A Pediatrician’s Perspective on Postpartum Depression Kellie Haworth, MD, FAAP Major, Medical Corps, United States Army Postpartum Support International

A Pediatrician’s Perspective on

Postpartum Depression

Kellie Haworth, MD, FAAPMajor, Medical Corps, United States Army

Postpartum Support International Military Coordinator

June 2011

AAP QuIIN PreSIP:

Why Pediatricians?• See moms more often than any other provider in

1st year postpartum– Newborn, 2 week, 1 - 2 month, 4 month, 6 month, 9 month, and

12 month well child visits– Other visits for acute problems

• Ability to recognize infant’s nonverbal signs of distress (AAP Bright Futures)– Looks at mother and others less than most infants– Vocalizes less than most infants– Tends not to exhibit positive emotional expressions– Exhibits lack of interest in objects and exploring– Exhibits fussy, irritable behaviors– Exhibits more averting behavior than most infants

• Pediatrician’s Role (AAP)– Ensure mother gets connected with other health professionals

and needed services– Help identify sources of support in community– Discuss practical issues that worry parents– Provide national and local support network information

AAP• Bright Futures

– Ask about maternal depression history• Prenatal visit

– Maternal well-being visit priority• Newborn, 1 week,

1 month, & 2 month visits

– Maternal depression anticipatory guidance priority• 1 month & 2 month

visits

– Family functioning visit priority• 4 month visit

– Assess for maternal depression• 1 month, 2 month, &

6 month visits

Coding• Diagnosis (ICD-9)

codes– “Maternal distress /

postpartum condition / complication” 669.04

– “Maternal condition affecting newborn” 760.9

– “Maternal condition suspected, not found” V89.09

– “Family disruption, other” V61.09

– “Counseling, parent-child problem” V61.20

– “Reported family history of psychiatric problems / mental illness (not retardation)” V17.0

– “Psychosocial support, lack from family” V62.4

– “No household member able to render care” V60.4

• CPT codes– “Administration

and interpretation of health risk assessment instrument” 99420• Recommended by

AAP for use with EPDS

– “Developmental testing, limited, with interpretation and report” 96110• Prior code for EPDS

– “Parenting class, non-physician, per session” S9444

– “Patient education, NOS, non-physician, individual, per session” S9445

• I’m not trained or qualified to see moms– You’re not seeing or treating

her, you’re screening and referring her

• I can tell by looking– What will she look like?– Pediatricians recognize only

~25% of mothers with depressive symptoms1

– Studies show significantly higher detection rates with use of screening tools1, 2

• I don’t have time– Potential for more visits– Potential for abuse / neglect

• I don’t get reimbursed– You can

• That’s someone else’s job… she’s not my patient– Similar to screening for

parental tobacco use– Increased costs and seeking

of medical care inappropriately– Her depression directly

affects your patient

• I don’t know what to do with a positive screen– Utilize community’s resources– Internet and printed resources

through national associations

• It’s not that big a deal– Significant long-term

psychological, developmental, and behavioral effects if mother left untreated

– Potential for suicide / infanticide

– It’s a big deal to them…

But I’m a pediatrician…

1. Henegan AM, Silver EJ, Bauman LJ, et al. Do pediatricians recognize mothers with depressive symptoms? Pediatrics 2000;106:1367–1373.2. Chaudron LH, Szilagyi PG, Kitzman HJ, et al. Detection of postpartum depressive symptoms by screening at well-child visits. Pediatrics

2004;113:551–558.

Case #1

4 days postpartum:– Difficulty establishing

breastfeeding latch

2 weeks postpartum:– Feelings of being

overwhelmed– Increased fatigue

5 weeks postpartum:– Feelings of sadness,

guilt, anxiety, crying– Not eating, bathing,

or sleeping– Unable to tend to

infant’s cries or breastfeed effectively

24 yo G1P1 mom, student, no prior psych hx

“The guilt of not being home with the baby became almost

unbearable. I found myself crying in bed almost nightly. I

would sob uncontrollably knowing I was sad, but not knowing

why. I would start to resent hearing my son’s cry, and then tear

myself up for thinking that way.”

As her Pediatrician at the2 week well child visit…

• What are you worried about?– Infant feeding / weight gain– Infant hygiene– Potential for neglect

• What guidance can you offer?– Encouragement of parenting abilities– “Fake it ‘til you make it”– Breastfeeding– Self-care for mom

• What interventions can you provide?– Lactation consult– Social Work Services consult– Home nurse visit– Support Group information

Definitions and Epidemiology

• Term “postpartum”– “Post” Latin for “after”– “Parturire” Latin for “labor pains”

• Term “Postpartum Depression”– “Perinatal Mood and Anxiety Disorders” (PMADs)

• Baby Blues, Postpartum Depression, Postpartum Anxiety and Panic Disorder, Postpartum OCD, Postpartum PTSD, Postpartum Psychosis

• Baby Blues– DSM-IV-TR diagnostic criteria

• Onset within first 10 days postpartum• Temporary• Does not impair functioning• Does not require intervention

– Symptoms• Feeling down• Feeling overwhelmed• Crying• Mood lability

– 60 - 80% of childbearing women

Case #1

8 weeks postpartum:– Loss of interest in

future career plans– Obsessive thoughts

of infant’s welfare– Intrusive thoughts– Thoughts of harming

infant to get sleep– Visual hallucinations

“This precious infant had

become the most important

thing in my life. Still, I found

myself thinking, ‘What if I just let

go of him? He would drop all the

way down the stairs.’ I

pictured him bouncing off of

each step and landing on the

floor at the bottom... ‘What if

I just let him cry and I walked

away? I could jump into the

car, drive away and never

come back’”


“When he cried, I tried to think of ways to get him to stop. I

thought of smothering him with a pillow. What was I

thinking? I would snap out of that thought, reassure myself that I

could never do such a thing, and go on. These were just

random disturbing ideas. Still, I hadn’t thought of such things

before… “

As her Pediatrician at the2 month well child visit…

• What are you worried about?– Infant’s needs being met– Potential for abuse

• What guidance can you offer?– Reassurance of infant’s health– Involve husband

• What interventions can you provide?– Psychology or Psychiatry consult– ? Child Protective Services


• Postpartum Obsessive-Compulsive Disorder (OCD)– Symptoms

• Obsessions (persistent thoughts or mental images)– Sense of horror about obsessions

• Compulsions (doing things repeatedly to reduce fears)• Intrusive, repetitive, usually ego-dystonic thoughts

– Knows thoughts are bizarre– Very unlikely to act on them

• Escapist fantasies• Tremendous guilt and shame

– 3 – 5% of childbearing women

• Postpartum Psychosis– Symptoms

• Delusions (strange beliefs)• Hallucinations (auditory or visual)• Similar symptoms to bipolar disorder

– Irritability, hyperactivity with decreased need for sleep, significant mood changes with poor decision-making

– Waxing and waning course– 5% suicide rate, 4% infanticide rate– 1 - 2 of 1,000 childbearing women (0.01 – 0.02%)

• 35% of childbearing women with bipolar disorder

– 67% recurrence rate with subsequent pregnancies

• More gradual onset• Recognize thoughts are

unhealthy• Extreme anxiety related to

thoughts• Overly concerned about

“becoming crazy”

• Acute onset• Do not recognize thoughts

and actions are unhealthy• May seem to have less

anxiety when indulging in thoughts and behaviors

Case #1

10 weeks postpartum:– Increased visual hallucinations

11 weeks postpartum:– Suicidal ideation with plan but without intent

12 weeks postpartum:– Request to drop out of school denied

Mom’s visit to PCM:– Dx: postpartum depression– TSH, fT4 WNL– SSRI offered, but refused– Lost to follow-up


Case #124 yo G1P1 mom, student, no prior psych hx

“I began to worry. What if I wasn’t being a good mother? What

if the baby needed something while I was at work? I wondered

what would happen if I wasn’t there. I wondered who would miss

me. I imagined the life of my family without me. Then I began

to think about suicide. I didn’t want to do it, but it would creep

into my head. As the days passed, it became a constant nagging

thought in the back of my mind. I could be driving, showering,

working, it didn’t matter. I found myself contemplating how I

would do it almost daily. I debated on which method I would

use and envisioned how much of a mess it would leave for my

husband to clean up if I did it violently. I could actually picture

him stooped over, cleaning up a pool of my blood. I decided to do

it quickly, cleanly, and easily. I played the scenario over and over

in my head, but then would catch myself and wonder what in the

world I was thinking. I would try to dismiss the idea from my

mind only to find myself considering it again a few hours later.”


