Pregnancy Related (Postpartum) Depression Screening
Every year, more than 400,000 infants are born to mothers experiencing depression in the US (in Colorado it’s 4,000). This is a condition that affects the health and well-being of whole families and has tremendous impact on the development and mental health of the child. Data from the 2009 – 2011 Colorado Pregnancy Risk Assessment indicates that pregnancy-related depression is the most common complication of pregnancy for women in our state. Women under the age of 19, African-American women, women on Medicaid, unmarried women, women with less than a high school education, and women living in poverty exhibited higher rates of depression (CDPHE, 2009). Click here for more information on the Colorado Pregnancy Risk Assessment data [pdf]. Research shows that children of depressed mothers are more likely to exhibit socio-emotional problems; delays or impairment in cognitive, linguistic, and social development; exhibit poor self-control; aggression; have poor peer relationships; and difficulty in school. For the majority of women, advice from a health care provider on ways to address the depression is effective in improving the depression. Regular screening improves outcomes for both the mother and the child.
A medical home for children is the place that post-partum women covered by Medicaid are most likely to be seen by professionals able to administer and respond to pregnancy-related depression screening within the critical first two months after birth. This may provide a critical lifeline to women struggling with this treatable condition and help prevent potential negative effects of maternal depression on infants. So, the child’s health care providers are in a unique and key position to identify and treat post-partum depression, now more commonly referred to as Pregnancy-Related Depression (PRD).
Edinburgh Postnatal Depression Scale (EPDS)
The Edinburgh Postnatal Depression Scale (EPDS) is the most well-known, validated instrument for screening pregnancy-related depression. It has 10 questions, is free, is relatively easy to score, and can be completed in less than 5 minutes by the mother. Typically, a score of >10 is indicative of a positive screen and can alert the provider that a mother needs additional behavioral health follow-up. The EPDS has been studied in various cultural groups and translated into multiple languages, making it applicable for a wide range of populations. However, it is important to note that this measure was developed in the United Kingdom, using phrases and language that would be commonplace and have broad understanding among that population. This can lead to translation difficulties outside of that cultural context.
Click here for access to the Edinburgh Postnatal Depression Scale (EPDS) in English [pdf]
Click here for access to the Edinburgh Postnatal Depression Scale (EPDS) in Spanish [pdf]
Instructions for using the EPDS [pdf]
|10 – 12||Possible depression; may present with/report some depressive symptoms||– Would likely benefit from educational materials and brief psychosocial intervention by the medical home provider or staff|
– Warrants follow-up (see below)
– Screen should be re-administered at next well visit to determine progress
|13 or greater||Likely to meet clinical threshold for depression||– Warrants educational materials and brief psychosocial intervention in the medical home|
– May need referral to a behavioral health provider. Can utilize resources listed below to help with this decision
– Need to follow referral and ensure mother got connected with treatment
– Screen should be re-administered at next well visit to determine progress
(on item 10)
|Endorsing suicidal thoughts or homicidal ideation||Requires immediate attention including assessment of level of intent and access to weapons/method (i.e. suicide plan); if unsure of next steps, call Rocky Mountain Crisis Partners (formerly Metro Crisis Services) at 844.493.TALK (8255).
– May necessitate hospitalization of the mother
Recommended Screening Schedule
Beginning July 2017, Medicaid allows for three maternal depression screenings within the first year postpartum. Screenings are recommended during the following visits: 0-1-month visit, the 2-month visit, and either the 4-month or 6-month visit. However, providers may screen any time up to 12 months postpartum.
Billing, Coding, Reimbursement Information
The pediatric primary care provider who sees an infant for a well-baby visit may now bill for postpartum depression screening on the mother using the Medicaid ID of the infant (effective August 1, 2014). The procedure code for postpartum depression screening is G8431 for a positive screen, and G8510 for a negative screen (Medicaid claims only). Use an appropriate diagnosis code. For CHP+ and commercial plans, bill using CPT 99420.
Acceptable screening tools include the Edinburgh Postnatal Depression Scale and the PHQ-9. Postpartum depression screening counts as an annual depression screen. Many of the largest commercial health plans also reimburse for this screening.
