UIC PERINATAL MENTAL HEALTH PROJECT

Perinatal Screening and Assessment

Considering all of the complications that are associated with childbearing, which conditions merit perinatal screening programs? This is a question that busy clinicians, health care administrators and policy makers must ask, given limited time, funds and personnel. In order for a screening program to be worthwhile, the following criteria should be met:

• The condition should be common in the population being screened.
• The risks associated with not recognizing and treating the condition should be substantial.
• The screening tools should be considerably more effective than current detection methods, have proven validity, and be acceptable to both clinicians and patients.
• Effective treatments should be available for those patients who are identified through the screening program.

The information to follow discusses the advantages and disadvantages of various screening tools and offers guidance about how to best assist pregnant and postpartum women who are identified in prenatal and primary care settings as experiencing depressive symptoms.

Screening Tools
Edinburgh Postnatal Depression Scale:

The Edinburgh Postnatal Depression Scale (EPDS) is the most widely recognized and validated peripartum depression screening tool. It is a 10 item self-report questionnaire. It was designed to screen postpartum women for depressive symptoms in a clinical setting, but has since been validated for use in non-clinical settings and during pregnancy as well. Each of its ten items receives 0-3 points based on the severity of the symptom, resulting in a total score of 0-30. A cut off value between 9 and 13 is selected by the clinician to identify women at risk of depressive disorders. The EPDS focuses on the affective and cognitive disturbances of depression rather than somatic symptoms. It does, however, include one question about sleep (Cox 1987). One of the primary advantages of the EPDS over other rating scales is that it accounts for normal physiological changes associated with the peripartum period. With other standard screening tools for depression, normal alterations in energy, appetite and sleep associated with childbearing could be confused with depressive symptoms and thus decrease specificity. The EPDS has been validated in many cultures and in diverse clinical populations. The EPDS has been translated into more than 20 languages. The EPDS maintains good sensitivity and specificity across these diverse settings.

The brevity of the EPDS is an important advantage over other screening options. With ten questions, it takes less than 5 minutes to complete. This makes its use relatively easy to incorporate into a busy clinical practice. It can be administered and scored by personnel who are not trained in psychiatric assessment. It is generally well accepted by both patients and clinicians (Cox 1996, Murray 1990, Werrett 2006, Milgrom 2005).

One of the primary disadvantages of the EPDS is that its questions do not correspond to specific DSM-IV criteria for depression. Therefore, if a woman screens positively with the EPDS, she must undergo an assessment that includes these Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)criteria before she can be formally diagnosed with depression. Although it is necessary to complete an assessment following any positive screen no matter what screening tool is used, the assessment interview may be more time consuming if the EPDS is the selected screening tool. Another limitation of the EPDS is that to date, there are insufficient data to determine whether it can be used to track responses to treatment over time.

Patient Health Questionnaire:

The Patient Health Questionnaire (PHQ-9) is a 9-item depression screening questionnaire derived from the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD PHQ) (Kroenke 2001). The PRIME-MD PHQ was developed for and validated in primary care settings and is based on DSM criteria (Spitzer 1999, 2000). PHQ-9 score ranges from 0-27. Each of the 9 items is scored from 0 (not at all) to 3 (nearly every day). The total score reflects the severity of the depression according to DSM-IV depression criteria. Like the DSM IV, the questions relate to what symptoms a patient has experienced over the past two weeks. Like the EPDS, the PHQ-9 has the advantage of being brief and easily scored (Kroenke 2001). The PHQ-9 can substantially speed up the assessment/diagnosis process because of its correlation to the DSM-IV. Changes in the PHQ-9 score have been shown to correspond to changes in depression status over time and can be used to evaluate treatment outcomes (Dietrich 2003).

It is important to note that the PHQ-9 was not designed for peripartum use (Spitzer 2000). Hence, endorsement of normal somatic adaptations that are associated with childbearing may limit its specificity and sensitivity in peripartum populations. In two studies, the PHQ-9 was shown to be a reliable and valid tool for measuring depressive severity in a prenatal clinic and in an obstetrics/gynecology clinic population (Spitzer 2000). However, there are no published validation data specifically in peripartum populations, other languages, or cross-cultural settings.

Postpartum Depression Screening Scale:

The Postpartum Depression Screening Scale (PDSS) was developed and validated in 2000, and has been used predominately in the United States (Beck and Gable 2000). It was intended to more closely reflect the experiences of women suffering from postpartum depression (Beck and Gable 2000). Its questions are based on symptoms reported by postpartum women in a series of qualitative research studies (Beck 1992, 1993, 1996). It is a 35-item self report questionnaire that assesses seven dimensions: Sleeping/Eating Disturbances, Anxiety/ Insecurity, Emotional Lability, Cognitive Impairment, Loss of Self, Guilt/Shame, and Contemplating Harming Oneself (Beck and Gable 2000) Each item receives a score from 1-5 based on degree of agreement with each statement. A cut-off score of 80 has been recommended when screening for major depression and a cut-off score of 60 when screening for major or minor depression (Beck and Gable 2001).