• Postpartum Anxiety and Panic Disorder– Symptoms

• Feeling very nervous• Recurring panic attacks

– Shortness of breath, chest pain, palpitations, “impending doom”• Many worries, fears, or “what ifs”• Restlessness• Agitation or irritability

– 11% of childbearing women

• Postpartum Post-Traumatic Stress Disorder (PTSD)– Symptoms

• Intrusive re-experiencing of traumatic event– Dreams, thoughts, mental images– Event usually related to conception or delivery

• Avoidance of stimuli associated with traumatic event– Thoughts, feelings, people, places, details of event

• Persistent hyper-arousal– Irritability, difficulty sleeping, hyper-vigilance, exaggerated startle

– 1 – 6% of childbearing women


• Postpartum Depression (PPD)– Most common complication of childbearing in US– 20% of all postpartum deaths due to suicide– DSM-IV-TR

• Does not recognize as separate diagnosis, but as ‘major depressive episode’ with ‘postpartum onset specifier’

• “Maternal attitudes toward infant are variable but can include disinterest, fear of being alone with the infant, over-intrusiveness that inhibits adequate infant rest”

– Symptoms• Sleep disturbance• Fatigue• Appetite disturbance with potential weight changes• Depressed mood• Diminished interest in activities• Psychomotor agitation or retardation• Feelings of worthlessness or excessive / inappropriate guilt• Diminished ability to think / concentrate or indecisiveness• Recurrent thoughts of death or suicidal ideation

– 12 – 14% of childbearing women• 7 – 17% of adult mothers• 26% of adolescent mothers

– 50 – 80% recurrence risk

Case #1

15 weeks postpartum:– Return visit to PCM– Began SSRI

17 weeks postpartum:– Discontinued

breastfeeding

20 weeks postpartum:– Resolution of all

symptoms

1 year postpartum:– Weaned from SSRI– No further symptoms


“A year after my son had been

born I was able to stop the

medication. I had come out

of the depression. I was a

functioning person again. I

hadn’t had any suicidal or

homicidal ideas in a long time.

The hallucinations of children

darting into the street had

stopped a couple of months

after starting the medication. I

was no longer crying.

However, my guilt did not

diminish. I had resolved

that I was a bad mother for

having not been there for

my child…”

As her Pediatrician at the4 month and 12 month

visits…

• What are you worried about?– Medications with breastfeeding– Breastfeeding loss– Maternal-child bonding– Maternal parenting skills

• What guidance can you offer?– Permission to quit breastfeeding– Upcoming toddler behaviors / discipline

• What interventions can you provide?– Social Work Services consult– Parenting classes

Infant Outcomes• Temperament / behavior

– Limited play and exploratory behaviors

– Less responsive to facial expressions

– Emotional lability– Increased drowsiness– Less sociable with strangers– Emotion regulation difficulty

• Cognitive development– Language delays– Lower scores on McCarthy

Scale of Children’s Abilities– Poor school performance

• Mental / emotional health– Hyperactivity– Defiance and disrespect– Higher rates of depression

in adolescence– Increased adolescent

substance abuse

• Preventive health and parenting practices– Shorter duration of

breastfeeding– Improper sleep positioning– Less play and reading– Less safety item use– Higher use of acute

healthcare services– Delay in immunizations

• Maternal-child interactions– Decreased reciprocity in

interaction of infant– Decreased enjoyment of

infant by mother– Lack of patience to soothe– Less active interactions– Decreased bonding and

attachment

• Potential physical harm– Abuse / neglect– Infanticide

Professional Associations• Postpartum Support International (PSI)• Marcé Society• North American Society for Psychosocial Obstetrics & Gynecology (NASPOG)

• National Alliance on Mental Illness (NAMI)• The Pacific Post Partum Support Society (PPPSS)• Women's Behavioral HealthCARE• National Center for Education in Maternal and Child Health (NCEMCH)• National Healthy Mothers, Healthy Babies Coalition (HMHB)• Lamaze International / Lamaze Institute for Normal Birth• American Society for Reproductive Medicine (ASRM)• National Institutes of Mental Health (NIMH)• National Institutes of Health (NIH)• Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN)

• American Academy of Family Physicians (AAFP)• American Academy of Pediatrics (AAP)• American College of Obstetricians and Gynecologists (ACOG)• American Medical Association (AMA)• American Psychiatric Association (APA)• American Psychological Association (APA)• American Nurses Association (ANA)• National Association of Social Workers (NASW)• American Public Health Association (APHA)• National Center for Complementary and Alternative Medicine (NCCAM)

Postpartum Support International (PSI)

• Non-profit organization

• Mission: “Promote awareness, prevention, and treatment of mental health issues related to childbearing in every country worldwide through support, education, advocacy, and research”

• www.postpartum.net

• Toll-free Help Line : 800.944.4PPD (4773) (English and Spanish)

• Volunteer Area Support Coordinators– In all 50 US states, Canada, Mexico, and 36+ other countries around world– Provide telephone and email support, information, access to local resources

• “Healthy Mom, Happy Family: Understanding Pregnancy and Postpartum Mood and Anxiety Disorders”– Educational DVD for families and providers– 4 survivor stories accompanied by up-to-date information given

by 3 experts

• Free phone "Chat with the Experts“– First Mondays of each month for dads, every Wednesday for moms– Facilitated by PSI Professionals

• Offer standardized training and education

• Resources for women, families, students, and professionals

Case #2

Pregnancy:– 12 weeks

• Started on SSRI• Started seeing therapist

– 35 0/7 weeks• Induced for fatty liver of

pregnancy and suspected HELLP syndrome

28 yo G2P2 mom, physician, prior h/o PPD

“I mentioned this to the OB on call a few days after my daughter was born.

He told me I must have ‘floaters’ in my eyes. After all, I knew logically

there were no bugs crawling on me. I reminded him of my prior

history since he wasn’t my original OB. He acknowledged me, but told

me I wasn’t really experiencing true hallucinations. There was no need to

change or add any medications. ‘Besides,’ he’d said, my ‘healthy baby

was worth a little delusion.’ I walked out of the office feeling

reassured. At my meeting with my therapist the next week, I mentioned

seeing bugs. She was stunned that the OB had dismissed that these were

likely hallucinations. He, of all people, should’ve been the one to

address the issue. She talked me into seeing a psychiatrist for

medication management ‘just in case’.”

1 day postpartum:– Continued SSRI– Breastfeeding– Visual

hallucinations

3 days postpartum:– Hallucinations

dismissed by OB

As her Pediatrician at the newborn follow-up visit…

• What are you worried about?– Medications during pregnancy– Medications with breastfeeding– Hallucinations = psychosis = EMERGENCY– OB / GYN

• What guidance can you offer?– Appropriate medication use with breastfeeding– Give Emergency contact numbers

• What interventions can you provide?– Involve husband– Home nurse visit– Social Work Services consult– Immediate Psychology or Psychiatry consult– Escort mom to Emergency Room

• Note mother-child interaction and assess attachment and bonding

• Ask specific questions– Resources, stressors, history of depression, suicidal ideation

• Listen!• Be prepared for her to deny her symptoms• Be prepared for her to be unwilling to seek treatment

Screening

• What NOT to say– This is a normal

reaction all new mothers experience

– Don’t worry about…

– You have so much to be happy about…

– A healthy baby is worth it…

– You would never really do…

– Join ‘new mom’ group

• What to say– You are not alone

– You are not to blame• Not something you

caused or could have prevented

• This is not something you can control

– With help, you will be well• It is okay to need help• Depression is treatable• Illness is temporary

– You are not “crazy”• This is not reflection of

you as person or mother• Intrusive thoughts are

different from psychosis

Now what?• Don’t screen until you know this answer!

• What should you do with an abnormal screen?– Provide reassurance and education– Ask whether mother has primary care provider and gain

permission to initiate conversation with that professional– Offer to initiate referral to mental health professional,

support group, or other therapeutic agency– Initiate immediate referral if mother shows severe

impairment, psychosis, or suicidal ideation– Refer to Early Intervention program for attachment concerns– Provide list of print and online resources– Schedule frequent office visits to follow up

• What should you document (infant’s chart)?– Maternal EPDS score, including score of question #10– Presence of maternal auditory or visual hallucinations or

suicidal or homicidal ideation– Health care professionals who were consulted or to whom

referrals were made– Follow-up plan (for both mother and child)– Current treatment (for both mother and child)

Case #228 yo G2P2 mom, physician, prior h/o PPD

1 ½ weeks postpartum:– Psychiatrist added SNRI to SSRI

2 months postpartum:– Increasing visual hallucinations– Auditory hallucinations– “Good insight” into illness– Increased SSRI and SNRI doses– Returned to work

4 months postpartum:– Depressive symptoms– Self-narration– Extended sick leave from work– Typical antipsychotic started

emergently– Continued to breastfeed

“Every waking

moment I had

some sort of

hallucination or

another. I found

myself narrating

every action I

performed. I couldn’t

stop hearing my own

voice in my head,

now in addition to

the hallucination of

shrieking children.

I saw bugs crawling

everywhere I

looked.”

Case #2

4 ¼ months postpartum:– Worsening depression– Homicidal ideation

“One of the days I was home alone with both kids, I paged Christi at work

and told her I was going to hurt my children. She asked where I

was, and I answered, ‘the bathroom’. She told me to lock myself alone

inside. ‘Do not open that door until I get there,’ she’d said. ‘I don’t care

if the baby’s screaming her head off, the 4 year old’s pounding on the

door, or the house is burning down! Don’t unlock the door until you hear

my voice.’ Christi left work unannounced and drove to my home. She

gathered some things together and took the kids in to daycare. She took

me back to work with her and watched me for the rest of the day. That

night she told my husband it was not safe for me to be alone

with my children.”


“I was crying and tired constantly.

I had slipped into a sadness I

couldn’t escape. Everything was

dark. I started to feel hopeless,

as if there was absolutely nothing that could save me from all of this. I

became unable to care for my infant daughter and unable to care

for myself. I began to think about ways to kill myself. I thought about

my children and what their lives would be like without me. I thought about

my husband and figured he’d be better off without me there crying and

crazy.”

