Depression in Pregnancy and Postpartum

Peripartum Depression is common. About 1 in 9 women experience peripartum depression defined as Major Depression during pregnancy and in the postpartum period.¹ In New York State, the rates of women who experienced depressive symptoms after childbirth vary between 10 and 22%.²

Peripartum Depression should be differentiated from maternity blues, sometimes called “baby blues” which is a more common (80%), benign and self limiting condition with sadness, tearfulness, difficulty sleeping and anxiety about being able to care for the baby. Maternity blues typically occur during the first few days after pregnancy and usually get better within 1 – 2 weeks without any treatment.³

Postpartum Depression commonly starts between 1 – 3 weeks after childbirth but can occur up to one year after having a baby. Women suffering from postpartum depression have more intense feelings of sadness, anxiety and despair and they meet full criteria for a Major Depressive Episode.

Risk factors for postpartum depression include a history of psychiatric illness including prior depression during pregnancy, limited social/partner support, intimate partner violence (IPV), history of substance use, pregnancy in adolescent women (under age 20) as well as women with lower socioeconomic status.⁴

Although clinicians and patients often focus on the risks of antidepressant treatment in pregnancy and breastfeeding, there is substantial evidence^5,6,7 that untreated depression will cause poor health and significant risk to both mother and child. Initiating antidepressant medications during pregnancy should always be based on clinical judgment carefully weighing the risks and benefits of medications vs. the risks of no treatment.

A useful resource that provides evidence-based information to healthcare professionals as well as the general public about medications and other exposures during pregnancy and while breastfeeding is the motherToBaby website.

For information and resources related to maternal depression screening in pediatric primary care settings, please contact the BHI team AHPBHIT@urmc.rochester.edu

1. Trends in Postpartum Depressive Symptoms. Ko JY et.al. CDC Weekly/February 17, 2017/ 66(6); 153-158.
2. CDC Pregnancy Risk Assessment Monitoring System (PRAMS). NYS 2016.
3. Am Fam Physician. 1999 Apr 15; 59(8): 2259-2260.
4. Depression During Pregnancy. BMJ. 2007 May 12; 334(7601): 1003-1005.
5. Kornstein & Clayton, Women’s Mental Health, 2002.
6. Tronick EZ, Weinberg MK. In Postpartum Depression and Child Development. 1997:54-81.
7. Kendig et al. (2017). Consensus bundle on maternal mental health:perinatal depression and anxiety. Obs Gynecol, 129(3), 422-430

Phases of Depression and Treatment Goals

Acute (6-12+ weeks)

Treatment Goals – Achieve response and move towards remission as evidenced by a decrease in symptoms and an improvement in functioning

Continuation (6-12 months)

Treatment Goals – Sustain remission and prevent relapse by targeting any residual symptoms; optimize functioning

Maintenance (> 1 year)

Treatment Goals – Sustain recovery and prevent recurrence

Throughout treatment provide psychoeducation about depression in adolescence and treatment options including self-management strategies. Offer supportive management such as active listening, and instilling hope. Engage family members with education and supportive strategies. Engage school to promote a supportive learning environment when youth and family consent.

PHQ 2/9 Administration and Workflow

PHQ 2/9 FAQs

How are the PHQ 2 and 9 tools used?

The PHQ 2 is a tool used to screen for depression, while the PHQ 9 tool is used to screen or diagnose depression, measure the severity of symptoms, and measure a patient’s response to treatment. The PHQ 2 and 9 are quick and easy to administer^1,2.

What is the difference between a PHQ 2 and 9?

The PHQ 2 is a preliminary screening tool administered prior to the PHQ 9. Anyone who scores 2 or more on the PHQ 2 will need to have a PHQ 9 administered and a clinical evaluation to confirm or rule out a diagnosis of depression.

Who can administer the PHQ 2 and 9 to patients?

