Perinatal Mental Health Toolkit Overview & Primer for Pediatric Primary Care Providers DC Collaborative for Mental Health in Pediatric Primary Care Overview The DC Collaborative for Mental Health in Pediatric Primary Care (the Collaborative) is a local public-private partnership dedicated to improving the integration of mental health in pediatric primary care for children in the District of Columbia. The Collaborative is particularly focused on supporting pediatric primary care providers (PPCPs) in the promotion of mental health among their youngest patients and those patients’ families, which includes perinatal mental health. The Collaborative supports PPCPs in screening for perinatal mood and anxiety disorders, such as postpartum depression, during well-child visits in the first year postpartum, and has created a Perinatal Mental Health Toolkit to aid PPCPs in this important work. The toolkit includes: 1) 2) 3) 4) 5)
Summary of Mood and Anxiety Disorders During Pregnancy and Postpartum Edinburgh Postnatal Depression Scale (English, Spanish and compendium of other translations) Screening & Referral Algorithm and Crisis Action Plan for the Edinburgh Postnatal Depression Scale Key Clinical Considerations in the Perinatal Period Perinatal Mental Health Community Resources
Why is postpartum depression important to pediatric providers? Perinatal mood and anxiety disorders (PMADs) affect between 10 – 20% of women, with even higher rates for low-income women. PMADs are one of the most common, yet underdiagnosed, complications of pregnancy and childbirth in America. They lead to increased costs of medical care, inappropriate medical care, child abuse and neglect, discontinuation of breastfeeding, family dysfunction, and adverse effects on early brain development.1 Birth outcomes can be negatively affected by PMADs in pregnancy,2,6-9 and PMADs can have a long-term impact on child outcomes. PMADs are associated with attachment insecurity,3 difficult infant/childhood temperament,3,10 developmental delay, and impaired language development.4,5 Treatment of maternal depression until remission is associated with decreased psychiatric symptoms and improved functioning outcomes among offspring.11,12 Despite the profound negative effects on mother and child, some of which improve with treatment,11,12 the vast majority of women with PMADs go untreated.13-16 What is known about PMAD screening in pediatric settings? Most perinatal care or obstetrical settings only see women at the 4-6 week postpartum visit, and only a minority screen for PMADs.17 Pediatricians may be the only medical provider many mothers see during the child’s first year of life.18,19 PMADs can be identified in pediatric settings during the first postpartum year.16 Training pediatric providers to detect and address PMADs can enhance pediatric providers’ impact on maternal mental health,20 carrying the potential to have a trans-generational impact. Can I bill for screening? If you are using the Edinburgh Postnatal Depression Scale and the child is insured through a DC Medicaid Managed Care Organization or DC Medicaid Fee-for-Service, you can bill using 96110 and receive reimbursement. For other screening tools and insurances, please consult the infant’s insurer. 1
When an infant is the patient Well-child visits provide an ideal opportunity to detect and address PMADs. As pediatric providers are most often not providing primary care to mothers, their main role is one of screening and referral. The Collaborative recommends screening at the following well-child visits (and at other times if indicated): 2 month visit 6 month visit 12 month visit The Edinburgh Postnatal Depression Scale (EPDS) Pediatric Screening & Referral Algorithm included in this toolkit offers guidelines for administering and responding to a screen. Even for those not screening positive (score of 13 or above), education and potential referrals for support and/or treatment may be indicated. For all parents with a positive screen: If the parent is already in mental health treatment, refer to/notify (with consent) parent’s provider. Give parent information and/or referral about community mental health resources. Refer to/notify* (with consent) parent’s PCP and/or OB/GYN for monitoring and follow-up. Consider scheduling brief follow-up visit for infant and parent in pediatric office. Assess for natural supports and encourage parent to utilize them. Most likely you will have only one parent in the office when a screen is positive. A depressed parent who is alone or feeling alone is at higher risk for suicide. It is important for someone else in the parent’s life to be aware of the presence of depression and be able to step in to help. If pediatric providers have clinical questions, they should call DC Mental Health Access in Pediatrics (DC MAP) at 1-844-30DCMAP. Information about DC MAP is available at www.dcmap.org. Assess if there is an acute crisis or safety concern. If there is a crisis or safety concern, refer to Crisis Action Plan or parent’s local Emergency Services. The Collaborative recommends that pediatric providers document the screening result in the medical record as you would with other risk factors that may affect the child health such as substance use or domestic violence. The Collaborative also recommends that pediatric practices continue to use their current strategies for appropriately documenting potentially sensitive family information. When a pregnant/postpartum young mother is the patient The Collaborative recommends that pediatric providers caring for pregnant teens or postpartum young mothers screen for perinatal mood and anxiety disorders during pregnancy and in the postpartum period. Questions that arise specific to mental health concerns during screening and/or providing care for a pregnant teen or postpartum young mother should be directed to DC MAP at 1-844-30DCMAP. Antidepressant medications and lactation Considerations for lactating women: SSRIs (and some other antidepressants) are considered a reasonable treatment option during breastfeeding. Most psychiatric medications are passed into breast milk, though in very low amounts. When antidepressants are indicated, the benefits of breastfeeding while taking antidepressants generally outweigh the risks. The benefits of other psychiatric medications, including benzodiazepines, 2
October 2015 antiepileptics, stimulants, and antipsychotics, may outweigh the risks of the medication during breastfeeding. It is important to consider the risk of untreated illness to the mother-baby dyad and balance this with the risk of medication use during breastfeeding. It is crucial that evaluation of the risks and benefits of medication use during breastfeeding is done on a patient-by-patient basis and considers the needs of the family. Recommendations are ideally made collaboratively with well-informed patients and family members. Monitor for side effects in nursing infants.
