a pediatrician’s perspective on postpartum depression kellie haworth, md, faap major, medical...
TRANSCRIPT
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’”
24 yo G1P1 mom, student, no prior psych hx
“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
Definitions and Epidemiology
• 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
24 yo G1P1 mom, student, no prior psych hx
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.”
Definitions and Epidemiology
• 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
Definitions and Epidemiology
• 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
24 yo G1P1 mom, student, no prior psych hx
“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.”
28 yo G2P2 mom, physician, prior h/o PPD
“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.”
28 yo G2P2 mom, physician, prior h/o PPD
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
28 yo G2P2 mom, physician, prior h/o PPD
“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...”
28 yo G2P2 mom, physician, prior h/o PPD
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...”
28 yo G2P2 mom, physician, prior h/o PPD
5 ¾ months postpartum:– Self request for hospitalization– Both antipsychotic doses again increased
As her Pediatrician at the6 month well child visit…
• 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
28 yo G2P2 mom, physician, prior h/o PPD
As her Pediatrician at the9 month well child visit…
• 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 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
“Incidence and Severity of Postpartum Depression Among Military Beneficiaries”
• 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
28 yo G2P2 mom, physician, prior h/o PPD
“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
AAP Bright Futures Guidelines
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
DSM-IV-TR Diagnostic Criteria
• 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
• “Postpartum Onset” Specifier– Onset must be within 4 weeks after delivery
DSM-IV-TR Diagnostic Criteria
• 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
• “Postpartum Onset” Specifier– Onset must be within 4 weeks after delivery
DSM-IV-TR Diagnostic Criteria
• 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
DSM-IV-TR Diagnostic Criteria
• 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
• “Postpartum Onset” Specifier– Onset must be within 4 weeks after delivery
DSM-IV-TR Diagnostic Criteria
• 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
• Cost of tool– Free
• 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
• Cost of tool– Free
• 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
• Cost of tool– Free
• 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
US State PPD Legislation
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”
US State PPD Legislation
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
US State PPD Legislation
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