A Pediatrician’s Perspective on Postpartum Depression Screening

1. A Pediatrician’s Perspective on Postpartum Depression Screening Kellie Haworth, MD, FAAP Major, Medical Corps, United States Army Postpartum Support International Military Coordinator AAP QuIIN PreSIP: June2011

2. Overview IACH Program Screening Tools 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 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, 2 month, 4 month, 6 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 Diagnosis (ICD-9) codes “Maternal distress / postpartum condition / complication” 669.04 “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. 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 2 - 8 weeks Pediatric Clinic Newborn, 2 week, 2 month, 4 month, 6 month, and 9 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 “Incidence and Severity of Postpartum Depression Among Military Beneficiaries”

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. When to screen Bright Futures says 1 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 Provider Trained staff member Social worker Emergency contacts Screening Suggestions

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. 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 Response to Screening 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: 1.800.SUICIDE (784.2433) National Suicide Talk Line: 1.800.273.TALK (8255) Specialized treatment centers Massachusetts General Hospital Center for Women’s Mental Health, Boston, MA http://www.womensmentalhealth.org/ UNC Center for Women’s Mood Disorders http://www.psychiatry.unc.edu/wmd/ Women and Infants Day Hospital, Providence, RI http://www.womenandinfants.org/ landingPage4.cfm?topicID=333& facilityID=7 Emory School of Medicine Women’s Mental Health Program, Atlanta, GA http://www.emorywomensprogram.org/ 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 Mental Health Center 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” • www.postpartum.net • Toll-free Help Line : 800.944.4PPD (4773) (English and Spanish) • Volunteer Area Support Coordinators • In all 50 US states, Canada, Mexico, and 36 other countries worldwide • Provide telephone and email 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 www.marcesociety.com/ 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) www.naspog.org/ 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 www.mchlibrary.info Research center of Georgetown University Collection of historical documents related to US maternal and child health PPD Knowledge Path http://www.mchlibrary. 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 www.nccp.org 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 511411 APA’s Healthy Minds: “How Do I Know if I’m Depressed?” www.healthyminds.org/expert opinion10.cfm Online Support Group http://postpartumdepression.yuku.com Online moderated discussion forums National Women’s Health Information Center 800-944-WOMAN www.4woman.gov Mother to Mother Postpartum Depression Network www.postpartumdepression.net Maternal and Child Health Hotline (800) 311-BABY (2229) (800) 504-7081 (Spanish) Health Resources and Services Administration (HRSA) www.mchb.hrsa.gov/pregnancyand beyond/depression

21. Internet Resources forDads, Families, and Friends Postpartum Dads Project http://postpartumdadsproject.org 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 http://www.bcnd.org 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” http://www.mayoclinic.com/health/ depression/MH00016 Anxiety Disorders Association of America: “Helping a Family Member” http://www.adaa.org/GettingHelp/Help AFamilyMember.asp Online support group for dads ww.postpartumdads.org Postpartum Education for Parents 1-800-311-BABY (2229) 1-800-504-7081 (Spanish) http://www.sbpep.org 24-hour support line available for one-to-one support Families for Depression Awareness http://www.familyaware.org/ 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 www.mchb.hrsa.gov/pregnancy andbeyond/depression Information about definition and symptoms of PPD and when to seek treatment

22. Miscellaneous Resources Blogs Postpartum Progress http://postpartumprogress. typepad.com I’m Listening by Jane Honikman http://janehonikman.com/ Unexpected Blessing http://unexpectedblessing. wordpress.com PTSD After Childbirth http://www.ptsdafterchild birth.org Beyond Postpartum www.atlantappdmom.blog spot.com Foundations Jennifer Mudd Houghtaling Postpartum Depression Foundation www.ppdchicago.org Jenny’s Light www.jennyslight.org Sounds of Silence Foundation www.soundsofsilence foundation.org Ruth Rhoden Craven Foundation www.ppdsupport.org Melanie’s Battle www.melaniesbattle.org Resources in Other Languages Medline Plus www.nlm.nih.gov/medlineplus/ languages/postpartumdepression. html 15 languages including Arabic, Japanese, Korean, Chinese, Vietnamese, Russian, Somali  Maternal & Child Health Library www.mchlibrary.info/nonenglish. html UCSF Depression Prevention Course (Muñoz) www.medschool.ucsf.edu/latino/ 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 www.heretohelp.bc.ca/other-languages French http://marce-franco phone.asso.fr/ German http://www.marcegesellschaft.de/

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 • http://www.womensbehavioralhealth.org/ • 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) • http://www.step-ppd.com/step-ppd/home.aspx • 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 www.paperinatal.org 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 http://www.nmha.org/go/ maternal-depression

28. Provider Resources-Model Programs Oregon Pediatric Society’s START program http://oraap.com/ 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) www.womensmentalhealth.org/library 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 www.nlm.nih.gov/medlineplus/ 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” • http://toxnet.nlm.nih.gov/ • Motherisk • http://www.motherisk.org/women/index.jsp • OTIS (Organization of Teratology Information Specialists) • www.otispregnancy.org

31. Questions?