Page 14 • RN Idaho May, June, July 2018 Evidence-Based Screening Practices for Postpartum Depression Sydney Parker, BSN, RN firstname.lastname@example.org Postpartum depression (PPD) is a mental health condition that impacts postpartum women of all ages, socioeconomic status, race, and backgrounds (Yawn et al., 2012; National Institute of Mental Health, 2018). Though there are many risk factors that increase the chance for women to experience PPD, there is no one method to prevent or predict who may experience it. Over 15% of women report PPD in their first-year postpartum, and the American College of Obstetricians and Gynecologists (ACOG) estimates 5-25% of postpartum women experience PPD (2015; Yawn et al., 2012). This would be roughly more than 10,000 postpartum women in the United States each year. Meanwhile, over 50% of women that experience severe depressive symptoms go unnoticed (Yawn et al., 2012). According to National Institutes of Mental Health (2018), there are numerous adverse maternal and newborn outcomes for undiagnosed or untreated PPD. A simple, evidence-based screening tool coupled with effective education could help to significantly reduce the number of undiagnosed/untreated women. Proper screening lending toward appropriate diagnosis and treatment may greatly decrease adverse effects and improve patient outcomes for both women and their children. Problem Many barriers to screening for PPD exist. PPD is highly stigmatized and many women are uncomfortable discussing or cannot identify symptoms of PPD (Byatt et al., 2013). Over 20% of women with PPD do not report symptoms. Additionally, while there are validated, evidence-based practice (EBP) screening tools for PPD, there is no universal standard in the United States for the use of such tools (Newland & Parade, 2016). This includes a lack of standard for: type of screening tool to use, when is the optimal time to screen postpartum, and where is the best location to conduct such screenings. Due to the lack of standardization in PPD screening, there is low physician use of a PPD tool and lack of education regarding PPD screenings. This perpetuates the cycle of decreased recognition and decreased treatment, opening a gap to poor maternal and newborn outcomes (Goldin- Evans et al., 2012). Up to 95-99% of children attend wellbaby care visits (WCV), such as at family practice (FP) September 13 September 13 September 14-15 Fall 2018 Fall 2018 Join us in Boise! Register Today Improving the way clinicians diagnose, treat, manage, and educate their patients. Clinical STD Update with Optional Clinical Practicum August 9, 2018 Boise, ID CNE/CME Available For more information: 206-685-9850 • uwptc.org • email@example.com REGISTER NOW for 2018 Activities! Workshop on Trauma Informed Care at the Riverside Hotel in Boise, Idaho Celebrate Nursing Dinner at the Riverside Hotel in Boise, Idaho LEAP Conference at the Riverside Hotel in Boise, Idaho Keynote Speaker: Alex Wubbels, BSN, RN Introduction to Leadership 3-Day Course - Boise Advanced Leadership Concepts Course TBD Visit www.nurseleaders.org to register! Contact Karin Iuliano at firstname.lastname@example.org with any questions or if you need assistance. or pediatrician offices, as well as follow-up postpartum appointments at obstetrician (OB) offices, making these optimal places to conduct screenings for PPD (Goldin- Evans et al., 2012). Therefore, the question remains: Does the use of a standardized evidence-based protocol for screening for postpartum depression (PPD) increase the number of mothers screened for and diagnosed with PPD when utilized at well child visits (WCV) and obstetric (OB) appointments during the first year postpartum? Current Screening Practices Currently in the United States, a universal standard for screening for PPD has not been established. While the American Academy of Pediatrics (AAP) currently recommends universal screening in the early postpartum period at WCV, OB appointments, home visits and community outreach centers, it does not specify a timeframe for screening or recommend a standardized tool (Newland & Parade, 2016). ACOG (2015) recommends at least one screening in the perinatal period using a validated screening tool, but does not provide a recommended timeframe for screening. ACOG (2015) also suggests the importance of more frequent “monitoring” of women with a history of anxiety or depression but does not provide a timeframe or evaluation recommendation. In an effort to increase screening practices, some states have tied reimbursement for physicians and practitioners to the completion of PPD screenings (Newland & Parade, 2016). Screening at Well Child Visits Van der Zee-van den Berg et al. (2015) completed a systematic review to determine if screening for PPD at WCV improves maternal and child outcomes. They found significant improvement in detection, referral, and treatment of PPD through screening at WCV using the Edinburgh Postnatal Depression Scale (EPDS). Yawn et al. (2012) also performed a systematic review to determine if universal screening for PPD improved maternal and newborn outcomes. Women were screened using either the EPDS, Patient Health Questionnaire-9 (PHQ-9), or the PHQ-2 (a modified version of the PHQ-9) at OB, WCV, and community outreach programs. The results indicated that at least two-thirds of the women were screened for PPD when seen at WCV or OB appointments, suggesting WCV as a feasible and reliable site for conducting PPD screenings (Yawn et al., 2012). Validated Screening Tools It is relevant to discuss what screening tools are evidence-based, or validated, for use in identifying PPD. Hanusa et al. (2008) recommends the EPDS as the most accurate screening tool. However, Gjerdingen et al. (2009) found in their study that the PHQ-2 was highly sensitive (100% predictive of PPD for initial screen) and that the PHQ-9 was highly specific (92-94% correct in identifying PPD), suggesting they would be good diagnostic tools. Based on the literature presented above, all are valid tools for use in accurate and efficient PPD screening. In reviewing these tools, it is clear, based on time required to complete a screening, the increased sensitivity and specificity of the tools, that the EPDS and PHQ-9 are the most recommended tools for PPD screening. ACOG (2015) presented all of the validated screening tools available for physician or provider use in a table format that may be helpful to providers in selecting the appropriate tool for