A Descriptive Assessment of Depression & Anxiety Symptoms

in an Outpatient Obstetric Clinic Sample: Screening for Symptoms in the Context of

Substance Use Histories

Teresa A. Lillis, M.A., ABI.1,2, Stephen Lassen, PhD.2, & Erin Smith, B.S.2

1. Rush University Medical Center, Dept. of Behavioral Sciences, Chicago, IL.2. University of Kansas Medical Center, Dept. of Pediatrics, Kansas City, KS.

✔

Conflict of Interest Disclosures for Speakers

1. I do not have any relationships with any entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, OR

2. I have the following relationships with entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients:

Type of Potential Conflict Details of Potential Conflict

Grant/Research Support

Consultant

Speakers’ Bureaus

Financial support

Other

3. The material presented in this lecture has no relationship with any of these potential conflicts, OR

4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:

1.

2.

3.

Health Promotion in the Postpartum• The birth of a child is a considered the greatest change in the family

life cycle (Nystrom & Ohrling, 2004).• A time of excitement and joy as well as considerable stress.

• North American women receive a great detail of medical attention and advice during pregnancy, but much less in the postpartum (Ayoola et al., 2010).• This shift can leave women vulnerable to psychological problems

arising in the postpartum.• Adequate screening for postpartum psychological issues with

provision of appropriate treatment-related referrals may improve the long-term health outcomes of both mothers and their babies.

Mental Health in the Postpartum• Postpartum Depression (PPD)is the most common mental health

issue.• Prevalence 10-20% of U.S. women and ~15% of women world-wide (Beck

et al., 2001; O’Hara et al., 2009).• Diagnostic criteria for PPD are the same as for a Major Depressive Episode

• For the previous two weeks:• Down/depressed mood nearly every day AND/OR loss of interest or pleasure in

previously enjoyable activities• Five or more of the following symptoms present most days:

• Significant change in appetite or weight• Insomnia or hypersomnia• Psychomotor agitation/retardation• Fatigue/loss of energy• Feelings of worthless/guilt• Difficulty concentrating/making decisions• Suicidal thoughts/plans/intent/attempts

• Onset limited 2 weeks-12 months postpartum.• Different from the “baby blues.”

• Birth-2 weeks postpartum; mildly depressed mood, tearfulness, fatigue.

Mental Health in the Postpartum Cont.

• Anxiety-related issues may also occur.• 12-20% experience generalized anxiety symptoms (Farr et al., 2014; Stuart et

al, 1998; Wenzel et al., 2005; Vesga-Lopez et al., 2008)• OCD symptoms in 11% (Miller et al., 2013)• PTSD symptoms in 9% (Beck et al., 2011)

• Depression and Anxiety disorders are highly comorbid in perinatal populations (Cohen & Pearlstein, 2010).• Discrete symptom presentation is the exception rather than the rule.

• Precise etiology for psychiatric disorder manifestation in perinatal populations is unclear.• Likely a diathesis stress disorder.

• An existing predisposition or genetic vulnerability is triggered by stress of pregnancy or labor/delivery.

• Risk Factors (Brockington, 2004):• History of Depression/Anxiety/other mental disorder, especially during

pregnancy• Poor social support• Lower Age, SES, and minority status

Perinatal Maternal Substance Use• The perinatal period is generally a time of reduced substance use

• Approximately 8-18% of childbearing women continue use of illicit and licit drugs (Connelly et al., 2014).

• Deleterious health outcomes related to perinatal substance use:• Prematurity, intrauterine/neonatal demise and poor long-term child

health outcomes (Bonello et al., 2014)

• In the general population, substance use is highly correlated with mental illness• Some studies have found perinatal substance use to be related to

worsening psychiatric symptoms severity in the perinatal period (Connelly et al.; Chisolm et al., 2009)

• Relationship remains unclear as other studies have not demonstrated this relationship (Forray et al., 2013).

