- What are the most commonly used screening tools for assessing postpartum depression?
Show/Hide Answer
In selecting a screening tool, it is important to use one that has been validated and is accepted clinically in your population; in this case, postpartum women. The most widely used screening tool for assessing postpartum depression is the Edinburgh
Postnatal Depression Scale (EPDS). It has been used internationally, and has been validated in several languages. Other tools for consideration include the Postpartum Depression Screening Scale (PDSS), the Patient Health Questionnaire (PHQ-9), andthe Center for Epidemiologic Studies Depression scale (CES-D).
Click here to view a list of these screening tools, complete with descriptions, sensitivity, specificity, and positive predictivevalue scores, pro and con analysis, as well as cost and availability information.
- What is the most appropriate setting to screen for postpartum depression?
Show/Hide Answer
Postpartum women interact with a multitude of healthcare providers, and therefore,
it is appropriate to incorporate depression screening into as many practices as possible.
Studies show that screening for postpartum depression is appropriate in the obstetrics/gynecology,
pediatric, and primary care settings. It is also helpful for nurses, social workers,
home health visitors, midwives, and depression care managers to be aware of the prevalence
and available options for treating postpartum depression.
- Can screening tools identify postpartum psychosis?
Show/Hide Answer
Because the existing validated screening tools focus primarily on depression, they
do not necessarily identify psychosis. However, they can indicate levels of distress.
Criteria in several of the tools have been established that set a threshold for immediate
intervention. For example, an answer of "Yes" to question #10 on the Edinburgh
Postnatal Depression Scale ("thoughts of harm to self or others"), regardless
of the answer to any of the other questions, indicates immediate clinical evaluation
is required. Additionally, clinicians are encouraged to exercise their clinical judgment
in assessing the patient's affect and presentation when developing a referral or
safety plan.
- What should I do if in my follow-up to screening I find out about other issues,
such as mental illness, psychosocial problems, or domestic violence?
Show/Hide Answer
It is not sufficient to use a screening tool in isolation. Having an integrated follow-through
plan that utilizes strategic partnerships with psychiatrists, depression care managers,
and the legal community can ensure that referrals will happen in an appropriate and
streamlined fashion. Take the time to develop as integrated a referral network as
possible to address these issues.
- Are all antidepressants excreted in breast milk?
Show/Hide Answer
Yes, all antidepressants are excreted in breast milk; some in higher concentrations
than others. The selective serotonin reuptake inhibitor (SSRI) class of antidepressants
is most commonly used in lactating women due to these medications' lower breast milk
concentrations. Clinical management of breastfeeding patients is dictated by the
patient's personal treatment history and response to medications, as well as the
preferential use of drugs with published data and a track record on the market. The
lowest
effective dose should always be prescribed. The National Library of Medicine
has recently posted an online database called Lac Med through TOX NET at
http://toxnet.nlm.nih.gov/.
Lac Med is a peer-reviewed and fully referenced database of drugs to which breastfeeding
mothers may be exposed. Among the data included are maternal and infant levels of
drugs, possible effects on breastfed infants, and alternate drugs to
consider.
- Will infants who are breastfeeding experience side effects from exposure to
antidepressants in breast milk?
Show/Hide Answer
Infants may experience colic, irritability, sedation, and slower weight gain as side
effects that can be observed when they are exposed to antidepressants. However, it
is important to carefully note infant behavior before initiating breastfeeding so
that accurate comparisons can be made. For example, if a baby is colicky every morning
at 2:00 AM, and continues to be so during breastfeeding, you can avoid attributing
this condition to the medication, freeing yourself to make note of other possible
changes in condition or behavior. It is also important to know that many infants
will not exhibit any side effects.
- Are there non-drug alternatives for treating postpartum depression?
Show/Hide Answer
A variety of non-drug alternatives can effectively treat postpartum depression. When
selecting an alternative treatment, it is important that they are evidence-based
therapies. In the psychotherapeutic realm, interpersonal psychotherapy (IPT) and
cognitive-behavioral therapy (CBT) have demonstrated efficacy in reducing depression
symptoms and improving functional status in postpartum women. Another option is bright
light therapy, which has shown efficacy for treating seasonal depression, and there
are some data to support treatment for nonseasonal depression.