We also recommend the NIH website LactMed (http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm), which contains information on medications to which breastfeeding mothers may be exposed. Community Resources A variety of community resources exist, from support groups to psychiatric treatment for mothers suffering from a perinatal mood and anxiety disorder.
Resources can be found in the Perinatal Mental Health section of the Collaborative’s Child and Adolescent Mental Health Resource Guide at http://dchealthcheck.net/resources/healthcheck/mentalhealth-guide.html or in the Perinatal Mental Health Community Resources section of this toolkit.
Home Visiting Programs Home visiting is an early childhood intervention that supports pregnant women and parents/caregivers in their role of raising children by bringing services to them in their natural setting: their home. The models provide visits for families on a weekly or monthly schedule. Home visitors utilize various screening tools to link families to needed community resources. Additionally, home visitors implement evidence-based programs that have been proven to help prevent child abuse and neglect, encourage positive parenting, and promote child development and school readiness. The District of Columbia offers these voluntary, family-focused home visiting services to expecting or new families with infants and children, which are delivered by trained home visiting professionals or paraprofessionals. For more information about home visiting services, please see the Early Childhood section of the DC Collaborative Child and Adolescent Mental Health Resource Guide at http://dchealthcheck.net/resources/healthcheck/mental-health-guide.html or the DC Home Visiting Council at http://www.dchomevisiting.org/about/ You may also contact the following based on the age of the child:
For home visiting referrals for prenatal up to age 2 of the baby contact: Fernanda Ruiz at 202-420-7178 or Mia Morrison at 202-302-6669. For home visiting referrals for ages 3 – 5 contact: Katherine Rosas at 202-265-0149.
Source: Adapted from Massachusetts Child Psychiatry Access Project for Moms’ A Primer for Pediatric Providers, available at www.mcpapformoms.org
References and Acknowledgements We would like to give special thanks to MCPAP for Moms for allowing us to use and adapt items from their Toolkit for Pediatric Providers available at http://www.mcpapformoms.org/ 1. Earls, Marian F., “Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice,” Pediatrics: 2010, 126, 1032. 2. Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry 2010;67:1012-24. 3. Forman DR, O'Hara MW, Stuart S, Gorman LL, Larsen KE, Coy KC. Effective treatment for postpartum depression is not sufficient to improve the developing mother-child relationship. Dev Psychopathol 2007;19:585602. 4. Deave T, Heron J, Evans J, Emond A. The impact of maternal depression in pregnancy on early child development. BJOG 2008;115:1043-51. 5. Paulson JF, Keefe HA, Leiferman JA. Early parental depression and child language development. J Child Psychol Psychiatry 2009;50:254-62. 6. Cripe SM, Frederick IO, Qiu C, Williams MA. Risk of preterm delivery and hypertensive disorders of pregnancy in relation to maternal co-morbid mood and migraine disorders during pregnancy. Paediatr Perinat Epidemiol 2011;25:116-23. 7. Suri R, Altshuler LA, Mintz J. Depression and the decision to abort. AJ Psychiatry 2004;161:1502. 8. Flynn HA, Chermack ST. Prenatal alcohol use: the role of lifetime problems with alcohol, drugs, depression, and violence. J Stud Alcohol Drugs 2008;69:500-9. 9. Gotlib IH, Whiffen VE, Wallace PM, Mount JH. Prospective investigation of postpartum depression: factors involved in onset and recovery. J Abnorm Psychol 1991;100:122-32. 10. Britton JR. Infant temperament and maternal anxiety and depressed mood in the early postpartum period. Women Health 2011;51:55-71. 11. Pilowsky DJ, Wickramaratne P, Talati A, et al. Children of depressed mothers 1 year after the initiation of maternal treatment: findings from the STAR*D-Child Study. Am J Psychiatry 2008; 165(9): 1136-1147. 12. Foster CE, Webster MC, Weissman MM. Remission of maternal depression: relations to family functioning and youth internalizing and externalizing symptoms. J Clin Child Adolescent Psychology 2008; 37(4): 714-724. 9 13. Smith MV, Shao L, Howell H, Wang H, Poschman K, Yonkers KA. Success of mental health referral among pregnant and postpartum women with psychiatric distress. Gen Hosp Psychiatry 2009;31:155-62. 14. Carter FA, Carter JD, Luty SE, Wilson DA, Frampton CM, Joyce PR. Screening and treatment for depression during pregnancy: a cautionary note. Aust N Z J Psychiatry 2005;39:255-61. 15. Marcus SM, Flynn HA, Blow FC, Barry KL. Depressive symptoms among pregnant women screened in obstetrics settings. J Womens Health (Larchmt) 2003;12:373-80. 16. Rowan P, Greisinger A, Brehm B, Smith F, McReynolds E. Outcomes from implementing systematic antepartum depression screening in obstetrics. Archives of Women's Mental Health 2012;15:115-20. 17. Chaudron L, Klein M, Remington P, Palta M, Allen C, Essex M. Prodromes, predictors and incidence of postpartum depression. J Psychosom Obstet Gynaecol 2001;22:103-112. 18. Chaudron LH. Review of beyond the blues: A guide to understanding and treating prenatal and postpartum depression. Birth: Issues in Perinatal Care 2004;31(1):75. 19. National Ambulatory Medical Care Survey (NAMCS) and Periodic Survey #42. American Academy of Pediatrics News Research Update Column;October 2001. 20. Chaudron L, Szilagyi PG, Campbell AT, Mounts KO, McInerny KT. Legal and ethical considerations: Risks and benefits of postpartum depression screening at well-child visits. Pediatrics 2007;119:123-128.
