Postpartum Progress

Senate Passes Healthcare Amendment That Includes Postpartum Depression Screening

This week, as part of the debate over healthcare reform, the U.S. Senate passed an amendment to Senator Harry Reid's healthcare bill that would support funding for postpartum depression screening.

This amendment, led by Senator Barbara Mikulski (D-MD), is unrelated to and separate from the Melanie Blocker Stokes MOTHERS Act, which does not include screening for postpartum depression among its provisions.  (The Melanie Blocker Stokes MOTHERS Act was passed by the U.S. House by is still stuck in committee in the Senate.)

As reported in the New York Times yesterday:

"Under Ms. Mikulski’s proposal, a federal agency, the Health Resources and Services Administration, would develop “comprehensive guidelines” recommending preventive care and screenings for women, and insurers would have to cover the services without any cost-sharing.

Ms. Mikulski said the services would include screenings for breast, cervical, ovarian and lung cancer, heart disease and diabetes, as well as postpartum depression and domestic violence."

Does ACOG's National Healthcare Reform Agenda Include Screening for Postpartum Depression?

Yesterday I saw something on Twitter discussing the American College of Gynecologists and Obstetricians' (ACOG) national healthcare reform agenda.  I decided to take a look and see what ACOG had to say about perinatal mood and anxiety disorders, if anything, when it comes to healthcare reform.

One of the documents ACOG has released is a list of services they believe "must be covered by insurance in any health care plan".   I read through that list and -- LO AND BEHOLD! -- in the section on pregnancy-related and infant care it includes this:

Mental health screening services, including screening and treatment for perinatal depression

ACOG considers this an "essential benefit".  So do I.  Thanks ACOG.

Awesome.

CBS Early Show: All New Mothers Should Be Screened for Postpartum Depression

I was fortunate to be able to appear via webcam this morning on the CBS Early Show.  On a segment called "Ask It Early" featuring their medical correspondent Dr. Jennifer Ashton, I asked whether she believed all new mothers should be screened for postpartum depression.  Her answer?  "Overwhelmingly yes." 

Here is the video:

Watch CBS Videos Online

Her words were very supportive for women with perinatal mood and anxiety disorders. 

Two Chicago Hospitals Standardize PPD Screening for Patients

Prentice Women's Hospital at Northwestern Memorial in Chicago has now made screening and education for posptartum depression a standard practice.  (Wahoo!) 

"Postpartum depression is under-recognized and under-treated," said Jacqueline Gollan, PhD, clinical psychologist at Northwestern Memorial and the Northwestern Medical Faculty Foundation Women's Behavioral Health Services Program.  "By establishing a clinical protocol to screen all obstetric patients for depression, we can better detect the emergence of mood disorders, offer treatment and improve the clinical outcomes of these patients."

The staff at Prentice has been extensively trained on how to screen women, interpret the screen and follow up on the results.  Screenings will now occur at the first prenatal visit, in the third trimester and at the 6 to 8 week postpartum checkup.  The hospital states that it offers a range of services for those with perinatal mood or anxiety disorders, including one-on-one counseling and support groups for new moms.

Even better, another Chicago hospital system is screening all of its pregnant patients for postpartum depression as well.  The Loyola University Health System has developed a comprehensive program that screens women for postpartum depression at 28 weeks, at delivery, at 2 weeks postpartum and at 6 weeks postpartum. (Thanks to Jennifer White at About.com for the heads up on this!)

How To Talk To New Moms About Intrusive or Scary Thoughts

Karen Kleiman at the Postpartum Stress Center has created a guide for healthcare practitioners on integrating a one-question screen on intrusive thoughts into their practice for postpartum women.  This one-page guide on "scary" thoughts may help you more comfortably discuss this with your patients.

For more from Postpartum Progress on intrusive thoughts, click here.

Danish Public Health Experts Recommend PPD Screening for All New Moms

The Copenhagen Post reports that public health experts in Denmark recommend screening all new mothers for postpartum depression.  This, after a research study there found that twice as many depressed mothers would receive treatment if all new mothers were screened.

"The study was carried out by the Centre for Public Health, Århus City Council and mothers’ support group Mødrehjælpen. They are now recommending that all new mothers be screened for depression, instead of the current system where only those suspected of postpartum depression are offered help.

Postpartum depression affects about 6 percent of all new mothers in Denmark and Finn Breinholt of the centre described it as a serious condition.

'It must be detected and treated early, otherwise the child’s first year can be marked by poor linguistic, intelligence and behavioural development,’ said Breinholt."

The study suggested that group counseling could be an important solution in helping new mothers feel less isolated.

An Open Letter to Time Magazine About Postpartum Depression

Monday, July 13, 2009

An Open Letter to the Editors of Time:

Time has done a great disservice to all mothers who are suffering and will suffer from postpartum depression (PPD).  In an article called “The Melancholy of Motherhood” journalist Catherine Elton writes a distorted story that no doubt has already begun to confuse and stigmatize women with PPD.   

We cannot understand why Time would choose to sensationalize what is a very serious medical issue for hundreds of thousands of women in the United States each year, and to create controversy around the MOTHERS Act, the one and only piece of legislation that would help to systematize support and services that are sorely lacking in so many places throughout our country.

There are several points in the article that concern us:

1.The MOTHERS Act is not “dividing psychologists” as Elton opines.  The American Psychological Association, the American Psychiatric Association and the National Association of Social Workers wholeheartedly endorse the MOTHERS Act.    In fact, you neglect to mention that much of the medical community supports the bill.  It has been publicly endorsed by the March of Dimes, the American College of Obstetricians and Gynecologists, the American College of Nurse Midwives, the National Healthy Mothers Healthy Babies Coalition, and the Association of Women’s Health, Obstetric and Neonatal Nurses, among many others.  You didn’t represent any of them in your piece, all of which are highly regarded organizations which have a long record of dedication to the health of both mothers and babies.

2. Elton calls screening controversial and infers it may not even work. Many women will tell you that screening saved their lives, and others who were not screened wish they had been so they could have received treatment sooner.  In fact, Elton interviewed at least two such women but they were not represented in the article.  Screening for PPD is an effective way to identify women who may have it.   Both the sensitivity (misses few sufferers) and specificity (some, but not too many false positives) of the widely-used and validated Edinburgh Postnatal Depression Scale, for instance, is very well-established.  We’d be happy to send you multiple, contemporary, highly-regarded studies that support this.    

3. Elton states that “… increased screening could lead to an increase in mothers being prescribed psychiatric medication unnecessarily.”  First, the MOTHERS Act does not require screening.  Second, none of the screening tools for depression were designed to take the place of evaluation by health care professionals, so it is manipulation to suggest that screening alone will yield treatment of any kind or specifically treatment via medication.  In a study of large scale universal screening efforts of more than 1000 pregnant and postpartum women, screening for depression did not lead to greater rates of treatment (Yonkers et al., Psychiatric Services, 2009).  This is because there are many barriers to treatment, regardless of a positive screen.  Additionally, for those who are able and choose to be treated, many women elect methods that don’t include medication (Pearlstein et al., Archives of Women’s Mental Health, 2006). 

 

4. Time should be more careful when discussing the causes of PPD.  We were surprised to see such a well-regarded publication misrepresent the results of a small research study that provided evidence to support the idea that a subset of women are more susceptible to hormonal changes as a trigger for depression, such as PPD, by prefacing the results with the unsubstantiated statement that “pregnancy hormones … have little to do with PPD in most cases.”  This study showed that for those with a known history of depression, the hormonal changes that occur following delivery may increase one’s risk for developing symptoms during the postpartum period.  Yet Elton attempts to use these results to support Michael O’Hara’s overgeneralization that women without prior history of “lots of anxiety and depressive symptoms” (what does this even mean objectively?!) “are unlikely to have problems in the postpartum period – not even close to likely.”  Reporting results out of context to support the opinions of a source is appalling. 

