SCREENING & TOOLKITS FOR CLINICIANS
TOOLKITS FOR CLINICIANS
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.
While 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.
The 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 .
There are times when psychotherapy alone is not enough to help those struggling with their mental health. Often times, people are prescribed psychotropic drugs to help enhance their wellbeing while still attending therapy sessions. However, taking psychotropic drugs could potentially pose a risk to the baby if the person struggling with their mental health is pregnant or breastfeeding.
The decision to use medications to treat a mother’s mental health condition should not be taken lightly. To help develop a treatment plan that best fits the mother’s needs while protecting her baby, please browse these resources that provide information on how to use psychiatric drugs during pregnancy and breastfeeding.
The Massachusetts General Hospital Center for Women’s Mental Health has created a Women’s Mental Health website that has an entire section around Breastfeeding and Psychiatric Medications. This section has blog articles written by physicians as well as links to clinical research studies.
You can find the specialty section of their website on Breastfeeding & Psychiatric Medications here, as well as use that to navigate to other areas of women’s mental health. Women’s Mental Health website
The National Institute of Mental Health has a section of its website dedicated to mental health medications with a special section on children, older adults, and pregnant women. It gives broad guidelines about which types of medications are thought to be safe for pregnant and breastfeeding women and which types to avoid. This information can be found on the NIMH website: National Institute of Mental Health
Mother to Baby is a non-profit dedicated to providing evidence-based information on medications during pregnancy and breastfeeding. On their website, they have fact sheets for almost 100 different types of medications and what research says about the safety of use during pregnancy, as well as similar fact sheets on herbal products, infections and vaccines, maternal medical conditions (including depression), substances of abuse, occupations exposures, and other common exposures. These fact sheets can be viewed online or downloaded as PDF in both English and Spanish.
Mother to Baby Fact Sheets
The American Congress of Obstetricians and Gynecologists also has many resources available on their website for members, including a chart that outlines the safety of the use of psychiatric medications during pregnancy and lactation. If you’re a member, be sure to visit their website to see the most up to date chart of medications.
Psychotherapy is a practical, effective method of non-medical treatment for mental health disorders. The most popular, evidence-based treatments for postpartum depression and other perinatal mood disorders are Cognitive Behavioral Therapy and Interpersonal Psychotherapy. Below are some guides for integrating CBT, IPT and other forms of therapeutic treatment into your practice.
The ECHO project was developed at the University of Michigan and is an adapted form of cognitive-behavioral therapy for those with postpartum depression which is designed to be completed in 8 sessions where each session is roughly 45 minutes long. The goal of the ECHO project is to have a therapy style that will help develop a realistic approach to address factors that stop those suffering from postpartum depression from being mentally well.
Interpersonal psychotherapy is a short term type of psychotherapy, roughly lasting 12 to 16 weeks. The main focus of IPT is resolving interpersonal problems or problems with your relationships with others. Those who perform interpersonal therapy believe that psychological symptoms are in response to such interpersonal problems.
The manual below was developed by the US Department of Veterans Affairs to use IPT to treat depression in veterans, however, it can easily be adapted for use with mothers and their partners who are suffering from postpartum depression.
The IWK Reproductive Mental Health Service and Family Resources Centres in Nova Scotia, Canada have developed a Mother’s Mental Health group therapy curriculum to help support new mothers. In this method of treatment, a small group of mothers comes together for information and support for 2 hours a week for 8 weeks. Each week focuses on something different and each focus point is openly discussed by all in the group to help promote personalized support for each mother in the group. In this type of therapy, child care is often included during group therapy sessions.
You can visit this link to find both their Mother’s Mental Health Toolkit: A Resource for the Community and the Mothers’ Mental Health Toolkit: Group Practice, a guide for community mental health workers who wish to organize and facilitate group therapy sessions.
ALTERNATIVE TREATMENT OPTIONS
In addition to medication and talk therapy, there are a number of different alternative treatments with varying degrees of research behind them.
Sleep and Exercise
Because depression can so strongly affect your sleep and energy levels, adjusting your sleep and exercise are widely thought to be effective mediators for depression symptoms.
Here are tips for getting better, more restful sleep, through the stages of your pregnancy and into postpartum. Additionally, you may want to use the Sleep and Mood Diaries.
