Please take a moment to complete this brief pretest. While taking the pretest is optional, your answers will help us determine whether the content provided in this presentation either mirrors or enhances your knowledge of this particular postpartum depression topic.

Physician Program: To take the pretest, please click here.

Nurse Program: To take the pretest, please click here.

Social Worker Program: To take the pretest, please click here.

Responsible PPD Screening: Rationale, Timing, and Follow-up

Presenter: Katherine L. Wisner, MD, MS
Panel: Linda H. Chaudron, MD, MS; Irene Frederick, MD; Pec Indman, EdD, MFT






Slide 1. I have the honor of starting first with the screening panel, which I'm thrilled about, particularly because my group in Pittsburgh, Pennsylvania just got a wonderful grant from the NIMH (National Institute of Mental Health) to screen a large population of women who deliver in Pittsburgh. Over the course of the next 4 years, we expect to screen close to 20,000 women for depression in a modeldemonstration project.




Slide 2. The objectives for this panel discussion are: to talk about prevalence and incidence of, particularly postpartum, but to some extent other psychiatric illnesses; to talk about the symptoms of depression, and what postpartum depression (PPD) means. We all use a variety of definitions. If we're going to screen for it, we have to answer the question: Are there screening tools, and how good are they? And no matter how good they are as tools, are they even usable in the context in which we work? We have to talk about barriers to screening, and issues that complicate getting patients who need care to the treatment they need. And finally, describe the ways in which we can implement and screen responsibly to identify and treat patients with postpartum depression.




Slide 3. In the last year or so, AHRQ (Agency for Healthcare Research and Quality) put out a meta-analysis on perinatal depression, and it's a wonderful epidemiologically-based report which basically said their best estimates of postpartum depression and depression during pregnancy was 14.5%. It's curious that they came up with this in both contexts, so that across the 9 months of pregnancy, the incidence rate they developed was 14.5%; out of their review of all the studies. And in the 3-month postpartum period, it was the same. So the rates are the same, but the time course covered varies. That's a lot of women: 1 out of 7 women [updated 1/18/08]. And it's incredibly costly to the woman, and to us as a society; again, juxtapose that against the fact that PPD gets one line in an OB text. You don't get a whole lot more in a psychiatric text. Maybe family practice texts have more, but OB sure doesn't.




Slide 4. Why is this the case? Why do we have an illness like this that we're not attending to? The epidemiology helps our case because certainly for women, the rate of depression is extremely high in the childbearing years. In this slide, we've got the prevalence of depression across the life cycle; so from younger to older in women, you have got this huge peak in the childbearing years, and it's roughly twice the rate of the prevalence of depression for men. So isn't it kind of unfair that these childbearing years are associated with the highest risk for depression?




Slide 5. Again, the epidemiology supports screening programs; why aren't we doing it? British data from the 1980s, which was the first large-scale population-based epidemiologic study done by Kendall, showed that admissions to their regional hospital (that he collected and linked with births in that same region), showed that this period of time, childbirth, was associated with a huge peak in admissions within the first 30 days. So you're looking across pregnancy and into the postpartum period, 2 years before, and 2 years after birth, in again, a population in a large region where the admissions are collapsed around childbirth. And these data are probably the reason that the DSM (Diagnostic and Statistical Manual of Mental Disorders)-IV says: An illness that begins within 30 days. But for those of us working in the field, a patient, Mrs. Jones, comes in at 40 days, and you say: Oh, DSM says you don't have postpartum-onset depression. How do we deal with these kinds of definitional issues as well, and what does it mean for screening if this is the way in which postpartum illnesses unfold?




Slide 6. I really like this title, "Public Health Scope of Postpartum Depression" — the most unrecognized medical condition of childbearing (which I usually add), where 1 out of 7 [updated 1/18/08] mothers experiences either major or minor depression, which by definition interferes with function. So we're sending out lots of women with PPD every day in America. What I found really interesting is that all states require PKU (phenylketonuria) screening, which occurs in 1 in 10,000 babies. And so I asked some friends about it, and the response was: Yeah, but PKU is treatable! There is this sense that somehow depression is not. There's interesting legislation requiring screening for postpartum depression in New Jersey, based upon New Jersey First Lady Mary Jo Codey, making postpartum depression her platform. So isn't it neat that finally an illness that affects not only the woman, but the entire family (and it affects 1 out of 7 women [updated 1/18/08]), will be screened for, in addition to the baby's 1 in 10,000 PKU risk.




Slide 7. For major depression, at least one of the symptoms must be: depressed mood or inability to enjoy.




Slide 8. So there's a state change that occurs in the woman that's coupled with this whole-body physiologic dysregulation illness. It's very clear that depression is a whole-body illness, and that many other illnesses — diabetes, hypertension, all kinds of illnesses — are more common in women with this disorder, and are in fact made more difficult to manage when they have major depression. We're really trying to get away from the sense that there's a mental illness and a physical illness, as if there's really a dichotomy. But that's how we organize things in our world, even in terms of medical treatment; to fragment the body in these ways. And I think the symptoms of depression really speak to how much of a physiologic disorganization this illness creates.




Slide 9. The postpartum specifier: this is somewhat old; you know the DSMIV, and clearly in DSM-V, this is going to need to be revised. Almost no researcher uses this definition of postpartum onset depression. The other curious issue is even here, we're speaking about depression, but those of you who work with real people know that they come in with postpartum onset OCD (obsessive-compulsive disorder), panic disorder, worsening depression on top of schizophrenia, and other syndromes. Why only mood problems? That's all we've looked at until recently, so much more work needs to be done even with what we're seeing in the real world.




Slide 10. Why aren't we screening? Do we have tools?




