Maternal Depression Screening and Referral Part 1: Rationale

1
Maternal Depression Screening and Referral Part
1 Rationale

• Katie Leon
• Visiting Nurse Services
• In Conjunction with
• Iowa Department of Public Health

2
Myths and Barriers to Detection

• Can you judge a book by its cover?
• No!
• The same is true for being able to tell if
  someone is depressed just by looking at them.

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Myths and Barriers to Detection

• Which woman is depressed?
• You cant tell by looking!

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Myths and Barriers to Detection

• Inaccurate or unrealistic media portrayals.
• Difficulty distinguishing normal adjustment and
  depression for individual and healthcare
  professionals.
• Misunderstanding and overemphasizing the
  importance of poverty.

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Myths and Barriers to Detection

• Media Portrayals May be Unrealistic

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Barriers to Detection Is it Depression or Normal
Pregnancy or Postpartum Symptoms?

• Changes in appetite
• Changes in weight
• Sleep disturbances/insomnia
• Fatigue/low energy
• Changes in libido

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Barriers to DetectionMy Client is Poor not
Depressed

• How do you expect her to feel in this
  situation?
• MYTH
• Not all women with limited economic resources are
  depressed
• Depression can make it difficult for all women to
  cope

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Prevalence of Depressed Mood by Income Level
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The Importance of Screening

• Direct service providers play a critical role in
  overcoming these barriers.
• Using a screening tool with all women that you
  see (not just the ones that you think seem or
  look sad), you can identify women who might be
  depressed, help them to recognize it and refer
  them for treatment.

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The Importance of Screening

• Recommendation of the USPTF
• The U.S. Preventative Services Task Force
  recommends screening adults for depression in
  clinical practices that have systems in place to
  assure accurate diagnosis, effective treatment,
  and follow-up.
• Source U.S. Preventative Services Task Force
  (2002). Screening for depression
  Recommendations rationale, Annals of Internal
  Medicine, 136, 760-764.

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The Importance of Screening

• A New Mothers Perspective
• Being told I was depressed helped in so many
  ways. It meant I could tell other people when
  they asked how I was. I was amazed how many
  people said they had had it themselves. Before,
  I couldnt tell anyone, I just pretended I was
  fine. I thought no one would understand. But
  everyone seemed to have a story about someone
  they had known who was depressed. If everyone
  was more open about it, people could help each
  other more.

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Why Use a Screening Tool to Identify Maternal
Depression?

• Screening with a tool is associated with
  increased detection
• Georgiopoulos et al., 1999, 2001
• EPDS screening resulted in increased chart-based
  diagnosis of PPD from 3.7 to 10.7 after one
  year of universal screening
• -Rochester, MN

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Why Use a Screening Tool to Identify Maternal
Depression?

• Without a screening tool depression was detected
  in 3.7 of the womans charts.
• With the EPDS, depression was noted in 10.7 of
  the charts.
• These results suggest that you miss about 7.0 of
  depressed women by relying on detection by
  looking.

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Maternal Depression ScreeningPart 2 Logistics
of Screening

• Development of the Edinburgh Postnatal Depression
  Scale (EPDS)
• Logistics of using the EPDS

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The Edinburgh Postnatal Depression Scale (EPDS)

• Developed by John Cox, Jenifer Holden Ruth
  Sagovsky
• 10 item, self report depression screening scale
• Has been reported as being acceptable to mothers
  and health workers (Cox Holden, A Guide to the
  EPDS)
• Simple to complete

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The Edinburgh Postnatal Depression Scale (EPDS)

• Characteristics
• 10 item scale
• Assesses mood aspects of depression
• Acceptable to women
• Validated to detect depression
• Translated into many languages (A Guide to the
  Edinburgh Postnatal Depression Scale)

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Stems of all 10 EPDS Items

• I have been able to laugh and see the funny side
  of things
• I have looked forward with enjoyment to things
• I have blamed myself unnecessarily when things
  went wrong
• I have been anxious or worried for no good reason
• Things have been getting on top of me

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Stems of all 10 EPDS Items (cont)

• I have felt scared or panicky for no very good
  reason.
• I have been so unhappy that I have had difficulty
  sleeping
• I have felt sad or miserable
• I have been so unhappy that I have been crying
• The thought of harming myself has occurred to me

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Introducing the EPDS to a Client

• Use words like mood and feeling instead of
  depression
• General statements about assessing how she is
  feeling may be more successful/acceptable
• For example, Sometimes it is good to check in
  with new moms to see how they have been feeling
  since having their baby. How have you been
  feeling lately?

