The American College of Obstetricians and Gynecologists (ACOG) now recommends screening for perinatal depression, stating that “clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standard, validated tool.” Having the backing of ACOG is certainly a big step in the right direction. But as we move toward universal screening, we must make sure that screening is seamless connected to follow-up and treatment.
What we have seen over and over is that most women with perinatal depression, including those identified through screening in obstetric practices, do not get appropriate treatment for their symptoms. Why? Dr. Nancy Byatt and colleagues published an analysis of intervention studies that may help us to improve the delivery of care to this population. In this report, they analyzed 17 studies where women were screened for perinatal depression, and they assessed levels of subsequent treatment.
If you look at the women who were screened for depression but received no additional intervention, rates of treatment were low. An average of 22% (13.8-33.0%) of women who screened positive for depression received at least one mental health visit.
The authors noted that the use of mental health services increased two to fourfold when screening was combined with additional interventions geared to decrease potential barriers to treatment. For example, studies including interventions offering systematic follow-up, supportive therapy, or support groups were associated with an average mental health care use rate of 31% Use of mental health services was even better when these interventions targeted both patient- and healthcare provider-derived barriers to treatment by using patient engagement strategies (44%, 29.0–90.0%), on-site assessments (49%, 25.2–90.0%), and perinatal care provider training (54%, 1.0–90.0%).
Taking these findings into consideration, Nancy Byatt has teamed up with other perinatal and behavioral health professionals to design and refine a program which could be used in an obstetric practice to identify and deliver treatment to women with perinatal depression. This program, which they call PRISM or PRogram In Support of Moms, was then beta-tested in an obstetric practice at a large academic tertiary care referral center in central Massachusetts.
A 1.5-hour training session is conducted where practice providers and staff receive information on screening and depression treatment, including a discussion of the risks and benefits of antidepressant use during pregnancy and lactation. Providers also receive training and resources to help destigmatize depression and encourage women to seek help. Providers receive a toolkit which includes screening, referral, and treatment protocols. (Information on what’s in the toolkit can be found here.)
A practice-specific approach to depression screening and treatment is developed. This includes determining the timing and setting for screening and a discussion of treatment protocols and referral. Providers and staff are trained to offer psychoeducation and other mental health resources and referrals during obstetric visits.
Probably one of the most important components of this intervention is access to mental health consultation with a perinatal psychiatrist via e-mail or telephone. Consultation consists of diagnostic support, treatment planning, guidance regarding medication treatment (including information on the safety of medications in pregnant and breastfeeding women), and advice on psychotherapy and community resources.
They tested PRISM in one obstetric practice of 14 providers. Prior to the program, none of the providers in this practice reported that they were routinely screening their pregnant and postpartum patients. Thirteen of the 14 providers attended the training. Of the 50 patients served during the beta-testing of the program, 40 (80%) completed the EPDS. Fourteen of the 40 screened patients (35%) scored ? 10 cutoff on the EPDS. No patient scored positive on the EPDS self-harm question. Every participating obstetric provider screened at least 50% of his or her patients. The consulting psychiatrist provided four consultations regarding assessment or treatment of perinatal depression.
On paper, the program looks great and includes everything we would like to see in an intervention, but the real-life implementation of the program is what counts. If we come back in a year, how many patients will receive screening? Fewer or more? And this study does not include any long term follow-up of the women who screened positive. Do they get treatment? Do they get better?
One of my concerns, in terms of the feasibility and longevity of this sort of program, is the increased load it places on obstetric providers. If 30% of the women screen positive (as noted in this study), they will require additional, more thorough evaluation. And how long will this evaluation take? If you are an obstetrician who sees 20 patients per day, how will you fold in the extra time it needs to evaluate six or seven additional patients? And what if one of those patients is reporting suicidal thoughts or intrusive thoughts about harming her child? How will that be managed in a busy outpatient obstetrics practice?
The biggest, and perhaps most insurmountable, problem is that we are trying to overcome the inadequacy of mental health services in our healthcare system by recruiting ancillary providers — for example, using obstetric providers to screen for and manage perinatal depression. Noting that screening alone cannot improve clinical outcomes, the ACOG opinion statement says that it “must be coupled with appropriate follow-up and treatment when indicated,” and – most critically – adds that clinical staff in the practice “should be prepared to initiate medical therapy, refer patients to appropriate health resources when indicated, or both.” The latter recommendation is followed by the statement that “systems should be in place to ensure follow-up for diagnosis and treatment.”
While there are now more and more programs offering training to obstetricians, midwives, and nurses so that they can better identify, and even manage, perinatal mood and anxiety disorders, I suspect that many obstetric providers may feel uncomfortable assuming the care of this patient population. While screening is important, we must also make sure we tend to the ACOG recommendations regarding appropriate follow-up and treatment. Because the stigma continues to be significant with regard to mental health issues in mothers and mothers-to-be and because there are concerns regarding the use of medication in pregnant and nursing women, we must make sure that after screening, we help women to access appropriate resources and treaters who are familiar with treating women during pregnancy and the postpartum period.
Ruta Nonacs, MD PhD
Byatt N, Pbert L, Hosein S, Swartz HA, Weinreb L, Allison J, Ziedonis D. PRogram In Support of Moms (PRISM): Development and Beta Testing. Psychiatr Serv. 2016 Aug 1;67(8):824-6. Free Article