- What should I tell my patient who wants to use herbal medication instead of pharmaceuticals to treat her
postpartum depression?
Show/Hide Answer
Any alternatives to pharmaceutical medications must be selected according to evidence-based
criteria. To date, limited studies have been performed on herbal remedies for the
treatment of postpartum depression. Omega-3 fatty acids have shown some beneficial
effect for the treatment of major depression, but further studies are warranted for
postpartum depression. The efficacy of St. John's wort in the treatment of depression,
and specifically postpartum depression, is questionable, and no studies have evaluated
its transfer into breast milk. Kava has demonstrated known effects on neurotransmitter
activity, and has been shown to be an effective treatment for moderately severe,
non-psychotic anxiety. However, Kava should not be used by women who are breastfeeding.
No studies have been performed on Chinese herbs in postpartum women.
- How do I treat a new mother who is suffering from posttraumatic stress disorder?
Show/Hide Answer
First, it is important that the patient is properly diagnosed with posttraumatic
stress disorder according to DSM-IV criteria. The
Perinatal Posttraumatic Stress
Disorder Questionnaire is a useful tool for identifying significant emotional distress
in mothers during the postnatal period. In clinical practice, approximately 15% of
pregnant, and 15% of postpartum women, will present with posttraumatic stress disorder
(PTSD). Having PTSD has the potential to predispose someone to comorbidities such
as depression, including postpartum depression, and anxiety. Physical complications
can also arise. Treatments for PTSD are the same as for treating postpartum depression:
pharmacotherapy, with or without psychotherapy or other evidence-based alternatives,
depending on the patient's preference and symptom severity.
- What percentage of new mothers with postpartum depression are victims of domestic
violence?
Show/Hide Answer
Approximately 4%-8% of women experience intimate partner violence (IPV) during pregnancy,
and about 3% will experience IPV postpartum. Studies of pregnant women showed an
association between having a history of sexual violence and the development of severe
depression in pregnancy. In addition to screening for postpartum depression, clinicians
are encouraged to screen for domestic violence as well. As always, when developing
referral and safety plans, it is important to form strategic partnerships with experts
to ensure appropriate follow-through for the patient.
- How do I approach treating a diverse postpartum population?
Show/Hide Answer
The DSM-IV provides a general cultural formulation for medical care, which can be
found in the appendices in the back of the reference book. It is hoped that the DSM-V
will integrate this concept more fully into each of the major treatment categories.
This cultural formulation looks at the cultural identity of the patient, the explanations
for the person's illness, the psychosocial environment, the levels of functioning,
and the cultural elements that affect the relationship between the individual and
the clinician. This cross-cultural patient model of illness allows the health professional
to more fully understand the patient's beliefs about their illness, and it is a recommended
approach when dealing with postpartum patients.
- Are there other resources for learning about cross-cultural care for postpartum
women?
Show/Hide Answer
A frequently used encyclopedia edited by Harwood,
Ethnicity and Medical Care: A Commonwealth
Fund Book (Harvard University Press, 1991) is often cited as a beneficial resource
in understanding cross-cultural medical care. Two online resources include the University
of British Columbia Press (
http://www.ubcpress.ca), and the Human Relations Area
File (HRAF) at Yale University. (
http://www.yale.edu/hraf/). Clinicians can also
feel encouraged that Medline has added cross-cultural medical issues to their search
database.
- I want to develop a postpartum depression referral network. Where do I start?
Show/Hide Answer
When developing a referral network, the concept of integrated care is crucial, such
that you include multiple provider types. Your network will be most effective if
it can incorporate as many of the following disciplines as possible: obstetricians,
pediatricians, mental health specialists, lactation consultants, childbirth educators,
midwives/nurse practitioners, visiting nurses, social workers, community support
groups, and even members of the legal community. There are also reputable national
and international organizations dedicated to advancing knowledge about postpartum
issues, and it is encouraged that they be approached for guidance as well. These
include the Marcé Society, Postpartum Support International, North American
Society for Psychosocial Obstetrics and Gynecology (NASPOG), and La Leche League
International.
