Prepared by: Elizabeth Stricker, BSN, RNC-OB
Postpartum depression is one of the most common complications of the postpartum period. It affects both the mother and the child and can cause difficulties with bonding, lack of sleep, early cessation of breastfeeding, and can progress to postpartum psychosis and suicide.
Studies in early childhood development reveal that maternal depression can also lead to long-term problems in the child, including behavioral struggles, poor sleep, and impaired development of cognitive and language skills.
Montana has a higher prevalence of depression in all populations and a higher prevalence in postpartum women specifically. In 2019-2020, 22.2% of postpartum women in Montana reported frequent mental distress. This is surpassed only by Arkansas at 23.2% and is significantly above the U.S. average of 13.6%.[i]
Nearly a quarter of Montana’s new mothers are struggling with mental distress daily. This statistic does not account for those still struggling, but not often enough to be considered “frequent,” those who minimize their symptoms, or those who are not accessing care and thus go unreported. Because of these factors, the actual number is likely higher.
Additionally, according to the most recent data available from the Centers for Disease Control and Prevention, Montana ranks first in suicide-related deaths in the overall population.[ii] Pregnant women are more likely than the overall population to have suicidal ideation, especially if the pregnancy is unwanted, they are faced with intimate partner violence, have socioeconomic struggles, or have a history of mental illness.[iii]
Because of this, it is crucial to screen all women during and after pregnancy for the symptoms of depression and to intervene appropriately.
When to screen?
Universal screening for Postpartum depression has been found to reduce overall rates of depression and increase rates of remission.[iv] ACOG recommends screening at least once during the perinatal period. The committee opinion also advises that women have contact with their healthcare providers within the first three weeks after giving birth and for a comprehensive visit between 4 and 12 weeks.
More visits are recommended for high-risk women and as needs arise. [v]
The importance of screening and providing anticipatory guidance for women at the moment you have the opportunity cannot be underestimated. In a randomized controlled trial of a group of African American and Hispanic women, it was found that 15 minutes of anticipatory guidance before hospital discharge, followed by a phone call at two weeks postpartum, significantly reduced postpartum depression and increased breastfeeding duration in the first six months postpartum.[vi]
Having the chance for follow-up is never guaranteed. According to nationwide statistics, an estimated 40% of women do not come to their postpartum visit.[vii] Postpartum support international recommends screening through pregnancy, at the first prenatal visit, in the second and third trimesters, at the six-week postpartum visit, again at 6 and 12 months postpartum and the 3, 9 and 12-month pediatric visits.[viii]
Talking to patients
How do we talk to patients to create a comfortable, judgment-free environment where they will open up honestly about how they are feeling?
Offering privacy is one thing we can do. Letting patients fill out screeners on their own can help increase the honesty of their answers. Include a lead-in statement on the screening tool or in your presentation of the tool so that patients will feel comfortable answering and not feel singled out:
- Please be as open and honest as possible when answering these questions
- It is not easy being a new parent, and it is okay to feel unhappy or worried at times. Since you have recently had a new baby, we would like to know how you are feeling.
- Please state the answer closest to how you have felt over the last seven days, not just today.[ix]
Reviewing the score with a patient gives you the chance to start a conversation. Use open-ended questions that do not suggest what the answer “should” be. Here are some examples:[x]
- It is not uncommon for a new mother to experience intrusive, unwanted thoughts that they might harm their baby. Have you had any such thoughts?
- It seems you are scoring high on this screening tool. How do you think you are feeling?
- What are some of the triggers that make you feel this way?
- If you had eight hours and a clean, quiet place to sleep, could you?
- If you did not have an infant and were feeling sad or anxious, what would you do to help those feelings?
- Tell me more about…
What screening tools to use for which situation
The most researched and validated screening measures for postpartum depression are the Edinburgh Postnatal Depression scale (EPDS), and the Patient Health Questionnaire 9 (PHQ-9)[xi][xii]
EPDS:
- Ten items
- Valid in the pre- and post-natal period
- Asks about the past seven days
- Includes questions that cover anxiety
- Sensitivity 59-100%, Specificity 49-100%
PHQ-9
- Nine items
- Wide use outside perinatal care- can offer a baseline if used before the perinatal period.
- Asks about the previous two weeks
- Does not detect anxiety—can be supplemented with the EPDS-3 to screen for anxiety.
- Sensitivity 75%, Specificity 90%
Suicide risk: When is it an emergency?