Slide 11. Yes, we have tools, and this is just a list of very specific measures for postpartum depression: the EPDS (Edinburgh Postnatal Depression Scale); Cheryl Beck's postpartum depression screening scale (PDSS); and some that are more generic screens for depression — the PHQ9, the BDI (Beck Depression Inventory), and the CES-D (Center for Epidemiologic Studies Depression) scale, which Cindi Logsdon uses a lot in her work with adolescents. So there are specific screening measures, and measures that have been used to screen populations for depression.




Slide 12. So we can't say we're not screening because we don't have screens — we have screens.




Slide 13. I'm going to ask you now about what your experience is with particular screening measures. We could put up sensitivity and specificity, everything we wanted in a screen, and you guys could say: Yeah, well, that's fine; it's sensitive and specific, all those funny words you guys use, but it doesn't work for my group. In your opinion, what do you use? What's the most reasonable measure to screen for postpartum depression?




Slide 14. The EPDS is a favorite; nobody likes the CES-D or the BDI. We have found in the work that we do that a lot of the primary care folks are far more familiar with the PHQ-9; the PDSS, many people know as well and like it, especially for clinical information, because it yields a lot of that as you do the measure. And the EPDS certainly is the one we use most often, and it's interesting to see there's a fair amount of consensus about that.




Slide 15. Given that we've talked about the EPDS, I have another question. There's a criticism of the EPDS, which may be why some folks didn't want to use it, which is that it doesn't ask much about somatic symptoms; it's more about functionality postpartum. There's just one somatic symptom, which is difficulty sleeping. Some investigators have suggested that many women present primarily with somatic symptoms postpartum, and that the EPDS may then miss that particular subgroup. So what do you think then within this context about using the EPDS? Is it an advantage? A disadvantage? Or who knows?




Slide 16. That's an interesting split. Even though we have an overwhelming number of people who like the EPDS, there is an interesting issue here.




Slide 17. This slide emphasizes how confusing all these terms are; that when you screen, you have to follow up with a diagnostic interview. We screen a patient, and she has a certain score, it means she's at risk for depression, but it doesn't mean she has it. So you have all of these possibilities to look at the data and look at how efficient your screening method is.




Slide 18. Sensitivity and Specificity




Slide 19. Sensitivity and Specificity (II)




Slide 20. If we think about and accept that we have reasonable screening tools, why don't people use them? The perceptions are that they're perhaps expensive, they're going to take time; how am I going to get paid for it? We can screen, but if there's no mental healthcare available, why screen? Or if the patient won't go, how do we deal with those kinds of barriers?




Slide 21. What are the barriers to identifying postpartum depression? Which one do you think is the most prominent of these 5, in your experience?




Slide 22. Most people think it's because it's not asked; there is a fair group endorsing that patients don't accept referrals. So we're beginning to perhaps understand why this is something that is more difficult to screen for than PKU.




Slide 23. If we decide that we are going to screen, when do we do it? Is it the first postnatal contact?




Slide 24. If I have to diagnose, what do I use? How do I refer? What the heck do I do?




Slide 25. Who Should Screen?




Slide 26. Who should screen for postpartum depression, if we as a society are going to make that choice to do it? What are your thoughts?




Slide 27. We have OB/GYNs and pediatricians in the group; we expect that in your offices, you'll be screening. That's great. A very nice mix. It's very interesting, I will say, in our screening grant, we are targeting the way we intervened to use option 4 (Insurance Carriers).




Slide 28. This is about when to screen.




Slide 29. I have one more question: Now that you've decided who is going to screen for postpartum depression, when are you going to screen? What would be the best time?




Slide 30. A whole group of people think during pregnancy and before you get to the postpartum period; not so many before discharge; and around 4 weeks after birth, peak time. In the grant we're doing, we're screening starting at 4 weeks, and attempting to contact the women to 6 weeks.




Slide 31. Works in Different Settings




Slide 32. Lessons From Successful Screening Projects




Slide 33. Goals for PPD Screening




Slide 34. Conclusion




Slide 35. "All women should be considered at risk for postpartum depresion, and all postpartum women should be screened."




Slide 36. Katherine L. Wisner, MD, MS: For the panel, you experts in screening have a chance to react to what you've heard. What do you experts in my panel have to offer about screening for postpartum depression? For example, responsible screening: you'd really like to implement a program.

Pec Indman, EdD, MFT: I'm Pec Indman. I'm a former family practice-trained physician's assistant. I have a doctorate in counseling, and a private practice in San Jose, and I'm very dismayed to say there's one OB/GYN office in my community that I know screens. They do use Cheryl Beck's postpartum depression screening scale. I think there's just resistance to screening at all, and I think we also have the problem of who do you refer to. I think those are 2 of the biggest barriers.

Dr. Wisner: When your OB/GYNs screen, do they have a set group of people they refer to?

Dr. Indman: Yes. They refer often to several people in the community that they know have had training in perinatal mood disorder treatment. So we have a small cadre of trained therapists. And many of the OBs will prescribe in my community.

Dr. Wisner: You have to have then, in your community, a set of OBs who are willing to provide the pharmacologic intervention. So is it an OB/therapist partnership?

Dr. Indman: Very often it is.

Dr. Wisner: That's an interesting model. My next colleague is Irene Frederick.

Irene Frederick, MD: I'm Irene Frederick, and I'm an obstetrician/gynecologist in Pittsburgh, Pennsylvania. I have had a kind of long and varied career, a lot of it in academics; a lot of interacting with family medicine. And I currently work in a setting which is a faith-based health center, and that's provided a very interesting perspective on this. Through working with Kathie and my fellow practitioners (all of whom are family doctors), I was able to get them to start using the EPDS during pregnancy; we actually do it at the first prenatal visit.

We have a perinatal social worker in the practice who's also a doula, who is wonderful, and our experience over the period of a year of tracking these patients — we don't have high numbers but there's a lot of consistency — is that of the vast majority of the patients who screen positive, about half of them will come in and will see the perinatal social worker to be assessed for depression.

