1. A Pediatrician’s Perspective on Postpartum Depression Screening
AAP QuIIN PreSIP:
A Pediatrician’s Perspective on Postpartum Depression Screening
June 2011
Kellie Haworth, MD, FAAP
Major, Medical Corps, United States Army
Postpartum Support International Military Coordinator

2. Overview IACH Program Screening Tools Coding IACH study results
EPDS
PDSS
CES-D
PHQ-2
PHQ-9
BDI
Coding
ICD-9
CPT
IACH study results
Screening Suggestions
Response to screening
What to do
What to document
What not to say
What to say
Patient Resources
Suggested list
Professional organizations
For moms
For families
Miscellaneous
Provider Resources
Education and training
Toolkits
Model Programs
References
Medication references

3. IACH Program Prevention Positive screens in Peds Outpatient screening
Education during pregnancy / childbirth classes by OB
Education in newborn nursery prior to discharge by nursing
Outpatient screening
When / where
Pediatric Clinic
Newborn, 2 week, month, 4 month, month, and 9 month well child visits
OB Clinic
6 week postpartum visit
Screened prn by lactation consultant
How
EPDS handed to mom by nurse during initial screening and vitals
Mom completes screen while waiting for provider in privacy of exam room
Provider reviews screen while in exam room
EPDS scores compared to those from last visit
Positive screens in Peds
Provider addresses concerns
Trained RN offers education
Provides handouts, information, resources list
Clinic Social Worker / Case Manager notified
Refers to PCM or OB (makes appt for mom)
Refers for therapy (makes appt for mom)
Refers for home nurse visit
Refers to Support Group
Telephone follow-up
Addressing Emergencies
Behavioral Health contact paged and will consult / assume care of mom in Pediatric Clinic
Developing hospital perinatal mood disorders team
2 PNP’s, 2 Psych techs
Immediate access to Behavioral Health and Social Work Services
Consultation with Pediatrician / PSI coordinator

4. Screening Tools

5. EPDS

6. PDSS CES-D

7. PHQ-2 PHQ-9

8. BDI

9. Coding CPT codes Diagnosis (ICD-9) codes
“Maternal distress / postpartum condition / complication”
“Maternal condition affecting newborn” 760.9
“Maternal condition suspected, not found” V89.09
“Family disruption, other” V61.09
“Counseling, parent-child problem” V61.20
“Reported family history of psychiatric problems / mental illness (not retardation)” V17.0
“Psychosocial support, lack from family” V62.4
“No household member able to render care” V60.4
CPT codes
“Administration and interpretation of health risk assessment instrument” 99420
Recommended for use with EPDS
“Developmental testing, limited, with interpretation and report” 96110
Prior code for EPDS
“Parenting class, non-physician, per session” S9444
“Patient education, NOS, non-physician, individual, per session” S9445

10. “Incidence and Severity of Postpartum Depression Among Military Beneficiaries”
Who
Women qualified to receive medical care at Ireland Army Community Hospital (IACH) Fort Knox
What
Screened for PPD
When / Where
OB/GYN Clinic
6 week postpartum visit
Infant age weeks
Pediatric Clinic
Newborn, 2 week, 2 month, 4 month, 6 month, and month well child visits
How
Using Edinburgh Postnatal Depression Scale (EPDS)
Positive screen
Total score = 10 or more
Positive score on question #10 (suicidal ideation)
Yield
18 month period
1877 EPDS screens
1043 women

11. “Incidence and Severity of Postpartum Depression Among Military Beneficiaries”
Incidence varied between Peds and OB/GYN Clinics

12. “Incidence and Severity of Postpartum Depression Among Military Beneficiaries”
Total incidence significant even 9 months postpartum
Should we screen throughout 1st year postpartum?
n=7

13. Screening Suggestions
When to screen
Bright Futures says month, 2 month, and 6 month well child visits
IACH study suggests every well child visit through first 9 months postpartum
Consistency minimizes awkwardness
What tool to use
Most convenient for individual practice
Educate all staff
Confirmation of dx
Not necessary by Pediatrician
Positive screen in primary care setting should have further evaluation
Delivery of screen
Front desk clerks upon check-in
Nursing with screening and vitals
With other questionnaires / ASQ
Ready for provider when enters exam room
Scoring of screen
Nursing
Provider
Addressing screen
Trained staff member
Social worker
Emergency contacts

