Perinatal Mental Health - Information for Health Professionals

Screening

Mental health screening can be implemented:

• Before the patient arrives,
• While the patient is waiting, or
• Verbally during a postpartum visit.

Postpartum depression screenings can be conducted during a well-child visit or Child and Teen Checkups (C&TC). Medicaid covers postpartum depression screenings of both parents (birthing and non-birthing) and will be billed under the child’s insurance. Review the C&TC Factsheets (depression screening) for more information about postpartum depression screenings within infant well child checks.

For current recommendations, policy, coding and billing specific to postpartum depression screening in the context of Child and Teen Checkups (C&TC), refer to the C&TC Section of the Minnesota Health Care Programs (MHCP) Provider Manual. SAMHSA’s Coding for Screening and Brief Intervention Reimbursement can also be referred to for information about billing SUD screening.

Screening Tools Specifically Developed for Pregnant and Postpartum People

Brief screening tools are designed to be done in less than five minutes. All tools below have been validated in English, some have been translated and validated in different languages. There are also some translated versions that may not have been validated. This most likely means that research studies have not been done using the tool in that language.

Edinburgh Postnatal Depression Scale (EPDS)

The EPDS is the most used depression screening tool in perinatal care. It has been translated into over 60 languages and has been validated for use with adolescents, new fathers, and non-birthing partners. The EPDS is approved for use, and billing, for postpartum depression screening in Infant, Child, and Teen Checkups (well visits) in Minnesota.

EPDS with scoring instructions:

• EPDS in English
• EPDS in other languages can be found at Perinatal Services BC and Health Translations.
• General validity studies recommend a cut-off of 11 or higher. Cut-off score varies in non-English language versions.

Notes:

• The EPDS-3 (Questions 3,4,5) has been validated as useful in some studies, including some in non-English languages.
• The EPDS 2 and the EPDS 5 have been shown to have inconsistent reliability or validity and are not recommended. 
• Best practice is to be screening fathers and partners, as well, using the EPDS or the PHQ-2.

Perinatal Anxiety Screening Scale (PASS) (Cut-off Score= 26)

The PASS reliably identifies perinatal people at risk of problematic anxiety. This scale assesses four categories of anxiety: acute anxiety and adjustment; general worry and specific fears; perfectionism, control, and trauma; and social anxiety.

Patient Health Questionnaire (PHQ-9)

The PHQ-9 is a nine question self-rating scale commonly used in screening for adult depression. It is not specific to pregnancy or postpartum, but it can be used for perinatal depression screening.
The PHQ-9 is approved for use and billing of postpartum depression in infant well visits and Child and Teen Checkups in Minnesota.

• PHQ-9 in English
• PHQ-9 in Karen (PDF)
• PHQ-9 in Somali
• PHQ-9 in Spanish
• PHQ-9 in Other Languages

Notes:

• The PHQ-2 is validated as a first-step screener for depression in adolescents and adults (to be followed by full PHQ-9 if the PHQ-2 is positive), but not for postpartum depression screening.
• The PHQ-9 has been shown to have good sensitivity and specificity for perinatal depression. However, the PHQ-9 may not be an adequate assessment (question #9) for suicidality.

Trauma Screening

Perinatal PTSD screening is an area in need of further research. Because we know there is a correlation between trauma history and PMAD, it is useful to screen patients for previous trauma, as well as trauma related to their pregnancy, childbirth and postpartum (including loss) experiences.
Promising screening tools for this population (many available in multiple languages):

• PCL-5
• City Birth Trauma Scale (with scoring)
• Adverse Childhood Experiences Screening (ACES)

Substance Use Screening

Universal screening, beginning at the start of pregnancy, can lead to earlier initiation of treatment, as well as reduce provider biases that occur with selective screening.

SURP-P and 4P's Plus were found to be highly sensitive substance use screening tools across all trimesters, race, and age groups.

The 4 P’s Plus asks:

• Parents: Have your parents had any past or present alcohol or drug issues?
• Partner: Has your partner had a past or present problem with alcohol or drugs?
• Past: Have you ever had a problem with alcohol or drugs?
• Pregnancy: Have you used alcohol or drugs during pregnancy?

An answer of yes to one or more questions indicates risk of substance use disorders.

To learn more about universal screening for substance use disorder and additional screening tools, read more from the Washington State Hospital Association (WSHA).

NOTE: A recent update to Minnesota Statute 260E.31 REPORTING OF PRENATAL EXPOSURE TO CONTROLLED SUBSTANCES made changes regarding mandated reporting of substance use during pregnancy. This law now supports pregnant people to continue to receive care during and after a pregnancy if they are using substances. For birthing people that continue attending provider appointments and are making efforts to not use substances during pregnancy, their providers are not required to report them to a local welfare agency. However, providers must report to a local welfare agency if the birthing person stops attending providers visits or are no longer working on a plan to stop using substances during pregnancy.

Screening Tools for Refugees and Asylum Seekers

Postpartum mental health screening is greatly underserved in this population. The Refugee Health Screener-15 (RHS-15) is a 15-item screen for symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD) that shows promise. This tool was developed in conjunction with refugees recently resettled in the United States and is translated into several languages. It is also recommended to ask questions about somatic symptoms alongside screening tools.