We had a 0%; outside referral for treatment or intervention of any sort; so if we refer them out, they don't go for a number of reasons. And those who we were able to work with within the practice in a doula model of intervention, with a lot of hands-on support, did very well. Unfortunately, tracking them postpartum has been a problem; a good portion of them have substance abuse issues, and we have found that relapse is very high in the 3- to 5-week postpartum period. They'll do okay for a few weeks after they go home, and then they revert to baseline, and we haven't been able to figure out how to prevent that. But the incidence of postpartum depression is so keenly tied to substance abuse, and I believe that the reason they're using substances is because their long-term lack of diagnosis of depression and other mental illnesses is why they're using in the first place.

Kathie and I have had long discussions about why there are barriers. I think in general, just to address OB/GYN practices, it's not in our mindset to screen for depression, and there's one very practical reason — and that is that OB/GYNs as a rule are not allowed to bill for any diagnostic code that is related to psychiatry. There is a whole sequence of numbers that is an automatic tip-off to the insurance company: do not reimburse. Family practitioners, internal medicine, psychiatrists, (I don't know about pediatricians), can bill for these codes, but as OB/GYNs, we cannot. So there's no motivation for an OB/GYN practice to screen. It takes us approximately 5 minutes, which doesn't sound like a lot, but in the course of an overall visit, it is a lot; to introduce the topic; to do the 10-question screen and then to do a very quick adding up of the numbers; and to have some initial impression with which to guide the patient. So, 5 minutes is a long time in an OB/GYN's life.

Dr. Wisner: The piece that you really point out is that when we do something like the EPDS or a measure, we're screening for depression, and the map on to that is: acute onset postpartum depression. And we are finding the same thing in the early pilot work in our screening study; that an EPDS has led us to a number of bipolar depressed women, women with substance issues — that the comorbidities are extensive, and a screen yields a lot of very significant illnesses that need to be treated.

Dr. Frederick: My experience over 25 years is that most women are basically pretty stable — their baseline is that they're very functional, they're stable and they don't have many problems. Those women who have a significant onset of postpartum beyond the blues, they recognize it. They self-refer. They will either call us, or they will call their family doctor or their internal medicine person. They recognize that something is wrong. It's the patients who have all the comorbidity, and who frequently are using other substances to treat their comorbidity themselves; those are the ones that are falling through the cracks, and those are the ones that are ending up in the newspaper.




Slide 37. Linda H. Chaudron, MD, MS: I'm Linda Chaudron, and I'm a psychiatrist in Rochester, New York, but my work has been primarily in pediatrics, working with pediatricians to screen mothers at well-baby visits. And in Rochester, the pediatric clinic at the university has been doing this since 2000, and using the EPDS at every well-baby visit in the first year. The reason we chose every visit is because then we catch them about 2-3 times, whereas if we tried one visit, then you'd miss a significant portion because they're a high-risk urban population.

And the issues for pediatrics, I think, are multilayered; they're not the mom's provider, but they are the child's provider, and therefore their primary responsibility is to the child, which then extends to the family. I've been working a lot with a pediatrician in Rochester, thinking about these ideas; about the boundaries for pediatricians and where do their responsibilities lie, and how much responsibility must they or should they take for the mother's mental health. So it's one thing to screen, but they don't treat. So then is referral enough?

And we know the good proportion of these women don't follow through with our referrals because the referral systems are a nightmare. You've got to go here, and then you've got to go there, and they don't have the energy, and they have the comorbid diagnoses, and multiple young children, and it's very difficult to navigate our system. So I think for pediatricians, there are many levels to consider. But I know from the feedback in our clinic that having done it now, they're happy they're doing it, because they're identifying women not just with postpartum depression, but it's a broader net to identify women with anxiety, women with bipolar, women who have other reasons that they'd like to talk, but they wouldn't bring it up and this opens up an opportunity. So when we think about screening, and we expand it beyond just postpartum, the research that I'm doing right now is finding that in this population of new moms, the postpartum onset probably isn't as novel, because a lot of them have pregnancy onset, and more likely life onset, and it may be exacerbated postpartum because they're not sleeping, and they have 3 young children under the age of 4, etc. So I think we need to think about comorbidity in our screening.

The barriers in terms of time and reimbursement and all that, I think we can surmount with enough pressure, and enough thoughtfulness behind it. Our clinic does it; they can't bill for the mother, but they can bill for some kind of extended pediatric visit if it requires further discussion. We have a system in our clinic to refer; we're lucky that way. Whether or not that can happen other places, we need to think about.

The question then becomes, though, do the mothers go? Where are the barriers? And one of the barriers that we found in my work following some of these women is they just don't go; they can't. There's too much going on in their lives for them to follow through with the systems, and so I think we have to think about other ways. And also, a lot of them don't want medications; they don't want to be sent to me! So what are they willing to accept, and what might be helpful? When to screen is a critical issue; during pregnancy is critical since a lot of this is pregnancy onset. I chose pediatrics because I don't think they're getting picked up in OB; so they're in pediatrics, they're willing to talk to the pediatrician.

The issue of when — some of the work that I did so far (and I'm getting feedback from the clinic), is that if you ask at the 2-week visit, you identify a lot of moms with high numbers, but they don't all stay high; so do you really want to act on every one who has a high score at 2 weeks, or more likely at the 2-month visit? Those are more predictive. Thinking about how you interpret the screen at different time points is going to be critical. Work I just did that is going to be published soon looks at that; about one third of women who did not have high EPDS scores in the first third of the year became depressed later on. So we're looking at different women; women who are depressed immediately postpartum, and then those later on in the year. Whether we're looking at the same or different women, and what the risk factors are, we don't know. But that's part of the screening issues as well.

Those are the things that I've thought about with regard to screening in terms of the multiple obstacles; many of which I think we can overcome. There's a lot of work to be done, though, to understand what women want and what they're willing to do, and how we can get them there.

