1. No category

PERINATAL EMOTIONAL DISTRESS E N H A N C I N G PAT I E N T E D U C AT I O N , S C R E E N I N G , A N D
T R E AT M E N T - R E F E R R A L P R O C E S S E S I N M AT E R N I T Y ,
P E D I AT R I C , A N D FA M I LY- H E A LT H C A R E S E T T I N G S
S A R A H B E S T , L M S W T H E S E L E N I I N S T I T U T E seleni.org/provider
TRAINING OBJECTIVES
1.
•  Review diagnostic and epidemiological data for mental
health concerns associated with pregnancy and the
postpartum period
2.
•  Identify care management strategies–including patient
education, preliminary screening, and treatment referral
processes–to implement in family health practices
3.
•  Access publicly available educational materials for staff,
patients, and families
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PERINATAL MENTAL HEALTH:
OVERVIEW
15-20%
experience a
perinatal mood
or anxiety
disorder
(PMAD).
~80% experience
the “Baby Blues.”
0.1-0.2% (1-2 in
1000) experience
postpartum
psychosis.
85% of childbearing
women experience
significant
emotional distress
during or after
pregnancy.
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PERINATAL MENTAL HEALTH:
BABY BLUES
“Baby Blues”
Experienced by
up to 80% of
childbearing
women
Symptoms
include
tearfulness,
irritability,
anxiety, and
overwhelm
Onset within
the first week
postpartum
Not a mental
health disorder;
further
Generally selfassessment
resolving within
indicated if
2-3 weeks
symptoms do
postpartum
not resolve by 3
weeks
postpartum
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PERINATAL MENTAL HEALTH:
“PPD” vs. “PMAD”
—  “Postpartum depression” (“PPD”) was historically used as
an umbrella term to describe clinically significant
emotional distress following childbirth.
—  Specialists now recognize that a number of distinct mental
health disorders, beyond depression, are common during
pregnancy and in the first year postpartum.
—  The phrase “perinatal mood and anxiety
disorders” (“PMADs”) is now used to describe this range
of disorders.
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PERINATAL MENTAL HEALTH:
PMAD EPIDEMIOLOGY
PERINATAL MOOD AND
ANXIETY DISORDERS = PMADs
More
common than
Most
Experienced
gestational
common
by 15-20% of
diabetes,
complication
childbearing
preterm labor,
of pregnancy
women
and low birth
weight
Symptoms
typically
develop 2-3
months after
delivery
Symptoms
CAN develop
during
pregnancy or
up to 1 year
postpartum
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PERINATAL MENTAL HEALTH:
PMAD EPIDEMIOLOGY
PMAD Risk Factors
Personal or family history
of depression or anxiety
Lack of social supports/
marital strain
Life stressors: poverty, job
loss, death in family
Adolescent pregnancy
History of physical or
sexual abuse
Unplanned pregnancy
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PERINATAL MENTAL HEALTH:
PMAD ETIOLOGY
BIOLOGICAL
Heredity, hormones,
nutrition, medication, sleep,
birth control, history of
depression or anxiety
SOCIAL
Finances, culture,
employment, others’
expectations,
responsibility load,
support network
PSYCHOLOGICAL
Thought processes,
distress tolerance,
personality traits,
interpersonal history,
core beliefs
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PERINATAL MENTAL HEALTH:
PMAD DIAGNOSIS
PMADs: Specialists recognize that symptom patterns
consistent with a number of distinct mental health
diagnoses develop during and after pregnancy.
Major
Depressive
Disorder
Generalized
Anxiety
Disorder
Obsessive
Compulsive
Disorder
Post-traumatic
Stress
Panic Disorder
Disorder
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PERINATAL MENTAL HEALTH:
PMAD DIAGNOSIS
Major Depressive Disorder:
Significant Symptoms
Sadness
Lack of
interest in
previously
pleasurable
activities
Poor
Sleep changes
concentration
Guilt
Suicidal
ideation or
behavior
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PERINATAL MENTAL HEALTH:
PMAD DIAGNOSIS
Generalized Anxiety Disorder:
Significant Symptoms
Excessive,
uncontrollable
worry
Feeling “on
edge”
Fatigue
Poor sleep and
concentration
Muscle
tension
Irritability
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PERINATAL MENTAL HEALTH:
PMAD DIAGNOSIS
Obsessive Compulsive Disorder:
Significant Symptoms
Obsessions =
Unwanted, intrusive
thoughts that cause
significant distress
Compulsions =
behaviors that
reduce distress
triggered by
obsessions
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PERINATAL MENTAL HEALTH:
PMAD DIAGNOSIS
Perinatal OCD Obsessions are unwanted, intrusive thoughts or images
Obsessions usually focus on baby’s safety
Mom often fears that she will harm baby.
Perinatal OCD Obsessions cause mother great distress.
Distress (anxiety) is clinically reassuring.
Distress indicates that thoughts are ego-dystonic.
