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Disclosures
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PAL for Moms 877-725-4666 (PAL4MOM)
• Partnership Access Line (PAL) for Moms
• Perinatal psychiatry telephone consultation
• Free for any healthcare provider in Washington State
• Mon-Fri 9-5
• Funded by State of Washington Health Care Authority (HCA)For information and care guides:
https://www.mcmh.uw.edu/pal-for-moms-faq
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OBJECTIVES
Let’s start with a case
Postpartum Depression
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Postpartum depression is more likely if:
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Outcomes
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Good News!
Other postpartum mental health disorders
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0
10
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Prenatal CareInitiated in First
Trimester
RecommendedNumber of Prenatal
Visits Attended
Timely PostpartumCare
Met Criteria
Met Criteria
Weir et al, 2011
Where to screen
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Of note
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Recommendations to Screen
• United States Preventive Services Task Force,
2016
• Depression screening for adults, including pregnant and postpartum women
• AAP Bright Futures
• recommends maternal depression screening at well-child visits as a best practice for pediatricians.
Recommendations to Screen
ACOG Committee Opinion #757, 2018
• Obstetric providers to complete a full assessment of “mood and emotional wellbeing” including postpartum screening with a validated instrumentfor depression and anxiety
NICE (National Institute for Health and Care
Excellence) CG192, 2014
• Screen with PHQ2 and GAD-2 during pregnancy and early postnatal period.
• EPDS or GAD7 if positive or at risk
• Consider ongoing screening until 1yr postpartumif regular contact with patient
When to Screen
• 75% have symptoms in first 3 months
• If no screening after 3 months, miss 25% of cases
• Suicide rate highest 9-12 months postpartum
• Bright Futures recommendation
• Well child visits at 1, 2, 4 and 6 months
• Every visit
• Parents with previous or current mental health
symptoms
How to Screen in the Era of COVID-19?
How are you doing this?
• Screening questionnaires as part of EMR
• Send questionnaires in advance
• Delay in seeing items related to suicidal thoughts
• Share screen and complete during visit
• Billing:
• As part of Well Child Visit: CPT 96161
• By interactive video/audio/phone/online patient portal: CPT 96127
Acceptability
• Patients - 80-90% find depression
screening to be acceptable, especially if:
• screening done by
paper/questionnaire/electronically
• results of screening discussed verbally
• they felt their healthcare professional was
engaged and empathetic
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Liability
• Screening is “standard of care”
• Systematic, standardized approach
• Documentation of screening for maternal
depression as a risk factor for the child
Documentation
• Minimum – record that screening took place
and that referrals / recommendations were
provided
• Options for documentation:
- In child’s record
- In a stand-alone file
- Send to parent’s provider
Screening Tools
• PHQ-2 – brief; needs follow up
• EPDS-validated; not generalizable
• PHQ-9 – validated; high somatic symptom
loading; generalizable
Screening tools
• Other considerations – languages? EHR?
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Screening with the PHQ-2
• 2 items
• In the last 2 weeks, how often have you been
bothered by:
• Little interest or pleasure in doing things
• Feeling down, depressed, or hopeless
• Not at all (0), several days (1), more than half the
days (2), nearly every day (3)
• Score of 3 or more has sensitivity of 83%,
specificity of 92% for major depression
• <1 minute to administer
Screening with the PHQ-2 (continued)
• Parental Wellbeing Project (Dartmouth)
• 1398 parents screened at well child visits
• Accepted by parents; 6% nonresponse rate
• 17% had positive response to one item; 6% had score
of 3 or above
• 56.5% with score of 3 or above thought they might
be depressed; 83.5% of these willing to take action
• In 85-90% of cases, required <3 minutes extra
pediatrician time; >10 mins in 2% of cases
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2 8 616
EPDS scores
• 10 items, each scored 0-3
• Items 1, 2, 4 are reverse-scored
• Score of 10 or more at 6-8 weeks
postpartum has 93% sensitivity, 83%
specificity for major depression
Reverse
Scoring
Comparing the PHQ-9 and the EPDS
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Triage/
intervention
Maternal Depression Screening: the Pediatrician’s Role
• To motivate screen positive parents to get help
• To enable discussions of the effect of maternal
depression on child development
• To provide lactation decision support
• NOT to diagnose or treat depression or other
mental health conditions
Mood Disorders Question-
naire(MDQ)
What do you do next?
http://cssrs.columbia.edu/wp-content/uploads/C-SSRS-Screener-with-Triage-Points-for-Primary-Care-2018-1.docx
ASQ screening
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https://suicidepreventionlifeline.org/wp-content/uploads/2016/08/Brown_StanleySafetyPlanTemplate.pdf
Interventions for positive depression screens
• Mild depression
• Education – common, not mother’s fault, will improve
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• Extra visits/follow up call
• Address social support, sleep deprivation; exercise
• Moderate depression
• Refer for mental health treatment (psychotherapy and/or
medication)
• Contact OB/PCP
• Suicidal thoughts/psychosis
• Refer to crisis/emergency services
Psychotropic Medications in Breastfeeding
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Antidepressants in lactation
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PPD recognition and treatment
16% treated
31% identified
50% screened
What can we do?
• Increase screening
• Support, encouragement to follow up on referrals
• Consultation
• Telepsychiatry, increasing access to perinatal behavioral health care
Resources
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Case
The mother of the 4-month-old has a PHQ-9 score of 16 and has a score of 1 on question 9. You question her further and she reports feeling hopeless at times, but denies active suicidal thoughts or plans. You explain that postpartum depression is common, does not mean she is a bad mother, and can be treated. You refer her for counseling and to her PCP for antidepressant medication. You also refer her to Perinatal Support Washington and talk with her about maximizing sleep, social support, and exercise.
Promoting First Relationships in Pediatric Primary Care
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