Pregnant People - Key Activity 11

KEY ACTIVITY #11:

Behavioral Health Screening, Including Postpartum Depression

 

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; behavioral health integration.

 

Overview

This key activity provides guidance on behavioral health screening during pregnancy and postpartum. All perinatal patients should be screened for mental health conditions. Prenatal and postpartum depression screening are both HEDIS supplemental measures. ACOG’s Committee Opinions #757, “Screening for Perinatal Depression 1,” recommends screening patients at least once during the perinatal period for depression and anxiety, and, if screening in pregnancy, it should be done again postpartum. Opinion #736, “Optimizing Postpartum Care 2,” recommends a full assessment of physical, social and psychological well-being within a comprehensive postpartum visit that occurs no later than 12 weeks after birth.[1]

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines depression as a disorder of the brain. It is a serious mood disorder that is more than just a feeling of being "down in the dumps" or "blue" for a few days. Postpartum depression (PPD) affects gestational parents after having a baby. It causes intense, long-lasting feelings of anxiety, sadness and fatigue, making it difficult for parents to care for themselves and/or their babies, as well as handle daily responsibilities. PPD can start anywhere from weeks to months after childbirth. The American Academy of Pediatrics (AAP) recommends that pediatricians screen people who have given birth for PPD at the infant's one-, two-, four- and six-month well child visits.

Mental health conditions during pregnancy and the first year after childbirth are one of the most common conditions during pregnancy and postpartum, affecting more than one in five individuals.[2] [3] [4] Despite the existence of validated screening tools and effective, safe treatments, these conditions are often underdiagnosed and inadequately treated. Without intervention, fewer than 25% of individuals with perinatal depression will receive any treatment, and even fewer will receive adequate treatment or achieve remission.[5] [6] Early detection and treatment can alleviate negative consequences of these conditions and improve patients’ quality of life.

According to The Institute for Diversity and Health Equity (IFDHE), part of the American Hospital Association (AHA), PPD affects one in eight people who have given birth; however, the risk is 1.6 times higher for Black people than white people. While the risk may be higher, Black people are less likely to receive help due to factors such as structural racism, a historical mistrust of the healthcare system, financial barriers, and stigma associated with mental health struggles. Perinatal mental health symptoms and issues among Black patients are often overlooked and under addressed. See Key Activity 4: Use a Systematic Approach to Decrease Inequities within the Population of Focus for additional guidance on addressing health disparities among pregnant patients.

Comprehensive screening in physical, behavioral and social health domains is necessary to identify patients’ needs and wants across a whole-person spectrum of health. Treatment for depression in pregnancy and postpartum involves multiple modalities, including counseling, group therapy, and medication, that can be tailored to the patient’s individual needs.

Technology can support screening for behavioral health conditions by delivering structured guidelines, protocols and clinical decision support to care team members responsible for carrying out assessments. It can also help by incorporating standardized screening tools into EHRs and care management and care coordination applications. These screening tools can also be made available directly to patients through patient outreach and screening technologies.

Understanding the prevalence of behavioral health conditions assists in program and resource development to track impact on health outcomes and to incorporate into risk stratification. Health information technologies used to track referrals are also important in care management.

Action steps and roles

Here is a sequence of steps that practices can use to implement screening for behavioral health conditions in the perinatal period.

1. Understand current recommendations for perinatal behavioral health screening.

Suggested team member(s) responsible: QI lead and frontline staff.

Current guidelines for screening are available from ACOG: Implementing Perinatal Mental Health Screening.

ACOG’s Clinical Practice Guideline 4: “Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum” recommends:

  • Everyone receiving well-person, prepregnancy, prenatal and postpartum care be screened for depression and anxiety using standardized, validated instruments.
  • Screening for perinatal depression and anxiety at the initial prenatal visit, later in pregnancy, and at postpartum visits.
  • Implementing mental health screening with systems in place to ensure timely access to assessment and diagnosis, effective treatment, and appropriate monitoring and follow-up, based on severity.
  • Completing screening for bipolar disorder before initiating pharmacotherapy for anxiety or depression, if not previously done.
  • When someone affirmatively answers a self-harm or suicide question, clinicians immediately assess for likelihood, acuity and severity of risk of suicide attempt and then arrange for risk-tailored management.
  • Clinicians provide immediate medical attention for postpartum psychosis.

