How to use this PowerPoint template · How to use this PowerPoint template Author: Millick, Karissa Created Date: 5/22/2020 8:46:30 AM

5/22/2020

RECOGNITION AND MANAGEMENT

OF POSTPARTUM DEPRESSION IN THE

PEDIATRIC OFFICE VISIT

MEREDITH SPADA, MD

ASSISTANT PROFESSOR OF

PSYCHIATRY

UNIVERSITY OF PITTSBURGH

SCHOOL OF MEDICINE

[email protected]

EYDIE MOSES-KOLKO, MD

ASSOCIATE PROFESSOR OF

PSYCHIATRY

UNIVERSITY OF PITTSBURGH

SCHOOL OF MEDICINE

[email protected]

OBJECTIVES

Describe the rationale for screening for postpartum depression

Describe a screening tool that is appropriate for identifying postpartum depression in the pediatrics office visit

Describe appropriate disposition planning for moms who present to a newborn/infant visit with postpartum depression

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PART 1

Why screen for postpartum depression?

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QUESTION 1

Which of the following is a potential consequence of

postpartum depression?

A. Fewer reports of child abuse and neglect

B. Improved parental adherence to safety guidelines

C. Increased rates of breastfeeding

D. Inappropriate medical care

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QUESTION 2

Which of the following is more likely in the offspring of

mothers with postpartum depression?

A. Impaired social interaction

B. Delays in language, cognitive, and social-emotional development

C. ADHD, anxiety, depression, and conduct disorder

D. All of the above

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QUESTION 3

Are you currently conducting screening for postpartum

depression in your practice?

A. yes

B. no

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QUESTION 4

What year did the American Academy of Pediatrics recommend

screening for postpartum depression?

A. 1995

B. 2010

C. 2013

D. 2019

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QUESTION 5

How much more likely are pediatricians to detect postpartum

depression when a screening tool is utilized?

A. 2X

B. 4X

C. 8X

D. 20X

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PART 2

IMPLEMENTING THE Edinburgh Postnatal

Depression Scale (EPDS)

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SCREENING FOR POSTPARTUM DEPRESSION

Edinburgh Postnatal Depression Scale

Widely used and validated

Ten-items; item 10 assesses suicidality

Score by summing items (3 items reverse scored)

AAP recommends screening at 1, 2, 4, and 6- month visits

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Earls 2010 Pediatrics

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EPDS – PAST 7 DAY REPORT

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Choices: not at all (0), Not very often (1), some of the time (2), most of the time (3)

1. I have been able to laugh and see the funny side of things

2. I have looked forward with enjoyment to things

3. I have blamed myself unnecessarily when things went wrong

4. I have been anxious or worried for no good reason

5. I have felt scared or panicky for no very good reason

6. Things have been getting on top of me

7. I have been so unhappy that I have had difficulty sleeping

8. I have felt sad or miserable

9. I have been so unhappy that I have been crying

10.The thought of harming myself has occurred to me

EPDS SCREENING

Scores ≥ 10 are suggestive of minor

depression

Scores ≥ 13 (postpartum) and ≥ 15

(antenatal) confer greater specificity for a major

depressive episode

Positive screen indicates risk NOT diagnosis

Gibson et al 2009 Acta Psychiatr Scand

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Staff gives

mom EPDS

Adapted from Cox et al 2017 JOGNN

Algorithm

Staff gives

mom EPDS

Clinician reviews +

responses with mom


Algorithm

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Staff gives

mom EPDS

Clinician reviews +

responses with mom

Clinician reviews

item 10 and

assesses for

safety


Algorithm

Staff gives

mom EPDS

Clinician reviews +

responses with mom

Clinician reviews

item 10 and

assesses for

safety

Review

EPDS

score

Score < 10

Provide education

Welcome contact if

symptoms appearAdapted from Cox et al 2017 JOGNN

Algorithm

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https://newmomhealth.com/

Staff gives

mom EPDS

Clinician reviews +

responses with mom

Clinician reviews

item 10 and

assesses for

safety

Review

EPDS

scoreScore 10-12

(concern for minor

depression)

