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Associate Professor, Maternal-Fetal Medicine
Departments of Obstetrics & Gynecology and Psychiatry
University of Colorado School of Medicine, CO, USA
Slide 2
Disclosures
Camille Hoffman No commercial or industry disclosures
Represented the Society for Maternal Fetal Medicine (SMFM) on the Council on Patient Safety in Women’s Health Care on this topic (for free)
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Objectives
Discuss Postpartum Depression Epidemiology-it’s common!
Review the implementation of traditional screening tools and places where we “miss” it
Consider methods for engaging patients and their families in recognizing signs and symptoms and linking treatment and support
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Council Participation on the Maternal Mental Health Safety Bundle
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Why Worry about PPD?
CDC estimates 8-19% of women will experience a depressive episode during or after pregnancy.
www.acog.org/Womens-Health/Depression-and-Postpartum-Depression
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Poor health care Substance abuse Cognitive delays Behavioral problems
Bodnar et al (2009) J Clinical Psychiatry. Cripe et al (2011). Paediatric Perinatal Epid. Flynn & Chermack (2008) J Studies on Alcohol and Drugs. Forman et al (2007) Dev Psychopathology. Grote et al (2010) Archives General Psych. Sohr-Preston & Scaramella, (2006) Clinical Child and Family Psychology Review. Wisner et al (2009) Am J Psychiatry.
Preterm delivery Low birth weight Preeclampsia
©MCPAP For Moms
Why Worry about PPD? Affects Mom, Child and Family
Untreated maternal depression can have a devastating effect on women, their infants and their families.
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Why Worry about PPD? In extreme form, depressive psychosis can lead to maternal suicide
and/or infanticide.
Maternal suicide within a year of birth is emerging as a significant cause of maternal mortality, and is probably underreported.
© 2016 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. Published by Lippincott Williams & Wilkins, Inc.
Maternal deaths in Colorado from 2004 to 2012 (N=211)
Metz T, Rovner P, Hoffman M, Allshouse A, Beckwith K, Binswanger I, Maternal Deaths From Suicide and Overdose in Colorado, 2004-2012. Obstetrics & Gynecology. 2016; 128(6):1233-1240. DOI: 10.1097/AOG.0000000000001695
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Ten-year pregnancy-associated mortality rates for deaths by violence and injury compared with the leading obstetric causes in Illinois, 2002-2011.
Koch A, Rosenberg D, Geller S. Higher Risk of Homicide Among Pregnant and Postpartum Females Aged 10-29 Years in Illinois, 2002-2011. Obstetrics & Gynecology. 2016; 128(3):440-446. DOI: 10.1097/AOG.00000000000015590
Maternal Mortality Risk: Homicide, Suicide
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The perinatal period is ideal for the detection and treatment of perinatal
depression and anxiety.
Regular opportunities to screen and
engage women in treatment.
Front line providers have a pivotal role.
De-stigmatize
Educate
Proactively initiate and welcome
conversation.
So, how do we miss it?......
©MCPAP For Moms
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Risk Factors
ACOG CO #630 – May 2015
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Risk Factors for PMADs/PPD
1. Akincigil A et al. Soc Work Health Care, 2010; 2. Rich-Edwards JW et al. J Epidemiol Comm Health, 2006; Howard LM et al. PLoS Med, 2013; 4. Wosu AC et al. Arch Womens Ment Health, 2015; 5. Lefkowitz DS et al. J Clin Psychol Med Setting, 2010
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Risk Factors for PMADs/PPDSwedish series (n=700,000, 1997-2008)
Silverman ME et al. Depression Anxiety, 2017
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Current RecommendationsUSPSTF Draft recommendation August 2018
USPSTF Recommendation January 2016
Recommends depression screening for pregnant women
Screening should be done both antepartum and postpartum.
ACOG published Committee Opinion #630 -May 2015
Screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool.
American Academy of Pediatrics guideline -2010
Pediatricians to screen mothers for depressive symptoms
at well child visits at 1, 2 and 4 months.
Recognized maternal depression can impact failure-to-thrive and other pediatric issues.
CDC and WHO
Within 12 months Postpartum
Council on Patient Safety in Women’s Health Care (Feb. 2016)
Recommends Bundle implementation
across settings.
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When should women be screened for Perinatal Mood and Anxiety Disorders (PMAD)?
Depression & Anxiety
At least once during the perinatal period
Depression
At least once during pregnancy and again postpartum
ACOG CO 630 May 2015; USPSTF JAMA 2016, draft recs 2018
Women found at risk should be referred for counseling
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Two-thirds of perinatal depression begins before birth
Pregnancy
33%
Postpartum 40%
Before pregnancy
27%
Wisner et al. JAMA Psychiatry 2013
Optimal screening times and intervals not identified.
Screen at least once during perinatal period using standardized, validated tool.
(ACOG, 2015)
Screen mother at 1,2, 4 and 6 mo. well-child visits. (Earls, 2010)
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ACOG CO #630 – May 2015. Reprinted in Kendig et al, Consensus Bundle on Maternal Mental Health, Obstet Gynecol 2017.