As her Pediatrician at the 4 month well child visit…

• What are you worried about?– Welfare of infant and other child– Maternal welfare– Medications with breastfeeding

• What guidance can you offer?– Insist on supervision of mom with children– Permission to continue breastfeeding

• What interventions can you provide?– Involve husband and other family– Escort to Emergency Room– ? Child Protective Services– Consult Psychiatrist to ensure safety of mother

and children

Medication FAQs• What about maternal psychoactive

medication use and breastfeeding?– SSRI’s most commonly used in lactating women due

to lower breast milk concentrations– Lowest effective dose should be prescribed– “Medications and Mother’s Milk”– “Drugs in Pregnancy and Lactation”– Evidence-based information about risk of maternal

exposures to developing fetus or infant • Maternal and infant drug levels, possible effects on breastfed

infants, alternate drugs to consider• National Library of Medicine online database “Lac Med”

– http://toxnet.nlm.nih.gov/• Motherisk

– http://www.motherisk.org/women/index.jsp– Affiliated with OTIS

• OTIS (Organization of Teratology Information Specialists)– www.otispregnancy.org

Case #2

“Christi called once again to check on me. I talked to her for awhile and

told her I was fine. I would get through somehow, I’d said. As we hung

up, I went to the bathroom and fished through the medicine cabinet. I

wanted to take something, anything, that would make the noise

in my head stop. I didn’t necessarily want to kill myself; I just

wanted to hurt what was on the outside enough that it would

kill the thing that was on the inside. I got out anything sedating…

sleep medicines, the narcotic I’d been prescribed after delivery, muscle

relaxers, and antihistamines. I had the samples of antipsychotic out. I

began to calculate how much of each I should take, and then decided I

should just take them all. I walked to the kitchen to get some water

to swallow the pills. As I started down the hallway, Christi walked in.

She’d left work to check on me. Although I’d told her I was fine, she

suspected something was up. I began to sob as I confessed to her

what I was doing. I admitted to her that I was not safe to be by

myself. I admitted to her that I was not safe to be alone with

my children. I wept at the thought that I had this beautiful new baby

with whom I should not be allowed to be alone.”


4 ½ months postpartum:– First suicide attempt interrupted

Case #2

4 ½ months postpartum:– Prescribed SSRI, SNRI,

typical antipsychotic, and atypical antipsychotic

– Breastfeeding discontinued

5 months postpartum:– Improved depression– Weaned from atypical

antipsychotic– Remained on SSRI, SNRI,

and typical antipsychotic

– Auditory and visual hallucinations continued

5 ¼ months postpartum:– Depressive sxs recurred– Atypical antipsychotic

restarted


“I couldn’t stand the idea of

my children watching me this

way. I was horrified at the

thought that they would

grow up hearing how their

mother was crazy. It

terrified me to think that my

husband would eventually not

be able to deal with the mess

my life had become and

would one day either go

crazy himself or leave me

behind. I figured I would

make their lives easier by

going away quietly and

permanently. This way they

wouldn’t have to continue

watching me slip away. It

would be a demonstration

of how much I loved

them… by protecting

them from myself.”

Case #228 yo G2P2 mom, physician, prior h/o PPD

5 ½ months postpartum:– Second suicide attempt interrupted– Hospitalization avoided through family safety plan

“I decided I would have the last say. I would be in control of the end of

my life before I was no longer able to control living it… My husband

came home from work for lunch unexpectedly early to find me sitting on

the bathroom floor staring at the different bottles of medications. They

were scattered in front of me as I was trying to figure out the best

concoction to make it all end. He looked at me, feigned a smile, and

asked me what I was doing. I looked up at him, but had no words. I

couldn’t explain how I felt, but now that I’d been caught, I added shame

to the list of emotions. He picked me up off the floor and walked me to

the couch. He stayed home from work and watched me the rest of the

day. I later found that he’d hidden all of the medications. He dosed my

meds out to me from then on. Although I searched several times, I

could not find them.”

Provider Resources• Specialized Treatment Centers

– Massachusetts General Hospital Center for Women’s Mental Health, Boston, MA• http://www.womensmentalhealth.org/

– University of North Carolina Center for Women’s Mood Disorders• http://www.psychiatry.unc.edu/wmd/

– Women and Infants Day Hospital, Providence, RI• http://www.womenandinfants.org/landingPage4.cfm?

topicID=333&facilityID=7

– Emory University School of Medicine Women’s Mental Health Program, Atlanta, GA• http://www.emorywomensprogram.org/

• MedEdPPD.org– Professional, educational, peer-reviewed website developed with

support of National Institute of Mental Health (NIMH)– Provides reliable evidenced-based tools for professionals and families

• Care Pathways algorithm– Designed for medical professionals evaluating postpartum women

to help determine if patient has reached positive or negative outcome since giving birth

– Outcome indicates if patient should be referred for additional mental health services or put on antidepressant regimen and monitored

• Screening tools• Expert CEU / CME presentations• Case studies• Provider FAQs

Case #2

“I stood in the kitchen doorway a few steps behind the couch where my

husband was sitting. Facing his back, I watched as he talked on the

phone. Suddenly it occurred to me that he needed to go away. I

was holding a pair of kitchen shears and decided to use them to stab

him in the back. I studied the scissors, determining whether or not they

were sharp enough to get the job done in one stroke. I walked behind

the couch, clenched the handle, and raised my arm behind him, staring

at the exact spot where I thought the blades should pierce. With my

hand poised, the notion passed. I remember feeling as though I’d

been thinking perfectly clearly when deciding to kill him. I wasn’t angry

at him. He hadn’t upset me or provoked me in any way. I’d felt that his

death would somehow be beneficial the instant before, but then

abruptly snapped back into reality and now was asking myself what

in the world I had been planning on doing...”


5 ½ months postpartum:– Homicidal intent with near-attempt– Both antipsychotic doses

increased

Case #2

“I told him what I’d been thinking as I put the scissors down. I was

ashamed and nervous about telling him, but knew that he needed to

know that I was getting worse. I then realized how serious this had

become. I’d thought it trivial when it was my own life that had been

threatened. Now, I had been terrifyingly close to committing

homicide. I asked the psychiatrist to admit me to the hospital.

Despite what I had almost done, my husband fought to keep me out.

He arranged a deal with the psychiatrist and me that I would never be

alone and, no matter what, he would make sure I was protected...”


5 ¾ months postpartum:– Self request for hospitalization– Both antipsychotic doses again increased


• What are you worried about?– Maternal welfare– Other household members’ safety

• What guidance can you offer?– Reassurance that children may not remember– Encourage marital counseling– Encourage faith-based affiliation

• What interventions can you provide?– Escort to Emergency Room– Consult Psychiatrist to ensure mother’s and family

members’ safety

Case #2

6 months postpartum:– Auditory hallucinations resolved

6 ¼ months postpartum:– All symptoms resolved

7 months postpartum:– Returned to work

8 months postpartum:– Weaned from typical antipsychotic

9 months postpartum:– Weaned from atypical antipsychotic



• What are you worried about?– Is she planning on having more children?

• What guidance can you offer?– Encourage family counseling

• What interventions can you provide?– Monitor for long-term effects of maternal

postpartum depression in children

• Who– Women qualified to

receive medical care at Ireland Army Community Hospital (IACH) Fort Knox

• What– Screened for PPD

• When / Where– OB/GYN Clinic

• 6 week postpartum visit– Infant age 2 - 8 weeks

– Pediatric Clinic• Newborn, 2 week, 2

month, 4 month, 6 month, and 9 month well child visits

• How– Using Edinburgh

Postnatal Depression Scale (EPDS)

– Positive screen• Total score = 10 or more• Positive score on

question #10 (suicidal ideation)

• Yield– 18 month period– 1877 EPDS screens– 1043 women

“Incidence and Severity of Postpartum Depression Among Military Beneficiaries”


• Incidence varied between Peds and OB/GYN Clinics

Peds OB/GYN IACH Civilian0%

10%

20%

30%

40%

12.5%

18.5%16.9%

13.0%

27.0%

29.5%31.3%

8.5%

Total Incidence of +EPDS and SI

Incidence +EPDS Incidence SI in +EPDS


• Total incidence significant even 9 months postpartum– Should we screen throughout 1st year postpartum?

</= 2 wks >2 wks - 2 mo

>2 - 4 mo >4 - 6 mo >6 - 9 mo >9 mo0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

13.3% 13.9%9.9% 10.3%

12.8% 14.3%

19.2%

29.3%34.8%

37.5%36.4%

100.0%IACH EPDS Results by Infant Age

Incidence +EPDS Incidence SI in +EPDS

n=156

n=710n=392

n=232

n=86 n=7

Case #2

11 months postpartum:– Weaned from SSRI

Current day:– Will remain on SNRI for life– No further psychiatric symptoms– No diagnosis of bipolar disorder


“I screen every new mother who walks through my clinic door

through the first twelve months of their child’s life. I’m now very

much interested in how she’s coping with the lack of sleep.

I ask probing questions about the presence of suicidal thoughts

without unease with how appropriate they may sound. I try to

provide support and encouragement to any mother who tells

me she’s overwhelmed…”

Screening Tips• When to screen

– Bright Futures says 1 month, 2 month, and 6 month well child visits

– IACH study suggests every well child visit through first 9 months postpartum

– Consistency minimizes awkwardness

• What tool to use– Most convenient for

individual practice– Educate all staff

• Confirmation of dx– Not necessary by

Pediatrician– Positive screen in

primary care setting should have further evaluation

• Delivery of screen– Front desk clerks upon

check-in– Nursing with screening

and vitals– With other

questionnaires / ASQ– Ready for provider

when enters exam room

• Scoring of screen– Nursing– Provider

• Addressing screen– Provider– Trained staff member– Social worker– Emergency contacts

Screening Tools

Edinburgh Postnatal

Depression Scale (EPDS)

Postpartum

Depression Screening

Scale (PDSS)

Center for Epidemiologic

Studies Depression Scale

(CES-D)

Patient Health

Questionnaire (PHQ-9)

Beck Depression

Inventory (BDI)

Source

Cox, J L , et al. Detection of postnatal

depression: development of the 10-item

Edinburgh Postnatal Depression Scale.