Dr. Wisner: Even the model is interesting because what I heard some of you say is: If we say we're screening for postpartum depression, we're after a somewhat limited group, but there's almost an expansion to using birth or pregnancy as a life cycle event around which to assess the health of the women, the baby, the family, and the community. Let's use that as a time to reassess and see if we can change the trajectory towards more health.




Slide 38. Dr. Wisner: With that, let me open it up to the audience.

Laurence D. Kruckman, MD: I'm Larry Kruckman from IUP (Indiana University of Pennsylvania), a university outside of Pittsburgh. I have a question for Irene. I've been on some of the panels with ACOG (American College of Obstetricians and Gynecologists), and they've tried to set protocol for members like you; I would assume you're a member. Do you know about those protocols? Because they do say that screening should be done, and is not 5 minutes of stress on you. In fact, I think they're asking even for staff members to do it, rather than you.

Dr. Frederick: There are a whole series of technical bulletins and protocols that ACOG publishes and unfortunately, and if there are other OB/GYNs in the room, speak up as well. Not being in traditional private practice, I'm not sure that I'm a good indicator of what's happening with that in private practice. I can tell you from just chatting with my colleagues who are in private practice that most people don't do it because they don't feel like they need to do it during pregnancy; that the patients do self-identify postpartum, and that they don't feel like they're missing that many.

And it brings up an important point because the patient population that I deal with is at very high risk, but they're at very high risk for psychiatric illness in general, and I think all of us in our practice setting recognize the problem. I don't think most OB/GYNs approach ACOG protocols from a patient advocacy standpoint; they approach them from medical/legal protection. It's standard of care, and I need to do this so I don't get sued. So unfortunately, a lot of the patient-related utility of those protocols are lost in the shuffle of medical/legal paranoia.




Slide 39. Seth Rubin, MD, MSCP: I'm Seth Rubin. I'm a family physician in Pittsburgh, Pennsylvania, in practice with Irene, so to speak. My question is for Dr. Chaudron. I was very interested in what you were saying about screening during pediatric visits, because I think really that's one of the times we absolutely should be doing it. Even in our family practice office, though, where we have instituted a pretty high level of screening for depression, whether it's done during adult visits not associated with pregnancy, or 2-3 times during pregnancy, we have really fallen down in our intention to do this during pediatric well-child visits. And I think that it's because, as physicians, we often think about things inside of a box: this is the child visit, this is the adult visit, this is the prenatal visit, and we're just going to check the urine and the blood pressure today. I'm just wondering if you could comment a little bit about how you break down those barriers to do that.

Dr. Chaudron: I appreciate the question, and I think it's really interesting because a lot of people when I've talked about pediatrics, have said: Oh, go to family practice, that's the perfect place, that should be so easy. But when I've talked to family practitioners, it's not as easy as those of us who are outside of family practice think. The way that we did it in pediatrics was we just made it standard. One of the things that I found is a lot of people are looking for who's the high-risk woman that you should screen, and then they don't screen anybody, or they think they're screening the high-risk woman, but the woman who comes in totally put together, even though she may be high-risk, she smiles, and nobody asks her. The anecdotal feedback I've gotten has been huge; for example, I've known this mom through 5 pregnancies, and I had no idea, and I give her this now as just standard practice, and she scores a 25 out of 30. I said: Did you really understand this? And she said: Yeah, nobody ever asked me this before.

I think there are 2 pieces. One was making it standard at every well-baby visit. We also put a place on the well-child form for the score, and for a comment on what the action was, so when you go down your checklist, it's there and you don't forget to do it. It's given out when the moms come in, and they have all those other papers, and they just do it then. Then the provider just goes through it when they do everything else. So I think standardizing it really helped; putting a place on the well-baby visit helped. And then I think more than anything, truthfully, has been the feedback from nursing staff and the physicians that it's made a difference. You only need a couple to make you realize this is really important, and we're glad we're doing it, and that has been, I think, the thing that has kept it going. I went in and said: Oh, this is a really good idea! And people said: Yeah, right. And then once they started doing it, it wasn't me that kept it going; it was their experiences. So that would be my view on that.

But I have a question for you. If you do that in your pediatric visit, how do you think about billing for it any differently if you have to talk to the mom for an extra 5 minutes, or how does that come from a family practice perspective?

Dr. Rubin: That was going to be my next question for you!

Dr. Frederick: Well, since I work in a family medicine setting, we also have a pediatrician on staff, and the way we got by at least getting the mothers' issues addressed is that we now have a system that's working reasonably well — that when a family member calls in to schedule the well-child exam, automatically the mother's name is put on the same practitioner's schedule for a visit; so an encounter document is generated for the mom and the baby. This is high motivation to do something, because now you have a piece of paper in front of you. We also have an electronic record, and one of the things that I've done in the first prenatal visit is I've built the EPDS right into the electronic record. So if you're doing a review of systems, you have to really work hard to ignore this great big thing you have to scroll down that's the EPDS. And that has helped tremendously. Anything as a physician that you don't have to think about and go get someplace else, is going to increase your productivity. If it's right there, right in front of you, you can't miss it.

In terms of the billing, we do have a problem in that the pediatrician cannot bill for that interaction unless the patient is under the age of 21; which is a lot of our people, because you're allowed to see them as a patient for the insurance company's purposes up to age 21. So that helps a little bit. But if it's a mom who's over 21 years old, that's lost revenue. Those are just some tricks.

Judy C. Chang, MD, MPH: From the OB's standpoint, you're right. There are a lot of different guidelines, statements, and committee reports that come through ACOG, and whether or not then the majority of obstetricians and gynecologists actually keep up to date with all of them, and follow them by the letter, I would highly doubt. I think that in general, they sort of read the big bulletin and say: We should be screening for depression. Which means that probably during the first pregnancy visit they'll ask: Are you depressed? Do you have a history of depression? Then, maybe during the postpartum visit they'll ask: Are you depressed? Do you feel sad? Do you feel like hurting your child? Do you feel like hurting yourself? So I don't think that there's going to be any adherence to any particular scales; there are certainly no calculations or anything going on, because calculations mean that you need to actually understand what the scale is doing, understand what the numbers mean, and be able to interpret things very quickly. If I see a number, and I haven't a clue, I'm probably going to ignore that number, unless there is something that actually tells you what's going on. We are also moving towards more electronic medical records in the outpatient clinic as well; we have incorporated the EPDS, and what we're hoping to do is instead of giving a score, we're actually going to say: This person may be at high risk for this. That way the interpretation is there, and you don't have to actually make the step of changing that interpretation.