Summary of Mood and Anxiety Disorders During Pregnancy and the Postpartum Period (PMADs) NOTE about “The Baby Blues”: This a temporary and common experience after childbirth, with peak onset 3-5 days after delivery and a maximum duration of two weeks. Features symptoms such as mood swings and excessive worry also seen in many PMADs. Can be a risk factor but is not a determinant for a PMAD and occurs in 80% of new mothers. Usually resolves naturally, though outside intervention such as a peer support group can be helpful.
What is it?
Depressive episode that occurs during pregnancy or within a year of giving birth.
When does it start?
Obsessive-Compulsive Disorder (OCD)
Posttraumatic Stress Disorder (PTSD)
A range of anxiety disorders, Intrusive repetitive thoughts Specific anxiety symptoms, including generalized anxiety, that are scary and do not make including nightmares, panic disorder and/or social sense to mother/expectant flashbacks, and hyperanxiety, experienced during mother. Compulsions (e.g., vigilance, experienced after pregnancy or the postpartum counting, hand washing) may traumatic events(s), period. or may not be present. including a traumatic birth. Onset can be anytime during pregnancy or first year postpartum. Peaks at 3-4 months. Can be triggered by weaning and/or when menstrual cycle resumes.
Sudden onset of psychotic symptoms following childbirth, in particular delusions regarding self and/or child(ren). Increased risk with bipolar disorder. Onset between 2 – 12 weeks after delivery. Watch carefully if sleep deprived for ≥48 hours.
History of perinatal mood/anxiety disorder Personal history of depression or anxiety Family history of depression or anxiety Recent, big life changes (in addition to pregnancy/new baby) Lack of social support Poor marital/partner relationship Multiples Difficult pregnancy Difficult infant temperament (colic, fussy) or related problems (sleep, feeding) Special needs/NICU baby Prior pregnancy or infant loss Infertility treatments Dysregulated baby-crying feeding, sleep problems. Change in appetite, sleep, Fear and anxiety, panic attacks, Disturbing repetitive thoughts energy, motivation, shortness of breath, rapid pulse, (which may include harming concentration. Negative dizziness, chest or stomach baby or harm coming to baby), thinking including guilt, pains, fear of adapting compulsive behavior to hopelessness, detachment/doom, fear of prevent baby from being helplessness, and going crazy or dying. harmed (secondary to worthlessness. May also Excessive sometimes obsessional thoughts about experience suicidal debilitating worry. harming baby that scare thoughts and evolution of May have intrusive thoughts women). psychotic symptoms. (see OCD).
Bipolar disorder, history of psychosis, history of postpartum psychosis (80% will relapse), family history of psychotic illness, severe sleep deprivation, medication discontinuation for bipolar disorder (especially when done quickly).
Risk factors for Depression, Anxiety, and OCD, plus:
Traumatic birth (in experience of mother) and/or Previous sexual trauma
Change in cognition, mood, arousal associated with traumatic event(s) and avoidance of stimuli associated with traumatic event.
Mood fluctuation, confusion, marked cognitive impairment. Bizarre behavior, insomnia, visual and auditory hallucinations. May have moments of lucidity. May include altruistic delusions about infanticide and/or homicide and/or suicide.
Obsessive-Compulsive Disorder (OCD)
How common is it?
Occurs in up to 20% of all new mothers. Low SES: 33-50%
Generalized anxiety: 6-8% Panic disorder: 0.5-3% Social anxiety: 0.2-7%
Resources and treatment
For depression, anxiety, PTSD and OCD: Self-Care: Exercise, Sleep, Nutrition, Time off from childcare Peer Support Groups Psychotherapy (Individual, Dyadic [mother-baby], Couples, Family) Medication
Reported in up to 4% of new mothers; likely higher due to fear of reporting.