Br J Psychiatry. 1987;150:782-6

Beck, C . A checklist to identif y

women at risk for developing

postpartum depression. J

Obstet Gynecol N eonatal N urs

J an-Feb 1998;27(1):39-46

N IM H

K roehnke K , Spitzer RL , Williams

J BW. The PHQ-9: Validity of a

Brief Depression Severity M easure.

J Gen Intern M ed . 2001;16:606-613

Beck A T , Ward CH,

M endelson M , M ock J ,

Erbaugh J . "A n inventory for

measuring depression". A rch

Gen Psychiatry. J une

1961;4:561–71

# items 10 35 20 9 7

D eliberately does not contain

self -report items related to

somatic symptoms

7 domains (sleep / appetite

disturbances, anxiety /

insecurity, emotional lability,

cognit ive impairment, loss of

self , guilt / shame,

contemplating self -harm)

D eveloped to cover most

diagnostic criteria for

depression

D erives scoring from 9

D SM -IV-TR diagnostic

criteria

2nd version reflects

D SM -IV-TR revisions

D eveloped for postpartum

women in outpatient setting

D eveloped for use in

postpartum women

L ittle published data on use in

postpartum women

Not validated for use in

postpartum women

D eveloped to measure

depression intensity,

severity, and depth

Primary care cutoff = 10 / 30 M inor depression = 60 M ild = 0 - 9 Sum indicates severity

Specialty care cutoff = 13 / 30 M oderate = 15 - 19

#10 indicates suicidal ideation Severe = 20 - 27

A ccuracySensitivity

Specificity 49 - 100% 72 - 98% 92% 88% cutoff -dependent

PPV 19 - 92% 33 - 88% 53% 31 - 51% cutoff -dependent

T ime 5 min 5 - 10 min 10 min 3 min 5 - 10 min

Cost Free $65 Free Free Free

cutoff -dependent

D epressive symptoms = 16 / 60 D epression = 21 for

general populationM ajor depression = 80

Description

Scoring

59 - 100% 91 - 94% 60% 88%

As a Pediatrician…

• as a Postpartum Support International coordinator, a researcher, an educator, an author, a support group leader, a mother, and as a postpartum psychosis survivor…

• What am I worried about?– Convincing other Pediatricians of the importance of

screening mothers for postpartum mood disorders

• What guidance can I offer?– Encourage Pediatricians to acquire education, offer

their support, and advocate for their patients and their families

• What interventions can I provide?– Promote awareness, prevention, and screening of

all mothers for postpartum mood disorders

Questions?

Appendices

• Extras– AAP Bright Futures– HRSA resource picture– Other National Associations– PSI awareness poster– PSI Provider Fact Sheet– MedEd PPD algorithm– Other Provider Resources– Resources for Moms / Families– Miscellaneous Resources– Postpartum Pact (Kleiman)– Postpartum Card (Kleiman)– OTIS website picture– DSM-IV-TR diagnostic criteria– PPD literature– IACH Example– Screening tools– PPD legislation

AAP Bright Futures Guidelines



Other National Associations• North American Society for

Psychosocial Obstetrics and Gynecology (NASPOG)– www.naspog.org/– Society of researchers, clinicians,

educators and scientists involved in women’s mental health

– Fosters scholarly scientific and clinical study of biopsychosocial aspects of obstetrics and gynecology

• National Institute of Mental Health (NIMH)– www.nimh.nih.gov/health/topics/

women-and-mental-health/index.html

• Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)– www.awhonn.org/– Section on postpartum depression

includes information on legislative advocacy and practice resources

– Organization’s position paper “The Role of the Nurse in Postpartum Mood & Anxiety Disorders”

• Womenshealth.gov

• Marce Society– www.marcesociety.com/– International organization

dedicated to prevention, understanding, and treatment of psychiatric illness related to childbearing

– Promotes, facilitates, and communicates about research into all aspects of mental health of women, infants, and partners around time of childbirth

– Encourages involvement from psychiatrists, psychologists, pediatricians, obstetricians, midwives, nurses, early childhood specialists, consumer advocacy, and self-help groups

• Mental Health America– www.nmha.org/– Leading nonprofit

• Health Resources and Services Administration (HRSA)– www.mchb.hrsa.gov/pregnancy

and beyond/depression

• Center for Postpartum Health– www.postpartumhealth.com

MedEdPPD.org

Other Provider Resources• Perinatal Depression

Information Network– Collects and organizes

information across US– Creates forum to bring together

maternal, child, and mental health providers, leaders, and families

– Lists specific contacts and other key information for each resource in network

– Online provider toolkits– Online training modules

• Research• Policy• Funding • Legislative initiatives

– Special features• Forum to pose questions and

discuss issues• Section on materials for

women and families

• Maternal and Child Health (MCH) Library– www.mchlibrary.info– By Georgetown University– Collection of historical

documents related to US maternal and child health

• Mental Health America: Maternal Depression- Making a Difference Through Community Action: A Planning Guide– http://www.nmha.org/go/maternal-

depression

• Knowledge Path: Postpartum Depression– http://www.mchlibrary.info/

KnowledgePaths/kp_postpartum.html

– Compiled by Maternal and Child Health Library at Georgetown University

– Offers current resources about prevalence and incidence of postpartum depression, identification and treatment, impact on health and well-being of new mother and her infant, and implications for service delivery

• Massachusetts General Hospital (MGH) Women’s Mental Health Center Library– www.womensmentalhealth.org/

library– Repository of information and

articles compiled into different specialty areas, including postpartum psychiatric disorders

Other Provider Resources• Spectrum Women’s Health

Toolkit for Healthcare Providers– Prepares healthcare staff– Garners financial and resource

support– Helps design postpartum

depression program– Step-by-step approach

• Create advisory team• Train staff• Begin screening• Establish follow-up protocols• Develop referral team• Implement groups and services• Launch telephone support and

information line• Create program evaluation

process– One kit costs $450

• Virginia Bright Futures– Has training website– Developed parent kit given to 70%

of new parents– Partnered with AAP Virginia

chapter, state Early Periodic Screening, Diagnosis, and Treatment (EPSDT), Resource Mothers, and Healthy Families Virginia to recommend PPD screening

• National Center for Children in Poverty, Project Thrive– www.nccp.org– Public Policy Analysis and

Education Center for Infants and Young Children

– Mission: “To increase knowledge and provide policy analysis that will help states build and strengthen comprehensive early childhood systems and link policies to ensure access to high-quality health care, early care and learning, and family support”

– “Reducing Maternal Depression and Its Impact on Young Children” published Jan 2008

• University of Washington’s “Keys to Postpartum Depression”– Created by nurse scientists at

University of Washington and members of Washington State First Steps Team

– 3 multimedia training modules• Understanding and Treating

Women with Perinatal Depression & Mood Disorders

• Relationship Focused Practice• Screening for Perinatal

Depression

Other Provider Resources• University of Illinois Chicago

(UIC) Provider Consultation Line– Consults for healthcare providers

with questions on detection, diagnosis, and treatment of perinatal depression and anxiety

– Consultants are UIC faculty and staff clinicians• Psychiatrists• Advanced practice nurse• Social worker

– Should not be construed as direct advice about managing any particular patient’s care

– Not a “hotline”– Response in 1 business day

• Pennsylvania Perinatal Partnership Community Collaboration Toolkit– www.paperinatal.org– Free 163-page toolkit

• Fact sheets• Tables• Website links• Talking points• Consultation lines• Treatment guides• Legislation information

• Oregon Pediatric Society’s START program– http://oraap.com/– Maternal depression screening

module– CME and MOC credits available– Goals

• Increase standardized health screening

• Increase awareness of community resources

• Enhance care coordination and communication

– Incorporates medical home, team-based care model• Includes primary care

providers (physicians, NP’s, PA’s), nurses, and office staff

– Training tailored to individual community• Uses physician trainers from

various geographic regions who know communities best

• Includes panel of representatives from local community agencies

• National Library of Medicine– www.nlm.nih.gov/medlineplus/

postpartumdepression.html

Resources for Moms• Text4baby

– National Healthy Mothers, Healthy Babies Coalition

– Free text messaging program for pregnant or new mothers

– English or Spanish– Delivers information 3 times

per week– Messages customized for each

woman's stage of pregnancy or baby's age• Health advice for pregnant

women and new moms • Nutrition tips• Access to free and low-cost

programs that provide medical care, food, and other services

• Tips and support for coping with stress of pregnancy and new motherhood

• Fun facts about baby development and milestones

– To sign up for Text4Baby:• Text “BABY” to 511411• Envia “BEBE” al 511411

para Español

• APA’s Healthy Minds: “How Do I Know if I’m Depressed?”– www.healthyminds.org/expert

opinion10.cfm

• National Women’s Health Information Center– (800) 944-WOMAN– www.4woman.gov

• Online Support Group – http://postpartumdepression.

yuku.com/– Online moderated discussion forums

• Mother to Mother Postpartum Depression Network– www.postpartumdepression.net

• Maternal and Child Health (MCH) Hotline• (800) 311-BABY (2229)• (800) 504-7081 (Spanish)

