and
treatment, impact on health and wellbeing of new mother and her infant, and
implications for service delivery
National Center for Children in Poverty, Project
Thrive



www.nccp.org
Public Policy Analysis and Education Center for
Infants and Young Children
“Reducing Maternal Depression and Its Impact on
Young Children” published January 2008
Resources for Moms

Text4baby

National Healthy Mothers,
Healthy
Babies Coalition

Free text messaging program
for
pregnant or new mothers

English or Spanish

Messages 3 times per week

Messages customized for stage
of
pregnancy or baby's age

Health advice for pregnant women
and new moms

Nutrition tips

Access to free and low-cost
programs that provide medical
care, food, and other services

Tips and support for coping with
stress of pregnancy
and new
motherhood

Fun facts about baby development
and milestones

To sign up text “BABY” to 511411

APA’s Healthy Minds: “How
Do I Know if I’m
Depressed?”

www.healthyminds.org/expert
opinion10.cfm

Online Support Group

http://postpartumdepression.yuku.com

Online moderated discussion forums

National Women’s Health Information Center

800-944-WOMAN

www.4woman.gov

Mother to Mother Postpartum Depression
Network

www.postpartumdepression.net

Maternal and Child Health Hotline
•
(800) 311-BABY (2229)
•
(800) 504-7081 (Spanish)

Health Resources and Services Administration
(HRSA)

www.mchb.hrsa.gov/pregnancyand
beyond/depression
Internet Resources for
Dads, Families, and Friends

Postpartum Dads Project






Anxiety Disorders Association of
America: “Helping a Family Member”


http://www.mayoclinic.com/health/
depression/MH00016
http://www.adaa.org/GettingHelp/Help
AFamilyMember.asp
Online support group for dads

ww.postpartumdads.org
Postpartum Education for
Parents





http://www.bcnd.org
Father-to-father community-based
workshop inspires men to become
confidently engaged with infants
and support their mates
Mayo Clinic: “Supporting A Friend
or Family Member with Depression”


http://postpartumdadsproject.org
Informational site focusing on what
men experience when their partners
have perinatal mood disorders
Offers stories and advice on how to
help partners
Boot Camp for New Dads


Families for Depression
Awareness



1-800-311-BABY (2229)
1-800-504-7081 (Spanish)
http://www.sbpep.org
24-hour support line available
for one-to-one support
http://www.familyaware.org/
resources/options.php
Helps families recognize and
manage various forms of
depression and mood disorders
Depression During and After
Pregnancy: A Resource for
Women, Their Families, and
Friends


www.mchb.hrsa.gov/pregnancy
andbeyond/depression
Information about definition
and symptoms of PPD and
when to seek treatment
Miscellaneous Resources

Blogs






Postpartum Progress

http://postpartumprogress.
typepad.com
I’m Listening by Jane Honikman

http://janehonikman.com/
Unexpected Blessing

http://unexpectedblessing.
wordpress.com
PTSD After Childbirth

http://www.ptsdafterchild birth.org
Beyond Postpartum

www.atlantappdmom.blog spot.com

Resources in Other Languages




Foundations





Jennifer Mudd Houghtaling Postpartum
Depression Foundation

www.ppdchicago.org
Jenny’s Light

www.jennyslight.org
Sounds of Silence Foundation

www.soundsofsilence
foundation.org
Ruth Rhoden Craven Foundation

www.ppdsupport.org
Melanie’s Battle

www.melaniesbattle.org



Medline Plus

www.nlm.nih.gov/medlineplus/
languages/postpartumdepression. html

15 languages including Arabic, Japanese,
Korean, Chinese, Vietnamese, Russian,
Somali
Maternal & Child Health Library

www.mchlibrary.info/nonenglish. html
UCSF Depression Prevention Course (Muñoz)

www.medschool.ucsf.edu/latino/
manuals.aspx#depressionprevention

Workbooks in Spanish, Japanese, Chinese
British Columbia Partners for Mental Health
and Addictions Information

Publications in Arabic, Chinese, English,
Farsi, French, Korean, Punjabi, Russian,
Spanish, Japanese, Vietnamese
Here to Help

www.heretohelp.bc.ca/other-languages
French

http://marce-franco phone.asso.fr/
German

http://www.marcegesellschaft.de/
Provider ResourcesEducation and Training

Postpartum Support International (PSI)

University of Washington’s “Keys to Postpartum Depression”


Created by nurse scientists at UW and members of Washington First Steps Team
3 multimedia training modules




Understanding & Treating Women with Perinatal Depression & Mood Disorders
Relationship Focused Practice
Screening for Perinatal Depression
Women's Behavioral HealthCARE




http://www.womensbehavioralhealth.org/
Committed to advancement of gender-based clinical care, advocacy, research, and
education
Provide preventive, curative, and promotive services to women of childbearing age,
their families, the public, and general medical community (psychiatry, obstetrics,
gynecology, and pediatrics)
Developed MedEdPPD.org