Maternal suicide exceeds hemorrhage and hypertensive disorders as a cause of maternal mortality. [xiii]
If patients are found to be at risk for self-harm or suicide, further intervention must take place immediately:
Any score greater than 2 on question 10 on the EPDS or a PHQ-9 score greater than 1 on question 9 indicates a risk of self-harm. Follow up these questions with a suicide-specific screening tool, such as the asQ Suicide Risk Screening tool,[xiv] or the Columbia Suicide Severity Rating Scale[xv]. Free online training for communities and health care providers is available for the C-SSRS at cssrs.columbia.edu.
The purpose of this is to open specific discussion around the patient’s current safety, their situation and intentions and if they have an active suicide plan. If they answer yes to questions indicating they intend to act on a plan to harm themselves (C-SSRS questions 4,5,6, and asQ question 5), they are considered to be at immediate risk.
- Ask more questions and clarify. If she feels her family or the baby would be better off without her, she is at very high risk.[xvi]
- Do not leave them alone. Safety is the first priority and hospitalization should be considered.
- If possible, help the client find a supportive adult to join them.
- Secure childcare.
- Contact the patient’s primary care provider or OBGYN to evaluate the patient.
- Create a safety plan with the patient.
- If necessary, contact CPS. If you cannot be sure that the children are safe, you can call CPS and ask for a consultation on the situation without giving any identifying information.
- Reassure the patient that this is not their fault and that measures are being taken for their safety and the infant’s safety while in this crisis.
- If they have an active plan and intent or are experiencing acute mania, or symptoms of psychosis (delusions, hallucinations, incoherent speech), they need to go to the local emergency department.[xvii]
Intervention is still needed for patients not at immediate risk but with elevated risk. It is important to note that identification of those at risk only shortens the period of depression if screening is combined with intervention.[xviii]
Social support
Social support from family and friends, faith communities, peer groups, cultural communities, email/ online support and telephone hotlines can help new parents feel that they are not alone. If a patient does not have adequate support in their lives, their health care team can help them get connected with support through peer groups, hotlines, and other resources. Just being able to talk to someone else and know that they are going through the same feelings can go a long way to help. In some communities, postpartum doulas and home-visiting nurse services may also be available.
Antidepressant therapy in pregnancy and lactation
Medications are a first-line intervention that can help balance the patient’s mood both during pregnancy and postpartum. Patients will often wonder about the infant’s safety with antidepressants during pregnancy and lactation. The prescribing physician will conduct a risk and benefit discussion with the patient, but here are some important things to note:
- Antidepressant therapy in pregnancy did not carry an increased risk of stillbirth in multiple studies.[xix]
- The risk of miscarriage in women taking SSRIs was not elevated over women with untreated depression.[xx]
- The risk of congenital anomalies is 3% in the overall population[xxi], and treatment with SSRIs does not increase this risk.
- SSRIs have been extensively studied during pregnancy, particularly fluoxetine and sertraline.
- Meta-analyses have found an increased risk of preterm birth associated with SSRI use during pregnancy. However, the average reduction in gestational age with their use is only 2-4 days.
- Antidepressant-exposed babies weigh an average of 3.4 ounces less than unexposed babies.[xxii]
- Side effects in neonates are present in 10-30%, usually lasting less than two weeks. In 3% of infants, side effects can be severe.[xxiii]
- Antidepressant use during pregnancy was not linked to any cognitive or behavioral outcome in children at 3 and 6 years.[xxiv]
- Uncontrolled mental health issues in the mother have adverse effects on the fetus, including a reduced gestational age of 4 days.[xxv]
- Depending on the medication, small amounts do pass into breast milk. Possible side effects exist, per reports. A causal relationship between these effects and antidepressant use has not been established.
LactMed is a resource available from the U.S. National Library of Medicine. It offers a searchable database online and in app form cataloging medications in lactation and their effects on breastfeeding infants.[xxvi]
Psychotherapy
Several evidence-based options exist for therapy-based treatment models, either as an option for women unwilling to start antidepressant therapy or as an adjunct.
- Cognitive Behavioral Therapy teaches patients to identify and change unhealthy and dysfunctional thinking patterns. It has been found to be effective for the prevention and treatment of maternal depression and anxiety.[xxvii]
- Another option for those without this resource nearby is internet-based Cognitive Behavioral Therapy, which is also effective.[xxviii]
- Interpersonal Psychotherapy typically lasts 12-16 weeks and aims to improve the patient’s social functioning through interpersonal relationships, a supportive network, and communication. It may include conjoint sessions with the patient’s partner to improve communication. IPT targets families’ grief processing, role transition, and interpersonal role disputes.[xxix] It is crucial to remember that any change in life is also a time of grief, even if there is also an element of desired joy.