Screening for Postpartum Mental Health

• Mental health screening integration into obstetric and well-child visits has improved (Olson et al., 2002; Guirguis-Blake et al., 2003).

• Most common screener, Edinburgh Postnatal Depression Scale (EPDS; Cox et al., 1987).• Beck Depression Inventory (BDI-II; Beck, 1996), CES-D, Postpartum

Depression Screening Scale (PDSS; Beck & gable, 2000), Patient Health Questionnaire-9 (PHQ-9; Spitzer et al., 1999), etc.

• The stigma of reporting emotional distress in the postpartum persists• Many at-risk postpartum women continue to missed by their

healthcare providers.• Systematic screening with treatment referral and follow-up needed to

improve maternal/child health outcomes (Gjerdingen & Barbara, 2007).

Current Study• A sample of 84 women from a Midwest Academic Medical Center

Obstetric Clinic completed the Brief-Patient Health Questionnaire (B-PHQ; Sptizer et al., 2000) at their 6-week postpartum visit.

• Brief-PHQ was chosen for its:• Brevity• Assessment of depression and anxiety symptoms• Comprehensive coverage of psychosocial stressors • Items pertaining to women’s health issues

• Limited/targeted EMR chart review conducted to confirm:• Ethnicity• Obstetric history• Characteristics from most recent delivery• Substance use history

Purpose of Study

• Describe frequency/severity of depression and anxiety symptoms reported in the obstetric sample.

• Assess the relationship between depression/anxiety symptoms and substance use history.

• Inform recommendations for postpartum mental health screening.

Brief Patient Health Questionnaire

Sample Demographics (N = 84)

White68%

African Amer-ican21%

Latina10%

Asian1%

Other1%

Ethnicity • Mean Age = 27.01 years• SD = 4.72• Range = 16-38

Obstetric Sample Characteristics

First Baby (P1) Second Baby (P2)

Third Baby (P3) Fourth Baby (P4)0

5

10

15

20

25

30

35

30

9

15

22

6 52 1

G1G2G3G4G6

# of

par

ticip

ants

*Sample = 84: Mothers of Singletons = 80, Mothers of Twins = 4

Most Recent Delivery/Birth Characteristics Delivery Type Term Below Weight Normal Overweight TOTAL

SVD preterm 3 1 0 4

early term 1 7 1 9

full term 1 28 5 34

late term 0 3 1 4

TOTAL 5 39 7 51

LTCS preterm 2 2 0 4

early term 2 6 0 8

full term 2 10 2 14

late term 0 1 0 1

TOTAL 6 19 2 27

Other preterm 2 0 2

early term 0 1 1

full term 0 1 1

TOTAL 2 2 4

TOTAL preterm 7 3 0 10

early term 3 14 1 18

full term 3 39 7 49

late term 0 4 1 5

TOTAL 13 60 9 82

EMR Substance Use History• Current/former use information obtained via EMR review.

• Matched updated information to the date of the 6-week visit/Brief-PHQ completion

• Not possible to verify whether former substance use occurred during most recent pregnancy or prior to pregnancy.

• Severity Classification for former/current use:• Smoking:

• Mild = < 1 pack/week • Moderate = 1-2 packs/week• Heavy = > 3 packs/week

• Alcohol:• Mild = “occasional” - 1-2 drinks/week• Moderate = 3-5 drinks/week• Heavy = > 5 drinks/week

• Drugs:• Mild = < 1/year• Moderate = “occasional” - 1-2x/month• Heavy = > 1/week

Substance Use CharacteristicsSubstance Use History?

