1. Targeting Postpartum Depression: An evaluation of the Edinburgh Postnatal Depression Scale in Pinellas County Florida Dorothy M. Miller, MSW, LCSW Pinellas County Health Department

2. A Mother’s Story

3. Background  50-75 percent of all new mothers experience these feelings of sadness after birth  1 in 10 new mothers experience various degrees of postpartum depression  Symptoms may occur: –After childbirth –During pregnancy –After a miscarriage or termination –Up to a year or so after delivery

4. Objectives  Pinellas County Health Department began using Edinburgh Postnatal Depression Scale (EPDS) in the Fall of 2002 to determine : –Number of pregnant and postpartum women screened positive –Major factors causing symptoms of depression –Referral process for clients receiving 12 or above on tool –Resources available to these clients –Barriers to mental health care

5. Methods  Edinburgh Postnatal Depression Scale (EPDS) (a short 10 question document) was selected as the screening tool  Care Coordinators were trained on administration and scoring of tool; with a score of 12 or above warranting a mental health referral  The first 1270 screens completed were used as the sample for the evaluation/ 271 scored 12 or above and of those 247 were open and used as final sample  File reviews and interviews with caseworkers were conducted for additional data

6. Results

7. Demographics  Race: –Asian.8%(2) –Black 32% (79) –Native American.2%(1) –White 67%(165)  Age: Average of 25 –13-17 years old: 8.5% (21) –18-24 years old: 42.5% (105) –25-35 years old: 44.5% (110) –35 years & above: 4.5% (11) Overall majority of high scores are white women between the ages of 18 and 35

8. Screen Administration  40%(99) during pre-natal period only  33% (81) during postpartum only  27% (67) at least twice (one prenatal/one postpartum) Overall 60% (149) were screened during the postpartum period

9.  21% (271) scored 12 or above  Average Score 15  Clients first screens: –14% (35) scored 12 –54% (133) scored 13-17 –32% (79) scored 18 or higher Scores

10. Changes in Scores  Of those screened pre-natally and postpartum (77): –19% 15 increased regardless of counseling –47% 36 decreased with minimum of 8 visits –34% 26 scored the same with counseling

11. Referrals and Compliance  97% (240) received referrals to an outside facility/in- house mental health advocate  Of those 240, over half (131/55%) completed an average of at least 8 weekly visits with a qualified mental health professional  10% (25) of clients met with a provider once but did not comply a specified plan  35% (84) refused any mental health services (reasons were as follows: stigma, depression was situational, partner or parent refusal, schedule conflict)

12. Referrals and Compliance **

13. Major areas of stress  29% (71) presented with a mental health diagnosis or history of depression  All chose “life issues” as major problem: finances, housing, transportation, education, child care, lack of insurance  About 20 % had substance abuse problems  10 % had parenting/or childbirth related issues  10% had domestic violence issues  5% had DCF or other legal involvement

14. Barriers  Lack of Insurance  Language Issues  Social Stigma  Wait times  Schedule Conflicts  Spousal/Parental Refusal  Transportation

15. Insurance Coverage Almost 50% of these clients lost medicaid coverage during postpartum period

16. Conclusions  A significant percentage (21%) screened 12 or higher verifying the need for more mental health services targeting this issue  The screening process should be more aggressive in capturing postpartum women; it is important not to rely on a negative screen during pregnancy and repeat screen during post-natal period to rule out specific symptoms of postpartum depression

17. Conclusions  Approximately one-third of clients declined mental health services due to social stigma  There is a need for multi-cultural and bi- lingual services in the community  Medicaid dollars should be utilized to provide more in-house mental health services for these clients

18. Public Health Implications  This screen is a “first step” toward addressing the mental health needs of pregnant and postpartum women.  The results cannot be generalized but should encourage policy makers to mandate a universal tool for providers for early detection of these symptoms in women.

19. Public Health Implications  One in 10 new mothers experience some symptoms of depression. If left untreated, tragic outcomes could prevail for the babies and their mothers.  Screening provides a mechanism to detect symptoms and connect women to resources to prevent these types of outcomes.

20. Acknowledgements  Claude Dharamraj, MD,MPH  Patricia L. Ryder, MD, MPH  Jane Bambace, M Ed  Pinellas County Health Department, Community Health Division

21. Contact Information  Dorothy Miller, Pinellas County Health Department –(727) 824-6900 Ext 11323 –Dorothy_Miller@doh.state.fl.us