 

2. Create a care gap report.

Suggested team member(s) responsible: QI lead and frontline staff.

Establish a baseline by assessing the percentage of patients or visits at which behavioral health screening occurred (e.g., postpartum depression screening was documented at 33% of visits at which postpartum depression screening is recommended to occur).

See Key Activity 3: Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care for additional guidance on care gap reports.
 

3. Flag all eligible patients for behavioral health screening and administer screening.

This should be programmed as an alert in the EHR so staff are aware at the time of visit.

There are many validated tools available. To screen for depression, consider:

To screen for anxiety, consider:

To screen for posttraumatic stress disorder (PTSD), consider:

To screen for bipolar disorder, consider:

  • Mood Disorder Questionnaire (MDQ), 14 questions.The MDQ needs to be done only once in the perinatal period as it queries lifetime experience as compared to the other screening tools, which ask how a person has felt in the last seven days to one month.

Combined tool:

 

4. Create a protocol to screen for behavioral health conditions.

Ensure standardized clinical workflows are in place for routine prenatal and postpartum screening. In many CHCs, medical assistants or other clinical support staff administer the mental health screenings in advance of the clinician visit. Clinicians then review the results and, if appropriate, offer relevant treatments or referrals.

To maximize completion of behavioral health and postpartum depression screening, the workflow should be executed at any visit where the new parent presents (e.g., at the first postpartum visit, integrated within the first well child visit with the pediatrician).

See the Perinatal Mental Health Conditions guide from Alliance for Innovation on Maternal Health.
 

5. Develop workflows for integrating postpartum mental healthcare, including provision of pharmacotherapy when indicated.

Identify mental health screening tools to be integrated universally in every clinical setting where patients may present.

  • Establish an evidence-based, person-centered response protocol based on what is feasible for each area of practice and local mental health resources. Ideally, responses are tailored to condition severity and are strength based, culturally relevant and responsive to patient’s values and needs.
  • Ensure staff can activate an immediate suicide risk assessment and response protocol as needed for patients with identified suicidal ideation, significant risk of harm to self and/or others, or psychosis.
  • Include each pregnant and postpartum person and their identified support network as respected members of and contributors to the multidisciplinary care team.
  • Provide information to prescribing providers and patients on evidence-based, safe pharmacological depression treatment options for pregnant and postpartum patients. ACOG has clinical practice guidelines outlining such medications.

 

6. Educate clinicians, frontline staff, administrative staff, patients and patients’ designated support networks on optimal care across the preconception and perinatal mental health pathway, including prevention, detection, assessment, treatment, monitoring, and follow-up best practices.

  • Facilitate trauma-informed training and education to address healthcare team member biases and stigma related to mental health conditions, including anti-racism considerations.
  • Incorporate mental health into multidisciplinary rounding to establish a non-judgmental culture of safety.
  • Provide staff and provider training on common modalities to treat depression in pregnancy and postpartum.
  • Engage in open, transparent, empathic and trauma-informed communication with pregnant and postpartum people and their identified support network to facilitate understanding of diagnoses, options and treatment plans.

 

7. Develop and maintain a set of referral resources and communication pathways between obstetric providers, community-based organizations, and state and public health agencies to address patient needs, including health-related social needs.

  • Establish care pathways that facilitate coordination and follow-up among multiple providers throughout the perinatal period for pregnant and postpartum people referred to mental health treatment.
  • Identify local resources for mental health conditions necessitating immediate treatment (e.g., postpartum psychosis, suicidality).
  • Ensure clear protocol for communication between pediatric providers and OB/GYN and primary care providers when a parent has a positive screen at a well child visit.
  • Incorporate resources that recognize the range of providers and services that can provide mental health support from community groups to licensed providers. Personalize referrals depending on the needs of the client.
    • Therapists, psychiatrists, doulas, midwives, social workers and new parenting groups.