No = 54Yes = 28

SmokingNo = 8

Yes = 20

Former Use = 12Mild = 6

Moderate = 3

Heavy = 3

Current Use = 8

Moderate = 3

Heavy = 5

AlcoholNo = 19Yes = 9

Former Use = 1Mild = 1

Current Use = 8Mild = 6

Moderate = 2

DrugsNo = 24Yes = 4

Former Use = 2Mild = 1

Moderate = 1

Current Use = 2Mild = 1

Moderate = 1

Substance Use Characteristics6

1 1

6

1 1

3 3

2

1 1

3

5

Mild

Moderate

Heavy

# of

resp

onde

nts

*Use of more than one substance: N= 5• All 3 substances, N = 1

• Smoking + Alcohol, N = 1• Smoking + Drugs, N = 3

Substance Use Severity• Substance Use Severity:

• Calculated based on frequency of use, number of substances used and whether the use was former or current

• Current use weighted more heavily than former use

Severe Use (Scores > 5)

Moderate (Scores 3-4)

Mild (Scores 1-2)

0 2 4 6 8 10 12 14 16

4

14

7

Severity Score(Range 1-8)

# of respondents

Depression Symptoms

Depression Symptoms

Loss

of Interest/

Pleasure

Feelin

g down/d

epressed

Trouble Sl

eeping

Fatigu

e/Low Energy

Increase

d/Reduce

d Appetite

Feelin

g Guilty

/like a Fa

ilure

Trouble Conce

ntrating

Psychomoto

r Agit

ation/Retard

ation

Suici

dal Though

ts0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Nearly Every DayMore than Half the DaysSeveral DaysNot at All

Depression Total Scores(Score Range 0-27)

No Sympto

ms (0)

Minim

al (1-4)

Mild

(5-9)

Moderat

e (10-14)

Moderat

e-Seve

re (15-20)

Seve

re (21-27)

28

35

17

41 0

#of p

artic

ipan

ts

Anxiety Symptoms

Anxiety Symptoms

0

4

8

12

9 912 12

5 52 2

NoYes

Have you had a Panic Attack in the past 4 weeks?No = 70Yes = 14

Depression/Anxiety Interference

Not at All; 76

Somewhat; 20.6

Very Much; 4 Extremely; 1

How Much Have These Symptoms Interfered in Your Daily Life?

Depression/Anxiety Symptom Summary• Most commonly reported depression symptoms:

• 1. Fatigue/Low Energy• 2. Trouble Sleeping• 3. Feeling Down/Depressed

• Severity of symptoms reported:• 33% experienced NO symptoms• 61% minimal-mild symptom severity• 6% moderate-severe symptom severity

• Only 14 respondents indicated a history of experiencing panic attacks

• 75% of the respondents did not feel impaired at all by depression and/or anxiety symptoms

Psychosocial Stressors

Pyschosocial Stressors

Health W

orries

Weigh

t/Beau

ty W

orries

Little/N

o Sexu

al Desir

e/Pleasu

re

Romantic P

artner D

ifficu

lties

Stress

of Cari

ng for C

hildren/Fa

mily

Stress

home/work/

school

Finan

cial p

roblems

No one to tu

rn to

for h

elp

Recent b

ad exp

erience

Trauma f

rom th

e past0%

10%20%30%40%50%60%70%80%90%

100%

Bothered a lot

Bothered a little

Not at all

Psychosocial Stressors Total Score(Score Range 0-20)

0

5

10

15

20

25

30

35

24

31

21

63

# of

res

pond

ents

Opened Ended Responses About Stress

“What is the most stressful thing in your life right now?• “My routine.”• “Taking care of everything that has to do around the house.”• “New baby and no sleep at night.”• “Taking care of my dad and dealing with my brother and sister.”• “Trying to lose weight.”• “Going back to work, and who will be taking care of my baby.”• “No car/money.”• “I have three kids, 3 and under!”• “Maintaining school work and handling 2 kids. [name] just found out

he will need surgery. Hard to accept.”

Opened Ended Response About Stress

Nothing31%

Childcare20%

Sleep3%

Finances12%

Work/Life Balance13%

Family Issues6%

Health Issues5%

Combination of one or more stressors

11%

Most Stressful Thing in Your Life Right now?