- I finally managed to get my patient referred for postpartum depression treatment,
but the earliest available appointment is in 2 months. What do I tell her to do until
then?
Show/Hide Answer
Providing transitional care until this "magic appointment" is as important
as the appointment itself. If a patient is presenting with postpartum psychosis,
immediate intervention and hospitalization is required. If she is presenting with
postpartum depression, you have several options. As her provider, you can refer her
to any of the reputable postpartum organizations, such as the Marcé Society,
Postpartum Support International, or La Leche League. They may be able to provide
transitional support. Also, encourage her to concentrate on self-care, as this is
critical to re-establishing normal function. Getting exercise and paying careful
attention to diet and sleep can improve mood to some extent. She can also explore
social options if she has reliable support from her family or her community. Healthcare
organizations may have depression care managers, home visiting nurses, or outreach
as a transition or to facilitate care. In addition, it may be quicker to obtain an
appointment with a certified therapist (social worker, psychologist, family and marriage
therapist, etc.) than a psychiatrist, and depending on the patient's needs may be
sufficient.
- I am a busy physician in a managed care environment. How do I develop efficient
screening and referral protocols for my postpartum patients within the limited time
that I have to see them?
Show/Hide Answer
There are a few things you can do to streamline your screening and referral system.
Incorporating a validated screening tool such as the Edinburgh Postnatal Depression
Scale (EPDS) into your patient contact report (electronically, if possible), will
make for one less document you will need to retrieve. Also, spending the time up
front to develop an integrated provider network will make it easier to institute
an efficient referral protocol down the line. All members of your team should be
aware of your internal procedures, as well as those of the providers in your network.
In addition, each member of your practice should be trained in coding and billing
procedures that allow reimbursement for services related to postpartum depression.
- I am committed to treating my patients who have postpartum depression, but
I am having difficulty getting reimbursed for providing these services.
Show/Hide Answer
Reimbursement by insurance carriers is one of the biggest obstacles healthcare providers
face when treating their postpartum patients. A further difficulty is the DSM-IV
definition limiting postpartum depression onset to 4 weeks postpartum. However, subsections
in the DSM-IV Sections 293 and 296 can provide guidance for billing if your patients
fit any of those categories. Although it has not been validated in the postpartum
setting, screening may be facilitated by using the Patient Health Questionnaire (PHQ-9),
since it is linked to DSM-IV criteria, and therefore, reimbursable. It may comfort
you to know that the Health Resources & Services Administration (HRSA) and Covenant
Contract Management Service (CCMS) divisions of the federal government are looking
into healthcare reimbursement for issues such as postpartum depression.
- What should I include in a training program so that my staff can screen and
refer patients for treatment for postpartum depression?
Show/Hide Answer
Your office staff will be the front line in your practice for ensuring that your
postpartum patients are screened for postpartum depression, and treated appropriately.
Since everything starts with screening, be sure to familiarize all members of your
team with the screening tool(s) that will be used in your practice and make them
a part of your standard operating procedures. Making screening routine will help
to decrease the stigma and will help to assure that all women are screened regardless
of whether the staff thinks they need it or not. We encourage all providers to develop integrated
referral networks, making sure that all contact information for referrals and local
emergency and non-emergency services (including perinatal services) are up-to-date.
It is especially important to ensure that emergency providers have a live person
for patients to speak to immediately.
- How should I instruct my staff to respond when presented with a postpartum
patient in distress?
Show/Hide Answer
As part of training your staff to identify and treat your postpartum patients, it
is important to have a triage questionnaire that appropriately queries patients who
may be in distress. As part of your integrated referral network, work with your strategic
partners, especially qualified mental health providers, to develop and implement
this questionnaire. It should be easily accessible for immediate use (whether in
person or over the phone). Mental health providers want to help because they realize
that they must be part of this team in order to immediately assist in the appropriate
intervention. As a last resort, have up-to-date hotline information available as
well.
