Targeting Postpartum Depression: An evaluation of the Edinburgh Postnatal Depression Scale in Pinellas County Florida

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. 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) Demographics 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% (148) were screened during the postpartum period

9. Scores • 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

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 at least 8 weekly visits with a qualified mental health professional • 10% (25) of clients met with a provider once but did not comply with 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