Slide 40. Dr. Chang: But one thing to consider: I'm an obstetrician/gynecologist from the University of Pittsburgh. A lot of my research has focused on intimate partner violence, and I think a lot of times there's definitely overlap in correlations. One of the issues with regard to intimate partner violence has been the controversy around screening, particularly in terms of what do we do when we actually have a Yes. Is it really valid? Do we have all of the criteria that actually say that this is a good screening test? One of the things that's occurring in the field of intimate partner violence is trying to move away from the classical notion of screening as a test to make a diagnosis, but to shift paradigms to be a little bit more holistic by saying: We just care about what's going on with women and their safety. And instead of making a specific diagnostic tool — here's a screening test, make a diagnosis— making it more broad by saying maybe we just need to increase awareness, make sure people know that there's support. Make sure that they know that I am supportive. Make sure that they know that there is going to be more of a systemic response to whatever needs she may have at that particular time.

Dr. Wisner: So instead of viewing them as screens, deciding that this is an acceptable topic for discussion.

Dr. Chang: There's a lot of debate in terms of a lot of the reasons for having prenatal visits, because in terms of measures of outcomes, we haven't necessarily changed anything. But if you really shift focus and start to think of prenatal visits as educational opportunities, then these are very valuable windows of opportunity that we can exploit to a certain extent for the betterment of the health of the women.




Slide 41. Margaret G. Spinelli, RN, MD: I'm Meg Spinelli. I'm a psychiatrist at Columbia University. My comment is that at Columbia now, on the antenatal screening questionnaire, they have: Do you have a personal history of depression; family history of depression; and are you depressed; which in and of themselves are pretty good indicators that a woman might be or become depressed postpartum. So sometimes it's not even having to go into that questionnaire.

On a larger scale, you were talking about the DSM. I think a real impediment to screening and identification of women is our 4-week specifier without a specific phenomenological picture to postpartum depression, despite the fact that clinically, we all see things very differently. People who are nonperinatal psychiatrists who are just practicing general psychiatry cannot get it into their heads that this can be diagnosed after 4 weeks. I see it in a different way. I see it in the courtroom: No, this is not postpartum psychosis because it occurred 6 weeks. Something very crazy, which can interfere with somebody's life; whether they live or die. But that's my question — what are we doing? Is it going to change? You mentioned it changing; are we going to have specific diagnostic criteria?

Dr. Wisner: There has been an NIMH/APA (American Psychiatric Association) group working on what research we will need to inform the DSM-V. In the gender white paper, there was quite an extensive section, some of which I contributed to, about the deficits in the current DSM-IV system with respect not only to postpartum, and pregnancy, but menstrual cycles; a whole group of core specifiers that could be related to life cycle events. So yes, there will be some changes, and more chance for input.




Slide 42. Laura Miller, MD: I'm Laura Miller. I'm a psychiatrist who heads the Illinois Perinatal Depression project, and the project was designed to address a number of the obstacles that several of you have raised, most notably what you raised about time being a major problem and other obstacles. The implicit model that people have been talking about here is a screen-and-refer model; meaning that you screen women, you figure out that those who have positive screens are in need of being assessed, and then you refer them to a mental health professional for assessment and treatment.

An alternative model is a perinatal depression management system that's like a stepped-care model, where some of the care (as some of you have alluded to), occurs within an OB/GYN setting or some other primary care setting, and then only certain women need to be referred to the scarce mental health resources. And you can be very systematic about such a model, having specific algorithms and criteria. In that kind of a model, we found that the PHQ-9 really has some major advantages, so I want to make a plug for considering that kind of a model, and considering that screening tool. The EPDS, while very well validated perinatally, is not linked to DSM criteria. For now, we are stuck with DSM criteria as a major basis for making clinical decisions, such as whether or not to medicate. So the PHQ-9 is directly tied into that. It does the screening, but it also does a great deal of the assessment. So instead of having to take 5 minutes, which is an eternity to all of the OB/GYNs I work with, it takes far less time.

In our pilot model, for example, a medical assistant administers the PHQ-9, and what the OB gets along with the patient walking in for the prenatal visit or the postpartum check up is: This woman meets criteria for moderate/major depression. Not that you don't do an assessment still, but your assessment is greatly facilitated by that. And then the PHQ-9 can be used to track treatment response. There are normed criteria. If you go X many points down from baseline, you're on track; if you go 50%; below, you're there, etc. Which is not so far the case for other screening tools. Another key thing that makes this work is consultation. So in this model, when women are cared for in a prenatal and primary care setting, they have all-the-time telephone access to mental health professionals who can consult with them to make it work in that setting.




Slide 43. Catherine Cerulli, JD, PhD: I too work in domestic violence and homicide, and many of the women that we see at court never see any of you; they are pregnant, they are new moms, they don't go for prenatal care, they don't get OB/GYN well-baby visits. They just aren't in your world. And to think about reaching some of the people you care about — just to give you an estimate — in our court, we get 200 victims a month filing petitions for protection orders. They're all women, largely. And in our criminal side, we get between 500 and 800 cases a month. We're just starting to bring post-doctorate psychologists down to family court and do on-site services, because when we did our pilot work, 92%; of the women said they wanted mental health services, and they would access it if it was given at the courthouse, which surprised us because we would think they want to get in and out as quickly as possible. They've worked so hard to get there — 3 buses, a babysitter, child care — that one-stop shopping would work for them.

