1. Who should be screened for perinatal mental health conditions?
All parents (mothers, fathers, people bearing children, and their partners) should be screened for mental health conditions.
2. When should patients be screened for perinatal mental health conditions?
The American College of Obstetricians and Gynecologists Committee Opinions #757 “Screening for Perinatal Depression” recommends screening patients at least once during the perinatal period for depression and anxiety, and, if screening in pregnancy, it should be done againpostpartum. Opinion #736 “Optimizing Postpartum Care” recommends a full assessment of physical, social, and psychological well-being within a comprehensive postpartum visit that occurs no later than 12 weeks after birth The American Academy of Pediatrics recommends screening for postpartum depression and anxiety at the 1, 2, 4, and ‘6 month well-child visits.
Nearly 26% of women with a history of anxiety or depression before or during pregnancy went on to experience symptoms of postpartum depression, compared to 8.3% of women without a history of mental health conditions (Utah Pregnancy Risk Assessment Monitoring System (PRAMS)). Pre-pregnacy depression and anxiety, and depression and anxiety during pregnancy are the biggest predictors of postpartum mental illness. Research suggests that among women who screen positive for depression in the postpartum period, the onset of depression occurred before delivery for the majority of women.
Screening should occur at the following times (when applicable):
- First prenatal visit or the first visit to establish care during pregnancy
- One time during each trimester of pregnancy
- 1 or 2 days after giving birth (postpartum)
- 2 weeks postpartum
- 6 weeks postpartum
- During all well-child checks for up to 6 months postpartum
3. What mental health conditions should a patient be screened for?
Depression and anxiety disorders are the most common mental health complications during the perinatal period. The Edinburgh Postnatal Depression Scale or EPDS is most sensitive for these 2 disorders. There are other screening tools that can be used to identify other perinatal mood and anxiety disorders.
4. What screening tools should be used?
Although there are many validated screening tools available, we recommend the Edinburgh Postnatal Depression Scale (EPDS). This screener is validated for perinatal depression, and has an anxiety subscale. The EPDS has been validated in more than 60 languages. It also comes up on Google when you search for “postpartum depression.”
We understand that all offices and clinic workflows are different, and some may have already established screening with other tools. The PHQ-9 is also validated for depression during the perinatal period; however, it will not be highlighted in this toolkit. For anxiety, the GAD-7 isrecommended. Additional screening instruments are included at the end of this toolkit.
Information on each screening instrument
We recommend using the Edinburgh Postnatal Depression Scale (EPDS) to screen women for depression and anxiety. This screening tool only has 10 questions and the scoring is out of 30 points. Any score of 10 or greater means the person could be experiencing depression or anxiety. Any answer other than “never” on question 10 indicates the person is at risk for suicide or self-harm and immediate help is needed . The anxiety subscale is also highlighted on the triaging algorithm.
Two or more significant life events, such as moving to a new address or having a family member become ill, have been shown to put a person at greater risk for perinatal mood and anxiety disorders. A patient may score moderately on the EPDS, but high on the risk factors and previous history of mental illness, meaning they checked 2 or more items on either of these. These patients should also be monitored closely and referred to additional mental health support and resources.We have provided a checklist immediately following this FAQ section to help screen your patients for significant life events and previous history that may indicate risk for perinatal mood and anxiety disorders.
Patients may have other mental illnesses that the EPDS doesn’t adequately screen for. Other screening tools that may be helpful include:
• PC-PTSD: screens for post-traumatic stress disorder (PTSD) using 4 questions
• Mood Disorder Questionnaire (MDQ): screens for bipolar disorder using 14 questions. The MDQ needs to only be done one time in the perinatal period because it asks about a patient’slifetime experiences as compared to the other screening tools which only ask how a person has felt in the last 7 days. We recommend screening all women for bipolar disorder. This should be done before prescribing an antidepressant because selective serotonin reuptake inhibitors (SSRIs), common medications used to treat depression, may trigger a manic episode.
5. Who hands out, scores, and responds to the screening tools?
Every office is different. The workflow for addressing perinatal mood and anxiety disorders needs to be tailored to each clinic or practice. Clinical support staff can provide the screening tools to families electronically before an appointment, at the time of check-in or appointment registration, in the waiting room, or while waiting for the provider in the exam room. Many electronic health records can be customized with templates for these screening tools.
