Regular Screening For Postpartum Mood and Anxiety Disorders (PMAD) Could Change Lives.
I was a missed opportunity.
In 2004, my newborn daughter missed her two-week pediatric appointment. My mother had to accompany me to the doctor. I couldn’t drive myself to the office. Why?
I was suffering from postpartum depression and anxiety. Not only was I unable to drive, but I couldn’t shower, sleep, or even eat. But when my pediatrician asked me how I was feeling, I said, “Fine,” just as I had when my OB called two days postpartum, despite the ongoing health issues I was dealing with related to preeclampsia and kidney stones. Fine? I was definitely not fine.
But flawed communications like this between women and their health providers happen every day, across cultural lines and in every country in the world. But these are not the conversations we should be having.
What would my pediatrician have done had I said, “I hate my baby. I made a mistake having a third child. I am sick out of my mind, and I have thought about ending my life.”
Not only was I not fine, I was never properly screened by a single professional on my care team. I was a missed opportunity for my team to deliver an important component of care—mental health screening.
How can we move from communicating information, to REAL conversation?
Pre/postpartum mental health issues are situational, usually short-lived, and not reflective of who a person is. Still, no one likes to admit weakness, defeat, or sickness. The stigma around mental illness is so powerful that there is extremely poor communication. Sufferers stay silent, and providers don’t ask the right questions.
When the statistics show that 1 in 7 women, and 1 in 10 spouses/partners suffer from a postpartum mood and anxiety disorder (PMAD), it is time to move from communication to real conversation. OB-GYNs, pediatricians, nurse-practitioners, midwives, doulas, adoption and surrogacy agencies, community health centers, and anyone who works in maternal health during or after a pregnancy should be screening pregnant women and new parents.
How do we use conversation to create action (screening)?
First, we must understand the difference. Imagine checking in for an appointment with your provider, and at the front desk you are handed a clipboard of paperwork to fill out. One of many forms is the Edinburgh Postnatal Depression Scale (EPDS), and you are asked to read the instructions and fill out the 10-item self-report form. You fill out the necessary forms and hand the clipboard back to the front desk or nurse. Sometimes there is no explanation as to what the EPDS form is, no explanation as to what it’s for, no explanation about why it’s part of your appointment. In fact you may never see it again.
Here’s another scenario. Imagine checking in for an appointment with your provider. You are called back to the exam room by the nurse who takes your vitals and tells you the doctor will be in shortly. When the provider (or screener like myself) comes in, this is what you hear, “As part of your comprehensive care, we screen all of our patients for pre- and postpartum mood and anxiety disorders using this screening tool. Having a baby is a huge life event and we recognize that it can be overwhelming. It’s okay to not feel okay. Check the answer that comes closest to how you have felt in the past 7 days, not just how you feel today. We will discuss it at the end of the appointment and address any questions you have.”
In which scenario are we likely to see honest answers and hear healthy follow-up questions from the mothers?
In this scenario, the conversation continues because the office has established a screening protocol and a procedure policy, can refer parents to mental health professionals, and can provide educational resources—all with the aim of getting parents the care they need. Your provider and office staff know the best next steps to take. This is conversation and action!
What is the screening tool called EPDS?
The Edinburgh Postnatal Depression Scale (EPDS) was created in Edinburgh Scotland in the 1980s thanks to funding from the Scottish Home and Health Department. The scale has since been approved for use with spouses and partners too. HERE is a link to the EPDS online. There are other screening tools as well you can find at The Postpartum Stress Centre.
Why is screening so important?
Screening for PMADs is important because not only can’t you always tell by looking, but due to stigma, women will hide their condition, even when directly asked, as I did.
PMADs are not detected and diagnosed by a blood test, x-ray, physical exam, or by discovering a growth somewhere on the body. They cannot be detected by a urine test, pap smear, or blood pressure cuff. The patient may appear “put together” and to be handling the transition into parenthood well, but that can be a façade, in place to reassure everyone, including herself, that there is no problem.
PMADs indeed have symptoms, but they are not easy to measure tangibly. This is where the EPDS (and other screening tools) can be used for detection, prevention, and intervention. It is important to note that the EPDS is not diagnostic and requires continued conversation. A high score may indicate depression and anxiety, but does not diagnose it. This is why perfunctory communication is not enough; the EPDS spurs further diagnostic testing and further conversation between patient and provider.
When we screen for postpartum mood and anxiety disorders (PMAD), we throw women a lifeline.
Postpartum Support International suggests the following screening frequency for pregnant and postpartum families:
- First prenatal visit
- At least once in the second trimester
- At least once in the third trimester
- Six-week postpartum obstetrical visit (or first postpartum visit)
- Repeated screening at 6 and/or 12 months in OB and primary care settings
- 3, 9, and 12 month pediatric visits
Where do we go from here?
Medical practice managers/clinic administrators can standardize screening for PMADs in their offices and clinics by including screening in their policies and procedures manual. Obstetric providers screen for issues like gestational diabetes and preeclampsia, why not perinatal mental health? In the pediatric setting, providers administer immunizations, check infant weight, and discuss breastfeeding, why not screen for perinatal mental health issues in parents who are the frontline of care for the infant who is their patient? There are numerous studies addressing the impact of PMADs on children (but that’s for a different blog post). We can also, as patients, request to be screened and start the conversation ourselves. But as long as doing so is difficult for so many women and their partners, providers need to be proactive and routinely screen.
This is conversation.
In my work, I help provider offices create a screening procedure and policy manuals, discuss national recommendations on screening frequency, discuss what codes they can bill, screen their patients, offer resources and education to both the patient and the office regarding follow-up steps and appropriate clinic response, and how they can stop missing opportunities to deliver complete care. I was a missed opportunity, but I don’t want you to be. It’s okay to not feel okay. Make sure your provider is screening.
It is so important to share this information about screening with others, so they can feel empowered to get the screening that they need!
Share this post with others, to help educate them on what proper screening postpartum looks like, so they can get the help they deserve!
Author Bio: Lynn Ingram McFarland resides in Portland, OR with her husband and daughter, her two older boys are both in college. She is a three-time survivor of PMADs, serves on the board of Postpartum Support International, is the founder and CEO of Ingram Screening, LLC for perinatal mental health, and is an advocate for all maternal health related issues. You can reach her at anytime via email, email@example.com , or phone/text 503-888-6489. Her website is https://ingramscreening.com