Regarding the bill in New Jersey about mandatory screening for postpartum depression: In our field, we have a handful of states that have mandatory screening for domestic violence, and it's raised some of the issues you brought up. But the issues that I would suggest be considered in looking at this bill is the fiscal mandates behind it; where are people going; what are the training requirements; who's doing it. We've had huge issues with the mandatory screening DV (domestic violence) bills that have been on the table.




Slide 44. Dr. Frederick: Kathie, can I then just say something in follow-up to her comment about on-site intervention? Your idea of bringing a practitioner into the legal setting is just so cool, and it's so neat that somebody's actually thinking about doing that. But the same is true even in something as simple as a family practice setting. I can't tell you how often we get these incredible stories from our patients — the same thing you're saying — I've taken 3 buses, I've lugged my 3 kids here and it's pouring down raining, or if it's in Pittsburgh, it's freezing cold and there's a foot of snow. There are all these different factors that play on people's energy. And if you're already depressed, you have no energy to begin with, so we're asking too much of these families to ask them to go somewhere else. And I would implore those of you that are in the mental health field right now to please continue to look for ways to get out of your office and get into our office, because that's what's going to make a difference. We all need to shift how we practice medicine. We have to stop thinking in terms of specialty. And what Judy was saying, about even just looking at prenatal care; it's not about prenatal care. It's about interacting with the patient and her family. I've learned in the last 5 years from working with insurance companies that mental health and physical health are seen as 2 different worlds. We never talk to one another, we don't think alike. The insurance companies separate us out, so any chance we had for dialogue they've now destroyed. It's really frustrating, but it's also the key, I think, to the answer of how to correct this stuff; we have to shift how we deliver care to the patient.

Dr. Wisner: If we think of these things as whole-body physiologic dysregulation illnesses; we need to put the body back together, the structure's against us because it's all separate.




Slide 45. Cindy-Lee Dennis, RN, PhD: I'm Cindy-Lee Dennis. I'm from the University of Toronto in Canada, and I'm a nurse researcher. In Toronto, we receive 51%; of all of Canada's immigrants, and people who are immigrating to Canada are primarily from China, Hong Kong, India, and the Arabic countries. So a lot of them do not speak English, or speak English as a second language. Currently, I have a providence-wide postpartum depression prevention trial underway where we're doing universal screening in 7 health regions, including Toronto and the surrounding GTA area. We track how many screens are being done every month, and we're going to be screening approximately 20,000 women. Right now, it varies from month to month, but approximately 25%;-30%; of mothers in Toronto cannot be screened with the EPDS because they do not speak sufficient language. If they do speak sufficient language, they're screening incredibly high, so we wonder if they're actually understanding these items. For example, one item is: Things are getting on top of me. They do not have that term in China. So there's some of those issues, and then of course what cutoff to use. Right now we're kind of assuming that women are speaking English, and that they understand the EPDS — there's a lot of literature out there suggesting that maybe we should be using a different cutoff score with non-English-speaking individuals who do have English as a second language as well. And I'd just like to ask the panel about their experiences dealing with women who do not speak English, or speak English as a second language. How do you screen for that, considering in some of these cultures, a mental illness is a huge stigma, and in some groups, it's grounds for divorce? So the chances of this woman honestly disclosing that she has a mental illness; she might not. It's challenging for these women. Any comments would be great.

Dr. Frederick: We have a fair number of Hispanic patients, and we use our Spanish-speaking doulas to actually translate. Since I also speak Spanish, it's very interesting to listen to what they're saying, because they're not translating verbatim. I think when you work with translators, you always need to remember that; so if you're bringing in all different languages, they are probably not translating exactly what is written there. They are culturally interpreting, and that's probably a good thing; I'm not saying that's a bad thing. Also, I'd like to broaden this to not just language, but culture, because our African-American patients, who are inner city patients, frequently young, interpret the EPDS very differently. And in fact, our perinatal social worker brought to our attention any time one of these patients scores 0 they either didn't understand, or weren't paying attention when you asked the thing. You have to go back and do it again. And she does it when she sees them, because she sees them in the childbirth education role, and she will often repeat the EPDS; when we got a 0, she might get a 7, 8, or 9. So there are a lot of cultural differences which I don't think are addressed, at least with the EPDS, and I've not used the other screens, so I can't comment; but I would guess that it's a similar problem. Using a translator is probably a good thing, but I like the idea that maybe we need to look at different ways of evaluating the score with other languages.

Dr. Dennis: In relation to the translator, lots of times, they are small communities, so you want to make sure that that translator is not from that woman's community, because you don't want it to get back to the community that she has some sort of depressive symptomatology. So the translators are great. The EPDS has been translated into all these diverse languages, but it has not been psychometrically tested here within a North American culture, so that semantic equivalence has not been assessed with these tools; so then there are problems there as well, in terms of what are we really saying to these individuals.

Dr. Chaudron: And I would say we have the same issue. We have primarily Hispanic and African-American populations, and the cultures are very different. But the other cultural groups we have in terms of the Southeast Asian groups, the communities — especially in a city like Rochester, which is only a million people — those groups are very small, and things get around very rapidly. We like to use diagnoses because it helps us bill, it helps us think about how we treat, it helps us think in a categorical way, but if we can use the tools as an opening for discussion without a diagnosis attached to them for those mothers, you might have an easier time getting them to answer the questions, or being able to use an interpreter and feel comfortable, because the answer is not: Are you depressed or not depressed, do you have a mental illness, do you not have a mental illness? It's: do you need help now that you have a new baby and you're new in a new country? These types of questions are designed to help you think about that more broadly, rather than yes, no, depressed, not depressed.

That's one of the things I've learned the most in the last few years about these screening tools is, they start as one thing, but morph into something else, and I think we have to somehow acknowledge that, and that's hard to educate providers when we're just trying to get them to use them. In a cultural way, that's really a critical issue.