 

The fact that women who have had depression or anxiety in the past are more likely to experience PPD is nothing new.  This is only one of many risk factors that have been identified.  Your article, however, attempted to make a previous history of depression or anxiety the single key to identifying PPD.  This will lead women who are ill but who have never been clinically diagnosed or treated for a mental illness to believe they must not have PPD.  Many women who suffer will tell you it was the first time they were ever treated for a mental illness and the first time they came to realize they may have suffered from depression or anxiety in the past.  You also leave out women who have no history of depression or anxiety but ended up with PPD for other reasons.  Perhaps you were not aware, for instance, that diabetes is a risk factor for PPD (Kozhimannil et al., JAMA, 2009), as is thyroiditis.  Women who deliver multiples or have babies born with serious health problems also have a higher risk of getting PPD.

 

5.  The language used in the article frustratingly minimizes the devastation that PPD can cause.  Such phrases as “the melancholy of motherhood” and “still, there is no denying that the postpartum period is a difficult one for many women” almost brush PPD off as a blue funk or a trying transition time for new moms.  This signifies a clear lack of understanding about the seriousness of this illness that somewhere between 10 and 20% of women around the world suffer.  PPD impacts a mother’s ability to function on a daily basis.  It is not a difficult period.  Elton asks, “Does PPD screening identify cases of real depression or simply contribute to the potentially dangerous medicalization of motherhood?”  It is no more medicalizing motherhood to identify and treat PPD than it is to identify and treat gestational diabetes, which is universally screened for and occurs in only 3.5% of mothers.

 

As Time reported in June, the National Academies fully endorses screening for parental depression and believes it is crucial, while also emphasizing that screening is not helpful unless there is effective follow up and treatment tied to it.  Supporters of the MOTHERS Act share that belief.  Although effective treatment is available, fewer than half of cases of postpartum depression are recognized (Gjerdingen et al., Journal of the American Board of Family Medicine, 2007).  Even fewer of those women ever receive treatment of any kind.

We are terribly sorry about the experience of the one mother quoted in your article, which happens on rare occasions, but we believe that the MOTHERS Act would actually go a long way to prevent what happened to her.   What this bill actually funds is research, education and awareness.  If these pieces are put in place, women, families and medical professionals will be better educated to prevent false positives from screening.  A well-trained and educated physician will know to refer the patient on to a specialist who can inform her of various treatment options and monitor her to ensure the treatment she chooses is effective.   A woman who has been made fully aware of the kind of services she should receive and the risks and benefits of the treatments available to her will be able to make the best choice for herself and her family.

Time focused on one potential but unlikely consequence of the MOTHERS Act rather than the actual content of the bill and why it is so sorely needed.  We are deeply disappointed.

Sincerely,

Mary Jo Codey, mother of 2, former first Lady of New Jersey, kindergarten teacher, New Jersey  

Carol Blocker, mother of Melanie Blocker Stokes, Illinois

Sonia Murdock, co-founder and executive director of the Postpartum Resource Center of New York, past president of PSI, New York

Cheryl Beck, DNSc, CNM, FAAN, mother of 2, Board of Trustees Distinguished Professor at the University of Connecticut School of Nursing, co-author of the  American Journal of Nursing  2006 Book of the Year award, Postpartum Mood and Anxiety Disorders: A Clinician’s Guide, Connecticut

Amy D. Gagliardi, mother of 4, Director of a Perinatal Health Clinic at a Federally Qualified Health Center, writer, researcher and chair of the Woman's Health Sub-Committee of Connecticut's Medicaid Managed Care Council, Connecticut

Valerie Plame Wilson, mother of 2, author of Fair Game, New Mexico

Adrienne Griffen, mother of 3, founder of Postpartum Support Virginia, and mid-Atlantic regional coordinator for Postpartum Support International, Virginia

Heidi Koss-Nobel, MA, mother, psychotherapist, Chairperson of Postpartum Support International of Washington, Washington

George J. Parnham, Attorney at Law, co-founder of the Yates Children Memorial Fund, Texas

Ann Dunnewold, Ph.D., mother of 2, licensed psychologist, author of Even June Cleaver Would Forget the Juice Box, past president of Postpartum Support International, Texas

Diane G. Sanford, Ph.D., internationally-recognized expert on pregnancy and postpartum emotional health, medical advisory board member on Babycenter.com, adjunct associate professor at the St. Louis University School of Public Health, Missouri

Catherine Connors, mother, author of the Her Bad Motherblog, featured parenting blogger at Beliefnet.com, Maternal Health Editor at BlogHer.com and Partner/Managing Editor at Mamapop.com, Canada

Tonya Fulwider, mother of 2, executive director of Perinatal Outreach & Encouragement, regional coordinator for Postpartum Support International, Ohio

Adrienne Martini, mother of 2, author of Hillbilly Gothic: A Memoir of Madness & Motherhood, New York

Katherine Stone, mother of 2, author of Postpartum Progress, the most widely-read blog in the US on postpartum depression, WebMD 2008 Health Hero, Georgia

Erin Reilly, co-founder of Sound of Silence, Friends of the Postpartum Resource Centerof New York, New York

Jen Stoll, mother of 2, executive director of The Postpartum Resource Center of Kansas, Kansas

Erika Krull, MS, LMHP, mother of 3, mental health counselor, author of the Family Mental Health blog on Psych Central, Nebraska

Wendy N. Davis, Ph.D., mother of 2, psychotherapist & perinatal mood disorders consultant, founding director of Baby Blues Connection, PSI Volunteer Coordinator, Oregon

Therese Borchard, mother of 2, author of the Beyond Blue blog on Beliefnet, author of several books including The Imperfect Mom: Candid Confessions of Mothers Living in the Real World, Maryland

Carol Peindl, RN, MSN, CNS, psychotherapist/nurse for the Prenatal and Postpartum Center of the Carolinas, PSI coordinator for the state of North Carolina, North Carolina

Diana Lynn Barnes, Ph.D., mother of 2, award-winning psychotherapist, past president of Postpartum Support International, California

Lauren Hale, mother of 3, author of Sharing the Journeyblog,  iVillage Community Leader for Postpartum Depression and Pregnancy & Depression/Mental Illness Message Boards, Georgia

Pec Indman, PA, EdD, MFT, mother of 2, psychotherapist, co-author of Beyond the Blues, A Guide to Understanding and Treating Prenatal and Postpartum Depression, Education and Training Chair of Postpartum Support International, expert panelist for the Maternal and Child Health Bureau/HRSA, California

Tara Mock, mother of 2, author of the Out of the Valley blog for Christian postpartum depression support

Ivy Shih Leung, mother of 1, author of Ivy's PPD Blog, New Jersey

Helen Ferguson Crawford, mother of 2, architect, Georgia

Karen Kleiman, MSW, founder and director of The Postpartum Stress Center, author of several books on postpartum depression, Pennsylvania

Joan Mudd, mother, founder of the Jennifer Mudd Houghtaling Postpartum Depression Foundation, Illinois

Susan Dowd Stone, MSW, LCSW, mother of 1, NJHSS Certified Perinatal Mood Disorders Instructor, Public Reviewer for the National Institutes of Mental Health, author and Adjunct Lecturer at the Silver School of Social Work at New York University, New Jersey

Marcie Ramirez, mother, co-founder of the Maternal Mental Health Task Force of Middle Tennessee, PSI Coordinator of Middle Tennessee, Tennessee

Amber Koter-Puline, mother of 1, author of the Beyond Postpartum blogand Atlanta support group facilitator, Georgia

Amy Tobias, mother, Indiana

Kimmelin Hull, PA-C, LCCE, mother of three, director of Pregnancy to Parenthood  and author of A Dozen Invisible Pieces and Other Confessions of Motherhood, Montana

Sylvia Lasalandra-Frodella, mother of 1, Constituent Relations for the former First Lady of New Jersey Mary Jo Codey, author of A Daughter’s Touch, New Jersey