- Attachment therapy is another option. This therapy focuses on encouraging parent-infant attachment. It uses peer support and therapeutic discussion to assess disruptions in bonding to strengthen attachment and remove barriers.[xxx]
We need to screen for depression early and often to support our new mothers and pregnant women. Language needs to be kind and non-judgmental to open conversations and provide a safe place for women during this season of their lives. With timely screening, we can offer the right interventions at the right time to reduce the mental struggle affecting Montana mothers.
Citations:
[i] America’s Health Rankings analysis of CDC, Pregnancy Risk Assessment Monitoring System or state equivalent, United Health Foundation, https://www.americashealthrankings.org/explore/health-of-women-and-children/measure/postpartum_depression/state/MT
[ii] National Center for Health Statistics, Stats of the State of Montana, CDC. https://www.cdc.gov/nchs/pressroom/states/montana/montana.htm
[iii] Postpartum Support International, Perinatal Mood and Anxiety Disorders, PMD Certificate Course Manual 2020
[iv] O’Connor, E et. al. Primary care screening for and treatment of depression in pregnant and postpartum treatment, Jan 2016. JAMA, 315(4), 388-406
[v] ACOG, 2021, https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care
[vi] Howell, E.A., et. Al. An intervention to extend breastfeeding among black and Latina mothers after delivery. Am J Obstet Gynecol 2014; 210: 239. 1-5
[vii] Bennet, W.L. et. Al. Utilization of primary and obstetric care after medically complicated pregnancies: an analysis of medical claims data. J Gen Intern Med 2014: 29: 636-45.
[viii] PSI, Certificate Course Manual 2020
[ix] PSI, Certificate Course Manual 2020
[x] Healthy mothers, healthy babies, the Montana Coalition. Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers. 2020
https://hmhb-mt.org/wp-content/uploads/2020/01/Protocol-Document-Final-BCBS-logo.pdf
[xi] HMHB-MT, Screening protocol. 2020
[xii] ACOG, Committee Opinion 757, 2018
[xiii] Palladino CL, Singh V, Campbell J, Flynn H, Gold KJ. Homicide and suicide during the perinatal period: findings from the National Violent Death Reporting System. Obstet Gynecol 2011;118:1056–63.
[xiv] NIMH, NIH, asQ Suicide Risk Screening Tool, Accessed October, 2022
[xv]CMS, CSSRS Screening tool, Accessed October, 2022
https://www.cms.gov/files/document/cssrs-screen-version-instrument.pdf
[xvi] Raskin, V. & Kleiman, K. This isn’t what I expected 2nd ed. Boston, MA: Da Capo Lifelong Books, 2013.
[xvii] PSI, Certificate Course Manual 2020
[xviii] Van der Zee-van den Berg, A.L. et al, Postpartum depression screening in well-child care and maternal outcomes, Pediatrics, October 2017, https://pediatrics.aapublications.org/content/140/4/e20170110.long
[xix] PSI, Certificate Course Manual 2020
[xx] Kjaersgaard, et. al. Prenatal antidepressant exposure and risk of spontaneous abortion-A population based study PLoS One. 2013 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0072095
[xxi] CDC, Data and Statistics on birth defects, 2022 https://www.cdc.gov/ncbddd/birthdefects/data.html
[xxii] Ross, L.E. et.al., Selected pregnancy and delivery outcomes after exposure to antidepressant medication: a systematic review and meta-analysis. JAMA Psychiatry, 2013 Apr,70(4): 436-43
[xxiii] PSI, Certificate Course Manual 2020
[xxiv] Nulman, et. al., Neurodevelopment of children following prenatal exposure to venlafaxine, selective serotonin reuptake inhibitors, or untreated maternal depression. Am J Psychiatry 2012, and Nulman, et al., Neurodevelopment of children prenatally exposed to selective reuptake inhibitor antidepressants: Toronto sibling study. J Clin Psychiatry. 2015 Jul;76(7)
[xxv] Huybrechts, et. at., Antidepressant use late in pregnancy and risk of persistent pulmonary hypertension of the newborn JAMA. 2015; 313(21):2145-2151
[xxvi]LactMed, National Library of Medicine, NIH, 2022 https://www.ncbi.nlm.nih.gov/books/NBK501922/
[xxvii] Sokol, L.E., A systematic review of the efficacy of cognitive behavioral therapy for treating and preventing perinatal depression. Journal of affective Disorders, 2015, 177. 7-21
[xxviii] Loughnan, et. al., Internet-based cognitive behavioral therapy (iCBT) for perinatal anxiety and depression versus treatment as usual: study protocol for two randomized controlled Trials, 2018, 19:56.
https://trialsjournal.biomedcentral.com/articles/10/1186/s13063-017-2422-5
[xxix] PSI, Certificate Course Manual 2020
[xxx] PSI, Certificate Course Manual 2020