Internet Resources forDads, Families, and Friends• Postpartum Dads Project

– http://postpartumdadsproject.org– Informational site focusing on what

men experience when their partners have perinatal mood or anxiety disorders

– Offers stories and advice on how to help partners

• Boot Camp for New Dads– http://www.bcnd.org– Father-to-father community-based

workshop inspires men to become confidently engaged with infants and support their mates

• Mayo Clinic: “Supporting A Friend or Family Member with Depression”– http://www.mayoclinic.com/health/

depression/MH00016

• Anxiety Disorders Association of America: “Helping a Family Member”– http://www.adaa.org/GettingHelp/Help

AFamilyMember.asp

• Online support group for dads– ww.postpartumdads.org

• Postpartum Education for Parents– 1-800-311-BABY (2229)– 1-800-504-7081 (Spanish)– http://www.sbpep.org– 24-hour support line available

for one-to-one support

• Families for Depression Awareness– http://www.familyaware.org/

resources/options.php– Helps families recognize and

manage various forms of depression and mood disorders

• Depression During and After Pregnancy: A Resource for Women, Their Families, and Friends– www.mchb.hrsa.gov/

pregnancy andbeyond/depression

– Information about definition and symptoms of PPD and when to seek treatment

MiscellaneousInternet Resources

• Blogs– Postpartum Progress

• http://postpartumprogress. typepad.com

– I’m Listening by Jane Honikman• http://janehonikman.com/

– Unexpected Blessing• http://unexpectedblessing.

wordpress.com– PTSD After Childbirth

• http://www.ptsdafterchildbirth.org– Ivy’s PPD Blog

• http://ivysppdblog.wordpress.com– Beyond Postpartum by Amber

Koter-Puline• www.atlantappdmom.blogspot.com

• Foundations– Jennifer Mudd Houghtaling Postpartum

Depression Foundation• www.ppdchicago.org

– Jenny’s Light• www.jennyslight.org

– Sounds of Silence Foundation• www.soundsofsilencefoundation.org

– Ruth Rhoden Craven Foundation• www.ppdsupport.org

– Melanie’s Battle• www.melaniesbattle.org

• Resources in Other Languages– Medline Plus Postpartum Depression

Resources• www.nlm.nih.gov/medlineplus/

languages/postpartumdepression. html

• 15 languages include Arabic, Japanese, Korean, Chinese, Vietnamese, Russian, Somali

– Maternal & Child Health Library• www.mchlibrary.info/

nonenglish.html– UCSF Depression Prevention Course

(Muñoz)• www.medschool.ucsf.edu/latino/

manuals.aspx#depressionprevention

• Workbooks in Spanish, Japanese, Chinese

– British Columbia Partners for Mental Health and Addictions Information• Publications in Arabic, Chinese,

English, Farsi, French, Korean, Punjabi, Russian, Spanish, Japanese, Vietnamese

– Here to Help• www.heretohelp.bc.ca/other-

languages– French

• http://marce-franco phone.asso.fr/– German

• http://www.marcegesellschaft.de/

Postpartum Pact (Kleiman)

Postpartum Pact (Kleiman)

PPD Card (Kleiman)

DSM-IV-TR Diagnostic Criteria

• Major Depressive Episode– At least 5 symptoms present during same 2-week

period• At least 1 is depressed mood or loss of interest /

pleasure• Represents a change from previous functioning

– Shouldn’t include symptoms due to general medical condition, mood-incongruent delusions, or hallucinations

– Does not meet the criteria for mixed episode– Clinically significant distress or impairment in social,

occupational, or other important areas of functioning – Not due to substance use or general medical

condition– Not better accounted for by bereavement– Symptoms persist for longer than 2 months or are

characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation

• “Postpartum Onset” Specifier– Onset must be within 4 weeks after delivery


• Generalized Anxiety Disorder– At least 6 months of "excessive anxiety and worry“– Significant difficulty in controlling anxiety and worry– Presence for most days of 3 or more of following

symptoms• Feeling wound-up, tense, or restless• Easily becoming fatigued or worn-out• Concentration problems• Irritability• Significant tension in muscles• Difficulty with sleep

– Symptoms are not part of another psychiatric disorder

– Symptoms cause "clinically significant distress" or problems functioning in daily life

– Not due to substance use or general medical condition



• Obsessive Compulsive Disorder– Obsessions:

• Recurrent, persistent thoughts, impulses, or images that are intrusive and inappropriate and cause anxiety or distress

• Not simply excessive worries about real-life problems• Attempts to ignore or suppress, or neutralize such thoughts,

impulses, or images with some other thought or action• Recognizes that obsessions are product of own mind

– Compulsions:• Repetitive behaviors or mental acts person feels driven to perform

in response to obsession, or according to rigid rules• Aimed at reducing distress or preventing event or situation

– Recognizes these are excessive or unreasonable– Cause marked distress, are time consuming, or

interfere with normal routine, occupation, or social relationships

– Content is not restricted to another disorder, if present

– Not due to substance use or general medical condition



• Post-traumatic Stress Disorder– Exposed to traumatic event where both present:

• Experienced, witnessed, or confronted with event that involved actual or threatened serious injury, or threat to physical integrity of self or others

• Response involved intense fear, helplessness, or horror

– Trauma persistently re-experienced in 1 (or more) ways: • Recurrent and intrusive distressing recollections of event• Recurrent distressing dreams of event• Acting or feeling as if traumatic event were recurring (includes

sense of reliving experience, illusions, hallucinations, and dissociative flashback episodes including those that occur upon awakening or when intoxicated)

• Intense psychological distress at exposure to internal or external cues that symbolize or resemble aspect of traumatic event

• Physiological reactivity on exposure to internal or external cues that symbolize or resemble aspect of traumatic event

– Symptoms of increased arousal, indicated by 2 (or more): • Difficulty falling or staying asleep• Irritability or outbursts of anger• Difficulty concentrating • Hypervigilance • Exaggerated startle response


• Post-traumatic Stress Disorder (cont’d)– Persistent avoidance of stimuli associated with trauma

and numbing of responsiveness, as indicated by 3 (or more) of following: • Avoids thoughts, feelings, or conversations associated with trauma • Avoids activities, places, or people that cause recollection of trauma • Inability to recall important aspect of trauma • Markedly diminished interest or participation in significant activities • Feeling of detachment or estrangement from others • Restricted range of affect• Sense of foreshortened future

– Duration of disturbance is more than 1 month– Clinically significant distress or impairment in social,

occupational, or other important areas of functioning



• Major Depressive Episode– “Severe With Psychotic Features” Specifier

• Delusions or hallucinations• “Mood-Congruent Psychotic Features” Specifier

– Content consistent with typical depressive themes• “Mood-Incongruent Psychotic Features” Specifier

– Content does not involve typical depressive themes– Includes persecutory delusions, thought insertion, thought

broadcasting, and delusions of control

• Brief Psychotic Disorder– Presence of 1 (or more) of following symptoms:

• Delusions• Hallucinations• Disorganized speech • Grossly disorganized or catatonic behavior

– Duration of episode at least 1 day but less than 1 month, with eventual full return to premorbid function level

– Disturbance not better accounted for by another disorder and not due to substance use or general medical condition

• “Postpartum Onset” Specifier

PPD Literature: Breastfeeding

• How Does Postpartum Depression Affect Breastfeeding? McCarter-Spaulding D, Horowitz JA. MCN Am J Matern Child Nurs. 2007 January/February; 32(1): 10-17.– Examined patterns of exclusive breastfeeding, combination feeding, and

exclusive bottle-feeding among women identified at 2 - 4 weeks postpartum with positive PPD symptoms

• Does maternal postpartum depressive symptomatology influence infant feeding outcomes? Dennis CL, et al. Acta Paediatr. 2007 Apr; 96(4): 590 - 4.– Examines relationship between diverse infant feeding outcomes (e.g. infant

feeding method, maternal satisfaction, infant feeding plans, breastfeeding progress, and breastfeeding self-efficacy) and postpartum depressive symptomatology using time-sequenced analysis

• A new paradigm for depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. Kendall-Tackett KA. Int Breastfeed J. 2007 Mar 30; 2(1): 6.– Psychoneuroimmunology research reveals that depression is associated

with inflammation manifested by increased levels of proinflammatory cytokines

• Antidepressant medication use during breastfeeding. Lanza di Scalea T, Wisner KL. Clin Obstet Gynecol. 2009 Sep; 52(3): 483 - 97.– Review of 31 empirical papers identifying most evidence-based medications

for use during breastfeeding• Breastfeeding and antidepressants. Field T. Infant Behav Dev. 2008 Sep; 31(3):

481-7.– Suggests breastfeeding is less common in postpartum depressed women

PPD Literature: Infant Growth

• Maternal postnatal depression and children's growth and behaviour during the early years of life: exploring the interaction between physical and mental health. Avan B, et al. Arch Dis Child. 2010 Jul 26.– South African study found association between child behavior problems and

stunted growth among children whose mothers experienced PPD• Impact of postnatal depression on infants' growth in Nigeria. Adewuya AO, et

al. J Affect Disord. 2007 Nov 6.– Impact of PPD on growth in first 9 months of life for infants in Nigeria

• Postpartum mood disorders and maternal perceptions of infant patterns in well-child follow-up visits. Orhon FS, et al. Acta Paediatr. 2007 Dec; 96(12): 1777-83.– Evaluates associations between PPD symptoms and maternal perceptions of

infant patterns with 1-year follow-up, and assesses impact of treatment on perceptions

PPD Literature:Child’s Temperament

• Effect of maternal antepartum psychological therapy upon early infant temperament. Yang J, et al. Zhonghua Yi Xue Za Zhi. 2009 Aug 4; 89(29): 2038-41.– Chinese study on whether group therapy for mothers in 2nd trimester has

impact on how they rated their infants' temperament postpartum• A follow-up study of postpartum depressed women: recurrent maternal

depressive symptoms and child behavior after four years. Josefsson A, Sydsjö G. Arch Womens Ment Health. 2007 May 29.– Investigates prevalence of depressive symptoms and self-reported health of

women with previous PPD symptoms• Infantile colic, prolonged crying and maternal postnatal depression. Vik T, et

al; for European Childhood Obesity Trial Study Group. Acta Paediatr. 2009 Apr 28.– Excessive, prolonged infant crying, as with colic, is associated with high

maternal depression scores• The impact of postnatal and concurrent maternal depression on child

behaviour during the early school years. Fihrer I, McMahon CA, Taylor AJ. J Affect Disord. 2009 Dec; 119(1-3): 116 - 23.– Ongoing impact of early and subsequent maternal depression on offspring

behavior in early school years• Childhood Behavioral Inhibition and Maternal Symptoms of Depression.