Medicaid primary care providers may also screen new mothers at a well-child visit using the mothers’ Medicaid ID number. Coding is the same as above.
If a behavioral health need is identified after screening, the pediatric provider should assist with referring the mother to a Behavioral Health Organization (BHO), or Regional Care Collaborative Organization (RCCO).
How To Implement
The first steps include deciding to begin screening for pregnancy-related depression and selecting a tool. There are various screening tools that may be appropriate for screening adult depression, including the widely used Patient Health Questionnaire – 9 (PHQ-9) or Beck Depression Inventory (BDI). However, our recommendation is the EPDS as it was developed, standardized, and validated specifically to identify pregnancy-related depression. Once the screening tool has been selected, the next step would be planning how (electronically or manually), when (our recommended schedule promotes screening at the 1 week, 2 week, and 2 month well child visits), and by whom the screening will be conducted at visits. CCHAP is able to help practices and clinics begin gathering resources for how to address positive depression scores – treatment and how recommendations will vary by severity and referral resources will vary by community/geographic location.
When PRD Screen Is Positive
Depending on the demographics of the practice or clinic, between 10 and 15% of women will experience PRD, but of those, approximately 85-90% will respond to counseling on lifestyle modification recommendations and increasing social support. This type of counseling can be provided by a provider or nurse in the infant’s medical home. The Colorado Department of Public Health and Environment (CDPHE) partnered with community organizations to develop a protocol that contains information on how to talk with mothers about pregnancy-related depression screening, identifies protective and risk factors, and provides guidance on how to determine treatment recommendations: Click here for Pregnancy-Related Depressive Symptoms Guidance.
Brief Psychosocial Intervention From Pediatric Providers
It’s important to remember that many women suffer from mild-to-moderate forms of pregnancy-related depression that can improve with lifestyle modifications and increased social support. For many families, pregnancy-related depression can be difficult to discuss and, depending upon the families’ cultural background, there may be little understanding of the impact of behavioral health conditions. Providers can begin conversations by expressing empathy or understanding that caring for a new baby can be overwhelming and challenging, explaining that the feeling is common and can be huge adjustment for mothers and families. Providers can also explain that the mother’s health is directly related to the health of the baby and that it is vital for new mothers to maintain their physical and emotional well-being as much as possible. For example, providers can start the conversation by saying:
“Being a mother for a newborn is very hard work. Many mothers feel overwhelmed or down. It’s really important for you and your baby that you feel well and supported. There are many things that other mothers feeling this way have found is helpful. Let’s think of ways to help you feel better.”
The following handout materials can be used to help mothers develop a brief action plan to manage mild to moderate pregnancy-related depressive symptoms:
- What to do when you feel blue…
- Pregnancy-Related Depressive Symptoms Patient Resource
- For Spanish-speaking mothers
Treatment options are different for pediatric and family practices depending on whether the mother is considered a patient in the practice or clinic. Only a small number of depressed mothers will require medication. Family physicians may feel comfortable in following the attached guidelines for starting medication.
For Mother’s Needing Mental Health Referral
For mothers on Medicaid who require a specialized referral to mental health, the local community mental health center or BHO can provide guidance on the referral process. Click here for a reminder of the BHOs and their regions. Mothers with commercial insurance plans will need to check with their insurance carrier about behavioral health resources. Things that may be important to ask: What types of services (e.g., medication, therapy, CAM modalities) are covered? How many sessions (therapeutic) are covered? What types of behavioral health providers (e.g., licensed psychologist, psychiatrist, LPC’s, licensed social workers) are covered? And how to access a list of covered providers in their respective geographic area. There are many resources available to help you decide on whether to refer and where to refer (listed below).
Many medical homes have told us they have gotten wonderful assistance from Rocky Mountain Crisis Partners, which is now open to families from any county, any time and their hotline is open 24/7. The phone number is 1-888-885-1222. They will advise you and will also assist the family directly.