Summary of Psychosocial Stressors• Most commonly reported stressors:

• 1. Concerns about weight/beauty• 2. Financial Concerns• 3. Stress/Demands of Childcare

• More variability in severity of stress:• 28% report no stress• 62% report minimal-moderate stress• 10% report severe stress

• Most stressful thing in life right now?• 20% = Childcare• 13% = Work/Life Balance Issues• 12% = Finances

Statistical Relationships:Depression, Anxiety &

Substance Use

Demographic & Obstetric Correlates

Age # of Live Births Infant Birth Weight Gestational

Term

Substance Use• Smoking -.396*

Depression/Anxiety Sx• Sleep Changes• Eating Changes• Feeling depressed• History of Panic Attacks• Sx Interference

-.222*

-.236*

.252*

.230*-.231*

-.233*

Stress Sx• Partner difficulties• Financial problems• No social support• Recent trauma• Childcare stress

-.288**-.247*-.375**

-.245*

-.237*-.374** -.365**

-.366**

(*p < .05, **p < .01)

• Ethnicity, # of pregnancies, and delivery type were not correlated with substance use or depression/anxiety/psychosocial stressor symptoms

Substance Use & Psychiatric Sx

Smoking Alcohol Drugs Substance Use Severity

Depression/Anxiety Items• Sleeping much less/more

• Fatigue

• Fear of Future Panic Attacks

• Symptom Interference .409*

.538*

.919**

.790**

.345**

.258**

.307**

Psychosocial Stressor Items• Worries about weight/looks

• Childcare Stress .394*

.501** .221**

(*p < .05, **p < .01)

• Current/former substance use collapsed across individual substance categories

Predictors of Depression Total Scores

B SE β R2

Step 1(Constant)

2.271 .382

Panic Attack History 3.657 .935 .396**.157

Step 2(Constant)

.537 .419

Panic Attack History 1.798 .834 .195*Substance Use Severity .297 .150 .169*Psychosocial Stressor Severity .452 .114 .396**Symptom Interference Severity 1.708 .697 .232**

.450

Step 2 R2 Change = .293, p < .01(*p < .05, **p < .01)

• Age, ethnicity, obstetric history and most recent birth characteristics were not significant predictors of depression total scores

• Single substance types were not significantly related to depression total scores

Summary of Statistical Relationships• Demographic & Obstetric Relationships:

• Age:• Younger respondents reported more sleep disruption, more psychiatric

symptom interference, more relationship and financial stress and low social support

• Parity:• women with more children were more likely to have had a recent panic

attack and report changes in their eating habits• Women with fewer children reported more relationship stress

• Infant Birth Weight:• lower infant birth weight was related to smoking history, feeling

depressed, greater psychiatric symptom interference, low social support and recent trauma.

• Gestational Term: • Shorter gestation was related to recent trauma and greater childcare stress

Summary Cont.• Substance Use & Psychiatric Symptom Relationships:

• Smoking and drug use history and overall substance use severity were strongly, positively related to increased impairment from psychiatric symptoms.

• Drug use and overall substance use severity were strongly related to items reflecting exhaustion and fatigue and worries about weight/looks.

• Current alcohol use was predominantly mild in this sample subset and was only related to increased childcare stress.

Summary Cont.• Although the sample as a whole generally appeared high-

functioning and with relatively low levels of reported distress, variability in depression scores were related to a number of psychosocial factors:• A history of panic attacks predicted higher depression scores.• After controlling for panic attack history, higher depression scores

were predicted by:• greater psychosocial distress• greater impairment from psychiatric symptoms• Increased substance use severity

Limitations & Recommendations

Limitations• Small, homogenous sample

• Relatively high-functioning, non-distressed• Cross-sectional assessment

• No ability for longitudinal follow-up of sample to confirm/disconfirm onset of mental health problem with appropriate diagnostic tools.