 

8. Screen and provide linkage to resources for structural and health-related social needs that may impact clinical recommendations for treatment plans.

  • Transportation, childcare and housing, among other factors, may impact a patient’s ability to adhere to a mental health treatment plan.

Source: Perinatal Mental Health Conditions Change Package.

Example of how this activity has been implemented

In one clinic, the quality manager and the clinic manager evaluated subsets of the data, including postpartum depression screening completion rates by age, gender, race, ethnicity and geographic location to narrow the focus of potential process improvement activities. The data demonstrated that pregnant Hispanic patients in three unique zip codes were 50% less likely to be screened for prenatal and postpartum depression as compared to other patients.

In response, clinic staff developed a focused outreach campaign for these patients. Educational materials were created in patients’ preferred languages to address frequently asked questions and concerns about depression and the need for depression screening, especially during the prenatal and postpartum periods. The MAs in the clinic – fluent in Spanish, the predominant language of the segmented population – conducted telephone outreach, discussing prenatal and postpartum depression, benefits and risks associated with not receiving screening, addressed questions, and helped patient schedule past due prenatal and postpartum care appointments.

One patient, Maria, had just delivered and brought in her newborn for their first well child visit. During her child’s visit, the practice MA had Maria complete a PHQ-9, and her score was 17 (moderately severe depression). The provider informed Maria’s PCP and initiated a referral for cognitive behavioral therapy. Maria’s PCP considered if an antidepressant medication was needed. The care manager created a care plan with Maria to include postpartum depression education and coaching on self-management. After 30 days, the care manager reviewed her patient panel and identified that Maria was due for a repeat PHQ-9. Outreach was initiated to get the patient scheduled for either an in-person or telehealth visit to follow up on how she was doing, and to complete an interval PHQ-9 to measure the effectiveness of care. Maria repeated a PHQ-9, and her score is still a 17 (still moderately severe depression). The care manager conducted a case review with the PCP and behavioral health clinician to discuss Maria’s treatment plan and initiate changes in treatment. Treatment changes, including a referral to a community-based peer support group for new moms, were reviewed with Maria, and the care plan was updated. Follow-up appointments were scheduled.

Endnotes

  1. Implementing Perinatal Mental Health Screening [Internet]. www.acog.org. [cited 2023 Dec 21]. Available from: https://www.acog.org/programs/perinatal-mental-health/implementing-perinatal-mental-health-screening#:~:text=ALL%20perinatal%20women%20should%20be%20screened%20for%20mental 
  2. Masters GA, Hugunin J, Xu L, et al. Prevalence of bipolar disorder in perinatal women: a systematic review and meta-analysis. The Journal of Clinical Psychiatry. 2022;83(5):21r14045. doi:10.4088/JCP.21r14045 
  3. Fawcett EJ, Fairbrother N, Cox ML, White IR, Fawcett JM. The prevalence of anxiety disorders during pregnancy and the postpartum period: a multivariate bayesian meta-analysis. The Journal of Clinical Psychiatry. 2019;80(4):18r12527. doi:10.4088/JCP.18r12527 
  4. isner KL, Sit DKY, McShea MC, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screenpositive depression findings. JAMA Psychiatry. 2013;70(5):490-498. doi:10.1001/jamapsychiatry.2013.87 
  5. Cox EQ, Sowa NA, Meltzer-Brody SE, Gaynes BN. The perinatal depression treatment cascade: baby steps toward improving outcomes. The Journal of Clinical Psychiatry. 2016;77(9):1189-1200. doi:10.4088/JCP.15r10174 
  6. Byatt N, Levin LL, Ziedonis D, Moore Simas TA, Allison J. Enhancing participation in depression care in outpatient perinatal care settings: a systematic review. Obstetrics and Gynecology. 2015;126(5):1048-1058. doi:10.1097/AOG.0000000000001067