1. Pregnancy Related Depression (PRD) Screening in the Pediatric Setting: Clinical Considerations, Complexities and Coordination
Bridget Burnett, PsyD
Kathryn Jantz, MSW, MPH
Sue Williamson, JD
In collaboration with:
Colorado Department of Public Health and Environment (CDPHE)
Colorado SIM Office
ENSW/SIM Collaborative Learning Session – Golden, CO
June 2, 2017

2. Learning Objectives for Presentation
PRD screening tools and how to select and interpret a screening tool
Best practices and recommendations on when to screen
How to administer the screen
Identify the appropriate interventions based on the score and practitioner judgment
Identify community resources, services and organizations for further referral and follow-up
Additional staff training may be required within the pediatric setting.
Clinical only- Sue

3. Colorado Pregnancy Related Depression (PRD) Facts
According to the DSM, Pregnancy Related Depression is a form of Major Depression that occurs within four weeks of delivery
Prevalence: Ten percent of Colorado mothers experienced frequent PRD symptoms (2011) (1)
Significant impact on children: Infants of parents with PRD often have delayed cognitive and psychological development, delayed motorized skills, lower vocalizations, and increased resource use
Screening is reimbursed: Medicaid (federal and state) supports and reimburses screening by the child’s medical provider under the child’s Medicaid ID
CDPHE and others don’t use DSM diagnosis
Behavioral health clinicians are moving to PMADs. In setting up strong processes and procedures around PRD, practices are preparing for a more holistic, PMADs approach.
(1) Colorado Department of Public Health and Environment Pregnancy Risk Assessment Monitoring System (PRAMS)

4. American Academy of Pediatrics (AAP) Position
Includes “assessment and consideration of parental and family environmental factors that may affect children’s health”, maternal depression being one of these.
Include bullets about importance- Sue

5. Additional Recommendations
United States Preventive Services Task Force (USPSTF) – depression in general adult population including pregnant and postpartum women
Centers for Medicare and Medicaid (CMS) – identifies importance of PRD screening and encourages child’s provider to refer mothers for appropriate care

6. Policy Perspective
Encouraged to administer PRD screenings in a pediatric setting
SIM initiative – PRD screening is a Clinical Quality Measurement (CQM)
Medicaid and other payers reimburse PRD screening in pediatric setting

7. When to Screen
The AAP recommends integrating postpartum depression surveillance and screening at the 1-, 2-, 4-, and 6-month visits.
Universal screening can normalize PRD, normalize the screening process and assure families that their pediatric office is a safe and appropriate place to talk about how things are going.
Mother may answer differently if they come alone
Mothers may change their responses as they gain comfort with the clinic

8. How to Administer the Screen
Workflow and Consistency are key
Caregivers may feel more comfortable completing the screen on pencil and paper
Caregivers may feel more comfortable completing the screen once roomed
Who is present during the visit may impact validity of the score. Assess and monitor dynamics and culture
Culture and language may impact the validity of the score
Verbally: no best practices

9. Introducing the Screen
The verbal and written introduction is an important part of normalizing the PRD screen
Can assure mothers that PRD is common and there are treatment options available

10. PRD Screening Tools
The Edinburgh Postnatal Depression Screen (EPDS) The Edinburgh Postnatal Depression Screen is recommended by the Colorado Department of Public Health and Environment (CDPHE) for screening in pediatric settings
Recommended in Ped setting by AAP, American Academy of Family Physicians, the American Congress of Obstetricians and Gynecologists, and the US Preventive Services Task Force
The Patient Health Questionnaire-9 (PHQ-9), which is a diagnostic tool for general depression
Poll the audience. Which one are you using? Why? Anyone who has switched tools? Any feedback on the tools? Bridget
Discuss shorter versions

11. EPDS Overview How are You Doing Today?
Please fill out the Edinburgh that is in your handouts (don’t worry, you won’t have to share your results).

12. EPDS Scoring Positive items receive a score of 1-3
10+ Indicates risk for Depression
14+ Considered a Positive Screen
Item 10 Self Harm
Clinical Judgement always supersedes scoring
Score of Zero can be just as concerning as 14+

13. PHQ-9 Overview

14. PHQ-9 Scoring Positive items receive a score of 1-3
Intended to assess symptoms within the past 2 weeks
Always review with the patient and assess for risk, especially if item #9 is endorsed.

15. Identifying Appropriate Interventions: Starting the Conversation
Stigma
“Many women feel anxious or depressed during pregnancy or postpartum”
“A woman deserves to feel well”
“Many effective treatment options are available”

16. Identifying Appropriate Interventions: Starting the Conversation
Explore Expectations: Pregnancy and postpartum experiences and expectations vary
“How are you feeling about being pregnant/a new mother?”
“What has surprised you about being pregnant/a new mom?”
“What has it been like for you to care for your baby?”
“What beliefs or practices related to pregnancy or soon after the baby is born are especially important to you?”

17. Identifying Appropriate Interventions: Starting the Conversation
Explore Social Support
“Who can you talk to that you trust?”
“How have your relationships been going since becoming pregnant/a new mom?”
“Who can you turn to for help?”

18. SAMPLE Sample Project CLIMB/CHC Screening Protocol
Talmi, 2007 Project CLIMB Children’s Hospital Colorado. Do not replicate without permission

19. Emergency Protocols
Do you have a written protocol for when a mother indicates she may be at risk for harming herself or her child?

20. Connecting to Care How many practices:
Coach mothers on self- help practices?
Refer by providing a phone number?
Refer through a warm handoff by calling a provider with the patient to help them make an appointment?
Very few people follow-up when they are simply provided a number to contact.

21. https:// Make a handout

22. Identifying Community Resources
What resources, services and programs are available in your community?
What kind of partnerships have you created in your community?
What are the gaps in your community with respect to resources, services and programs?
What is needed to close those gaps?

23. Let’s Practice Scenario Presentation
What are the facts you need to consider in this scenario? (Approach)
What would you do? (Plan)
What would you say? (Conversation)
How would you close the referral and resource loop? (Activation of caregiver)

24. Caregiver Campaign

25. Support Person Campaign
Campaign resources are available.

26. Billing and Coding
Private insurers have range of policies and coverage for PRD screening in practices
Colorado Medicaid (NEW!): 3 times a year
Billing and coding report

27. Operational Considerations
Develop written policies and procedures for documentation (including where the information is maintained and when and with whom it is shared)
Develop written policies for workflow including referrals and follow-up
Revise consent and notification forms policies and procedures especially around parental personal health information
Develop clear language for the verbal introduction of the tool and for a written cover sheet that is educational and destigmatizing
Clear written policies and procedures are important for limiting liability

28. Identified Gaps Trainings for staff on PRD
Referral lists for all communities and clinics
Reimbursement that supports comprehensive service and prevention associated with screening in a pediatric perspective
Official guidance around policies and procedures, consent, and data management

29. Acknowledgements CDPHE Denver Public Health Colorado SIM
Health Team Works
Project CLIMB Children’s Hospital Colorado