Lisa Jeli, mother of 1, California

Susan McRoberts, mother of 3, author of The Lifter of My Head: How God Sustained Me Through Postpartum Depression

Sara Pollard, RN, BS, Clarian Women’s Health Services, Indiana

Amy Burt, MA, mother of 3, director of operations, Perinatal Outreach & Encouragement for Moms, Ohio Coordinator for Postpartum Support International, Ohio

Diane Ashton, MSW, mother of 2, founder of PPD Support Hawaii, Hawaii

Laurel R. Spence, MS, PA-C, mother of 3, Assistant Professor, Baylor College of Medicine, clinical physician assistant, Women’s Specialists of Houston, Yates’ Children Memorial Fund/Women’s Mental Health Initiative advisory council member, speaker’s bureau Mental Health America – Houston and Postpartum Support International member, Texas

Sara Binkley-Tow, MA, CIMI, CHBE, PCD (DONA), executive director of Moms Bloom, Michigan

Sarah Pond, mother of 1, founder of Mama2Mama and early childhood development facilitator, Canada

Birdie Meyer, RN, MA, CLC, mother, president of Postpartum Support International, winner of the 2008 Award of Excellence in Advocacy from the Association of Women's Health, Obstetric and Neonatal Nurses, Indiana

Della Palacios, mother of 2, Florida

Kimberly Wong, founder and chair of the Perinatal Mental Health Task Force of Los Angeles, California

Dr. Shoshanna Bennett, Clinical Psychologist, past president of Postpartum Support International, founder and director of Postpartum Assistance for Mothers, author of "Postpartum Depression for Dummies", California

Ilyene Barsky, LCSW, The Center for Postpartum Adjustment, Florida

Study on Pediatricians Screening for Postpartum Depression

From the Healthy Mothers, Healthy Babies Newsletter: A study in the June 2009 edition of the journal Pediatrics examines the feasibility of screening for maternal depression as a standard part of well-child care, and looks at the prevalence and incidence of maternal depression at well-child visits during the first six months of life.  Providers in an adolescent-oriented maternity program were cued electronically to screen the mothers for postpartum depression when they opened electronic medical records of 0 to 6-month-old infants.  The study found that electronic cueing improved providers' compliance with screening for depression.  In addition, screening two months after delivery detects most mothers who become depressed during the first six months postpartum.

Also, Ivy at Ivy's PPD blog just did a roundup of all the postpartum depression screening news going on -- read it here.

National Research Council & Institute of Medicine Recommend New Strategies for Dealing with Parental Depression

I listened in on the press conference today by the National Academies on a new report from the National Research Council and Institute of Medicine on parents with depression.  Very exciting to hear the level of understanding about how depression impacts families and how important it is to address it. 

From today's news release (to read the entire news release, click here):

"Effective tools and strategies exist to treat and prevent depression, but only one-third of adult sufferers get treatment.  Although many factors affect children's development, parental depression can increase the chances for health, emotional and behavioral problems in children.  The report does not suggest that every parent with depression will inadvertently or deliberately cause harm to their children, but rather than parental depression increases the risks for spillover consequences during critical periods of child and adolescent development.

"'To break the vicious circle of depression, we need to refocus our view of this illness through a broader lens that sees the whole family, not just the individual with depression,' said committee chair and psychiatrist Mary Jane England, president, Regis College.  "Our report describes a new vision for depression care that would provide comprehensive services not just to adults, but to their children as well.  It will take significant policy changes to make this vision a reality, but the benefits warrant the effort.'"

Couldn't agree more.  Highlights:

• 7.5 million parents are affected by depression in the US each year.  16 million children live in those households.
• Only one third of adults who manifest depression are actually treated in any given year.
• Depression interferes with the quality of parenting and puts children at risk for poor health and development. 
• The National Academies endorses screening and believes it's crucial, but also emphasizes screening is not helpful unless there is effective follow up and treatment tied to it. 
• Individuals need an informed choice in the treatments they choose.  
• There are not enough mental health providers in certain areas of the country, and many primary care providers don't have the specific skills or awareness needed to treat parents with depression.
• They recommend parents be able to access screening and services in a variety of locations,including WIC, Headstart, schools and of course doctors' offices (OB/GYNs, pediatricians), community centers.
• They recommend the whole family receive care, with comprehensive services for the children as well as the parents.
• There is powerful evidence of the need for psychoeducation of parents, and they indicated that interpersonal education (such as in the doctor's office) is very effective.  Peer-to-peer support was mentioned as one way to do this.  Education is crucial and there is not a lot of good information out there.
• The group suggests that governors of each state convene a task force to develop and implement the strategies they recommend.

Also, a few facts from the press conference, most of which you probably know if you are a regular Postpartum Progress reader:

• Depression is extremely common and is a universal disorder that affects people regardless of education, race and income.
• The World Health Organization notes that depression is second only to heart disease in the level of disability and lack of productivity it creates in those who have it.
• Females have double the rates of depression of males.
• There are many causes of depression: genetic factors, environmental risks, biochemical factors, personal vulnerabilities and resilience.

I asked the panel to respond to the fears of those who worry that universal screening will just "overmedicalize" depression.  Their response was that screening will be effective if it is attached to treatment, so availability of services and follow through is important.  They also said they emphasize giving parents a choice among treatments by offering a variety of options.  (The same EXACT things I might point out that those in the perinatal mood and anxiety disorder community believe.)

As Dr. William Beardslee, Professor of Child Psychiatry, Children's Hospital in Boston, stated during the conference, "The first two years of life are crucial and we need very intensive interventions at that time for depressed parents."

To order the full report, click here. 

Here's WebMD's take on this.

Clinicians Miss Half of Postpartum Depression Cases

The Agency for Healthcare Research and Quality, which is part of the US Department of Health & Human Services, has posted a few pieces of research on postpartum depression from the last few years, including this one:

"About 13 percent of women suffer from the anxiety, hopelessness, desolation, and fatigue of postpartum depression (PPD) for the first 3 to 12 months of their children's lives. Yet, primary care physicians fail to recognize more than half of PPD cases, despite the availability of depression screening tools that can expedite diagnosis and treatment. Some women and clinicians may confuse PPD with "baby blues," which occur in more than 80 percent of mothers. However, baby blues begin within hours or days of delivery, are characterized by major mood swings rather than consistent depressive symptoms, and typically disappear 2 to 4 weeks postpartum.

While baby blues and minor depressive symptoms often clear spontaneously, PPD is a persistent form of major depression that develops within the first 2 to 6 months postpartum. Untreated PPD can devastate the mother (who loses her energy or joy in parenting), her child (who often has delayed psychological and cognitive development), and her family (with twice the risk of divorce within 2 years postpartum). In extreme cases, PPD can result in suicide and infanticide. Timely diagnosis and treatment of PPD can interrupt these cycles before damage to mother, child, and family become irreparable, explains Barbara P. Yawn, M.D., M.Sc., of the Olmsted Medical Center and University of Minnesota." 

NH Hospital Implements Comprehensive PPD Prevention Program

Just when you start to think no one is listening, you hear from an amazing healthcare provider like Alison Palmer in New Hampshire.  She sent a fantastic email about the work that she is doing at Elliot Hospital in Manchester. 

They will be starting an Inpatient Postpartum Depression Risk Assessment program in May.  An 11-item questionnaire will be distributed to every new mother after she delivers on the Maternity Unit.  Those found to be in the moderate, high or immediate risk categories for developing PPD will receive follow-up phone calls at home and also be offered visiting nurse visits.  Additionally, a PPD support group is held weekly on the hospital's campus.  They are hoping that the screening process and interventions they've set up will serve to prevent PPD as they are educating families and connecting them with resources BEFORE things have the chance to get out of control.  They also hope that universal screening will help to take the sting out of the stigma of talking about perinatal mood and anxiety disorders because the program will encourage nurses and providers to help patients understand these illnesses are a common complication of childbirth.  I wish Piedmont Hospital in Atlanta had done this for me!