The length of the PDSS is both an advantage and a disadvantage. Although it requires more time to complete and score, it also provides more detailed information about the mother’s symptomatology. Thus it may be helpful in guiding treatment. (Beck and Gable 2001).

One of the primary disadvantages of the PDSS is the limited number of published validation studies. Unlike the EPDS, the PDSS has not been studied in other cultures or languages. Additionally, its use has not been validated during the antepartum period. As with the EPDS, the PDSS requires a diagnostic interview to establish a diagnosis, which may prolong the assessment process. Furthermore, there are no published data on its acceptance by patients or clinicians, ease of use, completion time or who can appropriately administer and score the scale in the clinical setting.

Beck Depression Inventory:

The Beck Depression Inventory (BDI) was introduced in 1961, and has become one of the most widely used depression screening tools for the general population (Beck 1988). The BDI is made up of 21 items rated from 0-3. It assesses cognitive, affective, motivational and vegetative symptoms of depression. The cut-off score varies depending on the population being screened and the purpose of the screening (Beck 1988). In 1996, the BDI was revised to correspond with the DSM-IV; the revised version is known as the BDI-II.

Even though the BDI has been well validated in general populations (Beck 1988), it has not been validated for use in pregnant and postpartum patients. Some studies suggest that the BDI may be a superior tool after the initial depression screen has been completed (Milgrom 2005), and may more accurately assess the severity of depression.

Implementing a screening program includes:

• Choosing a screening tool appropriate for the setting. For example, a prenatal clinic may choose the EPDS due to its better validation in peripartum women; while a family medicine clinic may choose the PHQ-9 due to its suitability for use with a variety of patients, and its usefulness as an assessment and treatment-tracking tool.
• Choosing a cut-off score within the validated range. For example, cut-off scores in EPDS validation studies range from 10 – 13. A clinic aiming to identify as many patients as possible might choose 10 as a cut-off. A clinic with limited resources aiming to be certain to identify and help the most severe cases without overwhelming their system might choose a cut-off of 12 or 13.
• Determining when the screening questionnaire will be administered. Although no clear standard has been established as to when and how often women should be screened for peripartum depression, some sources recommend routine screening during prenatal visits, at the 6-week postpartum check up, and at well-child visits up through 6-12 months after delivery (Peindl 2004, Stowe 2005, Chaudron 2004).
• Determining who will administer and score the screening tool, and how the score will be communicated to the treating provider. For example, a clinic setting may train a medical assistant (MA) or case manager (CM) to explain the tool to patients as they check in for clinic visits, assist with completion as needed, and score the questionnaire. The MA or CM can then transmit the score to the treating health care provider via a designated place within an electronic medical record or a medical chart, taking care to protect patient confidentiality.

Assessment

Scoring above a cut-off point on a depression screening tool does not necessarily signify that a woman has major depression. It indicates, however, that she has a high likelihood of having major depression, and that she needs a clinical assessment. Such an assessment serves the following purposes:

• Making a diagnosis. Women who “screen positive” on self-report questionnaires may indeed have unipolar major depression. A clinician may wish to refer to the DSM-IV-TR depression criteria to aid in this assessment. However, they may also have bipolar disorder, minor depression, depression due to a medical condition (i.e. thyroid disease, anemia, HIV), or distress but no psychiatric disorder. It is of particular importance to differentiate between unipolar depression and bipolar disorder because antidepressants can trigger manic episodes in patients with bipolar depression. Further, women with bipolar depression are at high risk of experiencing mood episodes with psychotic features postpartum (Goldberg 2003, Miller 1999). The Mood Disorder Questionnaire (MDQ) is a 13-item self-report screening tool that can be used to detect Bipolar I and II disorder. This tool has been validated in the primary care setting (Hirschfeld 2005).
• Determining symptom severity. Mild to moderate unipolar, non-psychotic depression can often be treated by a trained primary or prenatal care provider, but severe depressive episodes, and depressive episodes with psychotic features, are usually best treated by a psychiatrist. Tools such as the PHQ-9 can be useful in evaluating depression severity; a score 20-27 on the PHQ-9 meets criteria for severe depression, 15-19 corresponds to moderately severe depression, 10-14 reflects moderate depression, 5-9 suggests mild depression, and 0-5 does not meet criteria for major depression. Alternately, a clinical interview can elucidate depression severity.
• Determining risk of suicide. Each of the commonly used depression screening tools contains at least one item about suicidal thoughts. Having suicidal thoughts does not necessarily mean that a woman is at immanent risk of killing herself, but it does mean that her level of suicide risk needs prompt assessment. The most relevant variables in assessing acute risk are whether she has intent to kill herself, whether she has a specific suicide plan, and whether she has the means to carry out this plan (e.g. a gun in her purse; an extra stash of pills that would be fatal in overdose). Data are limited on formal suicide risk assessment tools. Clinicians should not hesitate to ask about suicidal thoughts; asking does not put the thought of suicide into a patient’s mind if it was not already there. If any of these serious circumstances exist, the woman requires a prompt assessment by a mental health professional, usually in an emergency room (Brody 1995).