Discuss stress relief,

coping strategies, selfcare,

sleep hygiene

Provide resource list

Follow-up at next apt


Algorithm

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TALKINGTO MOM

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Review screen with Mom, including score and what it means

Reduce shame/guilt by emphasizing that PPD is

common,not her fault, and can be treated

Offer support

Discuss referrals if indicated (more on this to come)

Earls et al 2019 Pediatrics

CREATING A DETAILED RESOURCE LIST

Local non-emergency services

• Psychiatrists

• Psychiatric NPs

• Integrated BH primary care clinics

• Therapists

• Support groups

Local emergency services (if possible

include response time)

• Emergency rooms

• Mobile crisis team

• Crisis hotlines

• Crisis center

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Staff gives

mom EPDS

Clinician reviews +

responses with mom

Clinician reviews

item 10 and

assesses for

safety

Review

EPDS

score

Score > 12 (concern for

major depression)

Clinician alarmed by

psychiatric situation or

intent/plan for self-harm

or suicide

YES: Get input from psych

Arrange transport to ER

NO: Referral for therapy

and psychiatric evaluation


Consider IOP

Follow-up by phone & at

next apt


Algorithm

ASKING ABOUT SUICIDAL THOUGHTS

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Be direct, specific, and ask about

Feelings of hopelessness and despair->thoughts that life isn’t worth living

->passive wish to die->suicidal thoughts

Frequency, intensity, duration

Plans and behaviors, preparations for dying: timing, location, method

Last 48 hours, Last month

Homicidality

Worst ever ideation

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SUICIDE RISK ASSESSMENT

High Risk – Medical emergency

Suicidal ideation with a plan, with intent or attempt

Has made a serious or nearly lethal suicide attempt

Recent discharge from psychiatric inpatient unit

History of acts/threats of aggression

Command hallucinations

Psychotic

Emergency room

Involuntary commitment

Suicide precautions

SUICIDE RISK ASSESSMENT

Moderate/Low Risk

Thoughts of death, with or without plan, no intent or behavior

No imminent threat to self/others

If many risk and few protective factors, hospitalization may be

necessary

Crisis/Safety plan

Begin Treatment

Set up Behavioral Health Appointment

Follow-up call by office

Give patient resources if symptoms worsen

Re:Solve Crisis Network 1-888-796-8226

WPIC ER

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Staff gives

mom EPDS

Clinician reviews +

responses with mom

Clinician reviews

item 10 and

assesses for

safety

Review

EPDS

score


major depression)




or suicide

Score 10-12

(concern for minor

depression)

Score < 10






Consider IOP


next apt



sleep hygiene



Provide education

Welcome contact if

symptoms appearAdapted from Cox et al 2017 JOGNN

Algorithm

PART 3

CASES

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CASE 1

Ms. B is a 32 yo G1P1 who presents to her son's 2 month

visit.The son is overall healthy and growth is appropriate

EPDS =14 (0 for item 10)

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CASE 1 CONTINUED

When following up on the EPDS, Ms. B bursts into tears, stating that she has been having trouble getting out of bed. She has had difficulty sleeping, extreme anxiety, poor appetite, tearfulness, and difficulty coping.

She reports that she has been having the thought that it would be better if she didn’t wake up or if she died, however she denies SI/HI/intent/plan. She adamantly denies any thoughts to harm herself, baby, or anyone else.