Patients should be given enough time to complete the screening tool without feeling rushed. After a parent completes the screening tool, it should be scored by clinic staff and entered into the patient’s chart and electronic medical record. The provider should be made aware of the patient’s score before seeing the patient if they didn’t administer the screening themself. Scoring is straightforward and can be done by any level of caregiver. It is imperative the screening tool is scored before the patient leaves their appointment so any concerns indicated by the tool can be addressed. The United States Preventative Services Task Force recommends that therapy and support groups can help prevent and address perinatal mood and anxiety disorders.
Information about how to respond to a positive screen on the EPDS can found in the Triage Algorithm on page.
6. What are common risk factors for maternal mental health disorders?
Mental illness during pregnancy and postpartum is not limited to a particular culture, race, age, income or education level. No single cause has been identified for depression or anxiety during pregnancy or postpartum; however, there are several factors linked to the development of these conditions. Risk factors are important to recognize because someone may not score high enough on the EPDS to be considered at risk for
a mental illness but they have factors in their life which put them at risk.
Risk factors for maternal mental health disorders include:
- Personal history of depression, anxiety, or other mental health concerns
- Personal history of substance abuse
- Difficult pregnancy or delivery (especially NICU parents, or emergency c-sections)
- Being younger than 24 years of age
- Experiencing the death of close family members or friends
- Having a close family member or friend with a significant illness or disability
- Being isolated from family or friends
- Less than 5 hours of sleep
- Not having people in your life who can help you during difficult times (support system)
- Being a single parent
- Marital problems
- Lack of health insurance
- Family history of mental illness
- Significant life stressors in the last 12 months (such as losing or changing jobs, moving, change in marital status, etc.)
- History of trauma or abuse (emotional, sexual, or physical)
- Having a chronic illness, or onset of illness during pregnancy and postpartum
- Unmet expectations in pregnancy, labor and delivery, or postpartum (not following a birth plan, inability to breastfeed, etc.)
- Having multiples versus a singleton pregnancy
- Experiencing discrimination based on race, sexual preference and gender identity, or substance use disorder
- Financial stresses or having a household income that is below the federal poverty level
- Negative maternal feelings towards the pregnancy or baby
- Having an unintended pregnancy
If a person experiences 2 or more of these risk factors, there is a higher chance they will develop mental illness during pregnancy and the postpartum period. These patients should be closely monitored and referred to
mental health treatment, resources, and services.
7. What type of support can our office or clinic receive if we participate in screening?
UWNQC Maternal Mental Health Committee is ready to help you successfully implement perinatal screening, referral, and treatment protocols.
A gap analysis tool that outlines each step we recommend you do to implement an effective screening in your clinic or practice (which tools to use, how often to screen patients, how to administer the screening tools, and building a referral system including educational materials). The gap analysis tool will help evaluate your current clinic protocols and what things might be feasible to implement in the future.
Training for staff on PMADs both in-person, and via training videos.
Printed copies of this toolkit, SUNSHINE handout, or other instruments and resources in this toolkit.
8. How do you talk about mental health conditions in a strengths-based way?
Patients may be reluctant to discuss mental or emotional health challenges with family, friends, and providers for many reasons. As clinical support staff are often the first to interact with women regarding screening for mental health, it is important it is done with a strength-based approach that emphasizes:
• Mental and emotional health complications during pregnancy and postpartum are common.
• They are medical conditions, just like diabetes.
• They are treatable, and with appropriate help, patients will feel well again.
• Because mental health challenges are common, every pregnant and postpartum patient who is seen in the clinic is screened for these conditions – they are not being targeted.
• The practice cares for the whole woman.
When discussing treatment options, provide a balanced perspective of treated versus untreated illness and associated risks and benefits. Untreated illness has significant risk. Let parents know that a healthy parent is critical to the health of the baby and it is important to prioritize a parent’s health, including mental health. Because of this, you will be checking in with them and their mental health regularly throughout their obstetric care, or care for their child.
9. Where can I find educational materials for patients and families?
Perinatal patients and their families, or other members of their support system, should be proactively provided with education so that they are aware of signs and symptoms of perinatal mood and anxiety disorders. Having these conversations early in the pregnancy and again in the early postpartum period, can decrease stigma, normalize screening and detection, and encourage women to discuss any mental health concerns. An environment with ample displays of, and access to, mental health-related information can help to reduce this stigma, and empower women and their families to seek help, while letting women know that they are not alone.