Professional, educational, peer-reviewed website
Developed with grant from NIMH
Provides evidenced-based tools for professionals and families
• Expert CEU / CME presentations
• Screening tools
• Case studies
• Provider FAQs
• Care Pathways algorithm
• Designed for medical professionals evaluating postpartum women to help
determine if reached positive or negative outcome since giving birth
• Outcome indicates if patient should be referred for additional mental
health services or put on antidepressant regimen and monitored
Provider ResourcesEducation and Training

Support and Training to Enhance Primary Care for Postpartum
Depression (STEP-PPD)




http://www.step-ppd.com/step-ppd/home.aspx
Free training program solicited by NIMH
Educates primary care providers on evidence-based screening, diagnosis,
treatment, and referral for PPD
Tailors instruction to user by requesting information at registration




4 Program formats





Specialty (OB / GYN, Pediatrics, or Family Practice)
Discipline (physician, nurse, PA, or social worker)
Special characteristics of patient population (ethnicity, region, adolescents)
Web-based training
• Sponsored by University of Iowa Carver College of Medicine for 3 AMA
Category I credits
 Must purchase CME credit license for $15 and score >80% on quiz
• Learning objectives, case studies, interactive video clips, and resource links
• 3 Modules
 “Understanding PPD”
 “Assessing PPD”
 “Treating PPD”
• Comprehensive resource list including 3 screening tools
• Algorithms for assessment and treatment of PPD
In-person ½-day training
In-person grand rounds
Full-day “train the trainer”
Can purchase a pocket guide online or download for PDA
STEP-PPD
Provider Resources- Toolkits

Spectrum Women’s Health Toolkit for Healthcare Providers

Helps design PPD program in step-by-step approach

Create advisory team

Train staff

Begin screening

Establish follow-up protocols

Develop referral team

Implement groups and services

Launch telephone support and information line

Create program evaluation process
Prepares healthcare staff

Garners financial and resource support

One kit costs $450


Pennsylvania Perinatal Partnership Community Collaboration Toolkit



www.paperinatal.org
Free 163-page toolkit

Fact sheets, tables, website links, talking points, consultation lines,
treatment guides, legislation information
Mental Health America: Maternal Depression- Making a Difference
Through Community Action: A Planning Guide

http://www.nmha.org/go/ maternal-depression
Provider ResourcesModel Programs

Oregon Pediatric Society’s START program







http://oraap.com/
Maternal depression screen module
CME and MOC credits available
Goals

Increase standardized screening

Community resource awareness

Enhance care coordination and communication
Incorporates medical home, team-based care model

Includes primary care providers, nurses, and office staff
Training tailored to community

Uses physician trainers from various geographic regions who know
communities best

Includes representatives from local community agencies
Virginia Bright Futures



Has training website
Developed “parent kit”
Partnered with AAP Virginia chapter, state Early Periodic Screening, Diagnosis,
and Treatment (EPSDT), Resource Mothers, and Healthy Families Virginia to
recommend screening
Provider Resources- References

National Institute for
Healthcare Management
Foundation (NIHCM)



Perinatal Depression Information
Network

“Identifying and Treating Maternal
Depression: Strategies &
Considerations for Health Plans”
(Issue Brief June 2010)
Basic PPD information, statistics,
risk factors, screening
recommendations, screening tools,
legislation, management and
treatment, barriers, and resources




National Library of Medicine



www.nlm.nih.gov/medlineplus/
postpartum depression.html

University of Illinois Chicago
(UIC) Provider Consultation Line




Consults for healthcare providers
with questions on detection,
diagnosis, and treatment of
perinatal mood disorders
UIC faculty and staff clinicians
Not a “hotline”
Response in 1 business day

Collects and organizes information across
US
Creates forum to bring maternal, child,
and mental health providers, leaders, and
families together
Lists specific contacts and other
key
information for each network resource
Online provider toolkits
Online training modules

Research

Policy

Funding

Legislative initiatives
Special features

Discussion forum

Materials for women and families
Massachusetts General Hospital
Women’s Mental Health Center
Library (MGH)


www.womensmentalhealth.org/library
Repository of information and articles
Provider ResourcesMedications
 What about maternal psychoactive medication use
and breastfeeding?


SSRI’s most commonly used in lactating women due to lower breast
milk concentrations
Lowest effective dose should be prescribed
 References



Evidence-based information about risk of maternal exposures to
developing fetus or infant

Maternal and infant drug levels

Possible effects on breastfed infants

Alternate drugs to consider
Books

“Medications and Mothers’ Milk: A Manual of Lactational
Pharmacology” by Hale (Pharmasoft)

“Drugs in Pregnancy and Lactation” by Briggs, Freeman, and
Yaffe (Lippincott)
Internet sites

National Library of Medicine online database “Lact Med”
•
http://toxnet.nlm.nih.gov/

Motherisk

OTIS (Organization of Teratology Information Specialists)
•
•
http://www.motherisk.org/women/index.jsp
www.otispregnancy.org
Questions?
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A Pediatrician’s Perspective on Postpartum Depression