Posttraumatic Stress Disorder (PTSD)
Presents after childbirth in 29% of mothers.
Occurs in 1-2 in 1,000 births.
Additional complementary and alternative therapies options for depression include bright light therapy, Omega-3, fatty acids, acupuncture and folate.
Requires immediate psychiatric help. Hospitalization and medication are usually indicated. If history of postpartum psychosis, preventative treatment is needed in subsequent pregnancies. Encourage sleep hygiene for prevention (e.g. consistent sleep/wake times, help with feedings at night).
1 Adapted from Susan Hickman, Ph.D., Director of the Postpartum Mood Disorder Clinic, San Diego; Valerie D. Raskin, M.D., Assistant Professor of Clinical Psychiatry at the University of Chicago, IL (“Parents” September 1996) 2 O'Hara MW, Wisner KL. Perinatal mental illness: Definition, description and aetiology. Best Pract Res Clin Obstet Gynaecol. 2013 Oct 7. pii: S1521-6934(13)00133-8. doi: 10.1016/j.bpobgyn.2013.09.002. [Epub ahead of print] Revision 07.24.14
Copyright © MCPAP for Moms 2014 all rights reserved. Authors: Byatt N., Biebel K., Friedman, L., Lundquist R., Freeman M., & Cohen L. Funding provided by the Massachusetts Department of Mental Health.
Edinburgh Postnatal Depression Scale 1 (EPDS) Name: ______________________________
Your Date of Birth: ____________________
Baby’s Date of Birth: ___________________
As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check the answer that comes closest to how you have felt IN THE PAST 7 DAYS, not just how you feel today. Here is an example, already completed. I have felt happy: Yes, all the time Yes, most of the time No, not very often No, not at all
This would mean: “I have felt happy most of the time” during the past week. Please complete the other questions in the same way.
In the past 7 days: 1. I have been able to laugh and see the funny side of things As much as I always could Not quite so much now Definitely not so much now Not at all 2. I have looked forward with enjoyment to things As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all *3. I have blamed myself unnecessarily when things went wrong Yes, most of the time Yes, some of the time Not very often No, never 4.
I have been anxious or worried for no good reason No, not at all Hardly ever Yes, sometimes Yes, very often I have felt scared or panicky for no very good reason Yes, quite a lot Yes, sometimes No, not much No, not at all
*6. Things have been getting on top of me Yes, most of the time I haven’t been able to cope at all Yes, sometimes I haven’t been coping as well as usual No, most of the time I have coped quite well No, I have been coping as well as ever *7
I have been so unhappy that I have had difficulty sleeping Yes, most of the time Yes, sometimes Not very often No, not at all
I have felt sad or miserable Yes, most of the time Yes, quite often Not very often No, not at all
I have been so unhappy that I have been crying Yes, most of the time Yes, quite often Only occasionally No, never
The thought of harming myself has occurred to me Yes, quite often Sometimes Hardly ever Never
Administered/Reviewed by ________________________________ Date ______________________________ 1
Source: Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786 .
Source: K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199 Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title and the source of the paper in all reproduced copies.
Edinburgh Postnatal Depression Scale 1 (EPDS) 2
Postpartum depression is the most common complication of childbearing. The 10-question Edinburgh Postnatal Depression Scale (EPDS) is a valuable and efficient way of identifying patients at risk for “perinatal” depression. The EPDS is easy to administer and has proven to be an effective screening tool. Mothers who score above 13 are likely to be suffering from a depressive illness of varying severity. The EPDS score should not override clinical judgment. A careful clinical assessment should be carried out to confirm the diagnosis. The scale indicates how the mother has felt during the previous week. In doubtful cases it may be useful to repeat the tool after 2 weeks. The scale will not detect mothers with anxiety neuroses, phobias or personality disorders. Women with postpartum depression need not feel alone. They may find useful information on the web sites of the National Women’s Health Information Center and from groups such as Postpartum Support International and Depression after Delivery .
SCORING QUESTIONS 1, 2, & 4 (without an *) Are scored 0, 1, 2 or 3 with top box scored as 0 and the bottom box scored as 3. QUESTIONS 3, 510 (marked with an *) Are reverse scored, with the top box scored as a 3 and the bottom box scored as 0. Maximum score: 30 Possible Depression: 10 or greater Always look at item 10 (suicidal thoughts)
Users may reproduce the scale without further permission, providing they respect copyright by quoting the names of the authors, the title, and the source of the paper in all reproduced copies.
Instructions for using the Edinburgh Postnatal Depression Scale: 1. The mother is asked to check the response that comes closest to how she has been feeling in the previous 7 days. 2. All the items must be completed. 3. Care should be taken to avoid the possibility of the mother discussing her answers with others. (Answers come from the mother or pregnant woman.) 4. The mother should complete the scale herself, unless she has limited English or has difficulty with reading. 1
Source: Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786.
