SCREENING & TOOLKITS FOR CLINICIANS
TOOLKITS FOR CLINICIANS
SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION (SAMHSA)
The Substance Abuse and Mental Health Services Administration (SAMHSA) has created a toolkit for family service providers containing psychoeducation materials, tips for working with mothers who may be depressed, screening tools, brochures, and handouts for mothers with depression.
MASSACHUSETTS CHILD PSYCHIATRY ACCESS PROGRAM (MCPAP)
The Massachusetts Child Psychiatry Access Program (MCPAP) through the Massachusetts Department of Mental Health has created a toolkit for front-line perinatal care providers to assist with the prevention, identification and treatment of depression or other mental health concerns of pregnant and postpartum women.
This toolkit is available as a PDF for free download, or can be accessed as individual components such as a depression screening algorithm for obstetric providers and an antidepressant treatment algorithm.
IWK REPRODUCTIVE MENTAL HEALTH SERVICE AND THE FAMILY RESOURCE CENTRE
The IWK Reproductive Mental Health Service and the Family Resource Centre in Halifax, Canada have created this comprehensive toolkit geared towards community mental health providers.
The toolkit has sections on mothers’ wellness and self-care, mental health, assessment and screening, interventions and treatments, ways to support mothers’ recovery and a section for larger community action.
Screening & Detection
In January 2016, the US Preventative Services Task Force released its new recommendations for depression screening in the healthcare setting. They recommend depression screenings in the general adult population, including pregnant and postpartum women. These screenings should be implemented with “adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.” In addition, the American Congress of Obstetricians and Gynecologists has made similar recommendations for depression screening for all women, both as part of their yearly well-woman visit and during the perinatal period; specifically, that women be screened at least once during their perinatal period.
You can read ACOG’s full statement on their website:
ACOG’s Statement on Depression Screening
There are several different validated depression screening options available to clinicians. Below, we have compiled a list of the advantages and disadvantages of each type of screening so that you can make an informed decision about which screening tool works best for your purposes.
EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS)
This 10 item self-report questionnaire can be readily found online for free with scoring instructions.
It is easy to score, designed specifically for use in peripartum populations, is well validated during pregnancy and postpartum, available in over 20 languages, and is cross-culturally validated. The disadvantages of this screening tool are that it is not linked with DSM diagnostic criteria and that is cannot be used for assessment or treatment tracking. (Cox & Holden, 2003)
This online version is used in the Pediatric Residency Program at UCSF, Fresno and is used with permission.
PATIENT HEALTH QUESTIONNAIRE (PHQ-9)
This 9 item self-report questionnaire can also be readily found online for free with scoring instructions. It is easy to score with items and scores linked to DSM depression criteria, can be used to assess and track treatment response, and can be used not just for peripartum populations, but also for non-peripartum patients in the same clinic. The disadvantages of this tool are that is was no designed for peripartum use (somatic confounds), it has only been validated by 2 studies for peripartum use, and that it is best validated for tracking response to treatment. (Kroenke, 2001)
In 2010, Pfizer, Inc. made the PHQ-9 along with the GAD-7 (anxiety screener) available for free to the public with permission to use, replicate, translate, display, or distribute. It can be found for download, along with a manual for scoring online.
CENTER FOR EPIDEMIOLOGICAL STUDIES—DEPRESSION SCALE (CES-D)
This 20 item self-report tool is designed for community use. One study showed that it is better than the EPDS at identifying psychomotor retardation. However, there are potential somatic confounds and there are very few validation data for use on postpartum populations and none on antepartum. (Radloff, 1977)
The CES-D is in the public domain and is free to use.
BECK DEPRESSION INVENTORY II (BDI)
This 21 item self-report questionnaire is designed for use in clinic populations. It is not available for free online and must be purchased.
It is linked to the DSM and tracks response to treatment. However, there are very few validation data for use on postpartum populations and none on antepartum. There are also potential somatic confounds. (Beck, 1988)
More information on purchasing the rights to this screen can be found in the following link.
POSTPARTUM DEPRESSION SCREENING SCALE (PDSS)
This 35 item self-report designed specifically for postpartum use. It is not available for free online and must be purchased.
The advantages to this screening are that it does into greater symptom detail and reduces somatic confounds.
The disadvantages are that it is time consuming, not linked to the DSM, and has little validation data for postpartum populations and none for antepartum. (Beck & Gable, 2000)
More information on purchasing the rights to this screening can be found in the following link.
Beck, A. T., Steer, R. A., & Carbin, M. G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical psychology review, 8(1), 77-100.