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• Depression AND Anxiety
• Perinatal Populations Only
• >40 languages
http://linkingcare.org/ScreeningTool/EPDS
http://perinatology.com
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1
• Positive Screening Instrument
2• Diagnostic Interview
3
• Suicidality & Psychosis• Bipolar Disorder Screen
In an Ideal World…
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Distinguish Baby Blues & PPD
Baby Blues
• Peaks ~5th day PP
• Resolves within 10-14 days PP w/out treatment
• 50-80% of all new mothers
• Crying, worry/anxiety; feeling sad, moody, irritable, restless; anger or rage; symptoms do not interfere w/newborn care and resolve w/out intervention
Postpartum Depression (PPD)
• During pregnancy or w/in first 4 weeks PP (DSM5)
• Can persist if left untreated
• 8-20% (+) of new mothers in US
• Difficulty bonding; crying; worry/anxiety; doubt in ability to care for baby; feeling sad, moody, irritable, restless; anger or rage; anhedonia; sleep and/or appetite abnormalities; difficulty concentrating, withdrawal
Onset
Duration
Prevalence
Symptoms
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In the Ob’s or Midwife’s World:
Screen “positive”
Mild symptoms, Does not meet criteria
For clinical depression or anxiety
Moderate SymptomsMeets criteria for mild clinical depression, anxiety, or both
Severe Symptoms Meets criteria for severe clinical
depression, anxiety, or both
All of the above PLUSFacilitate urgent access to counseling
servicesStart on anti-depressant medication if
no history of maniaEarlier follow up in one week
Severe SymptomsWith suicidal or homicidal
features or
symptoms of mania or psychosis
At risk for harm to self, others,
or baby?
Education on worsening symptomsHealthy nutrition, physical activitySleepIntegrative strategiesHelp with family chores, childcareAssess available resources
yes
no
no
no
All of the above PLUSArrange follow up in 2 weeksOffer counseling or medications Ensure safety net: re family supportEmergency plan if symptoms worsen
TREATMENTPRESENTATION
Emergent referral for evaluation andpossible hospital admission
Slide 21 ©MCPAP For Moms
Seek psychiatric consultation
1Taken from the Composite International Diagnostic Interview-Based Bipolar Disorder Screening Scale (Kessler, Akiskal, Angst et al., 2006)
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Manage Suicidal Ideation
Screen patients with depression for
o Suicidal thoughts, how often in past 2 weeks?o Suicidal intent/plan
o What has stopped them so far?
o Availability/lethality of method
Activate emergency referral protocol for women with suicidal/homicidal ideation
o Consultation, transportation, admission
o Maintain open communication among team members
o Post event planning for care coordination and follow-up
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When to Seek Consultation
Failed response to medication
Persistent psychosocial problems
Complicated psychological problems
Actively suicidal
Discomfort in managing the problem
“Gut feeling”
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So how are we still missing it?Barriers to Diagnosis & Treatment
Perinatal Care Provider Barriers
Leddy M et al. J Psychosom Obstet Gynecol, 2011
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When Initiating Treatment…
….Get Everyone on the Same Page
Start treatment, start referral process (for postpartum period and beyond)
Coordinate care between maternity care, mental health, and primary care providers during the prenatal and postpartum period.
Establish a plan for care beyond the postpartum period
Assure release of information forms are in place.
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Strategies to engage patients and their families in recognizing signs and
symptoms: Talk About It
Normalize Perinatal Mental Health (PMH)
Include education in new patient packets along with
information on other common complications.
Review common symptoms often.
Include family and support system in educational process.
Helping families and support system understand “Red
Flags.”
Listen, Support, Offer help.
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Links for Patients, Families
• https://www.nichd.nih.gov/ncmhep/MMHM/Pages/index.aspx
• http://www.postpartum.net
• http://www.postpartumprogress.com/the-symptoms-of-postpartum-
depression-anxiety-in-plain-mama-english
• http://store.samhsa.gov/shin/content/SMA14-4878/SMA14-4878.pdf
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Healthcare Support
• Community Perinatal Mood Disorders Support Group
• Interdisciplinary teams
• Local and state programs
• County health clinics
• www.safehealthcareforeverywoman.org
• www.mcpapformoms.org
• www.colorado.gov/pacific/cdphe/pregnancy-related-depression
• www.nichd.nih.gov/ncmhep/MMHM/Pages/index.aspx
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Establish Local Standards
Consider:
Documentation of screening at specified intervals
Utilize EMR for reminders
Documentation of screening results
Documentation of plan of care
Documentation of referral and follow up
Appropriate diagnostic code
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Many Thanks:Maternal Mental Health: Perinatal Depression and Anxiety Patient Safety Bundle Workgroup
Chairs: Susan Kendig, JD, WHNP-BC
John Keats, MD
• Readiness• Emily Miller – Lead
• Susan Kendig
• Katherine Wisner
• Recognition • Tiffany Moore-Simas – Lead
• Ariela Frieder
• Chris Raines
• Response • Camille Hoffman – Lead
• Barbara Hackley
• Pec Indman
• Reporting & Systems Learning • Lisa Kay – Lead
• John Keats
• Kisha Semenuk
• Council Support• Lauren Lemieux
Slide 32
• Antidepressants in pregnancy- are some better than others?
• 3 slides, 6 minutes