Effective Handoffs And Follow-up Are Crucial
Effective coordination of the mother’s care and follow-up is critical to successful treatment. When a mother with PRD is identified at an infant’s visit, in addition to appropriate management at that visit, there should be communication with the mother’s partner and her primary care provider ( or obstetrical provider). If the mother does not have a primary care provider, contact the RCCO where the mother lives and have them work with her to establish one. Provide the PCMP with the results of the screening and any other actions taken as well as contact numbers or resources contacted. When a behavioral health referral is made by the infant’s medical home, follow-up and monitoring of the mother should be close until a behavioral health professional has seen her. Follow-up PRD screening should occur at subsequent infant visits until it appears the depression is better and follow – up is well established, even though these follow-up activities are not currently reimbursed. After consent is obtained, be sure the mother’s partner/significant other is consulted and kept in the treatment loop at all times, so the home situation can be part of the ongoing monitoring process.
Other Resources For Families And Clinicians
- Postpartum Support International: In addition to providing information and resources for families and communities, PSI also offers weekly support calls staffed by behavioral health professionals on Wednesdays for mothers and Mondays for fathers.
- Postpartum Support International – Colorado chapters: PSI has five local coordinators that can help practices or families locate community resources and support groups.
- Motherisk.org: Provides a wide-range of resources on various pregnancy related topics, including mood disorders and illicit drug use during pregnancy. Trained counselors are available by phone (for families and providers) Monday through Friday 9 AM to 5 PM EST for support and guidance. 1.877.439.2744.
- MedEd Postpartum Depression Information: This website is geared toward professionals and provides information on research outcomes in the area of pregnancy-related depression while also providing clinical tools and resources that can easily be incorporated into practice. Also provides printable information to give to families.
- Infant Risk Center (Texas Tech University): An empirical resource that provides up-to-date clinical information about a wide-range of topics related to pregnancy, including depression, substance use, and use of prescribed medications. Healthcare providers and families are encouraged to call Monday through Friday 8 AM to 5 PM Central time. 1.806.352.2519
- Local early childhood councils frequently have information on local programs that provide support to mothers and infants – as maternal depression is a developmental risk for a child. Connecting with these local resources can help you find programs in your community. Click to find your local Early Childhood Council [pdf].
- The Colorado Department of Public Health and Environment (CDPHE) provides information on pregnancy-related depression and resources for families and healthcare providers in Colorado.
- Cultural Considerations of Pregnancy-related Depression – Examines the cultural knowledge necessary for successful screening of pregnancy-related depression in private practice settings in the U.S. as well as referrals
to mental health providers by primary care physicians. Further, to explore situational factors that increase the likelihood of pregnancy-related depression across all cultures and the importance of culturally appropriate emotional and practical support that is essential to women during pregnancy and after child birth.
FOR WOMEN WHO MAY BE IN CRISIS
- Suicide Prevention Coalition of Colorado – Provides information about depression and suicide and has a map with resources in every county
- Rocky Mountain Crisis Partners – Emergency Mental Health and Substance Abuse Services for Colorado. Open to families from any county, any time – hotline is open 24/7. 1-888-885-1222. Providers are also welcome to call and ask questions about how to manage a psychiatric crisis situation. Cards, brochures and promotional materials are available upon request.
It is important to note that many cases of postpartum mood disorders that are reported in the popular media are about women struggling with postpartum psychosis (PPP). This is an extremely rare mood disorder that occurs in .1% of births (much less than postpartum depression). PPP often has a rapid onset and symptoms may include delusions, hallucinations, paranoia, hyperactivity, irritation, and difficulties communicating. Among this very small population of women, only a very small percent of cases will result in a mother harming her children or suicide. Most women with postpartum psychosis never harm anyone! It’s important to distinguish between postpartum psychosis and pregnancy-related depression as they have very different symptoms and need very different urgent treatment.
If you would like assistance with implementation of the EPDS, developing a screening schedule for pregnancy-related depression, developing a protocol to manage positive screens, reviewing how to provide the brief interventions, compiling specific referral resources for behavioral health, developing a system to follow up on women with PRD or have any other questions about pregnancy-related depression, contact us to learn more about CCHAP’s services.
View our Practice Manager’s Meeting recording on the topic of Pregnancy Related (Postpartum) Depression Screening for the Primary Care Practice: Screening, Resources & Referrals.