Dr. Dennis: I totally agree with you. And I think another point is to make sure that the mother completes this discussion with you while she's alone, while no family member is present. At the Marcé Society, they actually presented a really interesting tool that had faces representing anxiety, etc., instead of just words, so the mothers could point to that if they didn't speak English; so being creative in how we assess it, with of course, clinical judgment being paramount. Because often we just stick with that greater than 9, or greater than 12 cutoff and use that to guide our decision-making, instead of just using clinical judgment. I really like what you said about having it as a discussion point.

Dr. Chaudron: I think the other thing is, we often think about cultural competency as meaning we need someone from the same culture. I have a friend who's Korean who says if a Korean woman, nurse, or anybody were to ask me these questions, I would say No. But you as a Caucasian woman, I might actually disclose something. There's a different level. So I think we sometimes have to learn about different cultures, which is very hard to do. What we are thinking might be the right thing might not be the right thing to get at what we want.




Slide 46. Jeanne Watson Driscoll, PhD, APRN, BC: My name is Jeanne Watson Driscoll. I'm a clinical nurse scientist in private practice of psychotherapy and psychopharmacology in the Boston area. Most OB practices and pediatric practices employ nurses (nurse practitioners, clinical nurse specialists), who do a lot of the screening, or have a lot of the insight to pick up women who are in difficulty. And as far as the billing issue — bringing in a clinical nurse specialist in psychiatry — I have my own private billing numbers; so to have someone there in the office, in the practice. I find that when I give talks to the community about postpartum mood and anxiety disorders, women self-refer before they're pregnant, what is their risk factor. We can be doing more with childbirth educators who also are potential screeners. The biggest dilemma is the screening and who to refer to, because there are not a lot of perinatal mental health experts, though there are a lot of "experts" in women's mental health. I also think that if we stop splitting psychiatry and obstetrics, we are looking at the mental health mind/body connection of this woman, such that for the first time in her life, we have her; maybe we're missing 33%; of women, but the other 66%; are coming to an antenatal setting. The worst part is that they're not seen in a GYN office until they're 12, 14 weeks, and depression is often worse in the first trimester. So I think there's a lot of screening that's lost just in collaborative relationships. I think it's great to have all these tools, but so much of it, the clinical side, is a very intuitive assessment, and it's the relationship that opens the door. To take the staff; to increase their sensitivity to the relational connection, that you don't have to treat them, but you have to form the relationship, which then puts for the referral.

Dr. Indman: I think we need a many-pronged approach where we need to train women and consumers about what is the spectrum, what is postpartum depression, because what they've heard is that Andrea Yates had postpartum depression. So when they're asked: Do you have depression, do you think you're depressed? They'll say: Oh, no, I don't want to hurt my baby. So we need to train everybody. We need to train women not to stop their meds; we need to train the office staff on what to do when someone's calling on the phone crying, because if you say: Do you want to hurt your baby? They're going to say: No. And hang up. And then we don't treat numbers, we treat patients, we treat people. So I think that's important to remember with these screening tools.

Dr. Wisner: In the filming that we did of one of our research subjects for this program, we were asking her if anybody asked her about depression, or how she felt postpartum, and she said that she brought up with her physician that she might be depressed postpartum, and his response was: Don't worry; you're nothing like Andrea Yates. What a sad comment that is. Laura, you've been able to really connect with the OBs in what sounds like a much more seamless way than most of us, through some interesting constructs.

Dr. Miller: Yes. I just want to add an encouraging note a propos to reimbursement for screening as part of that process because, again, you can't ask OBs or anybody else to just do more than they're already doing with no additional resources. The key thing that we found working with OB/GYNs and primary care doctors is that there is just a level of busyness and a paucity of resources. The encouraging note is that collectively, we're beginning to amass enough data about what you alluded to in your introduction about the comorbidities of untreated perinatal depression — the increased obstetric risk, the increased risk to the babies, to the children — that as a body of data, it is becoming more convincing to those who pay for care. In Illinois, we were able to show those data to the Medicaid organization (which in Illinois is called Healthcare and Family Services), and to the legislature, and lo and behold, now in Illinois, all screenings for Medicaid patients are reimbursed. That allows practices, if they screen everybody, to pay for a case manager, or a medical assistant, or some other person to administer the screening program. In addition, Illinois is just about to go towards a Medicaid managed care system. We already have some, but we're about to ratchet it up tremendously, and built into that will now be, again, because they've truly become convinced of the importance of this, a mandate to screen; that any provider organization that wants to do Medicaid managed care business needs to screen for perinatal depression.

Dr. Chaudron: Laura, is the screening specific to OB/GYN and family medicine? Does it include pediatricians?

Dr. Miller: It includes pediatricians.

Dr. Chaudron: As a mandate?

Dr. Miller: The mandate is to the system. In other words, if a clinic or a system, a large system, wants to contract to be a provider reimbursed by a Medicaid managed care organization, they're going to be audited to see whether they screen. The mandated screening does not have to be a formal screening tool, but there has to be some evidence that in some way, shape, or form, that they looked for depression. It could just be documented that they asked one question, but they have to do something. The reimbursement is for a formal screening tool.

Dr. Wisner: Do you think your use of the PHQ facilitated some of the changes because more people were familiar with it? Plus, it also tends to put mental/physical back together. Can you talk a little bit about that?

Dr. Miller: We really teach the use of both the EPDS and the PHQ depending on the context. If we're talking about a prenatal context, such as doulas going out into the community who are really just working with prenatal people, and are not going to provide care themselves, but are going to refer, the EPDS is often a really good fit with that group. But when we're talking about a perinatal depression management system within an OB/GYN or family practice, then we find that the PHQ-9 is much better accepted because it's quicker, it's more familiar, especially in the family practice settings where people would like to screen all their patients, and not bother to figure out who's postpartum and who's not, and change screening tools. So we find that they're each really helpful in different settings.