Source: K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199
Escala Edinburgh para la Depresión Postnatal (Spanish Version)
Nombre de participante: ___________________________ Número de identificación de participante:
Fecha: _______________________________________ Como usted está embarazada o hace poco que tuvo un bebé, nos gustaría saber como se siente actualmente. Por favor MARQUE (√) la respuesta que más se acerca a como se ha sentido durante LOS ÚLTIMOS 7 DÍAS y no sólo como se ha sentido hoy. 6.
A continuación se muestra un ejemplo completado: Me he sentido feliz: Sí, todo el tiempo ____ Sí, la mayor parte del tiempo ____ No, no muy a menudo ____ No, en absoluto ____ Esto significa: “Me he sentido feliz la mayor parte del tiempo” durante la última semana. Por favor complete las otras preguntas de la misma manera.
0 1 2 3
He podido reír y ver el lado bueno de las cosas: Tanto como siempre he podido hacerlo ____ No tanto ahora ____ Sin duda, mucho menos ahora ____ No, en absoluto ____ He mirado al futuro con placer para hacer cosas: Tanto como siempre ____ Algo menos de lo que solía hacerlo ____ Definitivamente menos de lo que solía hacerlo ____ Prácticamente nunca ____ Me he culpado sin necesidad cuando las cosas marchaban mal: Sí, casi siempre ____ Sí, algunas veces ____ No muy a menudo ____ No, nunca ____
____ 2 ____ 1 ____ 0
Me he sentido tan infeliz, que he tenido dificultad para dormir: Sí, casi siempre ____ 3 Sí, a veces ____ 2 No muy a menudo ____ 1 No, en absoluto ____ 0
Me he sentido triste y desgraciada: Sí, casi siempre Sí, bastante a menudo No muy a menudo No, en absoluto
0 1 2 3 9.
He estado ansiosa y preocupada sin motivo alguno: No, en absoluto ____ 0 Casi nada ____ 1 Sí, a veces ____ 2 Sí, muy a menudo ____ 3
7. 0 1 2 3
3 2 1 0
Las cosas me oprimen o agobian: Sí, la mayor parte del tiempo no he podido sobrellevarlas Sí, a veces no he podido sobrellevarlas de la manera No, la mayoría de las veces he podido sobrellevarlas bastante bien No, he podido sobrellevarlas tan bien como lo hecho siempre
____ ____ ____ ____
Me he sentido tan infeliz que he estado llorando: Sí, casi siempre ____ 3 Sí, bastante a menudo ____ 2 Ocasionalmente ____ 1 No, nunca ____ 0
10. He pensado en hacerme daño: Sí, bastante a menudo A veces Casi nunca No, nunca
____ ____ ____ ____
ESCRIBA EL TOTAL DE SU PUNTAJE AQUÍ: 5.
3 2 1 0
He sentido miedo o pánico sin motivo alguno: Sí, bastante ____ 3 Sí, a veces ____ 2 No, no mucho ____ 1 No, en absoluto ____ 0
Edinburgh Postnatal Depression Scale (EPDS). Texto adaptado del British Journal of Psychiatry, Junio, 1987, vol. 150 por J.L. Cox, J.M. Holden, R. Segovsky.
3 2 1 0
Edinburgh Postnatal Depression Scale (EPDS) Scoring & Other Information ABOUT THE EPDS Response categories are scored 0, 1, 2 and 3 according to increased severity of the symptom. Items 3, 5-10 are reverse scored (i.e., 3, 2, 1, and 0). The total score is calculated by adding together the scores for each of the ten items. Users may reproduce the scale without further permission providing they respect copyright (which remains with the British Journal of Psychiatry) quoting the names of the authors, the title and the source of the paper in all reproduced copies. The Edinburgh Postnatal Depression Scale (EPDS) was developed to assist primary care health professionals in detecting mothers suffering from postpartum depression (PPD); a distressing disorder more prolonged than the “blues” (which occur in the first week after delivery), but less severe than puerperal psychosis. Previous studies have shown that PPD affects at least 10 percent of women and that many depressed mothers remain untreated. These mothers may cope with their baby and with household tasks, but their enjoyment of life is seriously affected and it is possible that there are long term effects on the family. The EPDS was developed at health centers in Livingston and Edinburgh. It consists of 10 short statements. The mother underlines which of the four possible responses is closest to how she has been
feeling during the past week. Most mothers complete the scale without difficulty in less than five minutes. The validation study showed that mothers who scored above a threshold 12/13 were likely to be suffering from a depressive illness of varying severity. Nevertheless, the EPDS score should not override clinical judgement. A careful clinical assessment should be carried out to confirm the diagnosis. The scale indicates how the mother felt during the previous week, and in doubtful cases it may be usefully repeated after two weeks. The scale will not detect mothers with anxiety neuroses, phobias or personality disorders. INSTRUCTIONS FOR USERS 1. The mother is asked to underline the response that comes closest to how she has felt during the previous seven days. 2. All 10 items must be completed. 3. Care should be taken to avoid the possibility of the mother discussing her answers with others. 4. The mother should complete the scale herself, unless she has limited English or has difficulty with reading. 5. The EPDS may be used at six to eight weeks to screen postnatal women or during pregnancy. The child health clinic, postpartum check-up or a home visit may provide suitable opportunities for its completion.
Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786. The Spanish version was developed at the University of Iowa based on earlier Spanish versions of the instrument. For further information, please contact Michael W. O’Hara, Department of Psychology, University of Iowa, Iowa City, IA 52245, e-mail: [email protected]
Edinburgh Postnatal Depression Scale Screening & Referral Algorithm for Pediatric Primary Care Providers During Well-Child Visits Explain the screen Feeling depressed or anxious is very common during pregnancy and/or after birth. 1 in 7 women experience depression, anxiety or frightening thoughts during this time. It is important that we screen for depression because it is twice as common as diabetes. It can also impact your and your baby’s health. We will be seeing you and your baby a lot over the next few months/years and we want to support you.
Score of 0-9: Normal/Negative Screen (likely not suffering at this time)
Provide education about risks/incidence. Use clinical judgment regardless of score. Provide Postpartum Support DC contact for support groups and other community resources: 202-643-7290 Suggested language: From the screen, it seems like you are doing well. Having a baby is always challenging and every parent deserves support. Do you have any concerns you would like to talk to us about? In the future, should you start to have a difficult time or develop depression or anxiety, please follow-up with your doctor or talk to me about it at your child's next visit.
Score of 10-12: At-Risk for Depression and/or Anxiety
Discuss results and provide education. Strongly consider making referral and/or providing Postpartum Support DC number: 202-643-7290 Suggested language: Based on what you've told me and your score, I am concerned that you may be having a difficult time or be depressed. It can be hard to feel this way when you have a baby/young child. There are things you can do to feel better. Let's talk about some ideas that might work for you.
Score of 13+: Positive Screen (likely suffering from Depression and/or Anxiety)
Discuss results and provide education. Make referral and/or give Postpartum Support DC number: 202-643-7290 Suggested language: Based on what you've told me and your score, I am concerned that you may be depressed. What you are feeling is real and it is not your fault. It can be very hard to feel this way when you have a baby/young child. Getting help is the best thing you can do for you and your baby. Many effective support and treatment options are available. Let's talk about some ideas that might work for you.
QUESTION #10 (SELF-HARM): If "Yes" – Hardly ever, Sometimes, or Yes, quite often – MOVE TO CRISIS ACTION PLAN Source: Adapted from Massachusetts Child Psychiatry Access Project for Moms’ Postpartum Depression Screening Algorithm for Pediatric Providers During Well-Child Visits, available at www.mcpapformoms.org
CRISIS ACTION PLAN Patient answers "YES" to #10 on EPDS or
Patient reports thoughts of harm to self or others Ask further Questions: •Intent: You have said that you think about killing or harming yourself. Have you made any plans? •Means: Can you describe your plans? or How have you thought about killing yourself (your infant)? Do you have access to [stated method]? •Likelihood: Do you think you would actually harm or kill yourself or someone else? •Protective Factor: What is keeping you from following through with your plan? •Impulsivity: Have you tried to harm yourself or someone else in the past?
If patient has a plan and provider or patient feels she cannot be safe then follow the next steps: •Do not leave patient by herself or alone with baby •Ask patient about supportive person in their life (husband, parent, friend) •Request permission to make this person aware of current circumstances •Engage them to plan for: child care, transportation to emergency services, emotional support
Coordinate immediate psychiatric/crisis intervention or evaluation •Be familiar with Emergency Department policies and referral processes •When no resources are available, call 911 (ask for Crisis Intervention Officer if available)
If patient is NOT in the office and feels she CANNOT be safe or worries if she will be safe then follow the next steps: •Ask where she is and if she is alone •Assess degree of risk, as above •Arrange for immediate psychiatric/crisis intervention or evaluation while patient remains on phone •Assess availability and proximity of resources and support
Source: Adapted from Crisis Action Plan discussed at “Transforming Science into Strategy: A Multidisciplinary Model for Perinatal Mood Disorder Screening” presentation by Alison Palmer at PSI Conference 2013
Key Clinical Considerations When Assessing the Mental Health of Pregnant and Postpartum Women Assessing Thoughts of Harming Baby Thoughts of Harming Baby that Occur Secondary to Thoughts of Harming Baby that Occur Secondary to Obsessions/Anxiety Postpartum Psychosis Good insight Poor insight No psychotic symptoms Symptoms of psychosis (eg. auditory and/or visual hallucinations) Thoughts are intrusive, scary, and cause mother anxiety Delusional beliefs with distortion of reality present Ego-dystonic Ego-syntonic Suggests NOT a risk of harming baby
Medication May Not be Indicated Mild depression based on clinical assessment No suicidal ideation Able to care for self/baby Engaged in psycho-therapy or other nonmedication treatment Depression has improved with psychotherapy in the past Strong preference for and access to psychotherapy
Suggests AT RISK of harming baby Medication Treatment Should be Considered Moderate or severe depression based on clinical assessment Suicidal ideation Difficulty functioning caring for self/baby Psychotic symptoms present History of severe depression and/or suicidal ideation and/or attempts Comorbid anxiety diagnosis or symptoms
Risk Factors for Postpartum Depression Personal history of anxiety disorder, major depression and/or postpartum depression Family history of mood or anxiety disorder Difficulty breastfeeding Fetal/Newborn loss Lack of personal or community resources Financial challenges Complications of pregnancy, labor/delivery, or infant’s health Teen pregnancy Unplanned pregnancy Major life stressors Violent or abusive relationship Isolation from family or friends; lack of social support Substance use/addiction
Other Considerations During Clinical Assessment Past history of psychiatric diagnosis Previous experience with counseling or psychotherapy Previous psychiatric medication History of other psychiatric treatments such as support groups History of substance use or substance use treatment Excessive anxiety and worry Trauma history Domestic Violence
How to Talk about Perinatal Depression and Anxiety with Moms How are you feeling about being pregnant/being a mother? What things are you most happy about? What things are you most concerned about? Do you have anyone you can talk to that you trust? How is your partner doing? Are you able to enjoy your baby?