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CASE 1

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DISCUSS WITH YOUR GROUP

BABY BLUES

Self-limited

Maternal role functioning not affected

Within 10 days of delivery

50-80% of new mothers

Symptoms: tearfulness, irritability, anergia,

overwhelmed feelings30

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PERINATAL DEPRESSION: THEMES

Anxiety, worry, overwhelmed

GAD is more common in postpartum women than the general population

Thoughts racing “Brain won’t shut off”

Insomnia

Panic symptoms

Self-blame, guilt

Inadequate mother

Things will never be the same again; hopelessness

Suboptimal delivery/medical complications Marrs et al (2009) J Aff Disorders

Staff gives

mom EPDS

Clinician reviews +

responses with mom

Clinician reviews

item 10 and

assesses for

safety

Review

EPDS

score


major depression)




or suicide

Score 10-12

(concern for minor

depression)

Score < 10






Consider IOP


next apt



sleep hygiene



Provide education

Welcome contact if

symptoms appear


Algorithm

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DOCUMENTATION IN INFANT'S CHART

Type of screening tool used

Discussion with mother/parents (whether positive or negative)

If indicated: followup and referral plan

There is no reason to open a chart on the mother because she

is not receiving treatment

Earls et al 2019 Pediatrics

CASE 2

Ms. C is 21 year old G3. She presents with her 1 month old

daughter

She lives with her mom and 3 children

She scores a 15 on the EPDS and responds "yes, quite often" to

question 10 regarding thoughts of harming self

She reports a history of severe postpartum depression

following the birth of her first child34

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You followup the EPDS and perform a suicide screen

What questions would you ask to assess for suicidality?

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CASE 2 CONTINUED

CASE 2 CONTINUED

She reports that she has had suicidal thoughts to overdose on

over the counter medications. She feels hopeless.

She denies that she has taken steps to move forward with this

plan including googling how much she would need to take.

What is your plan?

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CASE 2

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Staff gives

mom EPDS

Clinician reviews +

responses with mom

Clinician reviews

item 10 and

assesses for

safety

Review

EPDS

score


major depression)




or suicide

Score 10-12

(concern for minor

depression)

Score < 10






Consider IOP


next apt



sleep hygiene



Provide education

Welcome contact if

symptoms appear


Algorithm

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CASE 3

27 yo MF presents with her 2 year old son and 6 mo old

daughter who she is breastfeeding

She reports fears that something horrible could happen to her

children

Has panic attacks, very poor sleep, low energy and difficulty

functioning

She scores a 22 on the EPDS and responds "yes, quite often" to

question 10 39

CASE 3 (CONT’D)

You dig deeper:

She refuses to leave children for fear of their safety despite her husband’s suggestion that she should visit with a friend to help relax

She is having both children sleep in her room at night so that she can check on their breathing

She is fearful of using the stairs because she is worried she will drop her children

She has stopped cooking and is ordering takeout because she has repeated distressing images of stabbing her children with a knife. This is extremely distressing for her.

PCP recommended Zoloft, but she was too fearful about side effects, on self, nursing infant, and fear if she were to become pregnant and how it would affect fetus

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CASE 3

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OBSESSIVE-COMPULSIVE SYMPTOMS

Obsessions = Irrational, intrusive thoughts

25% of perinatal women have obsessions; 3-9% of perinatal women have OCD

Examples: Aggressive, harm befalling loved ones, contamination

Obsessions are ego-dystonic, very distressing, and mothers try to resist them or avoid

danger

Compulsions = Irresistible urges

Checking repeatedly on infant “won’t let child out of my sight”

Breastfeeding/pumping schedule

Preventing contact with germsWisner, Hudak et al AJP; Fairbrother and Woody AWMH 2008

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Staff gives

mom EPDS

Clinician reviews +

responses with mom

Clinician reviews

item 10 and

assesses for

safety

Review

EPDS

score


major depression)




or suicide

Score 10-12

(concern for minor

depression)

Score < 10






Consider IOP


next apt



sleep hygiene



Provide education

Welcome contact if

symptoms appear


Algorithm

Thanks for your attention!

[email protected]

[email protected]

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Documents

How to use this PowerPoint template · How to use this PowerPoint template Author: Millick, Karissa Created Date: 5/22/2020 8:46:30 AM