their practice. Competence with Screening An additional piece to consider when discussing screening mothers at WCV and OB appointments is provider competence and comfort with initiating the screening. Byatt et al. (2013) found in a study of 90 postpartum women that mothers felt concerned about the inability of providers to discuss, assess and refer them for PPD. Additionally, Chadha-Hooks et al. (2010) found in a survey of providers and residents that most clinicians were unfamiliar with the validated screening tools for PPD, such as the EPDS. The authors additionally identified that OB providers were more familiar with the EPDS than pediatricians, suggesting that the use of this tool to screen at WCV would require further physician education. In fact, Goldin-Evans et al. (2012) review of screening practices found that only 55% of physicians screened for PPD, and that of those, only 25% used an evidence-based screening tool when assessing postpartum mothers. Note that these studies are six or more years old and thus current practice may be improved. Conclusions Based on the literature, several conclusions can be drawn on which to make recommendations for standardized screening practices for PPD. First, it is evident that initiating screening at WCV and OB appointments increases the percentage of screenings preformed for PPD, making these ideal locations in which to conduct screenings and implement universal screening recommendations. While there are many validated screening tools for screening for PPD, the literature illustrates that the PHQ-9 and EPDS are the most reliable and recommended screening tools. Finally, Evidence-Based Screening continued on page 15
May, June, July 2018 RN Idaho • Page 15 Evidence-Based Screening continued from page 14 a lack of education and training on screening for PPD by pediatricians was clear in earlier studies (2010-2012); both providers and patients report the need for further education on PPD screening at WCV. It is important for clinicians to understand the barriers to screening for PPD. The literature presented indicates the lack of a universal screening recommendation for PPD and demonstrates the need for physicians/ healthcare providers to have improved education in order to successfully screen and appropriately engage in conversations regarding PPD. It is also evident that women fear both the stigma associated with PPD and the lack of physician engagement and ability to screen/ discuss PPD which ultimately deters them from seeking help when they suspect symptoms. While identification through screening is a crucial first step, referral sites and treatment options must also be considered in order to successfully manage PPD. A lack of consistent follow-up for postpartum appointments or WCV is a sizable barrier with implications for future discussion. American Nurses Association/ ANA Idaho Membership – It’s Your Choice! It’s Your Privilege! Just Because You Received This Publication, Doesn’t Mean You Are an ANA Idaho Member Significance to Nursing Nurses are the backbone to healthcare: their thorough assessments and patient education, advocacy for patients, leadership abilities, and role as change agents in the utilization and implementation of EBP make them key players in a rapidly changing industry (Yoost & Crawford, 2016). From their work in clinics, schools, and public health to acute care and academic settings, nurses are the frontline in managing patient care. As such, this issue is significant to nurses engaged in assessing and educating postpartum patients in outpatient OB, FP, and WCV visits. The ability to initiate screening tools for PPD, recognize signs and symptoms, educate patients and physicians on PPD, and report findings to physicians are all essential in the early and timely detection and treatment of PPD. Goal: Increased screening + improved competency and education + decreased barriers = Increased recognition and referral for PPD to improve maternal and newborn outcomes References American College of Obstetricians and Gynecologists (2015). Screening for perinatal depression. Retrieved from https//m. acog.org/Clinical-Guidance-and-Publications/Committee- Opinions/Committee-on-Obstetric-Practice/Screening-for- Perinatal-Depression?IsMobileSet=true Byatt, N., Biebel, K., Friedman, L., Debordes-Jackson, G., & Ziedonis, D. (2013). Women’s perspectives on postpartum depression screening in pediatric settings: a preliminary study. Archives of Women’s Mental Health, 16(5), 429-432. Chadha-Hooks, P. L., Hui Park, J., Hilty, D. M., & Seritan, A. L. (2010). Postpartum depression: an original survey of screening practices within a healthcare system. Journal of Psychosomatic Obstetrics & Gynecology, 31(3), 199-205. Gjerdingen, D., Crow, S., McGovern, P., Miner, M., & Center, B. (2009). Postpartum depression screening at well-child visits: Validity of a 2-question screen and the PHQ-9. Annals of Family Medicine, 7(1), 63-70. Goldin-Evans, M., Phillipi, S., & Gee, R. (2012). Examining the screening practices of physicians for postpartum depression: Implications for improving health outcomes. Women’s Health Issues, 25(6), 703-710. Hanusa, B., Scholle, S., Haskett, R., Spadaro, K., & Wisner, K. (2008). Screening for depression in the postpartum period: a comparison of three instruments. Journal of Women’s Health, 17(4), 585-596. doi:10.1089/jwh.2006.0248 National Institute of Mental Health (2018). Postpartum depression facts. Retrieved from https://www.nimh.nih.gov/ health/publications/postpartum-depression-facts/index.shtml Newland, R. P., & Parade, S. H. (2016). Screening and treatment of postpartum depression: Impact on children and families. Brown University Child & Adolescent Behavior Letter, 32(1), 1-6. Postpartum Support International (PSI). (2018). PSI Awareness Poster. Retrieved from: http://www.postpartum.net/resources/ psi-awareness-poster/ van der Zee-van den Berg, A. I., Boere-Boonekamp, M., IJzerman, M., Haasnoot-Smallegange, R., & Reijneveld, S. (2017). Screening for postpartum depression in well-baby care settings: A systematic review. Maternal and Child Health Journal, 21(1), 9-20. Yawn, B., Olson, A., Bertram, S., Pace, W., Wollan, P., & Dietrich, J. (2012). Postpartum depression: Screening, diagnosis, and management programs 2000 through 2010. Depression Research and Treatment, 2012. Yoost, B.L. and Crawford, L.R. (2016). Fundamentals of nursing. St. Louis, MO: Mosby/Elsevier.
© Copyright May 2018 - Arthur L. Davis Publishing Agency, Inc.