"Chances are we're not picking up postpartum depression, we're picking up women who already were suffering from depression, because the screening asks them how they've been feeling for the last seven days," observes Jennifer Rousseau, DNP, a women's health nurse practitioner who led the screening program initiative.
The importance of screening new and expectant mothers for depression is receiving greater attention after the U.S. Preventive Services Task Force, a volunteer panel of health experts that advises the government, on Jan. 26 issued a recommendation for depression screening that for the first time specifically included pregnant and postpartum women. Because of this new recommendation, health insurance now must cover these screenings.
Nonetheless, putting the recommendation into practice and seeing to it that women with significant symptoms of depression receive help remains a challenge. "Screening is really great, but what does the obstetrician or mental health professional do when they have the information?" asks Natalie Stevens, PhD, assistant director of outpatient psychotherapy at Rush. "Finding resources is the challenge, depending on the location of that provider."
Rush is helping address this challenge. In the past few years, the Medical Center has initiated both a program to screen mothers for depression within the first two days following childbirth and a program to refer pregnant and postpartum women with depression to specialized treatment.
'When women get treatment, those babies get better'
Many women are in need of such help. Studies have found that up to 13 percent of postpartum women experience minor depression, and up to 6 percent meet the criteria of a major depressive disorder, Stevens says. "Another study shows there may be increased risk of developing depression in the second trimester of pregnancy," she adds.
Those numbers are driven by the enormous changes women undergo during and after pregnancy. "It's the hormonal changes and physiological changes that pregnancy causes and the stress of childbirth and actually having a child, especially for first time mothers," says Mona Shattell, PhD, RN, chairperson of the Department of Community, Systems, and Mental Health Nursing in the Rush University College of Nursing.
"Pregnancy can be a challenging time," Stevens adds. "It has the potential to be a life stressor that exceeds a woman's ability to cope. There might be financial strain, limited family support. It's a combination of biological, emotional and social factors that combine to make a woman vulnerable to psychological distress."
Many of these women are at a loss to understand their illness or how to get help for it. "One of my friends said she had postpartum depression, and she didn't know about it or what to do about it," Shattell recalls. "Because of the stigma, she didn't bring it up to her obstetrician, and she felt isolated and alone. She would have been so happy if someone had asked her about it. Asking the questions makes it okay."
In addition to a mother's own suffering, depression can have significant negative effects on a child that begin even before birth. "There is an association between depression in pregnancy and impaired fetal development," Stevens explains. "Women are more likely to deliver preterm and are more likely to have babies that weigh less than they should.
"Postpartum, it really affects the attachment and the relationship between mother and baby," she continues. "A woman wants to bond with her baby, but a depression interferes with maternal sensitivity and responsivity."
As a result, children of mothers with untreated depression can have delays in cognitive, emotional and motor development, and they're at risk in adolescence to have depression themselves and violent tendencies, Rousseau warns. "When women get treatment, those babies get better," she says. "That's why it's so important. The earlier we can diagnose it, the easier it is to treat, and the more likely it is that treatment will be effective."
Testing is simple, inexpensive and effective
The standard tool to screen for depression in pregnant and postpartum women is a questionnaire known as the Edinburgh Postnatal Depression Scale. Tests have shown that the scale is accurate, even at low levels of stress that may be clinically significant, according to Stevens.
It also is easy and cost-effective to administer. The patient fills out the questionnaire herself, and the provider just has to tally the answers and check the score to see if it indicates depression. When Rousseau, an assistant professor ofwomen, children and family nursing, first piloted Rush's screening program, she determined the cost was only $3.23 for a negative screen, and $4.98 for a positive test.
The pilot program found that 23 percent of new mothers weren't getting screened at the traditional six-week postpartum visit. Since Rush launched the universal screening program launched in August of 2013, 98 percent of the new mothers in the Family Birth Center have chosen to accept the invitation to receive the screenings, which are voluntary. Last year, 40 patients screened positive for depression and another 118 screened as mildly depressed.
Stevens currently is piloting another program in one of Rush's outpatient obstetric clinics to provide screenings to pregnant women in their second or early third trimester of pregnancy. "We want to catch any symptoms of psychological stress that could be treated before the patients give birth," she explains.
Pregnant and postpartum women suffering from depression can receive specialized care from Rush's Center for Women's Behavioral and Mental Health. A collaborative effort between the Department of Psychiatry and Department of Behavioral Sciences, the center offers both psychotherapy and medication treatment that takes into consideration patients' concerns for the effect of drugs on their child.
"Patients who show symptoms of depression are referred over to us and seen in a couple of weeks. They're able to be evaluated for the need for additional treatment relatively quickly," says Stevens, who is an assistant professor of behavioral sciences.
Early detection of depression is a key factor in women being treated successfully, adding to the importance of screening during pregnancy. "We've found that a lot of postpartum women are not coming for mental health treatment," Rousseau says. "But if they are diagnosed prenatally and get treatment prenatally, our results show that 100 percent of women will continue the care postpartum."
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