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Introducing the EPDS to a Client

• Health and social service professionals obtain
  information regarding clients health and social
  functioning on regular basis.
• Blood pressure
• Maternal weight
• Maternal smoking
• Birth control
• Infant weight, height, well baby visits,
  developmental progress

Depression screening is part of routine health
assessment
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Repeating the EPDS

• We cannot assume that health and social
  functioning indicators will not change from one
  contact to another.
• It is important not to rely on old information on
  health indicators at one of the assessment points
• Symptoms of depression can change in their
  intensity and prevalence at any time

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Longitudinal Course of Depression Pregnancy
through 1-Year Postpartum
Depression can occur or reoccur at any time
during pregnancy or the postpartum period!
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Where Should EPDS be Administered?

• Privacy is important
• Ask client about their environment and comfort
  level
• Administer in a place that allows discussion of
  individual items that are elevated

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How Is the EPDS Administered?

• Use the EPDS form WITHOUT the scores
• Ask woman to underline the response that most
  closely approximates her feelings
• Ask that client complete all items

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How Is the EPDS Administered?

• continued
• Always review elevated items. This tool requires
  that you discuss her elevated responses with her
  in order to better understand her mood.
• Clinical judgment should also be used

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How is the EPDS Scored?

• Items are scored from 0 to 3 normal0, severe3
  and totaled (see scoring sheet)
• Add the total for the scores on all of the items
• EPDS score that is 12 is considered
  elevated/significant
• A woman with an unexpectedly low score should
  always be further assessed

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A High EPDS Score Telling the Client

• Talk with the woman about each elevated item and
  explore her feelings
• If her low mood seems temporary, reassure her
  that you are available for further help and let
  her know how to contact you.

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A High EPDS Score Telling the Client

• continued
• Check back with client in about a week
• If her low mood continues, follow agency
  guidelines for referral

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A High EPDS Score Telling the Client

• Telling a woman her EPDS score is high
• An elevated temperature indicates that something
  might be wrong
• EPDS is like a thermometer a high score simply
  indicates that the woman might have some of the
  symptoms of depression
• Role play 3 High EPDS.

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Discussing the Effects of Depression

• Low mood can affect many aspects of your daily
  functioning
• How does your low mood affect your house work?
• How does your low mood affect your relationship
  with your children and the other significant
  people in your life?
• How has your low mood affected your work?

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Discussing the Effects of Depression

• Review basic information in understandable
  language
• Non-blaming stance-convey that depression is
  robbing her of enjoying her children.
• Explain that depression can be overcome
• With non-native speakers of English, helpful to
  ask them for their words for abstract concepts
  like bonding or depression
• Reassure client that women often misinterpret
  their symptoms or are reluctant to admit being sad

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What if Suicide Item is Endorsed?

• It is important for providers to know what to do
  if this item is elevated
• Which score will count as elevated?
• Are clear agency/community guidelines
  established?

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Referring for Evaluation or Treatment.

• It is important for the person administering the
  EPDS to facilitate a referral for further
  diagnostic assessment or treatment
• Arrange for treatment (antidepressant medication,
  psychotherapy)
• Arrange for follow-up

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Making Referrals

• Options for making Options for First
  Visit
• referrals Send client
  
• Let client contact Take client
  first time
• provider only
• Make phone call but Take client always
• hand phone to client Arrange day care
  and
• Make appointment for transportation
• client

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Referring for Evaluation or Treatment.

• May be helpful to
• Normalize their experience and explain the
  prevalence of perinatal depression
• Emphasize that depression is treatable
• Discuss the successful forms of treatment
  including medication and talking to someone
• Discuss the services and the process

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Referring for Evaluation or Treatment.

• Explore her worries and concerns about talking to
  someone.
• Some common concerns
• Fear of being crazy
• Fear/guild of being viewed as not capable, not a
  good mother/wife
• Fear of being a failure
• Fear of losing children
• Resistance from others
• Worry about divorce
• Confidentiality issues.

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Following up with Clients in Treatment

• Follow up is a very important part of this
  process
• Did your client make the connection
• How did their first visit go?
• Is the contact continuing?
• What was the outcome of the referral?
• Is your client satisfied with services?
• Is it helping?

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Linguistic and Socio-cultural Issues

• Cultural differences in discussing mental health
  issues can be major
• Literacy is sometimes a problem
• Languages are not homogenous

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Available EPDS Translations

• Arabic Khmer
• Chinese Konkani
• Czech Maltese
• Dutch Norwegian
• French Portuguese
• German Punjabi
• Greek Slovenian
• Hebrew Spanish
• Hindi Swedish
• Icelandic Urdu
• Italian Vietnamese
• Japanese

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EPDS and Interpreters

• EPDS translations
• Good relationship with interpreter
• Ask interpreter to translate everything that is
  said and tell the client that the interpreter
  will do this
• Allow extra time, be patient
• Use simple language
• Address client directly using first person
• Maintain good eye contact
• Check interpreters understanding and level of
  comfort with EPDS and mental health issues

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Challenges of Cross-Cultural Depression Assessment

• Women from different cultures will have
  different
• Concepts of depression
• View of discussing their feelings
• Birth culture expectations
• Cultural gender roles
• Feelings about Westernized assessment and
  treatment