14. Now what? Don’t screen until you know this answer!
What should you do with an abnormal screen?
Provide reassurance and education
Ask whether mother has primary care provider and gain permission to initiate conversation with that professional
Offer to initiate referral to mental health professional, support group, or other therapeutic agency
Initiate immediate referral if mother shows severe impairment, psychosis, or suicidal ideation
Refer to Early Intervention program for attachment concerns
Provide list of print and online resources
Schedule frequent office visits to follow up
What should you document (infant’s chart)?
Maternal EPDS score, including score of question #10
Presence of maternal auditory or visual hallucinations or suicidal or homicidal ideation
Health care professionals who were consulted or to whom referrals were made
Follow-up plan (for both mother and child)
Current treatment (for both mother and child)

15. Response to Screening What NOT to say What to say
Note mother-child interaction and assess attachment and bonding
Ask specific questions
Resources, stressors, history of depression, suicidal ideation
Listen!
Be prepared for her to deny her symptoms
Be prepared for her to be unwilling to seek treatment
What NOT to say
This is a normal reaction all new mothers experience
Don’t worry about…
You have so much to be happy about…
A healthy baby is worth it…
You would never really do…
Join ‘new mom’ group
What to say
You are not alone
You are not to blame
Not something you caused, could have prevented, or can control
With help, you will be well
It is okay to need help
Depression is treatable
Illness is temporary
You are not “crazy”
This is not reflection of you as person or mother
Intrusive thoughts are different from psychosis

16. Patient Resource List National 24 hour crisis lines
National Suicide Help Line: SUICIDE ( )
National Suicide Talk Line: TALK (8255)
Specialized treatment centers
Massachusetts General Hospital Center for Women’s Mental Health, Boston, MA
UNC Center for Women’s Mood Disorders
Women and Infants Day Hospital, Providence, RI
landingPage4.cfm?topicID=333& facilityID=7
Emory School of Medicine Women’s Mental Health Program, Atlanta, GA
Professional Organizations
Internet
Blogs
Online support groups
Regional
Maternal-Child Health programs
PSI coordinators
Crisis line
Support groups
Local
Emergency
Law enforcement
Emergency Room
Mental Health Center
Crisis line
Mental Health providers
Psychiatrists and PNPs
Psychologists
Social Workers
Therapists
Other providers
OB / GYN
Family Practitioners
Midwives
Other professionals
Home Health nurses
Doulas
Lactation consultants
Case Managers
WIC office
Early Intervention Services
Head Start program
Next Door
Faith Communities
Family members
Spouses / significant others
Extended family

17. Professional Organizations
Postpartum Support International (PSI)
Marcé Society
North American Society for Psychosocial Obstetrics & Gynecology (NASPOG)
National Center for Education in Maternal and Child Health (NCEMCH)
National Institute for Healthcare Management Foundation (NIHCM)
Women's Behavioral HealthCARE
Mental Health America (MHA)
Association for Postnatal Illness (APNI) (UK)
National Alliance on Mental Illness (NAMI)
National Healthy Mothers, Healthy Babies Coalition (HMHB)
Center for Postpartum Health
The Pacific Post Partum Support Society (PPPSS)
Lamaze International / Lamaze Institute for Normal Birth
Womenshealth.gov
American Society for Reproductive Medicine (ASRM)
National Institutes of Mental Health (NIMH)
National Institutes of Health (NIH)
Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN)
American Academy of Family Physicians (AAFP)
American Academy of Pediatrics (AAP)
American College of Obstetricians and Gynecologists (ACOG)
American Medical Association (AMA)
American Psychiatric Association (APA)
American Psychological Association (APA)
American Nurses Association (ANA)
National Association of Social Workers (NASW)
American Public Health Association (APHA)
National Center for Complementary and Alternative Medicine (NCCAM)

18. Postpartum Support International (PSI)
Non-profit organization
Mission: “Promote awareness, prevention, and treatment of mental health issues related to childbearing in every country worldwide through support, education, advocacy, and research”
Toll-free Help Line : PPD (4773) (English and Spanish)
Volunteer Area Support Coordinators
In all 50 US states, Canada, Mexico, and 36 other countries worldwide
Provide telephone and support, information, local resources
“Healthy Mom, Happy Family: Understanding Pregnancy and Postpartum Mood and Anxiety Disorders”
Educational DVD for families and providers
4 survivor stories accompanied by up-to-date information given by 3 experts
Free phone "Chat with the Experts“
First Mondays of each month for dads, every Wednesday for moms
Facilitated by PSI Professionals
Offer standardized training and education
Resources for women, families, students, and professionals

