We know that screening moms for symptoms of postpartum mood and anxiety disorders (PMADs) is key to identifying the mothers who need help and referrals. New York City recently announced they’re mandating screening for all moms. We celebrate that endeavor and strongly wish all hospitals in all states, cities, and towns would follow suit.
But it seems daunting, right? All moms? Is that even possible? How does a hospital even go about setting that up? Wouldn’t it be a lot of work?
Turns out that it really doesn’t have to be all that difficult.
Yesterday a study was released in the Archives of Women’s Mental Health concerning the process and results of setting up a “hard stop” screening for perinatal mood and anxiety disorders. At the mother’s postpartum checkup, a doctor hits a point in the electronic charting which cannot be passed without entering a number from the Edinburgh Postnatal Depression (EPDS), an accepted mental health screening for PMADs. A number must be entered before the chart can be closed out.
So, how did it work?
The study took place at Mount Sinai Hospital OB/GYN Ambulatory Practice. The practice delivers approximately 1,000 babies per year and serves a large minority population, 88% of which are enrolled in Medicaid or Medicaid HMO. Minority mothers dealing with financial problems face a higher risk for postpartum depression, according to the CDC.
In response to the Health Information Technology for Economic and Clinical Health Act (HITECH), the practice switched to electronic charting, which can offer many benefits to patients and healthcare providers alike. In this case, switching to an electronic charting system allowed for the implementation of the “hard stop,” forcing physicians to record a number before moving forward with the chart. The practice added this in 2009, and began tracking the results as of January 1, 2010.
Between January 1, 2010 and December 31, 2013, 2092 of the 2102 women that returned for their postpartum visit were screened for PPD in response to this “hard stop.” That’s 99.5% of the mothers that returned for their appointment. Only 10 women in this 4 year period do not have a record of a depression screening.
Of those ten women:
- Three had notes indicating a language barrier which made the screening impossible
- Three mothers refused to complete the screening
- Four had no screening number entered.
Of the mothers who completed the EDPS screening:
- 74.2% of the postpartum women reported some change of mood since delivery
- 16.6% were probably depressed
- 9.2% expressed symptoms associated with clinically significant depression
- 25.8% were referred for follow-up psychiatric care
Okay, so what does all this mean for moms, health care providers, and the hopeful future of mandatory screening? In short: Setting up a screening process doesn’t need to be an arduous task. This model works. I was able to talk to Michael E. Silverman, Ph.D., Assistant Professor of Psychiatry at Icahn Medical School at Mount Sinai and one of the doctors involved in this study. I asked him what this study shows other health care institutions about setting up screening. He replied with some encouraging words.
“This is a simple solution to implement a standardized screening program. It doesn’t solve all the problems, but what it does do is put the onus of the detection on the practitioner as opposed to forcing the patient to do something that for one reason or other might make them uncomfortable. I see this more about implementing quality assurance in postpartum healthcare. But, as legislation towards screening becomes more common, having it out there prevents a “we haven’t quite figured out how to do it yet” response. That is, no need to reinvent the wheel.”
Hospitals and other providers now have a model to follow, allowing for easier implementation of something that once seemed daunting. That’s exciting for all of those who care about moms receiving quality mental health care.
But… I still felt a little bit of concern about the numbers. If you look closely, you’ll see that 4493 delivered babies at the practice between 2010 and 2013, but only 2102 returned for their postpartum visit. That’s not even half of the mothers who gave birth returning for their postpartum appointment. (46.8 %) I asked Silverman if prenatal screening for things like antenatal depression and a family or personal history of mental illness would be of benefit.
Women in living in low socioeconomic status represent the least compliant population in respect to postpartum care. At MSSM we have worked tirelessly to get these women to return, even having nurses call them to remind them of their upcoming appointments. Unfortunately, there are so many barriers (financial, cultural, social, etc), and the effort while heroic, does not yield significant returns. At this very moment we are analyzing the data to determine the demographic and perinatal factors associated with those who do not return. Who are they? What are the characteristics of their delivery? How many children do they already have? What age are they? Once we do that (and we will publish it), we’ll design an intervention study to see if we can increase this return rate. Obviously, the most concerning group are that those who are most depressed—because they are the least likely to return!
After reading this study and hearing Silverman’s answers to my important questions, I feel hopeful for the future of our moms, including those most vulnerable. We remain hopeful that universal screening will eventually happen for new moms, and we feel encouraged that people recognize the need for more mental health care for those who are often underserved.
The future looks like it’s brightening. Thank you to Dr. Silverman and his team.
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