Their program was inspired, by the way, by the work being done in Michigan by Spectrum Health.  They used their PPD Program Development Toolkit to establish their own comprehensive program.

Alison also started a Perinatal Mood Disorder Taskforce in January comprised of healthcare providers, therapists, visiting nurses, and hospital staff in Southern New Hampshire to work together on addressing maternal mental health issues.  May will be PPD Awareness Month in New Hampshire, and Alison has all sorts of plans to do outreach in the area.

Alison and Elliot Hospital, you will be heroes to the women you will undoubtedly help with this caring and comprehensive new program.  Thank you, thank you, thank you!!!!!  I know if I lived in Manchester, Elliot Hospital would be the place where I'd want to deliver my baby.

For more on the topic of universal screening for PPD, click here.

Study Finds Internet Effective Way to Administer PPD Screens

The March 2009 issue of Maternal Child Health Journal offers a study from researchers at George Washington University and Johns Hopkins that examined using the Internet to screen for postpartum depression symtpoms.  The Postpartum Depression Screening Scale (PDSS) and the Edinburgh Postnatal Depression Scale were used and then compared with the results of screens administered in person.

The study found that a higher proportion of Hispanic and Asian women participated on the Internet compared to the in-person study.  (Interesting!)  It also found that the PDSS had excellent "internal consistencies and construct validity", which I think means it was very effective no matter how it was administered.  The Internet sample also reported more risk for major postpartum depression (PPD) compared to the community sample (23% vs. 12%). They concluded that the Internet is a viable and feasible tool to screen for PPD.

I just love this place!  I'll be adding this study to the speech I give on how women with perinatal mood and anxiety disorders use the Internet.  If you're interested in having me speak at your event, let me know!  (Plug.  Plug.  Plug.)

Two New Studies on Therapy & Screening for Postpartum Depression

There are two new pieces of research on postpartum depression in this month's issue of the journal Psychiatric Services. 

The first took a look at whether culturally relevant, enhanced brief interpersonal psychotherapy (IPT-B) offers better advantages to low-income depressed pregnant women than the normal care used to treat this population.  The "IPT-B" consisted of a beginning "engagement" session, followed by 8 sessions before the birth and maintenance IPT up to 6 months postpartum.  The sessions were specifically enhanced to make them culturally relevant to socioeconomically disadvantaged women.  Unfortunately the abstract does not indicate what those enhancements were, but if you have an online subscription you can download the full text.  Anyway, the results of the study showed the women had significant reduction in depression symptoms prior to childbirth and postpartum. 

For the second study, researchers at Yale University took a look at the Healthy Start depression initiative to see whether it results in reduced rates of depressive symptoms and increased rates of detection, referral and treatment among pregnant and postpartum women.  The results found that the Healthy Start depression initiative did not change the levels of depressive symptoms or increase use of depression treatment. 

According to the Materna & Child Health Bureau, the perinatal depression initiative was launched to increase the number of women who sought treatment, increase the number of providers who recognized the signs and symptoms and provide screenings.  The Yale researchers, according to the abstract, found that "universal screening and support for treatment referral by paraprofessionals did not reduce the overall rates of depressive symptoms of perinatal women who received care at publicly funded obstetrical clinics."  They suggest that future screenings should engage women more severely affected by these disorders.  From what I can tell, but I can't be sure, they didn't use the Edinburgh Postnatal Depression Screening Scale to identify the women, so I'm wondering if the screening tool was part of the problem.  Just curious.  I'd like to know more about this.

Someone out there who loves me and who has a subscription to Psychiatric Services could be a real hero and send me the full texts.  ;-)

Blood Tests & Screening to Identify Postpartum Depression: What Happens When Either Test Turns Out Positive?

As I shared with you earlier this week, new research has found that a blood test may be able to identify postpartum depression in the future.  Dr. John Grohol at Psych Central has followed up on that news with some commentary about how a blood test in the future might lead to even fewer OB/GYNs doing screenings of pregnant and postpartum women and asking them the kind of questions that should be asked.  He makes a great point.  Find the story here.

It's true that we have very effective screening tests right now that can be used to identify women who have postpartum depression, and it's true that not enough doctors use them.  Dr. Grohol posits that the reason is " ... because doctors are either unaware of these screening tests, or trust in their own clinical judgment ..."   Trusting in clinical judgment doesn't work.  Researchers Wilen & Mounts found that, when screening for depression in the healthcare setting is based on clinical observation alone, 50% of women suffering from depression are missed.  And Olsen et al found that pediatricians rarely identify maternal depression through a routine inquiry about symptoms.  It is clearly important that screening tools like the Edinburgh Postnatal Depression Scale be used to identify PPD effectively.

I agree with Dr. Grohol's assessments, but I believe there is another significant contributing factor to the lack of screenings:  Many docs don't have psychiatric resources available to offer a patient should her screening test indicate the need for professional treatment. 

This story from last week in the St. Cloud Times points out a problem we have around the country: a lack of mental health professionals that is leading people to long waits or no treatment at all.  We have even fewer healthcare providers with any kind of training or experience treating women with perinatal mood and anxiety disorders.

"Angela Broska-Smith is a clinician at St. Cloud Hospital's Recovery Plus who suffers from anxiety. She had to go to a primary care physician for medication.

'I had postpartum depression, and I started using medication that had been prescribed for pain ... and things got worse and worse until I ended up in a substance abuse program,' said Broska-Smith, who formerly worked at Lutheran Social Service.

She is worried others who struggle with mental health issues can't afford the time off, or the expense of travel, to find an available psychiatrist."

When I do speeches all around Georgia about perinatal mood and anxiety disorders I hear directly from staff and doctors at OB/GYN offices and labor & delivery nurses who say they do want to screen but have nowhere to send their patients.   There is either a lack of mental healthcare services entirely, or there are a handful of people but none have any experience treating women with these illnesses.  We need to make sure that every state has organizations like the Postpartum Health Alliance in San Diego, Postpartum Support Virginia, the Postpartum Resource Center of New York, the comprehensive network of Postpartum Support International, PSI of Washington State, and the fledgling Georgia Postpartum Suport Network to identify every resource available and to work with the healthcare community to get even more developed.  And we need to make sure that the psychiatric professionals who are out there are aware of the tools they can access to get better educated on perinatal mood and anxiety disorders, like PSI's training workshops or books like Therapy & the Postpartum Woman: Notes on Healing Postpartum Depression for Clinicians and the Women Who Seek Their Help or Perinatal & Postpartum Mood Disorders: Perspectives & Treatment Guide for the Healthcare Practitioner. 

Stroller Strides Educates Women on PPD

Stroller Strides, the fitness program from moms and babies, has created a special page on its website focusing on postpartum depression, with information, links and the Edinburgh Postnatal Depression Screening test.  Thanks to Adrienne Griffin for giving me the heads up on this, and thank you Stroller Strides!

National Depression Screening Day in October

Friday, October 10 is National Depression Screening Day.  This day of awareness focuses on the very important role of screening.  To learn more, or find out how to bring NDSD events to your area, visit http://www.mentalhealthscreening.org/, e-mail ndsd@mentalhealthscreening.org or call (781) 239-0071.  I know a couple of years ago when I served as a spokesperson for the event they specifically included postpartum depression screenings.  I'm not sure if that's still the case -- it doesn't look like it after a quick drive through the website. 

Finding Places Where the Referral System Works for Women with Perinatal Mood Disorders

Last week I spoke at the annual conference of the Georgia Perinatal Association.  What a great group of RNs, social workers, OBs and others!!  I really enjoyed sharing with them as much information as possible about the spectrum of perinatal mood and anxiety disorders, and appreciated how interested they were in the topic.  So many of them came up to me afterwards to say that they had implemented screening and education -- they are really doing their best to share the latest information with their patients, look for risk factors and utilize screening tools to identify sufferers. 