Source: Adapted from Massachusetts Child Psychiatry Access Project for Moms’ Key Clinical Considerations When Assessing the Mental Health of Pregnant and Postpartum Women, available at www.mcpapformoms.org
PERINATAL MENTAL HEALTH COMMUNITY RESOURCES Contains resources for treating mothers who may be experiencing postpartum depression or anxiety, or be in need of other supports during pregnancy or the postpartum period.
Postpartum Support International – Greater Washington, DC Area Mission/Purpose
PSI’s mission is to promote awareness, prevention and treatment of mental health issues related to childbearing. PSI has a network of over 150 volunteer coordinators in every state in the U.S., as well as in many foreign countries.
Postpartum Support DC
Postpartum Support Maryland
Postpartum Support Virginia
202.643.7290 [email protected]
240.432.4497 [email protected]
703-829-7152 [email protected]
PSl: DC Support Groups
PSl: MD Support Groups
PSI: VA Support Groups
MD Coordinator: VA Coordinator: PSI coordinators are trained to provide Lynne McIntyre Nadia Monroe Adrienne Griffen supportive counseling and resource information to mothers, their families, and the providers who serve them. To contact coordinators in other states and countries, please visit: PSI: US Support Group & Area Coordinators
Outpatient Treatment Programs (e.g., assessment, therapy, med management) Organization George Washington University Medical Center, Department of Psychiatry & Behavioral Sciences - The 5 Trimesters Clinic Medical Faculty Associates Building 2120 L Street NW 6th Floor WDC 20037
Services Provided Help women assess need for treatment before, during or after pregnancy for mood or anxiety disorder. Each woman meets once or twice with a psychiatrist-intraining; partners may be included. Each case is reviewed by senior psychiatrists specializing in perinatal mental health. Services include: outpatient evaluation and screening; short-term individual therapy and medication 1
Ages Served Child-bearing age women
Insurance, Referral, & Availability Insurance: No insurance is taken. $60 for initial assessment; $25 for follow up appointments. If finance is an issue, please call anyways.
Referral: Asks that patient tells intake coordinator the
Summer 2015 Foggy Bottom/GWU – Orange and Blue Bus: D1, D3, D5, D6, H1, L1, N3, 38B P: 202-741-2888 and specify that you want to be seen in the 5 Trimesters Clinic. Mary’s Center for Maternal & Child Care Maternal Mental Health Program Mental Health Department
management; couples and family therapy; access to community resources.
Languages: English only.
1707 Kalorama Road NW WDC 20010 Bus: 90, 93, 96, X3, S1, S2, S4, S9
referring physician to ensure appropriate referral.
Outpatient psychotherapy and psychiatry Reproductive mental health specialists on staff for individual therapy. Support & education groups offered in both Spanish & English; contact for details and referrals
Private insurance accepted for MH treatment if patient is also medical patient at Mary’s Center
Referral: No referral necessary.
Availability: Generally 1-2 weeks for PMH services; sometimes longer for general MH services.
Insurance: Most major private insurance and MedStar Family Choice (DC MCO).
Referral: No referral necessary.