Moehler E, et al. Psychopathology. 2007 Aug 20; 40(6): 446 – 52.– Explores whether maternal postnatal psychopathology is predictor for

behavioral inhibition in offspring• Maternal depression and infant temperament characteristics. McGrath JM,

Records K, Rice M. Infant Behav Dev. 2008 Jan; 31(1): 71-80. Epub 2007 Aug 21.– Women from third trimester of pregnancy through 8-months postpartum

rated their depression and perception of infant's temperament at 2- and 6-months postpartum

PPD Literature:Mother-Infant Bond

• Effective treatment for postpartum depression is not sufficient to improve the developing mother-child relationship. Forman DR, et al. Dev Psychopathol. 2007 Spring; 19(2): 585 - 602.– Tested whether psychotherapeutic treatment for mothers with PPD results in

improved parenting and child outcomes• Maternal attachment state of mind moderates the impact of postnatal

depression on infant attachment. McMahon CA, et al. J Child Psychol Psychiatry. 2006 Jul; 47(7): 660 – 9.– Empirical studies reveal significant association between maternal

depression and insecure mother-child attachment• Postpartum depression, delayed maternal adaptation, and mechanical

infant caring: A phenomenological hermeneutic study. Barr JA. Int J Nurs Stud. 2008 Mar; 45(3): 362 - 9. – Australian study focused on impact of delayed maternal adaptation due to

PPD and effects on normal infant development• A case study of postpartum depression & altered maternal-newborn

attachment. Zauderer CR. MCN Am J Matern Child Nurs. 2008 May-Jun; 33(3): 173-8.– Case study of new mother with PPD and altered attachment to newborn

• Mother's stress, mood and emotional involvement with the infant: 3 months before and 3 months after childbirth. Figueiredo B, Costa R. Arch Womens Ment Health. 2009 Mar 4.– Negative fetal emotional involvement increases risk of poorer infant

emotional involvement, anxiety, and depression at 3 months postpartum• What's in a smile? Maternal brain responses to infant facial cues. Strathearn

L, et al. Pediatrics. 2008 Jul; 122(1): 40 - 51.– Viewing own child's happy face lit mothers' brain reward centers

• Antenatal mood and fetal attachment after assisted conception. Fisher JR, et al. Fertil Steril. 2008 May; 89(5): 1103 - 12. Epub 2007 Aug 13.– Postpartum mood disorder prevalence and parenting difficulties for women

who conceived with assisted reproductive technologies

PPD Literature: Parenting

• The impact of postpartum depression on mothering. Logsdon MC, Wisner KL, Pinto-Foltz MD. J Obstet Gynecol Neonatal Nurs. 2006 Sep - Oct; 35(5): 652-8.– Describes impact of PPD on maternal role

• Individual and combined effects of postpartum depression in mothers and fathers on parenting behavior. Paulson JF, et al. Pediatrics. 2006 Aug; 118(2): 659-68.– Examines effects of maternal and paternal depression on parenting

behaviors consistent with anticipatory guidance recommendations• The role of paternal support in the behavioural development of children

exposed to postpartum depression. Letourneau N, Duffett-Leger L, Salmani M. Can J Nurs Res. 2009 Sep; 41(3): 86 - 106.– Fathers' ability and availability to provide social support for depressed

partners may affect childrens' behavioral outcomes such as anxiety, hyperactivity, and aggression

PPD Literature: Pediatricians

• Survey of Characteristics and Treatment Preferences for Physicians Treating Postpartum Depression in the General Medical Setting. Thomas N, et al. Community Ment Health J. 2007 Oct 24.– Characteristics of physicians who routinely provide medical care for

postpartum mothers and their treatment preferences for managing PPD• Raising the awareness of primary care providers about postpartum

depression. Logsdon MC, et al. Issues Ment Health Nurs. 2006 Jan; 27(1): 59 - 73.– Methods to raise primary care provider awareness about PPD, eliminating

major barrier to mental health treatment of postpartum women• The association between maternal depression and frequent non-routine

visits to the infant's doctor - A cohort study. Chee CY, Chong YS, Ng TP, Lee DT, Tan LK, Fones CS. J Affect Disord. 2008 Apr; 107(1-3): 247 - 53.– Women experiencing depressive symptoms were found more likely to bring

their infants to pediatrician for non-routine visits• Antenatal depression predicts depression in adolescent offspring:

Prospective longitudinal community-based study. Pawlby S, Hay DF, Sharp D, Waters CS, O'Keane V. J Affect Disord. 2008 Jul 3.– 16-year study showed 4.7 times greater risk of depression for teens who

were exposed to maternal antenatal depression • Effectiveness of a discharge education program in reducing the severity of

postpartum depression. A randomized controlled evaluation study. Ho SM, et al. Patient Educ Couns. 2009 Apr 17. [Epub ahead of print].– Randomized controlled study found women who received discharge

education intervention on PPD were less likely to have high depression scores compared to control group at 3 months postpartum

• Postpartum depression in adolescent mothers: an integrative review of the literature. Reid V, et al. J Pediatr Health Care. 2007 Sep - Oct; 21(5): 289 - 98.– Review of 12 research articles to provide better understanding of depression

among adolescent mothers in 1st year postpartum

PPD Literature: Screening • Can pediatricians accurately identify maternal depression at well-child visits? Mishina H,

et al. Pediatr Int. 2009 Oct 6. [Epub ahead of print].– Determined whether 2-item screening tool improved physician recognition of PPD during

well child visits• Screening for postpartum depression at well-child visits: is once enough during the first 6

months of life? Sheeder J, et al. Pediatrics. 2009 Jun; 123(6): e982-8.– Maternal PPD prevalence at well child visits up to 6 months postpartum

• Screening for maternal depression in the neonatal ICU. Mounts, KO. Clin Perinatol. 2009 Mar; 36(1): 137 - 52.– Screening for PPD in NICU could identify women with depressive symptoms and facilitate

referral for follow-up services• Healthy Start screens for depression among urban pregnant, postpartum and

interconceptional women. Harrington AR, et al. J Natl Med Assoc. 2007 Mar; 99(3): 26 - 31.– Examines perinatal depression in north/ northeast Omaha, NE

• Legal and ethical considerations: risks and benefits of postpartum depression screening at well-child visits. Chaudron LH, et al. Pediatrics. 2007 Jan; 119(1): 123 - 8.– Ethical and legal considerations of screening for PPD at pediatric visits weighed against

screening risks and benefits• Postpartum depression screening: importance, methods, barriers, and recommendations

for practice. Gjerdingen DK, Yawn BP. J Am Board Fam Med. 2007 May - Jun; 20(3): 280 - 8.– Potential benefit of mass screening to improve PPD recognition and outcomes

• Universal screening for postpartum depression: an inquiry into provider attitudes and practice. Delatte R, et al. Am J Obstet Gynecol. 2009 May; 200(5): e63 - 4.– Obstetricians' attitude toward and use of EPDS to screen for PPD

• Postnatal depression and child outcome at 11 years: the importance of accurate diagnosis. Pawlby S, et al. J Affect Disord. 2008 Apr; 107(1-3): 241 - 5.– Face-to-face clinical interview more accurate than EPDS for PPD

• Parental Depression Screening for Pediatric Clinicians: An Implementation Manual By Ardis Olson, MD, www.cmwf.org– Found 2-question paper-based screen followed by discussion with mother and

pediatrician was both feasible and effective in identifying women who needed follow-ups or referrals

– Found paper screen far more effective compared to verbal interview

IACH Example• Prevention

– Education during pregnancy / childbirth classes by OB

– Education in newborn nursery prior to discharge by nursing

• Screening process– When

• Screened in Pediatric Clinic at newborn, 2 week, 2 month, 4 month, 6 month, and 9 month well child visits

• Screened prn by lactation consultant

• Screened in OB Clinic at 6 week postpartum visit

– How• EPDS handed to mom

by nurse during initial screening and vitals

• Mom completes screen while waiting for provider in privacy of exam room

• Provider reviews screen while in exam room

• Positive screens– Provider addresses concerns– PSI-trained RN offers education

• Provides handouts, information, resources list

– Pediatric Clinic Social Worker / Case Manager notified• Refer to PCM or OB• Refer for therapy• Refer for home visit• Telephone follow-up• Refer to Support Group

• Addressing Emergencies– Behavioral Health contact

paged and will consult / assume care of mom in Pediatric Clinic

– Developing hospital perinatal mood disorders team• 2 PNP’s, 2 Psych techs• Immediate access to

Behavioral Health and Social Work Services

• Consultation with Pediatrician / PSI coordinator

Edinburgh PostnatalDepression Scale (EPDS)

Source: Cox, JL, et al. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987; 150: 782 - 6.