Their chief concerns?  Foremost is the issue of what to do next once a woman is identified as someone who may be suffering PPD or another perinatal mental illness.  Our nation is suffering from a shortage of mental health providers, and we certainly don't have very many people specifically trained on treating perinatal mental illness.  Are the few that are trained taking patients?  What if the woman has too long of a wait to get in to see the psychiatrist?  It seems to me that everyone's biggest concern at the conference was where to send their patients and how to make sure they are cared for effectively.  Secondly, what about reimbursement for screening?  Many states' Medicaid programs don't offer reimbursement, including Georgia.  (Kudos to the few that do, like Illinois!)  And then there's insurance -- what about women who don't have psychiatric coverage and can't afford therapy or meds?  What about the women who don't have transportation to get to the doctor?  How can they ensure that these women will be cared for properly?

I thought I'd bring their questions to you, across the country, and ask what innovative programs you have seen that complete the second half of the treatment picture -- education and identification comes first, but then we must have referrral and treatment to complete the circle.  If you have seen this done well in your state, let me know at stonecallis@msn.com and I will share your knowledge of best practices with the readers of Postpartum Progress.

Researchers Find 3-Question Screening Test Effective in ID'ing PPD

A New Study in the September issue of Journal of Pediatrics found that asking three questions can be very effective in identifying new mothers who may be suffering postpartum depression.

The researchers, from the Colorado Adolescent Maternity Program (CAMP), found that a three-item anxiety sub-scale of the Edinburgh Postpartum Depression Scale turned out to be a better screening tool than the two other abbreviated versions which are almost the same as the commonly used Patient Health Questionnaire.  The subscale identified 16 percent more mothers as depressed than the original, longer questionnaire.

For this sub-scale, new mothers were asked to answer “Yes, most of the time,” “Yes, some of the time,” “Not very often” or “No, never” to the following statements:

• I have blamed myself unnecessarily when things went wrong.
• I have felt scared or panicky for not very good reason.
• I have been anxious or worried for not very good reason.

“We chose these three questions, because other studies have suggested that postpartum depression has a large anxiety component, and those three questions are related specifically to anxiety,” said study co-author Jeanelle Sheeder, a senior instructor in pediatrics at the University of Colorado in Denver. “That subscale would probably be reasonable in other populations as well, because a lot of postpartum depression in general is related to that feeling of not knowing what to do and being scared or panicky.”

The study authors concluded that the brevity and reliability of the EPDS-3 make it an attractive screening tool for primary healthcare providers who simply want to detect potential depression and not to assess its severity.  These patients can then be referred on to a psychiatric professional for full diagnosis and treatment.

PPD Study in Pittsburgh Offers Participants Care & Support Services

A reminder that any woman who gives birth at Magee-Womens Hospital in Pittsburgh can participate in a five-year, $2.5 million study funded by the National Institute of Mental Health, the only large-scale research screening program in the country.

Mothers who score more than 10 points on a postnatal depression screening scale are eligible for home visits and referrals to mental health and other support services, according to Dr. Katherine Wisner, director of the Women's Behavioral HealthCARE program at Western Psychiatric Institute and Clinic and a leader of the study, which has served nearly 5,000 women since its inception two years ago.

For more information, visit the Women's Behavioral HealthCARE website.

Upcoming PPD Screening Event in Massachussetts

Shrewsbury Youth & Family Services in Shrewsbury, MA, will be holding a special event on Tuesday, September 2nd from 9am to 6pm offering free PPD screenings, the opportunity to speak to clinicians and information on perinatal mood disorders.  For more information, call 508-845-6932.

Study Finds Significant Numbers of Women Experiencing Depression Symptoms Postpartum

Childbirth Connection, a leading national not-for-profit organization that works to improve the quality of maternity care, today released "New Mothers Speak Out, National Survey Results Highlight Women's Postpartum Experiences."  The combined survey results from two "Listening to Mothers" surveys provide an in-depth look at women's postpartum experiences during the first eighteen months after giving birth.

The survey utilized validated tools to screen for postpartum depression and traumatic stress associated with childbirth, and found that notable portions of mothers experienced symptoms of depression and of traumatic stress many months after giving birth, according to Reuters.

"Postpartum mothers experience a troubling burden of physical and emotional health challenges after giving birth. Although many of these problems abate over time, far too many women were still experiencing them from 6 to 18 months after birth. With more than 4.3 million births each year in the United States, it is an urgent priority to better understand the reason for these challenges, their implications for women and their families, ways to prevent distress and morbidity, and ways to help women and families before they experience detrimental effects," stated Maureen Corry, MPH, Executive Director of Childbirth Connection.

The study also looked into breastfeeding experiences, co-sleeping, social support from others and maternity leave benefits and employment issues.

 

"The overall picture is of recent mothers engaged in a juggling act, carrying multiple and sometimes conflicting responsibilities while experiencing high levels of social, physical and emotional health challenges. There are concerns about whether large segments of this population have access to adequate health and social services and social support. We are letting our mothers and babies down at one of the most critical and vulnerable times in their lives. These survey results are a clarion call to action for programs, policies, clinical services, and research to better understand and improve the experiences of new mothers and their families," said Corry.

The "Listening to Mothers Postpartum" survey reached 903 U.S. women, ages 18-45, who gave birth in a hospital to a single infant in 2005, with the infant still living at the time of the survey. The survey was carried out by Childbirth Connection, a national non-profit focused on improving the quality of maternity care through research, education, advocacy and policy, in partnership with Lamaze International and conducted by Harris Interactive.  The "New Mothers Speak Out" report, along with survey questionnaires, details about the survey methodology and related documents, are available at www.childbirthconnection.org/newmothersspeakout/

Matria Healthcare Launches MaternaLink PPD Screening Program

Matria Healthcare, LLC, a subsidiary of Inverness Medical Innovations, Inc., announced today that it has launched its MaternaLink Postpartum Depression (PPD) Screening Program, a service to help identify new moms at risk for PPD. The program's focus is to provide earlier clinical evaluation and support, better mental health and improved clinical and financial outcomes.

Matria will partner with health plans, Medicaid and employers to confidentially screen new moms. Matria's trained staff will use a validated screening tool to assess a new mom's potential risk factors for postpartum depression. Depending on the results, new moms are then referred to behavioral health providers for additional evaluation and treatment.

The new MaternaLink PPD program is an expansion of Matria's Total Maternal-Newborn Solution (TMNS), which comprises services that cover the entire continuum of maternal-newborn care from risk screening, education and case management to home-based OB services and NeoLink, a comprehensive NICU case management program. All participants receive 24/7 access to highly-experienced OB and NICU trained nurses who work in tandem with patients' physicians' plans of care.

"As more health plans and employers begin offering Matria's new PPD screening services to their members and employees, we look forward to the opportunity to positively impact the lives of moms suffering from this treatable but often ignored, medical condition," said Gary Stanziano, M.D., executive vice president of Matria Women's and Children's Health.  Matria Healthcare is a leading provider of integrated comprehensive health enhancement programs to health plans, employers and government agencies.

Note:  From the news release below I am unable to tell what type of screening tool they plan to use or exactly how the process works.  It will be interesting to find out.

Screening in Hawaii; Misguided Opposition to the MOTHERS Act

Here are some links to women writing about PPD in the blogosphere:

Diane in Hawaii writing about the organizations that conduct PPD screenings in the Aloha state

Tiffani writing about the MOTHERS Act and the misguided opposition to it

Addressing Maternal Depression: Opportunities in the Pediatric Setting

Amy Gagliardi recently published a white paper called "Addressing Maternal Depression: Opportunities in the Pediatric Setting" in Impact, a publication of the Child Health and Development Institute of Connecticut, funded by the Children's Fund of Connecticut.  The paper, which you can find here, posits that the pediatric or family medicine primary care practice is an ideal venue for the detection of maternal depression and discusses issues around screening in these environments as well as potential screening tools. 

Amy is director of the Perinatal Depression Project at Community Health Center Inc. in Middletown, CT, and is a fellow at the Edward Zigler Center in Child Development and Social Policy at the Yale School of Medicine.  The article was co-authored by Lisa Honigfeld.