19. Professional Organizations
Marce Society
International organization dedicated to prevention, understanding, and treatment of psychiatric illness related to childbearing
Promotes, facilitates, and communicates about research into all aspects of mental health of women, infants, and partners around time of childbirth
Encourages involvement from psychiatrists, psychologists, pediatricians, obstetricians, midwives, nurses, early childhood specialists, consumer advocacy, and self-help groups
North American Society for Psychosocial Obstetrics and Gynecology (NASPOG)
Society of researchers, clinicians, educators and scientists involved in women’s mental health
Fosters scholarly scientific and clinical study of biopsychosocial aspects of obstetrics and gynecology
National Center for Education in Maternal and Child Health (NCEMCH)
Maternal and Child Health Library
Research center of Georgetown University
Collection of historical documents related to US maternal and child health
PPD Knowledge Path
info/KnowledgePaths/ kp_post partum.html
Offers current resources about prevalence and incidence of postpartum depression, identification and treatment, impact on health and well-being of new mother and her infant, and implications for service delivery
National Center for Children in Poverty, Project Thrive
Public Policy Analysis and Education Center for Infants and Young Children
“Reducing Maternal Depression and Its Impact on Young Children” published January 2008

20. Resources for Moms Text4baby
National Healthy Mothers, Healthy Babies Coalition
Free text messaging program for pregnant or new mothers
English or Spanish
Messages 3 times per week
Messages customized for stage of pregnancy or baby's age
Health advice for pregnant women and new moms
Nutrition tips
Access to free and low-cost programs that provide medical care, food, and other services
Tips and support for coping with stress of pregnancy and new motherhood
Fun facts about baby development and milestones
To sign up text “BABY” to
APA’s Healthy Minds: “How Do I Know if I’m Depressed?”
opinion10.cfm
Online Support Group
Online moderated discussion forums
National Women’s Health Information Center
WOMAN
Mother to Mother Postpartum Depression Network
Maternal and Child Health Hotline
(800) 311-BABY (2229)
(800) (Spanish)
Health Resources and Services Administration (HRSA)
beyond/depression

21. Internet Resources for Dads, Families, and Friends
Postpartum Education for Parents
BABY (2229)
(Spanish)
24-hour support line available for one-to-one support
Families for Depression Awareness
resources/options.php
Helps families recognize and manage various forms of depression and mood disorders
Depression During and After Pregnancy: A Resource for Women, Their Families, and Friends
andbeyond/depression
Information about definition and symptoms of PPD and when to seek treatment
Postpartum Dads Project
Informational site focusing on what men experience when their partners have perinatal mood disorders
Offers stories and advice on how to help partners
Boot Camp for New Dads
Father-to-father community-based workshop inspires men to become confidently engaged with infants and support their mates
Mayo Clinic: “Supporting A Friend or Family Member with Depression”
depression/MH00016
Anxiety Disorders Association of America: “Helping a Family Member”
AFamilyMember.asp
Online support group for dads
ww.postpartumdads.org

22. Miscellaneous Resources
Blogs
Postpartum Progress
typepad.com
I’m Listening by Jane Honikman
Unexpected Blessing
wordpress.com
PTSD After Childbirth
birth.org
Beyond Postpartum
spot.com
Foundations
Jennifer Mudd Houghtaling Postpartum Depression Foundation
Jenny’s Light
Sounds of Silence Foundation
foundation.org
Ruth Rhoden Craven Foundation
Melanie’s Battle
Resources in Other Languages
Medline Plus
languages/postpartumdepression. html
15 languages including Arabic, Japanese, Korean, Chinese, Vietnamese, Russian, Somali 
Maternal & Child Health Library
html
UCSF Depression Prevention Course (Muñoz)
manuals.aspx#depressionprevention
Workbooks in Spanish, Japanese, Chinese
British Columbia Partners for Mental Health and Addictions Information
Publications in Arabic, Chinese, English, Farsi, French, Korean, Punjabi, Russian, Spanish, Japanese, Vietnamese
Here to Help
French
phone.asso.fr/
German

23. Provider Resources- Education and Training
Postpartum Support International (PSI)
University of Washington’s “Keys to Postpartum Depression”
Created by nurse scientists at UW and members of Washington First Steps Team
3 multimedia training modules
Understanding & Treating Women with Perinatal Depression & Mood Disorders
Relationship Focused Practice
Screening for Perinatal Depression
Women's Behavioral HealthCARE
Committed to advancement of gender-based clinical care, advocacy, research, and education
Provide preventive, curative, and promotive services to women of childbearing age, their families, the public, and general medical community (psychiatry, obstetrics, gynecology, and pediatrics)
Developed MedEdPPD.org
Professional, educational, peer-reviewed website
Developed with grant from NIMH
Provides evidenced-based tools for professionals and families
Expert CEU / CME presentations
Screening tools
Case studies
Provider FAQs
Care Pathways algorithm
Designed for medical professionals evaluating postpartum women to help determine if reached positive or negative outcome since giving birth
Outcome indicates if patient should be referred for additional mental health services or put on antidepressant regimen and monitored