Ego-dystonic intrusive thoughts pose no increased risk of harm to baby.
Ego-dystonic thoughts are inconsistent with
mother’s values, beliefs, and behavior
Differentiated from psychotic thoughts, which
DO make sense to mother and DO increase risk.
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PERINATAL MENTAL HEALTH:
PMAD DIAGNOSIS
Panic
Disorder:
Significant
Symptoms
•  Panic Attacks: sudden episodes of intense fear or distress
•  Physical symptoms of panic attacks: palpitations,
sweating, trembling, shortness of breath, dizziness,
tingling, chest pain, GI distress
•  Psychological symptoms of panic attacks: fear of going
crazy, fear of losing control, feeling of unreality
•  Fear of triggering panic attacks leads to avoidant
behavior
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PERINATAL MENTAL HEALTH:
PMAD DIAGNOSIS
Post-Traumatic Stress Disorder:
Significant Symptoms
Can develop
after one
experiences an
event that
threatens her
own or loved
ones’ lives (e.g.,
childbirth
trauma, NICU
stay)
Recurrent,
intrusive
memories of
the traumatic
event;
nightmares;
flashbacks
Avoidance of
trauma-related
thoughts,
feelings, or
external
reminders
Mood
disturbance;
irritability;
angry
outbursts;
difficulty
concentrating
Physical
arousal; hypervigilance;
exaggerated
startle response;
sleep difficulty
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PERINATAL MENTAL HEALTH:
IMPLICATIONS OF UNTREATED PMADS
MOTHER
INFANT
Chronic mental
health symptoms
Insecure
attachment
patterns
Social withdrawal;
avoids infant;
increased risk for
abuse/neglect
Learning
disabilities
Maladaptive
coping (e.g., drugs
or alcohol)
Cognitive and
attention deficits
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PERINATAL MENTAL HEALTH:
IMPLICATIONS OF PMAD TREATMENT
Early
Identification
Early
Intervention
Effective
Symptom
Management
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PERINATAL MENTAL HEALTH:
POSTPARTUM PSYCHOSIS
Postpartum Psychosis
0.1-0.2%, or
1-2 of 1000,
childbearing
women
Symptoms
include: rapid
shifts in
Onset within
Associated
mood,
days or 2-3 with previous
confusion,
weeks
episodes of
erratic
postpartum bipolar illness
behavior,
delusions,
hallucinations
Psychiatric
emergency;
risk for
increased
suicide or
infanticide
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PATIENT CARE MANAGEMENT:
OVERVIEW
—  The risks of untreated perinatal psychiatric disorders are
well established.
—  Medical providers who care for childbearing women and
their families serve as important sources of information
and support. —  Specific care management strategies will vary between
providers–based on staffing patterns, scheduling
challenges, and other practice/program resources.
—  Under all circumstances, however, practitioners should
include variations of patient education, preliminary
screening, and treatment referral processes.
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Recommendations
PATIENT CARE MANAGEMENT:
SUMMARY
Patient Education
Ongoing Preliminary
Screening
Treatment Referral
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PATIENT CARE MANAGEMENT:
EDUCATION
—  Patient education can be provided through a variety of
media, including informational posters and education
pamphlets.
—  However, one on one conversations between childbearing
women and medical or social service providers are
considered ideal.
—  Patient-education conversations should begin early in the
maternity, pediatric, or family care relationship, with
check-ins continued for the duration of care.
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Patient Education should
include information about…
PATIENT CARE MANAGEMENT:
EDUCATION
Prevalence
Risk Factors
Range of
Symptoms
Prognoses
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PATIENT CARE MANAGEMENT:
EDUCATION SAMPLE SCRIPT
•  “Emotional distress is very common during and after pregnancy.”
Prevalence
Risk
•  “It’s hard to predict who might struggle, but paying attention to risk factors–like a personal or
family history of depression, anxiety, or other mental illness; recent stressful events; and
inadequate social supports–can help us stay alert to any problems that might arise.”
•  “Be sure to let me know if you are BOTHERED by any thoughts or feelings that you have–
whether feelings of sadness, worry, irritability, or even anger. These might be normal, but they
Symptoms could also be symptoms of a perinatal mental health problem.”
Prognosis
•  “The earlier we address your symptoms, the faster you can feel better. Perinatal MH disorders
can be treated effectively, so please don’t suffer in silence.”
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PATIENT CARE MANAGEMENT:
SCREENING INSTRUMENTS
—  Reliable, scientifically validated screening instruments
have been developed for a wide range of mental health
concerns.
—  But because such a wide range of disorders are associated
with pregnancy and the postpartum period, a
comprehensive standardized screening instrument
demonstrating increased risk for perinatal emotional
distress has not yet been validated.
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PATIENT CARE MANAGEMENT:
SCREENING INSTRUMENTS
Meanwhile, the American Academy of Pediatrics has recommended that pediatricians administer one
of two screenings for postpartum depression at infant well-child visits. Though there are limitations to
both instruments, either screening is appropriate for antepartum or postpartum screening in maternity
and family care settings as well.