Available Journal Articles on Perinatal Mood Disorders

The Archives of Women's Health just published a study by Lee Cohen, Zach Stowe, Lori Altshuler and others on a screening scale for antepartum depression, or depression during pregnancy.  From Springerlink:

"There are currently no validated clinician-rated scales that assess for depression specifically during pregnancy. We sought to develop a brief, convenient screening tool to identify depression in pregnant women in the community setting. Prospective mood data using the 28-item Hamilton Depression Rating Scale (HDRS) were collected monthly in 196 pregnant women with a history of a major depressive disorder. These data were analyzed to delineate those HDRS items associated (elevated) with normal pregnancy vs. those indicative of a pregnant woman meeting diagnostic criteria for a major depressive episode. Endorsement of symptoms on seven items of the HDRS were highly predictive of having a major depressive episode during pregnancy. We present a well-validated, brief scale to screen pregnant women for clinical depression. Whether this study will generalize to women who do not have a history of major depression remains to be studied."

So there you have it.  I'm not exactly sure what all of that means, but what I did find out is that the Archives of Women's Health has several different studies/journal articles available for purchase on SpringerLink which should be of interest to clinicians, including:

• Desired assistance versus care received for postpartum depression: access to care differences by race
• An audit of pregnant women with severe mental illness referred during the first 2 years of a new perinatal mental health service
• The Edinburgh Postnatal Depression Scale detects but does not distinguish anxiety disorders from depression in mothers of infants
• The relationship between women's attachment style and perinatal mood disturbance: implications for screening and treatment
• Pregnant women’s cortisol is elevated with anxiety and depression — but only when comorbid

Also:

• from Current Psychiatry: Postpartum depression - What to tell patients who breastfeed
• from the Journal of Women's Health:  Screening for Depression in the Postpartum Period: A Comparison of Three Instruments
• from the British Journal of Psychiatry: Duration of antidepressant use during pregnancy and risk of major congenital malformations

Study Finds Edinburgh Postnatal Depression Scale Effective For Identifying Women At High Risk for PPD

The Journal of Women's Health reported this week the results of research comparing three screening instruments used to identify women with postpartum depression during the first 6 months after delivery -- the Edinburgh Postnatal Depression Scale (EPDS), the Patient Health Questionnaire (PHQ-9) and the Postpartum Depression Screening Scale (PDSS). The study, conducted by the University of Pittsburgh, concluded that administering the EPDS by phone at 6-8 weeks postpartum was an efficient and accurate way to identify women at high risk for PPD.  For more information, click the link above.

PPD Screening Program in MI Receives Grant

The American Psychiatric Foundation (APF) has named five universities as the recipients of Helping Hands Grants, and one of the winning programs focuses on postpartum depression.

Michigan State University College of Human Medicine Upper Peninsula Campus in Marquette, Michigan, is being awarded the grant for the "Upper Peninsula Maternal Emotional Support Program" to implement a network of postpartum depression (PPD) risk assessment screening opportunities, professional educational curriculums and integrated community outreach efforts for all new mothers in the Upper Peninsula.  This program will establish a consistent risk assessment screening progam for PPD at Marquette General Hospital, educate health professionals in the use of PPD screening tools and provide outreach and community resources to at-risk mothers to reach 2,300 patients, physicians and staff.

Each of the five recipients receives a $5,000 grant for a community mental health service project initiated and managed by medical students under the supervision of medical faculty. The Helping Hands Grant Program raises awareness of mental illness and the importance of early recognition and builds an interest amongst medical students in psychiatry and working in underserved communities. The American Psychiatric Foundation is the philanthropic and educational arm of the American Psychiatric Association. The mission of the foundation is to advance understanding that mental illnesses are real and can be effectively treated. For more information, please visit the foundation's Web site at http://www.psychfoundation.org/ . The awards are made possible through an unrestricted educational grant from Otsuka America Pharmaceutical, Inc.

Go State!  (I'm an MSU alumna.)

Postpartum Progress Speaks Out in Full Support of MOTHERS Act

I said I would speak out on the ridiculous campaign being waged through petitions and blogs right now to block passage of the Melanie Blocker Stokes MOTHERS Act ... so here goes (hold on to your hats, folks):

I am truly peeved and disappointed at the breathless, hysterical ranting going on about the MOTHERS Act.  Many of those who oppose it seem to have done LITTLE to NOTHING to inform themselves about the actual bill and the organizations that support it.  Falsehoods are being spread.  Here are some examples:

"A federal bill that is dangerous to mothers and their newborns but being promoted under the guise of ensuring that 'new mothers and their families are educated about postpartum depression, screened for symptoms, and provided with essential services ...'  This is quite simply false ... it will push more mothers onto dangerous antidepressant drugs ..."

"If this bill is passed, any money spent on screening will be a complete waste of tax dollars.  The results will be an INCREASE in the severity and frequency of postpartum depression and an increase in violence and suicide."

"This legislation will ensure that new mothers and their families are also subjected to such treatment as they are screened for symptoms and provided so called 'help' that pushes these new mothers over the edge."

"The bill was originally proposed in response to the death by suicide of Melanie Stokes, a pharmaceutical rep. who took her own life by leaping from a balcony several stories off of the ground. Contrary to popular understanding it was not post-partum depression that killed Melanie, but the numerous antidepressant drugs she was taking ..." 

I'm not sure what algorithm they're using that would indicate that doing more to identify and treat these illnesses would lead to more PPD -- is this the new math they're teaching in schools?  And I have no idea how in good conscience they could spread lies about Melanie Blocker Stokes when her fearless and amazing mother Carol has worked so hard to get legislation like this passed so that other mothers can avoid the pain she has had to endure in losing her daughter. 

Now I know standards dictate that I don't share with you what these people are saying because it somehow gives them a voice.  But I'm blowing up the standards today, because I think my readers need to know exactly what is being said, so that you can be moved to speak up about it and defend the importance of the MOTHERS Act.  (One of the organizations behind this push is CCHR.  CCHR is the Church of Scientology.  Need I say more?)

The Melanie Blocker Stokes MOTHERS Act does NOT recommend drugs or require drugs or endorse drugs.  What is does is the following:

• Encourage the Department of Health and Human Services to coordinate and continue research to expand the understanding of the causes of, and find treatments for, postpartum conditions. 
• Encourage a national public awareness campaign to be administered by HHS to increase awareness and knowledge of postpartum depression and psychosis.
• Encourage HHS to make grants available for projects for the establishment, operation and coordination of systems for the delivery of essential services to individuals with postpartum depression.

There is no nefarious undercurrent, no plot by "the man."  The simple point is to continue to look into the causes of postpartum mood disorders, to let people know they exist and to provide better support services for the women who have them and their families.   Period, the end.  Every woman has the choice to decline participation in a screening, and every woman has the choice to look at all of the various treatment options available to her and choose the best one for her, whether it includes medication, therapy, alternative treatments, support groups or some combination thereof. 

Do I agree that we must be careful to only treat those who are ill?  Of course.  Do I agree that we must be careful in the types of treatments that are used, and must recognize the risks of taking certain treatments as well as the risks of not taking them?  Of course.  But I will not allow fearful conspiracy theorists to derail what is most important, which is getting our country's healthcare system to eliminate the stigma of mental illness, recognize the prevalence of postpartum mood disorders, learn more about their cause, allow new mothers who are suffering to feel safe in getting professional help and identify the best and safest treatments possible.

Please add your thoughts.  Scroll to the bottom of this post and look for the comments link to speak out.  C'mon girls - USE YOUR VOICE.

Here are links to other great comments about the opposition and the importance of supporting the MOTHERS Act.  If I've missed your response, let me know and I'll add it to this list.