• Not able to confirm pre-existing mental health diagnoses.• EMR review to assess substance use may have resulted in an

under/over-estimation of actual current/former substance use• Brief-PHQ’s lack of assessment of anxiety disorders and

symptoms, outside panic attack history

Where Do We Go From Here?• Women should continued to be screened for perinatal mental

distress.• Risk factors to consider based on this study:

• Younger mothers, multiparous mothers, and mothers with a history of shorter gestation and/or low infant birth weight

• Comorbid mental health problems• History of substance use, especially the number of substances used

and the frequency of use• Reported impairment from psychiatric symptoms• Number and severity of psychosocial stressors

How Do We Get There From Here?• Although any screener is better than no screener…

• Screeners with items that ask about “stress” in addition to face valid depression/anxiety items may circumvent propensity for underreporting

• Screening for postpartum substance use also prone to underreporting (Magura & Kang, 1996; Osterea et al., 2001).• Quasi-anonymous methods may increase perinatal substance use

disclosure (Beatty, Chase, & Ondersma, 2013).• Chart review not ideal, but may provide a context for assessing

overall physical and psychological risk in the postpartum• Good screening needs good follow-up.

• Treatment-related and follow-up referral decisions could be conceptualized with Stepped Care Model.

Stepped Care Model

No Symptoms (0)

Minimal (1-4)

Mild (5-9)

Moderate (10-14)

Moderate-Severe (15-20)

Severe (21-27)

28

35

17

4

1

0

Patients with few or no presenting problems

=Usual Care

Patients with potential concerns

=Treatment Referral Info

and/or Mental Health Consult

Intensive&

Immediate Care(*suicidal ideation)

Stepped Care Model

Stepped Care Model Decision Making: Sample Language

Patients with few or no presenting problems

=Usual Care

• Usual Care:• “Thanks so much for completing our mental

health screener. From the looks of your responses, it sounds like you’re doing pretty well, maybe just a little fatigued?

*clarify any endorsed symptoms*• “OK, well please keep an eye for any major

changes in your mood or if you feel like the fatigue is starting to affect your ability to function during day.”

*if needed, differentiate “normal” postpartum physical/psychological symptoms from potentially clinically significant symptoms*

• “You can always let your child’s Pediatrician know when you go for well-baby visits…

• Or feel free to call us back too, if you’re not sure…”

• [We’ve got lots of good resources to help with those symptoms if they persist or get worse.]”

Patients with potential concerns

=Treatment Referral Info

and/or Mental Health Consult

• Potential Concerns:• “Thank you so much for completing

our mental health screener. From your responses, it sounds like you’ve been feeling really down and are pretty stressed about heading back to work.”

• *clarify any endorsed symptoms*

• “I’m concerned about your mood and how much support you may or may not have right now to manage the stress of going back to work. I’d to share some resources with you that I think might help both of those things.”

• [“Would you be open to speaking briefly with our mental health consultant?”]

• [medication/therapy/both]

Stepped Care Model Decision Making: Sample Language

Intensive&

Immediate Care(*suicidal ideation)

• Intensive & Immediate Care:• “Thank you for completing our mental

health screener. I really appreciate your honesty and bravery in sharing how extremely difficult the postpartum has been for you.”

• *validate & clarify endorsed symptoms*• “I’m very concerned for your safety and

want to get you set up with [medication/therapy/both] today. You don’t have to suffer through this alone.”

*instill hope, especially for patients with suicidal thoughts*

*safety contract for suicidal ideation**hospitalization for acutely suicidal patients*

Stepped Care Model Decision Making: Sample Language

Acknowledgments• Dr. Stephen Lassen, Clinical Supervisor• Ms. Erin Smith, Research Assistant• University of Kansas Medical Center OBGYN Department & Staff

• Dr. Carl Weiner, Department Chair• KUMED OBGYN Attending Physicians & Residents

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