Recommendations for education:
• Provide educational materials to all new prenatal patients and again to patients at their postpartum visit.
• Place posters, pamphlets, and other materials throughout your offices.
Educational materials include but are not limited to the mental health worksheet, SUNSHINE or BAILANDO, and the half sheet of additional resources, all included in this Toolkit and downloadable online.
10. Where can I get additional training in Perinatal Mood and Anxiety Disorders?
A consultation line is available for medical providers who may have additional questions about the overall screening process, or who feel they may benefit from the guidance of fellow medical professionals on the treatment of patients on a case-by-case basis. The Perinatal Psychiatric Consult Line is staffed by reproductive psychiatrists who are members of PSI and specialize in the treatment of perinatal mental health disorders. The service is free, available by appointment and can be accessed at https://www.postpartum.net/professionals/perinatal-psychiatric-consult-line.
Additionally, Postpartum Support International holds regular two-day Components of Care trainings, along with additional two-hour specialized trainings for Psychopharmacology and Psychotherapy. These trainings can be found at www.postpartum.net.
Local maternal mental health specialists can be requested for trainings by contacting the Maternal and Infant Health Program at the Utah Department of Health. These trainings would include local data, information on signs and symptoms, risk factors for Utah parents, and resources. Requests can be made by emailing: [email protected].
Edinburgh Postnatal Depression Scale (EPDS)
EPDS screening and interpretation instructions
The EPDS was developed for screening postpartum women in outpatient, home visiting settings, or at the 6–8 week postpartum examination. It has been utilized among numerous populations including U.S. women and Spanish speaking women in other countries. The EPDS consists of 10 questions. The test can usually be completed in less than 5 minutes. Responses are scored 0, 1, 2, or 3 according to increased severity of the symptom. Items marked with an asterisk (*) the anxiety subscale. The total score is determined by adding together the scores for each of the 10 items, making the highest possible score 30.
Validation studies have utilized various threshold scores in determining which women were positive and in need of referral. Cut-off scores ranged from 9 to 13 points. Therefore, to err on safety’s side, a woman scoring 10 or more points or indicating any suicidal ideation – that is she scores 1 or higher on question #10 – should be referred immediately for follow-up. Even if a woman scores less than 10, if the clinician feels the client is suffering from depression, an appropriate referral should be made. The EPDS is only a screening tool. It does not diagnose depression – that is done by appropriately licensed health care personnel.
Users may reproduce the scale without permission providing the copyright is respected by quoting the names of the authors, title and the source of the paper in all reproduced copies.
The EPDS can be found in other languages here: https://www.dchealthcheck.net/documents/10-2015-EPDS-Translations.pdf
Instructions for users
1. The mother is asked to underline 1 of 4 possible responses that comes the closest to how she has been feeling the previous 7 days.
2. All 10 items must be completed.
3. Care should be taken to avoid the possibility of the mother discussing her answers with others.
4. The mother should complete the scale herself, unless she has limited English or has difficulty with reading.
Maternal Mental Health Referral Network:
MaternalMentalHealth.utah.gov
The Maternal Mental Health Referral Network is a consolidated directory for all providers who have been trained in Maternal Mental Health here in Utah. The database is searchable by: provider type, location, insurance (including no insurance), and specialty type. We recommend providers who have undergone training be listed. Providers who will not be prescribing or providing psychotherapy are only required to attend six hours of maternal mental health training from a variety of training bodies. Providers who will prescribe or provide psychotherapy are required to attend 12 hours of training.
Help Me Grow Utah (English and Spanish)
English and Spanish: 801-691-5322
Help Me Grow Utah not only provides the Edinburgh Post Natal Depression Scale (EPDS) both online and over the phone, but they also provide services in both English and Spanish. Help Me Grow has access to the entire directory of maternal mental health providers, and will follow up with clients for free to ensure they are seeking appropriate help in a timely manner. Help Me Grow Utah will also make outbound calls if a practice or provider chooses to use them as a resource and referral service. Contact Help Me Grow for their referral form. All services are free of cost to Utah residents and providers.
Mother to Baby Utah: 801-328-2229
Mother to Baby Utah is a free, private, and easy-to-use service that answers questions
about medications, drugs, chemicals and other environmental exposures that can
potentially harm an embryo, fetus or infant. Providers can use Mother to Baby to
consult regarding medication during pregnancy and postpartum.