• Susan Stone, President of PSI - this is so beautifully written - you MUST read it
• Spin Me I Pulsate
• Buoy for Perinatal Blues & Beyond
• Postpartum Perspective
• Unexpected Blessing/Sharing the Journey
• Depression Introspection

Why Universal Screening for PPD is Necessary

I found an excellent article on Health Commentary calling for universal screening for PPD written by Amy Gagliardi, a writer and research based at Yale University.  Check out the whole piece, but here is a highlight:

Wilen and Mounts in their article, Women with Depression – “You Can’t Tell by Looking” suggest that when screening for depression in the health care setting is based on clinical observation alone, 50% of women suffering from depression are missed.  In a study of 888 pediatricians, Olson et al conclude that even during the postpartum period when pediatricians have frequent contact with mothers and babies, pediatricians rarely identify maternal depression through a routine inquiry about symptoms or through family history.  In fact, the most common identification method reported was the physician’s overall impression or the impression in combination with 1 or 2 questions about the mother’s symptoms. Only 4% of the physicians in this study reported using formal diagnostic criteria to identify maternal depression while none reported using a validated screening tool to identify maternal depression. 

Universal screening is a necessary prerequisite towards the identification and treatment of maternal depression and this is not a responsibility specific to any one discipline.  Whether we are discussing perinatal depression, which is depression during pregnancy and the postpartum period, or depression at any time throughout the life course, systematic and universal screening is the most effective way to identify depression.  Of interest is a study which utilized a 2 question screen of mothers during well child visits. One group of mothers received the screen on paper while the other group was screened by means of a scripted interview.  Although both methods were proven to require very little time, the paper screen was verified to be a more effective model.

AMA Newspaper Focuses on Barriers to Caring for PPD Moms

American Medical News, the newspaper of the American Medical Association has just published a great story on postpartum mood disorders called "Beyond the Baby Blues: A Spectrum of Postdelivery Conditions."  It features myself and a host of fabulous doctors, including Dr. Marlene Freeman, Dr. Shoshanna Bennett and Dr. Katherine Wisner among others.  It covers barriers to care by physicians, which is extremely important given that we're trying to get a bill passed in the Senate asking for more education and training of doctors, among other things.  Here is my favorite quote from the article:

"This is a disease that lives between specialties [obstetrics/gynecology, psychiatry, pediatrics]," Dr. Wisner added. "Patients are running around in circles."

Exactly.

Blue Cross of California Launches "Maternity Depression Program"

Blue Cross of California announced yesterday that it has launched a Maternity Depression Program that provides new moms depression screenings, education, and support to help them obtain behavioral health treatment during and post-pregnancy.  Details from the press release:

"The Maternity Depression Program is designed to provide information and screening tools to all Blue Cross members who are new mothers while simultaneously identifying members who are at high risk for depression. Since May 2007, Blue Cross has mailed more than 13,000 educational packets to new mothers.

Members who screen positive are encouraged to either share the results with their physician or contact a Behavioral Health Clinician for additional screening, referrals or coordination with providers. If a member needs extra support she can call to enroll in the program and the clinician will provide follow-up calls as necessary. Members can receive depression education, assistance in understanding their treatment options and support to obtain appropriate care. Behavioral Health staff can help to coordinate care with the member's medical team. Routine follow-up is also provided until such time that the member is fully engaged in treatment.

Additionally, because PPD is usually under detected and under treated, Blue Cross has delivered more than 10,000 provider tool kits to California OB/GYN practitioners and pediatricians. These "tool kits" include physician Continuing Medical Education course material, educational hand outs for their patients, and sample screening tools. "The tool kits were an enhancement to our Maternity Depression program developed after conducting several focus groups with pediatricians, OB/GYNs, primary care physicians and women who have infant children. The sessions clearly demonstrated the deep level of trust patients have with their pediatrician, OB/GYN and primary care physician," said Brian A. Sassi, president and general manager Blue Cross of California. "The most important thing to remember is that there is help for these new mothers."

"Through the Maternity Depression Program, Blue Cross provides new mothers, their family members and physicians with information and tools to identify mothers at risk for Postpartum Depression. The physician can then evaluate the mother to better understand her concerns and behavioral changes or if there are signs of significant depression," said Cheryl Noncarrow, president of Behavioral Health for Blue Cross of California. "Screening to identify issues and referring into treatment is a start in helping to restore normalcy for new moms."

Blue Cross members wishing to obtain more information can call (866) 785- 2789 and tell a representative that they may be experiencing postpartum emotional changes.

Study Suggests New Moms' Mental & Physical Health Be Monitored Past 6 Weeks, But Who Will Do It?

A new study in the November/December 2007 issue of the Annals of Family Medicine takes a much-needed look at the postpartum health of working mothers.  The study looked at moms who return to the workplace 11 weeks after childbirth and found that they continue to need evaluation of their fatigue levels and mental and physical symptoms beyond the normal 6-week postpartum checkup.

"At 11 weeks postpartum these employed mothers continued to experience several childbirth-related symptoms, indicating a need for ongoing rest and recovery. Postpartum evaluations should include screening for anxiety and depression and evaluation of fatigue and other physical symptoms, including those related to job stress."

The study recommended that women showing continued symptoms should receive counsel on strategies to decrease job stress and increase social support at work and home, and that physicians should talk with them about the possible need for intermittent leave under the Family and Medical Leave Act to help them manage symptoms.

One of the most fascinating comments was this, from Pat McGovern, PhD, MPH at the School of Public Health at the University of Minnesota in Minneapolis, and her colleagues who wrote the study:

"The traditional medical perspective of the postpartum period refers to the time after childbirth that is required for the reproductive organs to return to their nonpregnant state, a process that takes approximately 6 weeks. Many physicians perceive this time as one requiring little assistance other than the recommended single postpartum visit ..."

All new mothers know this is true but I don't think I've ever seen it stated so plainly.  Our healthcare professionals are essentially focused on making sure our uteruses (or is it "uteri"?) are in working order ... but the rest of us?  Not so much. 

Dr. Laurie Barclay writes on Medscape.com:

"Because of the increased prevalence in the workplace of mothers with infants, greater understanding of factors that could improve postpartum health and facilitate return to work is greatly needed. Recovery from childbirth and successful return to work may be affected by personal factors such as preexisting health status, parity, breast-feeding, and social support from family and friends; as well as work-related factors including the timing of return to work, job stress, and support in the workplace."

Honestly, I think the results of this study apply equally to women who don't go back to work.  All new mothers suffer a compounding list of stresses that make it difficult to cope with daily responsibilities, and there is no specific group of healthcare professionals who has taken on the task of monitoring our whole health.   

Which group of clinicians will make sure women are properly evaluated and counseled?  The study specifically cites the need for screening new moms for anxiety and depression, but who will do it?  At the moment, no group of doctors taken on the job of providing that safety net.  I sometimes wonder whether they're all hoping someone else will step up to the plate so they can be relieved of the duty.  Sure, there are pockets of doctors and nurses in different places throughout the country who have recognized the importance of paying more attention to the health of new moms over a more extended period of time, but as a general rule many ignore it, and I wonder if some of the larger physicians' groups aren't actually against it.

The OB/GYNs are concerned with taking responsibility for the process of pregnancy and childbirth.  The pediatricians are primarily focused on the health of the baby.  Your primary care physician may not see you for months unless you come down with the flu, so they may never know if you're having problems.  They all say they don't have time, they don't have the proper training, they aren't reimbursed for it, they worry about the legal ramifications, etc.  And they're right on all those points.  Yet mental health screenings and treatment remain completely necessary if we care about having healthy mothers in this country. 

New moms are just not very likely to wander by the office of a mental health professional and drop in to say hello.  These people are specialists, for whom you generally need a referral.  We need a comprehensive nationwide process to get mothers mental healthcare if they need it, where the doctors responsible for screening and referral have buy-in and there is a clear line of sight.  Somebody is going to HAVE to take responsibility for this, so we need to work together to begin developing workable solutions.  Hopefully the MOTHERS Act will help to address this when it is passed, and it becomes federal law that all women are screened for postpartum depression and anxiety.  Notice I sad when, not if.