The Minnesota Well-being and Emotions Check (WE-Check) tool can be used to assess adults ages 18 and older. The tool consists of five questions about common reactions and feelings that people might have when they have experienced things like war, loss, or political violence. The tool is also available in different languages (under Screening Tool).

Treatment

Evidence-Based Treatment Options

Outpatient Therapy

When possible, referring patients to a therapist with specialized training in perinatal mental health is helpful, and leads to better outcomes. Evidence-based approaches shown to be helpful with the perinatal population in both individual and group settings are:

• Cognitive Behavioral Therapy (CBT) 
• Interpersonal Psychotherapy (IPT) 
• Mindfulness-based stress reduction & Dialectical Behavior Therapy (DBT)
• Self-compassion skills

Research has shown that online therapy (individual or group therapy) offers expanded options, especially for those with limited access to care, childcare, or parents who prefer the privacy of their home. 

Intensive Options

Sometimes a higher level of care is warranted, and parents can benefit from Day Treatment or Intensive Outpatient (IOP) programs, ideally one whose focus is on perinatal mental health. Day Treatment or IOP programs offer a combination of individual and group therapy and meet for several days of the week for several hours. Many allow parents to bring their babies along (and during the COVID-19 pandemic have offered services virtually).

Medication

Many pregnant and postpartum parents are reluctant to take medications. This is partly due to misinformation, concern about safety of medications, or cultural beliefs. Information for discussion with patients weighing the risks and benefits of medication treatment:

• Sharing the risks of not treating, or undertreating, increases the potential for relapse, and how it can impact the ability to care for a newborn.
  • Note: the risk of relapse is critical for patients who are already taking medication and may discontinue taking them abruptly without speaking with you. This is especially risky for those who have a personal or family history of bipolar disorder or psychosis.
• Adapting and providing information in several formats and in the patient’s primary language.
• Where appropriate, involve partners, family, or caregivers in conversations about options.

Handout for Pharmacy to Accompany New Prescription

Pregnancy and Lactation Labeling Rule (PLLR) - June 2015
This Rule phased out the pregnancy letter category (A, B, C, D, or X) to address the potential maternal and fetal consequences of discontinuing needed drug therapy during and after pregnancy.

The following resources are continually updated with information about risks specific to pregnancy and lactation:

• Organization of Teratology Information Specialists: Mother to Baby has helpful fact sheets, articles, and podcasts (English & Spanish) that can be printed and shared with patients, as well as professional resources. You can also email an expert with questions.
• Texas Tech University Health Sciences Center: The InfantRisk Center provides free phone call for patients or professionals to speak with an expert for guidance or reassurance, as well as up-to-date research. Call 1-806-352-2519.
• National Library of Medicine: LactMed provides details about drugs and chemicals impact on pregnancy, and data on levels in breastmilk and infant blood, as well as possible adverse effects. Evidence-based data and alternative suggestions are also provided.

Substance Use Treatment

A Minnesota survey of hospital staff indicated assessing for substance and opioid use during pregnancy is a challenge, especially in rural areas where resources are limited.

There are programs available to support pregnant people who use substances. Help Me Connect is an online service and resource navigator that connects expectant families to services in their local communities. Search “substance use”.

Emergency Care & Self-Harm

Assessment of suicide risk is necessary to determine whether a patient requires emergency hospitalization or can continue outpatient care. Ask patients directly about thoughts of suicide or self-harm for severity, frequency, and intent.

The following increases the risk of suicide during or after pregnancy:

• Diagnosis of bipolar disorder
• Having a history of suicide attempts
• Abrupt discontinuation of psychotropic medications before, or during, pregnancy
• Sleep disturbances in the postpartum period
• Relationship with interpersonal violence
• Having a stillbirth

Training and Consultation

Training/Toolkits

• Massachusetts General Center for Women’s Mental Health offers free virtual courses in perinatal treatment and psychiatry. CME’s available
• Massachusetts Child Psychiatry Access Program (MCPAP) for Moms has an Obstetric Provider Toolkit available for health providers. Resources include assessment and management of perinatal mood and anxiety disorders and substance use disorders (SUDs)
• MDH Family Home Visiting Toolkits
• MDH Family Home Visiting Improving the Culturally Appropriate Delivery of Depression Screenings (Video)
• Pregnancy & Postpartum Support MN (PPSM) offers both local and national trainings
• Postpartum Support International (PSI) offers trainings and certification programs, as well as conferences
• PSI and American College of Obstetricians and Gynecologists (ACOG): Perinatal Mental Health: Culturally Informed Approaches to Screening, Assessment, and Treatment (Register online to access the recorded video)

Free Consultation

PSI Perinatal Psychiatric Consult Line

• Call or complete the online form for an appointment time and is staffed by reproductive psychiatrists

Massachusetts General Center for Women’s Mental Health

• Free virtual rounds
• Field questions and share resources that guide decision-making and patient care
• 2-3:00 p.m. EST on Wednesdays