• Description– Developed to screen

postpartum women for depression in outpatient setting

– 10-item self-report rating scale

– Sensitive to change in severity over time

– Translated into 23 languages• Not all validated

– Deliberately does not contain self-report items related to somatic symptoms

• Scoring– Minor depression= 8 - 9– Major depression= 8.5 -

15– Positive score on #10

indicates need for immediate intervention

• Accuracy (depends on cutoff)

– Sensitivity= 59 - 100%– Specificity= 49 - 100%– PPV= 19 - 92%

• Time to complete– 5 minutes

• Cost of tool– Free

EPDS

EPDS

EPDS

Relevant Literature:• Berle J, et al. Screening for postnatal depression: Validation of the Norwegian

version of the Edinburgh Postnatal Depression Scale, and assessment of risk factors for postnatal depression. J Affect Disord 2003; 76(1-3): 151 - 6.

• Boyd RC, Le HN, Somberg R. Review of screening instruments for postpartum depression. Arch Womens Ment Health. 2005; 8: 141 - 153.

• Chaudron LH, et al. Detection of Postpartum Depressive Symptoms by Screening at Well-Child Visits. Pediatrics. 2004; 113(3): 551 - 558.

• Cox J, et al. Validation of the Edinburgh Postnatal Depression Scale (EPDS) in non-postnatal women. J Affect Disord. 1996; 39(3): 185 - 189.

• Cox J, Holden J. Perinatal Mental Health: A guide to the Edinburgh Postnatal Depression Scale. The Royal College of Psychiatrists; 2003.

• Eberhard-Gran M, et al. Review of validation studies of the Edinburgh Postnatal Depression Scale. Acta Psychiatr Scand. 2001; 104(4): 243 - 249.

• Garcia-Esteve L, et al. Validation of the Edinburgh Postnatal Depression Scale (EPDS) in Spanish mothers. J Affect Disord. 2003; 75(1): 71 - 76.

• Gaynes BN, et al. Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes. Summary, Evidence Report/Technology Assessment No. 119. (Prepared by the RTI-University of North Carolina Evidence-based Practice Center under Contract No. 290-02-0016.) AHRQ Publication No. 05-E006-1. Rockville, MD: Agency for Healthcare Research and Quality. February 2005. [US Department of Health and Human Services]

• Murray D, Cox JL. Screening for depression during pregnancy with the Edinburgh Depression Scale. J Reprod Infant Psychol. 1990; 8(2): 99 - 107.

Postpartum Depression Screening Scale (PDSS)

Source: Beck, C. A checklist to identify women at risk for developing postpartum depression. J Obstet Gynecol Neonatal Nurs Jan - Feb 1998; 27(1): 39 - 46.

• Description– Written at 3rd grade

level– 35-item scale– 7 domains

• Sleeping / eating disturbances

• Anxiety / insecurity• Emotional lability• Cognitive

impairment• Loss of self• Guilt / shame• Contemplating

harming oneself

– Validated in English and Spanish by author

• Scoring– Minor depression= 60– Major depression= 80

• Accuracy– Sensitivity= 91 - 94%– Specificity= 72 – 98%– PPV= 33 - 88%

• Time to complete– 5 - 10 minutes

• Cost of tool– Kit (25 forms and

manual)= $65– 25 forms= $29.95

PDSS

Relevant literature:• Beck CT, Gable RK. Further validation of the Postpartum Depression

Screening Scale. Nurs Res. 2001 May - Jun; 50(3): 155 - 164.• Beck CT, Gable RK. Postpartum Depression Screening Scale: development

and psychometric testing. Nurs Res. 2000 Sep - Oct; 49(5): 272 - 282.• Boyd RC, Le HN, Somberg R. Review of screening instruments for

postpartum depression. Arch Womens Ment Health. 2005; 8: 141 - 153.• Lee DT, et al. Postdelivery screening for postpartum depression. Psychosom

Med. 2003 May-Jun; 65(3): 357 - 361. • Clemmens D, Driscoll JW, Beck CT. Postpartum depression as profiled

through the depression screening scale. MCN Am J Matern Child Nurs. 2004 May - Jun; 29(3): 180 - 185.

Patient HealthQuestionnaire (PHQ-9)

Source: Kroehnke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a Brief Depression Severity Measure. J Gen Intern Med. 2001; 16: 606 - 613.

• Description– Self-administered

version of PRIME-MD diagnostic instrument for common mental disorders (depression module)

– Derives scoring system from 9 DSM-IV-TR criteria for depressive disorders

– Is validated depression screening tool linked to DSM-IV-TR criteria

– Has not been validated in postpartum women


• Scoring– Minor depression= 0-9– Moderate / moderately

severe depression= 15-19

– Severe depression= 20-27

– Positive answer to suicidal ideation is positive screen

• Accuracy (scores >10)

– Sensitivity= 88%– Specificity= 88%– PPV= 31 - 51% (cutoff-

dependent)

• Time to complete– Less than 3 minutes

PHQ-9

PHQ-9

Relevant literature:• Huang FY, Chung H, Kroenke K, Delucchi KL, Spitzer RL. Using the Patient

Health Questionnaire-9 to measure depression among racially and ethnically diverse primary care patients. J Gen Intern Med. 2006 Jun; 21(6): 547 - 552.

• Grypma L, Haverkamp R, Little S, Unutzer J. Taking an evidence-based model of depression care from research to practice: making lemonade out of depression. Gen Hosp Psychiatry. 2006 Mar-Apr; 28(2): 101 - 107.

• Martin A, Rief W, Klaiberg A, Braehler E. Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population. Gen Hosp Psychiatry. 2006 Jan-Feb; 28(1): 71 - 77.

• Bergus GR, Hartz AJ, Noyes R Jr, Ward MM, James PA, Vaughn T, Kelley PL, Sinift SD, Bentler S, Tilman E. The limited effect of screening for depressive symptoms with the PHQ-9 in rural family practices. J Rural Health. 2005 Fall; 21(4): 303 - 309.

• Ruoff G. A method that dramatically improves patient adherence to depression treatment. J Fam Pract. 2005 Oct; 54(10): 846 - 852.

• Pinto-Meza A, Serrano-Blanco A, Penarrubia MT, Blanco E, Haro JM. Assessing depression in primary care with the PHQ-9: can it be carried out over the telephone? J Gen Intern Med. 2005 Aug; 20(8): 738 - 742.

• Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999 Nov 10; 282(18): 1737 - 1744.

Center for Epidemiologic Studies Depression Scale (CES-D)

Source: National Institute of Mental Health; LS Radloff

• Description– 20-item instrument– Developed by NIMH– Detects major

depression in adolescents and adults in community samples

– Easy to answer questions

– Covers most diagnostic criteria for depression

– Has been used in cross-cultural populations

– Little published data on use in postpartum women


• Scoring– Range from 0 - 60– Depressive

symptomatology indicated at score of 16 or more

• Accuracy (13% prevalence)

– Sensitivity= 60%– Specificity= 92%– PPV= 53%

• Time to complete– 10 min

CES-D

CES-D

Relevant Literature:• Beeghly M, Weinberg MK, Olson KL, Kernan H, Riley J, Tronick EZ. Stability

and change in level of maternal depressive symptomatology during the first postpartum year. J Affect Disord. 2002 Sep; 71(1-3): 169 - 180.

• Boyd RC, Le HN, Somberg R. Review of screening instruments for postpartum depression. Arch Womens Ment Health. 2005; 8: 141 - 153.

• Chaudron LH, Klein MH, Remington P, Palta M, Allen C, Essex MJ. Predictors, prodromes and incidence of postpartum depression. J Psychosom Obstet Gynaecol. 2001 Jun; 22(2): 103 - 112.

• Locke R, Baumgart S, Locke K, Goodstein M, Thies C, Greenspan J. Effect of maternal depression on premature infant health during initial hospitalization. J Am Osteopath Assoc. 1997 Mar; 97(3): 145 - 149.

• Mosack V, Shore ER. Screening for depression among pregnant and postpartum women. J Community Health Nurs. 2006 Spring; 23(1): 37 - 47.

Beck Depression Inventory (BDI)

• Description– Developed to measure

intensity, severity, and depth of depression

– 2nd version reflects DSM-IV-TR revisions

– 21 items, each with 4 possible responses• Items 1 to 13 assess

psychological sx• Items 14 to 21

assess physical sx

– Primary care version (BDI-PC) composed of 7 self-reported items


• Scoring– Sum indicates severity– General population

• Depression= 21 or more

– People clinically diagnosed• Minimal symptoms= 0 -

9• Mild depression= 10 - 16• Mod. depression= 17 -

29• Severe depression= 30 -

63

• Accuracy (depends on cutoff)

– Content, concurrent, and construct validity extensively tested

• Time to complete– 5 - 10 min

Source: Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. "An inventory for measuring depression". Arch. Gen. Psychiatry. (June 1961); 4: 561 – 71.

BDI

BDI

Relevant Literature:• Beck AT, Guth D, Steer RA, Ball R. Screening for major depression

disorders in medical inpatients with the Beck Depression Inventory for Primary Care. Behav Res Thera. 1997; 35: 785 – 91.