(crossposted at BlogHer.com)

Participants Needed for Online Survey On New Postpartum Distress Scale

Karen Kleiman has sent out the following information on research she is conducting into a new postpartum distress scale.  She needs participants who have babies up to 12 months old to complete a survey (Bummer - I can't participate!).  If you meet this criteria, I hope you'll take the survey.  The link to it is below:

As many of you know, I have been collaborating with a research team at the University of Pennsylvania School of Medicine who have expertise in postpartum distress and scale design. We have performed an initial statistical analysis on a new postpartum distress scale.

At this stage, we would like to re-test our proposed scale items, along with established measures, such as the Edinburgh Postpartum Depression Scale (EPDS).

We need approximately 100 postpartum women (with babies up to 12-months old) to complete this phase of the study. I am hoping that you will post a link to the questionnaire, which is offered online, for your members or your clients, to help us further validate this measure.

The survey will probably only be up for a month or so.

Click here to participate.

British Columbia Screens Women for PPD Both During & After Pregnancy

Click here for a link to an article in the Toronto Sun about antenatal depression, or depression during pregnancy.  One highlight:

"Recognizing the need to find and help this sub-population, Misri, in partnership with B.C.'s ministry of h ealth, has implemented a screening initiative using a respected self-reporting depression scale.

In British Columbia, pregnant women will receive the screening tool when they are about 28 weeks pregnant, and six to eight weeks postpartum."

Gov. Blagojevich Needs to Sign PPD Legislation in Illinois

Here's a link to a story about Mary Howorth, who was instrumental in getting legislation passed in Illinois calling for screening of women for postpartum mood disorders.  The legislation is awaiting signature from the governor of Illinois, Rod Blagojevich.  Here's hoping the governor gets with it, and soon!  The women of Illinois need him to put pen to paper!

New Study Says Docs Not Probing for Signs of PPD

From WRAL.com in North Carolina:

"A new study suggests a majority of doctors are not probing new mothers for signs of postpartum depression.

Of the 228 physicians responding to the survey who said they had seen women for postpartum visits in the previous three months, 79 percent said they were unlikely to formally screen the patients for depression ...

'We believe that it is very important that physicians work some type of depression screening into postpartum visits,' said Betsy Sleath, lead author of the study and a professor in UNC's School of Pharmacy. 'Perhaps even more important, women shouldn't be afraid or embarrassed to raise this issue with their doctor. We're expected by society to be happy when we have a child so sometimes it's hard to talk about the fact that women feel sad, or that it's hard being a new mother.'

Physicians and other health care professionals use a variety of tools such as a patient health questionnaire and the Edinburgh Postnatal Depression Scale to determine a woman's risk of postpartum depression.

Dr. Bradley Gaynes, one of the study's co-authors and a psychiatrist with UNC Health Care, said checking for signs of depression can be as simple as asking a new mother two questions:

• Has your interest in your usual activities changed?
• Do you feel depressed or hopeless?

'We recognize that physicians must cope with many demands on their time,' Gaynes said. 'But depression is one of the most common postpartum complications, and a postpartum depression needs to be identified before it can be treated. We encourage clinicians to always check for signs of depression during postpartum visits. These questions represent the core symptoms of a major depressive disorder.'

An estimated 13 percent of new mothers are affected by postpartum depression. The study, conducted by researchers at the University of North Carolina at Chapel Hill, will be published June 6 in the North Carolina Medical Journal."

PPMD Deserves Attention No Matter Who Gets It

This is a link to a story from United Press International, from the annual meeting of the American College of Obstetricians and Gynecologists that was held earlier this month.  (Sorry it took me this long to get to it!)  Here's what I loved about it:

"'Unfortunately, it seems that pre-natal and post-natal depression only gets attention in tragedies or when celebrities are involved," said Stanley Zinberg, vice president for practice activities for the American College of Obstetricians and Gynecologists.

"We screen for many diseases that occur far less often than peri-partum depression," Sharon Phelan, professor of obstetrics and gynecology at the University of New Mexico in Albuquerque, told United Press International."

I noticed this recently with the hearings on Capitol Hill about the Mothers' Act and the Melanie Blocker Stokes Act.  News outlets from as far as away as the Middle East wrote about Brooke Shields testifying at the recent hearing.  Everyone wants to talk about it because Brooke Shields was there. No offense to Brooke, who I'm so pleased was willing to testify along with others, but why the frenzy over her appearance and not over the HUNDREDS OF THOUSANDS of women and children who suffer yearly from postpartum mood disorders.  Why not a frenzy over the children who've been killed or the women who've committed suicide?   Can we really not get excited about doing something about this issue unless Brooke Shields shows up??! And I would bet Brooke would agree with me.  I would imagine she doesn't want this to be about her, but about helping women get better treatment.  Congress needs to do something, regardless of who shows up to tell their story.  There are countless stories, and every one of them is heartbreaking.

New Bill Introduced in Maine for Postpartum Mental Health Education And Screening

It looks like there is also now a bill in the state of Maine to make PPD screenings mandatory at 6-weeks post birth and to require doctors to educate women on postpartum mood disorders during their pregnancy.  The bill (LD 792, An Act Concerning Postpartum Mental Health Education) is sponsored by state Senator Nancy Sullivan (D).  On Feb. 15 it was referred to the Maine Senate's Committee on Health and Human Services.  Ladies in Maine, contact your local representatives to get this passed!!

Telephone Screening A Reliable Method to Identify PPD

Here's an interesting tidbit:  Oakland University in Rochester, Michigan, conducted a study on the reliability of telephone screening for identification of postpartum depression.  Eight weeks after discharge from the hospital, 106 women participating in the study were screened over the phone using the Postpartum Depression Screening Scale (PDSS).  The results found that, as compared to in-person screening, telephone screening is a reliable method to screen for postpartum symptomatology that may occur later than the 6-week office visit.

Screening Bill Introduced in IL State Legislature

Postpartum psychosis survivor Mary Howorth has shared with me that she has been working with members of the Illinois state legislature to get a bill passed to require perinatal mood disorder screening.  The bill, called the Postpartum Mood Disorders Prevention Act, has finally been introduced by state Senator Don Harmon (D). (If you click on the link and then click on full text, you can read it in its entirety.)  It also has a new co-sponsor, Illinois Senator Jacqueline Y. Collins (D).  Let's hope it gets passed!  Residents of Illinois, please contact your local representatives!  Thank you, Mary.

Edinburgh Scale May Not Be Broad Enough to Identify Women With Postnatal Anxiety

A study recently conducted at the Swinburne University of Technology in Australia has found that the Edinburgh Postnatal Depression Scale (EPDS), while fairly accurately identifying women suffering from postpartum depression, often misses those women suffering postnatal anxiety without depressive symptoms.  As so much discussion lately has focused on the importance of requiring ob/gyns to screen women at the 6-week postnatal checkup, I think this study is highly important.  We must ensure that we use the best screening tool available once we are finally able to get screenings conducted with all women who've given birth.  As postpartum mood disorders cover a wide spectrum, we can't use a tool that may miss out on identifying certain women who are suffering.

According to the study, "... postnatal depression has received considerable research and clinical attention, however anxiety and stress in the postpartum has been relatively ignored. Along with the widespread use of the Edinburgh Postnatal Depression Scale (EPDS), depression has become the marker for postnatal maladjustment. Symptoms of anxiety tend to be subsumed within diagnoses of depression, which can result in anxiety being minimized or overlooked in the absence of depression. Some researchers have identified the need to distinguish between postnatal depression and anxiety, and to discern cases where depression and anxiety co-exist ... [Using the Depression Anxiety Stress Scale (DASS-21), a broader scale than the EPDS], found that 10% of the women in the study showed symptoms of anxiety and stress without depression ... The prevalence of anxiety and stress in the present study points to the importance of assessing postnatal women for broader indicators of psychological morbidity than that of depression alone. The DASS-21 appears to be a useful instrument for this purpose."