Sleep Diary Download
Mood Diary Download
Yoga and Relaxation
Recently yoga has begun to receive a lot of attention as a possible remedy for depressive symptoms. Although there is not a large body of research to support that, a 2015 review of research into yoga as a treatment for depression in pregnant women showed that prenatal yoga may be helpful to decrease maternal depressive symptoms, that both depressed and non-depressed women can benefit from yoga, and that integrated yoga (which includes physical exercise, but also pranayama, meditation, or deep relaxation) seems to be more effective in treating depression than just physical-exercise-based yoga.
Complementary and Alternative Therapies
Although ample research has shown that many medications pose minimal risk to developing fetuses and breastfeeding babies, many women still choose to not rely on medications for depression treatment in this period. In order to identify other effective and safe treatments for mothers in the perinatal period, more attention is being given to researching complementary and alternative medicine therapies for perinatal depression. An article in the peer-reviewed journal Best Practice & Research Clinical Obstetrics & Gynaecology reported on some common complementary and alternative medicine therapies:
- 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.
Transcranial Magnetic Stimulation
Transcranial magnetic stimulation (TMS) is a relatively new therapy for treatment of depression symptoms that have recently been approved by the FDA and is now often covered by insurance plans. It is generally used as a last resort after medications have proven ineffective. It consists of using a magnet to administer a series of pulses in rapid succession to an isolated portion of the brain. Research on non-pregnant patients has shown that TMS is effective as at least a subset of commercially available antidepressant medications, and also has been shown to have few side effects and is well tolerated by patients.
Less research has been done on TMS as an effective treatment in the realm of perinatal depression. However, a search of current research revealed one pilot study of the use of TMS to treat postpartum depression in mothers who were not using antidepressant medications. Although the treatment produced promising results, more research is necessary to make any validated claims about the effectiveness of TMS in the treatment of perinatal depression.
Deligiannidis, K. M., & Freeman, M. P. (2014). Complementary and alternative medicine therapies for perinatal depression. Best Practice & Research Clinical Obstetrics & Gynaecology, 28(1), 85-95.
Gong, H., Ni, C., Shen, X., Wu, T., & Jiang, C. (2015). Yoga for prenatal depression: a systematic review and meta-analysis. BMC psychiatry, 15(1), 1.
Schutter, D. J. L. G. (2009). Antidepressant efficacy of high-frequency transcranial magnetic stimulation over the left dorsolateral prefrontal cortex in double-blind sham-controlled designs: a meta-analysis
It’s always good to have handy information close by for both you and your patients.
Once 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
FOR LESS IMMEDIATE NEEDS
Visit our Get Help page to find the PSI and 2-1-1 resources in your area. If you are looking for a behavioral health provider, housing assistance, or support groups, you can also use the Statewide Florida Moms MH Resource Directory to find services near you.
If you are located in the Big Bend Area of North Florida, you can use the Mental Health Council of the Big Bend Provider Directory to find licensed behavioral health providers near you which are searchable by specialty, insurance type, and more.
Postpartum Support International (PSI) is an organization dedicated to raising awareness of PMADs and providing support to parents and families across the country. In Florida, there are volunteer coordinators dedicated to providing information, support, and local resources to help those struggling during pregnancy and postpartum. Click here to visit the Florida PSI website To contact the Statewide PSI Coordinator, Naomi Rosenkranz, you can text or call her at 305-859-1071 or email firstname.lastname@example.org.
2-1-1 is available for human service information and assistance. They are available 24 hours a day to listen and provide emotional support, crisis counseling, suicide prevention, and information & referrals. You do not have to be in crisis to call, there is no eligibility criteria, and their services are free. They help you navigate through the maze of community services in a nonjudgmental manner.
Substance Use Disorder Resources
The Substance Abuse and Mental Health Services Administration (SAMHSA) has ample resources for finding treatment and services for alcohol, drug, or mental health problems. Click here to Find Help at SAMSA.
The Florida Perinatal Quality Collaborative Maternal Opioid Recovery Effort (MORE) Initiative works with providers, hospitals, and other stakeholders to improve identification, clinical care and coordinated treatment/support for pregnant women with opioid use disorder and their infants. The project focuses on standardizing OUD screening, prevention, treatment, and comprehensive discharge planning. Click here to access their Online Tool Box. To access the FPQC MORE video library, click here . These are great to kickstart a conversation in your department on the topic, incorporate into training or events, and to raise awareness of best practices for OUD treatment in the perinatal population.