25. Provider Resources- Education and Training
Support and Training to Enhance Primary Care for Postpartum Depression (STEP-PPD)
Free training program solicited by NIMH
Educates primary care providers on evidence-based screening, diagnosis, treatment, and referral for PPD
Tailors instruction to user by requesting information at registration
Specialty (OB / GYN, Pediatrics, or Family Practice)
Discipline (physician, nurse, PA, or social worker)
Special characteristics of patient population (ethnicity, region, adolescents)
4 Program formats
Web-based training
Sponsored by University of Iowa Carver College of Medicine for 3 AMA Category I credits
Must purchase CME credit license for $15 and score >80% on quiz
Learning objectives, case studies, interactive video clips, and resource links
3 Modules
“Understanding PPD”
“Assessing PPD”
“Treating PPD”
Comprehensive resource list including 3 screening tools
Algorithms for assessment and treatment of PPD
In-person ½-day training
In-person grand rounds
Full-day “train the trainer”
Can purchase a pocket guide online or download for PDA

26. STEP-PPD

27. Provider Resources- Toolkits
Spectrum Women’s Health Toolkit for Healthcare Providers
Helps design PPD program in step-by-step approach
Create advisory team
Train staff
Begin screening
Establish follow-up protocols
Develop referral team
Implement groups and services
Launch telephone support and information line
Create program evaluation process
Prepares healthcare staff
Garners financial and resource support
One kit costs $450
Pennsylvania Perinatal Partnership Community Collaboration Toolkit
Free 163-page toolkit
Fact sheets, tables, website links, talking points, consultation lines, treatment guides, legislation information
Mental Health America: Maternal Depression- Making a Difference Through Community Action: A Planning Guide
maternal-depression

28. Provider Resources- Model Programs
Oregon Pediatric Society’s START program
Maternal depression screen module
CME and MOC credits available
Goals
Increase standardized screening
Community resource awareness
Enhance care coordination and communication
Incorporates medical home, team-based care model
Includes primary care providers, nurses, and office staff
Training tailored to community
Uses physician trainers from various geographic regions who know communities best
Includes representatives from local community agencies
Virginia Bright Futures
Has training website
Developed “parent kit”
Partnered with AAP Virginia chapter, state Early Periodic Screening, Diagnosis, and Treatment (EPSDT), Resource Mothers, and Healthy Families Virginia to recommend screening

29. Provider Resources- References
Perinatal Depression Information Network
Collects and organizes information across US
Creates forum to bring maternal, child, and mental health providers, leaders, and families together
Lists specific contacts and other key information for each network resource
Online provider toolkits
Online training modules
Research
Policy
Funding
Legislative initiatives
Special features
Discussion forum
Materials for women and families
Massachusetts General Hospital Women’s Mental Health Center Library (MGH)
Repository of information and articles
National Institute for Healthcare Management Foundation (NIHCM)
“Identifying and Treating Maternal Depression: Strategies & Considerations for Health Plans” (Issue Brief June 2010)
Basic PPD information, statistics, risk factors, screening recommendations, screening tools, legislation, management and treatment, barriers, and resources
National Library of Medicine
postpartum depression.html
University of Illinois Chicago (UIC) Provider Consultation Line
Consults for healthcare providers with questions on detection, diagnosis, and treatment of perinatal mood disorders
UIC faculty and staff clinicians
Not a “hotline”
Response in 1 business day

30. Provider Resources- Medications
What about maternal psychoactive medication use and breastfeeding?
SSRI’s most commonly used in lactating women due to lower breast milk concentrations
Lowest effective dose should be prescribed
References
Evidence-based information about risk of maternal exposures to developing fetus or infant
Maternal and infant drug levels
Possible effects on breastfed infants
Alternate drugs to consider
Books
“Medications and Mothers’ Milk: A Manual of Lactational Pharmacology” by Hale (Pharmasoft)
“Drugs in Pregnancy and Lactation” by Briggs, Freeman, and Yaffe (Lippincott)
Internet sites
National Library of Medicine online database “Lact Med”
Motherisk
OTIS (Organization of Teratology Information Specialists)

31. Questions?