Beck, Cheryl Tatano, and Robert K. Gable. “Postpartum Depression Screening Scale: development and psychometric testing.” Nursing research49, no. 5 (2000): 272-282.
Cox, J., & Holden, J. (2003). Perinatal mental health: A guide to the Edinburgh Postnatal Depression Scale (EPDS). Royal College of Psychiatrists.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The Phq‐9. Journal of general internal medicine, 16(9), 606-613.
Radloff, L. S. (1977). The CES-D scale a self-report depression scale for research in the general population. Applied psychological measurement, 1(3), 385-401.
TREATMENTWhile you may be a professional in your field, you might not be a professional when it comes to helping a patient struggling with perinatal depression. Below are links to helpful information on various topics that will help guide you in the right direction when it comes to helping your patients through a difficult time in their lifes.
TREATMENT GUIDELINESThe following links may assist professionals with treating patients who are pregnant or are in their postpartum period and in need of mental health treatment. The American Psychiatric Association provides Clinical Practice Guidelines and Quick Reference Guides on their website for a myriad of mental health disorders. Please visit their site to access the content: Clinical Practice Guidelines and Quick Reference Guides . The Massachusetts Child Psychiatry Access Program created a toolkit to help those in the perinatal care profession in the prevention, identification, and treatment of mental health concerns (with a focus on depression) in pregnant and postpartum women. This toolkit includes a Depression Screening Algorithm for Obstetric Providers and an Antidepressant Treatment Algorithm. Please visit their website to download PDFs of the entire toolkit or just the components relevant to your practice needs: Massachusetts Child Psychiatry Access Program Toolkit . The Center for Integrated Health Solutions (CIHS) is a partnership between the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) and is run by the National Council for Behavioral Health. The CIHS has a portion of their website dedicated to the integration of behavioral health (mental health and substance use problems) into primary care services. There are resources, webinars, practice models, and links to additional helpful guides such as a WHO intervention guide for mental, neurological, and substance use disorders for non-specialist health settings. All of these resources can be found on the SAMHSA website at: SAMHSA website resources .
ALTERNATIVE TREATMENT OPTIONS
- There is evidence for augmentation with omega-3 fatty acids, exercise or folate with standard treatments for perinatal depression
- Bright light therapy may be a reasonable therapeutic option for some individuals who prefer non-pharmacologic interventions.
- Acupuncture and massage may provide benefit in the treatment of perinatal depression at this time, but should not replace more standard therapies.
REFERRAL RESOURCESOnce it has been determined that a woman needs additional help and support, there are ample local resources and services available to help. It’s just a matter of knowing where to look and how to access them. FOR IMMEDIATE NEEDS
- National SUICIDE PREVENTION LIFELINE: 1-800-273-TALK (8255)
- The National Alliance on Mental Illness (NAMI) provides helpful guidelines for a crisis situation (be sure upon calling for an ambulance to specify that this is a “mental health emergency” and ask for responders with crisis intervention training).
- The National Alliance on Mental Illness Helpful Guidelines
- Statewide Mental & Behavioral Health Directory – FLMomsMHResources.org
- Florida State University College of Medicine’s Tallahassee Area Mental Health Referral Guide: This online resource of local mental health and social service providers is searchable by provider specialty and accepted insurances.
- FSU College of Medicine’s Tallahassee Area Mental Health Referral Guide
- The Substance Abuse and Mental Health Services Administration (SAMSA) also has ample resources for finding treatment and services for alcohol, drug, or mental health problems. Find Help at SAMSA
- 2-1-1 Big Bend is a local 24-hour hotline that provides crisis intervention and assistance, assessment, emotional support, and referrals to local agencies for all human service needs spanning from mental health to rent assistance or childcare. They provide their directory online Big Bend 211 Help Line for self-service, or dial 211 to be connected to a 2-1-1 hotline counselor for help.
- Postpartum Support International (PSI) is an agency created specifically to provide education and peer support to women and their families as they journey through perinatal mood and anxiety disorders. They have online and phone-in support groups for mothers AND FOR THEIR PARTNERS.
- Additionally, Tallahassee and the surrounding areas are served by three volunteer peer-support coordinators who are on call 24/7 to talk to any local women who need support or help connecting to services. Visit their website at Postpartum.net to connect to online resources or call a local PSI Coordinator for additional assistance. AMY L KIMMEL Telephone: (850) 491-5807 Email: firstname.lastname@example.orgCATHERINE MUNROE Telephone: (850) 284-9544 Email: email@example.com SUSAN LIIPFERT SHELTON Telephone: (850) 583-6814 Email: firstname.lastname@example.org