Evaluating Suicide Risk

Passive death wish: “Has it gotten to the point where you started wishing you were dead?”

Suicidal ideations: “Have you had thoughts about hurting yourself or killing yourself?”

Intent: “Do you ever have the desire to act on these thoughts?”

Plan: “If you killed yourself, how would you go about it?”

Access to means: “Do you have access to a gun? Do you have extra medication around your home? Have you ever saved up medication in case you might need it to overdose?”

Safety measures: “When you have suicidal thoughts, what do you do? Do you tell anyone or seek the company of supportive people? Do you take steps to counteract these thoughts?”

Protective factors: “What prevents you from acting on these thoughts (religion, children, etc.)?”

• Determining risk of harm to the baby. Thoughts about harming a baby are relatively common in women with postpartum depression (Jennings et al. 1999). In the great majority of cases, these thoughts are “ego dystonic”, meaning that the woman has no intention or desire to act on the thoughts and finds them highly distressing. In a small minority of cases, there is a significant risk that a woman will act on thoughts of harming a baby. In these cases, the mother may have an intent or impulse to carry out the thoughts. Sometimes this is due to delusional thinking or command hallucinations. In other cases, the mother may plan to kill the baby in conjunction with her own suicide so that it is not abandoned, or may wish to protect or “save” the baby by ending its life. The presence of psychotic symptoms greatly increases the risk of infanticide.
• Assessment can distinguish these high-risk cases from the more common low-risk cases. In eliciting thoughts about harming a baby, it can be helpful to normalize the experience – e.g. “It’s not uncommon for mothers to have thoughts of harming their babies, even if they wouldn’t act on the thoughts. Has this happened to you?”

Low-risk vs. High-risk Thoughts of Harming a Baby in Women with Postpartum Depression

Ego-dystonic	Ego-syntonic
No intent to kill	Intent to act on the thoughts
Mother feels distress and shame about the thoughts	Often part of a plan for the mother to kill herself
Common accompaniments of non-psychotic depression and obsessive compulsive disorder (OCD)	Often influenced by delusional thinking and/or command hallucinations
	Rare

Models of health care delivery for perinatal depression

Once a woman has been identified as suffering from perinatal depression, the care provider must decide on a treatment approach. Some prenatal care providers prefer to refer patients to a mental health specialist for care. However, as many as half of all patients referred to mental health specialists do not complete the referral (Katon 1995) This resistance may result from stigma connected to formal mental health treatment, or simply the inconvenience of seeking care at another facility (Tam 2002; Carter 2005). Women may be more accepting of care from a prenatal care provider that they know well and trust. Treatment of mild to moderate unipolar, non-psychotic depression can occur in prenatal care settings if prenatal care providers have:

• Adequate training: Training can occur through online programs, workshops, and seminars.
• Readily accessible consultation with mental health professionals: Prenatal care providers can utilize consultation to discuss diagnostic uncertainty, medication options, potential side effects, treatment resistance, and appropriateness of referrals.

A Depression Disease Management Model.

Disease management models (DMM’s) are evidence-based treatment algorithms that are used to manage diseases such as hypertension, diabetes mellitus, and depression within primary care settings. DMM’s offer cost effectiveness, improved patient compliance, decreased patient stigma and inconvenience, and improved outcomes (Katon 1997). It guides the care provider through screening, assessment, treatment and referral options. This algorithm uses a stepped care approach to guide providers in identifying when a referral to specialty care is necessary. Stepped care has been widely studied and has proven efficacy in the treatment of depression in the general population (Katon 1995). Although it has not been developed or tested in the treatment of perinatal depression, stepped care can be adapted for this purpose.

Peripartum major depression is a highly prevalent condition that increases the risk of adverse outcomes for women and their offspring. Formal screening far surpasses routine clinical evaluation in effective detection of peripartum depression. However, in order to improve outcomes, a screening program must be linked with an effective system for assessing women with “at risk” screening results, and treating women identified as having depression. A Peripartum Depression Management Model incorporated into prenatal and/or primary care settings, backed up by readily available consultation with mental health professionals, shows promise for substantially improving the lot of women and their children at this vulnerable and formative time of life.