Contacts: For perinatal-specific MH needs, Lynne McIntyre Manager, MMH Program P: 202-545-2061 [email protected] For general MH needs, including Peds: Cindy Flores Senior Program Assistant 202-420-7122 [email protected] http://www.maryscenter.org/mentalhealth MedStar Georgetown University Hospital – Perinatal Mental Health Clinic 2115 Wisconsin Avenue Suite 200 WDC 20007 Bus: 30N, 30S, 31, 33
Offers outpatient evaluation and treatment of psychiatric disorders and adjustment problems experienced by women who are transitioning into motherhood. Provide diagnostic evaluations and multidisciplinary treatment for women experiencing mood and anxiety disorders during pregnancy and postpartum, infertility-related distress, pregnancy loss, and difficulty with the transition
P: 202-944-5400 for appointments 2
Child-bearing age women
Availability: Generally 1 week to 1 month. Insurance: Medicare, Medicaid, and all Medicaid MCOs in DC accepted; also uninsured DC residents.
Summer 2015 http://www.medstarhealth.org/Pages/Se rvices/Mental-Health/Psychiatry-atMedStar-Georgetown-UniversityHospital.aspx
to motherhood. In cases where psychiatric medication is necessary, psychiatrists with expertise in use of medication in pregnant and lactating women are available. Reproductive psychiatrists on staff, as well as residents in training, and part-time therapists who specialize in perinatal mental health. Services are generally time-limited for 1 year postpartum (may be longer dependent on when woman is diagnosed)
Availability: Currently not accepting new patients.
Director: Aimee Danielson, PhD. Providers may call Dr. Danielson directly with questions at 202-944-5412.
Provides evidence-based information and guidance about the safety; or risk to the developing fetus/infant; of maternal exposure to drugs, chemicals, diseases, radiation and environmental agents.
Child-bearing age women
Provides evidence-based information about medications and other exposures during pregnancy and while breastfeeding.
Child-bearing age women
Ages Served Childbearing-age women
Insurance, Referral, & Availability No cost for group or other services. Email or telephone communication with PSI volunteer is necessary before attending first group.
New and second time mothers
P: Helpline for mothers and health care providers: 1-877-439-2744 www.motherisk.org MothertoBaby P: Helpline for mothers, health care professionals, and the general public: 1-866-626-6847 http://www.mothertobaby.org/
New Mother’s Groups Organization Postpartum Support International DC Contact: 202-643-7290 [email protected]
Services Provided Telephone, email and in-person supportive counseling Referrals for reproductive mental health specialists in DC Twice-monthly peer support group in NW DC (English) for moms experiencing depression, anxiety and related symptoms
Languages: Spanish & French Provides educational and emotional support groups for new and second time around mothers in the DC area led by professional mental health educators. 3
$175-$325 depending on chosen workshop
Summer 2015 Other Support Groups for Expectant/New Moms (not clinically led/based)
Child-bearing age women
Services Provided Comprehensive and current regional directory of specialized mental health providers, support groups, advocacy organizations, and other clinical resources pertaining to perinatal mental health.
Ages Served Child-bearing age women
Insurance, Referral, & Availability Free
Contains information on drugs and other chemicals to which breastfeeding mothers may be exposed. Includes information on the levels of such substances in breast milk and infant blood, and the possible adverse effects in the nursing infant. Suggested therapeutic alternatives to those drugs are provided, where appropriate. All data are derived from the scientific literature and fully referenced. Provides evidence-based information and guidance about the safety; or risk to the developing fetus/infant; of maternal exposure to drugs, chemicals, diseases, radiation and environmental agents.
Child-bearing age women
Child-bearing age women
Provides evidence-based information about medications and other exposures during pregnancy and while breastfeeding.
Child-bearing age women
Mamistad: Groups in DC and NoVA http://www.meetup.com/Mamistad/ Moms on the Hill (MOTH - A virtual and real-world community for parents living in Capitol Hill.) http://www.facebook.com/pages/Moms-on-TheHill/83988628593 Mothers of North Arlington, VA (MONA is a local social and support group for mothers) http://www.monamoms.org/
Mamistad – one-time fee of $50 if placed in private group
Online Resources Organization DC-MD-VA Perinatal Mental Health Resource Guide
Search or download guide at: http://www.dmvpmhresourceguide.com LactMed – Drugs and Lactation Database
P: Helpline for mothers and health care providers: 1-877-439-2744 www.motherisk.org MothertoBaby P: Helpline for mothers, health care professionals, and the general public:
Summer 2015 1-866-626-6847 http://www.mothertobaby.org/
Research Studies Organization National Institute of Mental Health Division of Behavioral Endocrinology www.patientinfo.nimh.nih.gov/Postpartu mDepression.aspx Contact: Annie Shellswick, LCSW-C 301-402-9207 [email protected]
Services Provided Series of outpatient studies to learn more about the cause of and effective treatments for PPD. Study participants are women with current PPD and past PPD. Select participants receive a hormone patch to treat PPD symptoms.
Ages Served Contact NIMH for details
Insurance, Referral, & Availability No charge; participants may be compensated.
Source: DC Collaborative for Mental Health in Pediatric Primary Care’s Child & Adolescent Mental Health Resource Guide available at: http://dchealthcheck.net/resources/healthcheck/mental-health-guide.html Updates, questions or comments, please contact Sarah Hoffman at [email protected] or Lynne McIntyre at [email protected]