• U.S. Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. Depression in primary care. Vol 1. Detection and diagnosis. Rockville, Md.: Government Printing Office, 1993; AHCPR publication no. 93 - 0550/1.

• Stowe ZN, Nemeroff CB. Women at risk for postpartum-onset major depression. Am J Obstet Gynecol. 1995; 173: 639 – 45.

• Gotlib IH, Whiffen VE, Mount JH, Milne K, Cordy NI. Prevalence rates and demographic characteristics associated with depression in pregnancy and the postpartum. J Consult Clin Psychol. 1989; 57: 269 – 74.

• Holcomb WL Jr, Stone LS, Lustman PJ, Gavard JA, Mostello DJ. Screening for depression in pregnancy: characteristics of the Beck Depression Inventory. Obstet Gynecol. 1996; 88: 1021 – 5.

• Salamero M, Marcos J, Gutierrez F, Rebull E. Factorial study of the BDI in pregnant women. Psychol Med. 1994; 24: 1031 – 5.

• Georgiopoulos AM, Bryan TL, Yawn BP, Houston MS, Rummans TA, Therneau TM. Population-based screening for postpartum depression. Obstet Gynecol. 1999; 93: 653 – 7.

Miscellaneous PPD Literature

• Postpartum Depression, Marital Dysfunction, and Infant Outcome: A Longitudinal Study. Roux G, et al. J Perinat Educ. 2002 Fall; 11(4): 25 - 36.– Longitudinal study explores relationship of PPD and marital dysfunction on

infant outcomes from birth to 2 ½ years• Changes in maternal depressive symptoms across the postpartum year at

well child care visits. Chaudron LH, et al. Ambul Pediatr. 2006 Jul-Aug; 6(4): 221 - 4.– Describes incidence, continuation, and resolution of symptoms during the

postpartum year in urban women experiencing high depressive symptom levels at one or more well child visits

• Is difficult childbirth related to postpartum maternal outcomes in the early postpartum period? Hunker DF, et al. Arch Womens Ment Health. 2009 Apr 7. – Relationship of adverse events in labor or delivery and depressive symptoms,

functional status, and infant care at 2-weeks postpartum• Mental Illness as a Risk Factor for Uninsurance Among Mothers of Infants.

Noonan K, et al. Matern Child Health J. 2008 Nov 7.– Diagnosis of mental illness, both prenatally and postpartum, is associated

with low likelihood of having health insurance• Postnatal depression and mother and infant outcomes after infant massage.

O Higgins M, et al. J Affect Disord. 2008 Jul; 109(1-2): 189 - 92. – Depressed mothers who attended infant massage classes had greater

reductions in depression scores than those who attended a support group• Postpartum Depression: Essentials for Intervening. Healthy Start Inc. and

Women's Behavioral HealthCARE, Reynolds S, Svidergol D, Costello P. Western Psychiatric Institute and Clinic, May 2005.

National PPD Legislation

• Melanie Blocker Stokes MOTHERS Act– MOTHERS ACT stands for Mom’s Opportunity to

Access Health, Education, Research, and Support for Postpartum Depression Act

– Will help provide support services to women suffering from PPD and psychosis

– Will help educate mothers and their families about these conditions

– Will support research into causes, diagnoses and treatments for PPD and psychosis

US State PPD LegislationIllinois• Senate Bill 15 “Postpartum Mood Disorders Prevention Act” became law in 2008• Calls for early PPD screening by front-line health workers such as pediatricians,

primary care doctors, nurse practitioners and obstetricians• Medicaid covers PPD screenings and treatment• Screening using approved instrument is reimbursable for women enrolled in

health care and family services, from pregnancy through 1 year after delivery• If done during infant’s well-child and episodic visits, screening can be reimbursed

through infant’s coverage• Infants and toddlers of mothers with mental health diagnoses (including

depression) are automatically eligible for Early Intervention program• Through contract with managed care organizations and primary care case

management network, state requires prenatal and postpartum depression screening using approved validated standardized tool, referral, treatment, and ongoing monitoring and tracking for enrollees

• Complementary state law requires women and families be educated about perinatal mental health disorders in prenatal and labor and delivery settings, and that women be invited to take assessment questionnaire in prenatal, postnatal, and pediatric care settings

• Perinatal Mental Health Consultation Service operated by University of Illinois at Chicago, in partnership with the Illinois Chapter of American Academy of Pediatrics and Academy of Family Physicians, offers provider consultative services and education and training to clinicians to develop competencies in assessment and treatment of maternal depression

• Education and quality improvement initiatives include stepped-care model development– Includes self-care kits to be disseminated statewide that provide information

on when and where to access resources• Includes support for postpartum depression crisis intervention through hotlines

US State PPD LegislationIowa• Iowa Perinatal Depression Project

– Expanded screening, early identification, and effective treatment referrals– Housed within Bureau of Family Health within Division of Health Promotion

and Chronic Disease Prevention of Iowa Department of Public Health• In collaboration with 3 other state departments, statewide advocacy organization,

and University of Iowa, sponsors statewide train-the-trainer program– Trains staff in early childhood, maternal health, case management, and

mental health programs, as well as Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), nursing, and home visiting staff

– Includes mentorship component– Requires agency-level commitment to screening– Reimburses agencies for staff time

• Collaborated with University of Iowa to develop web-based training for physicians known as STEP (Support and Train to Enhance Primary Care)– Contains consultation component– Enhances state’s capacity in primary care to identify and treat PPD

• Produced pocket guide for health care professionals that includes treatment, coding, and billing information

• Established provider and consumer website providing referral information that identifies mental health providers in all 99 counties, details of payment requirements and their specific training in perinatal depression– Primary care providers who access this service can also get free

consultation with University of Iowa–based mental health clinician• Added 2 depression screening questions from PHQ to Department of Human

Services–approved Prenatal Risk Assessment tool required for all providers• Funds toll-free telephone resource and referral information line

US State PPD Legislation

Kentucky• Kentucky Health Access Nurturing Development Services (H.A.N.D.S.) Reach Out

about Perinatal Depression Project– Housed in Kentucky Department of Public Health– Runs home visiting program that promotes supportive and healthy

environment for mothers and their newborns– Home visitors trained through Madison County Health Department and

University of Louisville– Developed stepped-care protocol for referral and treatment of women

depending on scores on self-administered PPD screening tool

Louisiana• Louisiana Perinatal Depression Project

– Through Louisiana Department of Health and Hospitals– Provided mental health treatment and case management to women,

infants and their support partners in metropolitan New Orleans– Trains providers about perinatal depression and infant mental health

Massachusetts• HB 3897, An Act Relative to Postpartum Depression, passed January 2009

– Stipulates treatment and coverage for maternal post-partum depression– Details periodic screenings in multiple settings, interventions,

collaborations, referrals, statewide professional development and trainings, and public awareness campaigns


Maine• LD 792/SP 241, February 2007

– Provides information on and screening for prenatal and postpartum mental health issues to pregnant women and mothers of children under 1 year of age and information to partners, spouses or fathers, and family members

Minnesota• Postpartum Depression Education and Information Bill (S.F. 2278) passed in 2006

– Requires all providers of prenatal care have information about PPD available to pregnant women and their families

– Requires hospitals and other health care facilities provide new mothers and their families with written information about PPD

– Included statutory requirements and best-practice guidelines for where and when information ought to be offered

New Jersey• New Jersey S213, Postpartum Depression Law, signed into law in 2006• Introduced by State Senate President Codey, inspired by wife Mary Jo Codey• 1st in US to require healthcare providers and facilities to screen women who have

recently given birth for postpartum depression and to educate women and families

• Budget of $4.5 million provided for comprehensive program, including establishment of statewide perinatal mental health referral network

• Program called "Speak Up When You're Down”


Oregon• House Bill 2666 passed in 2009• Created statewide workgroup on maternal mental health disorders within

Department of Human Services• Includes representatives from families, early childhood, and maternal care

providers• Will address vulnerable populations across state• Will identify successful projects implemented in Oregon and other states and

recommend programs, tools, and funding sources to initiate needed projects• Will make report to legislature identifying actions to be taken by 2015 to reduce

risk of harm to women and their children• In January 2010, introduced resolution to designate every May as Maternal Mental

Health Awareness Month

Texas• HB3318 introduced in 2009• Potentially 1st infanticide law in US• Would apply to women who commit infanticide within 12 months of giving birth• If jurors find defendant guilty of murder, they can take testimony about

postpartum issues into consideration during trial's punishment phase


Virginia• House Bill 2310 passed in 2003• Required all hospital staff (nurses, doctors, etc) to distribute perinatal depression

statistics and materials

Washington• SB 5898 and HB 1427 passed in 2005• Ordered public information campaign on postpartum depression• Mandated council conduct proactive public information and communication outreach

campaign concerning significance, signs, and treatment of PPD• "Speak Up When You're Down" campaign created and implemented as result

West Virginia• H.B. 4052 Uniform Maternal Screening Bill passed in April 2009 as SB307• Requires women undergo prenatal risk screening upon entering prenatal care• Created Maternal Risk Screening Advisory

California• Assembly Concurrent Resolution 105 (ACR 105) passed State Assembly April 2010• Proclaims month of May every year as Perinatal Depression Awareness Month

Documents

A Pediatrician’s Perspective on Postpartum Depression Kellie Haworth, MD, FAAP Major, Medical Corps, United States Army Postpartum Support International