Edinburgh
Postnatal
Depression
Scale
Two-Question
Screen
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PATIENT CARE MANAGEMENT:
SCREENING INSTRUMENTS
Edinburgh
Postnatal
Depression
Scale
Two-Question
Screen
•  Publicly available 10-question instrument
•  Pros: Gold-standard; strong reliability/validity; translated
into several languages
•  Cons: Assesses depressive symptoms only; follow-up
needed for comprehensive assessment and diagnosis
•  Publically available 2-question instrument
•  Pros: Strong reliability/validity; easily, verbally
administered
•  Cons: Measures general, depressive symptoms only;
follow-up needed for comprehensive assessment and
diagnosis
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PATIENT CARE MANAGEMENT:
SCREENING INSTRUMENTS
Edinburgh & Two-Question Screen
Screen for depressive symptoms only
Providers should therefore follow up by asking,
“Is there anything about the way you’re feeling or thoughts
you’re thinking that bothers you?”
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PATIENT CARE MANAGEMENT:
SCREENING INSTRUMENTS
Please
note…
Screening instruments are not intended to be
diagnostic.
Positive screening indicates increased risk for
diagnosis only.
Patients with positive screenings or who report other
emotional distress must be referred to mental health
providers for comprehensive assessment.
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PATIENT CARE MANAGEMENT:
TREATMENT REFERRAL
A positive screen should result in referral for comprehensive assessment and/or treatment.
REMEMBER the following special circumstances:
Tearfulness, irritability,
anxiety, and feelings of
overwhelm within the first
2-3 weeks postpartum may
be the Baby Blues and may
not require formal treatment.
Active suicidal ideation or
signs of psychosis, by
contrast, should be
connected to psychiatric
emergency services
immediately.
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PATIENT CARE MANAGEMENT:
TREATMENT REFERRAL
—  The availability and quality of perinatal mental health
specialists varies widely among communities. Maternity
and pediatric care providers are encouraged, nonetheless,
to identify and develop professional relationships with at
least one board certified psychiatrist and one licensed
psychotherapist–whether a psychologist, clinical social
worker, family therapist, or professional counselor–who
have experience treating emotional distress in childbearing
women.
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PATIENT CARE MANAGEMENT:
TREATMENT REFERRAL
PSYCHIATRIST
THERAPIST
AVAILABILITY AND
QUALITY WILL VARY
AMONG
COMMUNITIES
BOARD CERTIFIED:
REPRODUCTIVE EXPERTISE
IDEAL
LICENSED PSYCHOLOGIST,
CLINICAL SOCIAL WORKER,
FAMILIY THERAPIST, OR
PROFESSIONAL COUNSELOR
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PATIENT CARE MANAGEMENT:
TREATMENT REFERRAL
TIPS FOR BUILDING A REFERRAL NETWORK:
—  Contact psychiatry chairs at area teaching hospitals to inquire about
treatment and referral resources.
—  Contact a local coordinator for the nonprofit group Postpartum
Support International (www.postpartum.net) to inquire about local
treatment resources, including free and low-cost support groups.
—  Review the referral list for alumni of the postgraduate training
program at the Postpartum Stress Center, a premier treatment center
for perinatal mood and anxiety disorders, at
http://postpartumstress.com/admin/get-help/where-can-i-get-help/
professional-referrals/.
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PATIENT CARE MANAGEMENT:
TREATMENT REFERRAL SAMPLE SCRIPT
—  “Feeling down or worried from time to time is normal
during and after pregnancy. I’m worried, however, that
you might be at increased risk for developing a perinatal
mood or anxiety disorder, which is something that up to
20% of new moms experience. Hormones probably play a
part, but that doesn’t mean that you can’t feel better. I’d
like to refer you to a specialist I trust to take a closer look
at whether your thoughts and feelings are getting in the
way of enjoying your pregnancy/baby.”
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One one one conversation
between provider (physician,
nurse, or social worker) and
woman
Emphasize prevalence, risk
factors, symptoms, and
prognoses for perinatal mental
health concerns
Every prenatal, postpartum, or
well-child infant visit
Edinburgh, Two Question
Screen, or unstructured clinical
interview
Is there anything about your
mood or thoughts that seems
off to you?
Treatment Referral
Written materials
Ongoing Pre-Screening
Patient Education
PATIENT CARE MANAGEMENT:
TREATMENT REFERRAL
Refer to licensed mental health
professional for comprehensive
evaluation and treatment
planning, including decisions
regarding medication.
Check in with woman at
subsequent prenatal,
postpartum, or well-child
infant visits.
With positive screen…
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PATIENT CARE MANAGEMENT:
EDUCATIONAL RESOURCES
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THANK YOU FOR YOUR PARTICIPATION.
For more information, including a comprehensive reference
list, please contact the Seleni Institute at (212) 939-7200 or
at [email protected].
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