Dr. Kruckman: Following up on what Laura was talking about, I work in a very large rural area outside of Pittsburgh, and we have a perinatal education program that is quite beefed up with a postpartum component. And we work very closely with the psychiatrists — there are really only 2 or 3 in the whole region in that county area — and we work with the pediatricians and OB/GYNs; there are only 4 OB/GYNs. So talk about being stressed and having 5 minutes as a limitation. What does the panel think about what we do, and that is, have the perinatal educators who are trained actually do the screening as well? No one mentioned that; although we voted that pregnancy was #2 as the area to be screened. Any reaction to perinatal educators doing the screening?

Dr. Indman: My understanding in England is they use perinatal home visitors. Home visitors have been used for years in England, and I think it's been shown to be very effective. If the idea is screening, I think even office staff can do screening. So I think it's just, again, having a referral network if someone screens positive, or has issues or concerns, to have a place where you can send them to get those addressed.

Dr. Chaudron: If you train people to understand the tool and what the tool says — the bad side of the tool with untrained people is: Oh my God, they got a 10. And they don't want to follow up. I have to call the emergency room, or they replied positively on item #10 of the EPDS (which is the suicidal question), and they think: Oh my God, I've got to call the police. That's the down side for any of us, but if we're at least in a setting where you can call your colleague, that's different than if it's being conducted from home by somebody who's more of a lay person. But I think with training and with a system — the critical piece for screening is the system of care. I don't think our referral system is very good for the majority of women. We feel really good that we screened, and we've told women: Here's where you can go. But they don't go. So we need to change the next step. But at least the education of your childbirth educators then gets that education to the women. So if women can identify for themselves, even if they don't recognize it or identify it as depression. They may be right. It's not depression, it's an anxiety disorder, or it's a substance use disorder, or bipolar disorder, whatever it is; at least they've now gotten some inkling that this is beyond what you might expect as normal adaptation, and they can then pursue help. It may be through their church. It may be through their family member. But at least now they have that window of understanding and opportunity. So I don't see why not. I'm with Pec. The more we can educate anybody, the better off we are, but we have to do it in a context that gets out of the "are you sick or not sick" mindset.




Slide 47. James K. Boehnlein, MD: I'm Jim Boehnlein. I'm a psychiatrist at the Oregon Health and Science University in Portland, Oregon, and a lot of my work is related to cross cultural psychiatry. I want to reinforce something that Dr. Chaudron said earlier about the importance of cultural issues; that the person that we're seeing who might not be from the same culture as we are may feel more comfortable talking with us about a particular issue, and may not feel at all comfortable talking with somebody from their own culture because of confidentiality issues. A lot of the communities in many of the cities tend to be small, even though the cities might be large; so things get around very easily. Also, people are immigrants and refugees, and in the countries from which they came, it was actually acceptable and that was the norm; that things were shared within the community. So that's considered the norm, even though as people acculturate to the United States and to the majority Western cultures, they begin to question whether that's really acceptable, or whether they really want that.

The other thing I want to emphasize is that with many of the cultures that we work with, they may want to have things shared within the family, but we have to actually ask people whether they want that or not. In my work, just because of resources and the allocation of resources, I often will be seeing more than one member of the same family, and very commonly, I will see people together, whether it's a parent and an adult child, or 2 spouses. The majority of the time that I see people, I will see them as a group or as a family, but I ask people if they would like to meet independently with me to discuss certain things, and that will often occur itself.

The other issue is the gender difference between the clinician and the patient. I found that much of the time, that hasn't been a big issue; it's been less of an issue in treating or addressing more medically-based issues in women's health. But on a humorous note, sometimes when there have been relationship issues; for instance, some Cambodian patients that have been coming to see us for 15, 20 years. We know each other really well, we have a very good relationship. But I'm always surprised when I hear from the Cambodian case manager and counselor who I've worked with for 10 years. She'll tell me after a session: Well, the patient said, please don't tell Dr. Boehnlein, but I have a new boyfriend, and I would like to talk to you about this some time next week when I can come in and talk to you privately; meaning the counselor. And these are people that I've known for sometimes 15, 20 years. So those cross-cultural issues regarding gender are very real, not only in Southeast Asian cultures, but in all the cultures that we're going to work with.

Dr. Spinelli: I work with a group in New York called the Central Harlem Perinatal Project which is part of the Department of Health, and they hire people like myself and other experts to be disseminated into the community to teach in small perinatal networks, or to a group of nurses, but at different levels, so you're always teaching social workers, nurses, and doctors. I mention that because we do have such a wealth at the top, and that it's important to sprinkle that down.




Slide 48. Dr. Wisner: Cheryl, can you talk about your experience with Healthy Start? Cheryl's been a big teacher of mine in terms of getting me out of the ivory tower system and into the real world.

Cheryl Squire Flint: Good afternoon. I'm Cheryl Squire Flint. I'm the executive director of Healthy Start, Inc. We have both an urban and a rural project. Our rural project is in the city of Pittsburgh, Allegheny County; our rural project is about 50 miles from Pittsburgh in Uniontown, Pennsylvania, or Fayette County. We service that entire area. And we find that sharing the wealth is one of the things that we feel works best for us; that is, making sure that our field staff are trained by those individuals who are experts in the field and sharing that knowledge. We have a group of professionals and paraprofessionals that work on a multidisciplinary team to deal with women at 4 stages: preconception; prenatal; postpartum; and after that, general women's health issues. And everyone on that multidisciplinary team has input into it, and learns from one another. We're working with the medical community, we're working with the universities, we're working with the public health systems throughout the state of Pennsylvania. We're also working across the commonwealth; we're working with maternal and child health programs, and everyone is sharing knowledge about cultural issues; about how to best reach those persons who are most in need. When you're working with an urban population, and you're also working with a population in Appalachia, there are unique features for each one of those groups; and that our personal values don't take priority, is the key, and that we appreciate and come to learn what works best in each community.