The PHQ 2 and 9 are useful tools for integrated care settings, as they can be administered by a variety of different staff and can be used with different approaches. The PHQ 2 and 9 should be completed by the patient, usually in the waiting room, and then scored by a staff person. Often administrative staff, medical assistants, care managers or nursing staff will score this form and subsequently enter the score into the electronic health record. In cases where patients have difficulty with reading or comprehension, a staff member can assist the patient in completing the tool. Assistance with completing the tools can be provided by any level of staff who has been trained in understanding the purpose and importance of the PHQ tools and in strategies for engagement and completion of the tools.

A score of 10 or above and/or a positive answer on question 9 of the PHQ 9, which is a screening for suicidal symptoms typically require further evaluation and a clinical intervention by the primary care provider, care manager or BH staff in the practice or via referral ^3,4. A workflow will need to be developed to identify appropriate staff responsibilities and procedures for responding to these scores. This workflow includes review by the team (primary care provider, care manager and behavioral health staff, if available). Patients receiving intervention should be provided with regular follow up and tracked for improvement in their PHQ 9 score. The administration of the PHQ for follow up can be done in person, using phone calls and/or a smartphone application^5,6. Results from studies that have analyzed telephonic and electronic administration of the tool have demonstrated that these methods yield similar results to being administered in person.

In which populations should the PHQ 2 and 9 tools be used?

The PHQ 2 and 9 are appropriate to be used with individuals 12 years of age and older. Alternative screening tools have been developed and validated for use among special populations including youth and older adults. These alternative tools can be accessed at: https://aims.uw.edu/resource-library/phq-9-depression-scale.

How often should the PHQ 2 depression screening tool be administered?

The U.S. Preventive Services Task Force (USPSTF) recommends screening for depression in adolescents ages 12 – 18 and in adults, including pregnant and postpartum women. “Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.”⁷ The American Academy of Family Physician recommendations mirror those of the USPSTF.⁸ The American Academy of Pediatrics recommends depression screening for adolescents beginning at age 11.⁹ At this time, there is no definitive guidance on how frequently someone should be screened for depression. The USPSTF states: “The optimum interval for screening for depression is also unknown; more evidence for all populations is needed to identify ideal screening intervals. A pragmatic approach in the absence of data might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted.”¹⁰ Certain populations with higher risks for depression, such as those with HIV infection, may be considered for regular screening. For example, the NY State AIDS Institute HIV guidelines recommend screening “for depression as part of the annual mental health assessment and whenever symptoms suggest its presence.”¹¹ There is growing consensus that screening using evidence-based tools like the PHQ 9 is a critical component of delivering integrated care.

What does AHP recommend?

The AHP Behavioral Health Integration (BHI) team recommends screening for depression in individuals ages 12 and over at least once yearly. Peripartum women should be screened at least once during their pregnancy and postpartum period. Individuals who score positive on the PHQ 9 (score 10 and above) should be screened again every 4 weeks to assess their progress and guide their treatment. It is important to note that although the recommendation is to perform a follow up screen every 4 weeks, patients may need to be have follow up visits in person or by phone more frequently. This is particularly true in adolescents with depression.¹² Clinical judgement should always guide the frequency of follow up in depression.

The frequency of PHQ 9 screening usually reverts back to yearly after 2 consecutive screens are deemed negative (score below 5).

Interpretation of the PHQ 9 scores and recommended actions.

Each item on the PHQ 9 is rated on a 4-point scale (0=Not at all; 1=Several days, 2=more than half the days; and 3=Nearly every day). The total score can range from 0 to 27, with higher scores indicating greater severity of depression. As a screening instrument, the PHQ 9 cannot replace sound clinical judgment. Before deciding on treatment, the clinician must carefully evaluate those with scores indicative of depression for coexisting situational issues such as suicidal thoughts; substance use; medical illnesses presenting with anergy, insomnia, or anorexia; or other comorbid psychiatric condition.¹³

1. Kroenke K, Spitzer R, Williams W. The PHQ-9: Validity of a brief depression severity measure. JGIM, 2001, 16:606-616.
2. Pfizer to Offer Free Public Access to Mental Health Assessment Tools to Improve Diagnosis and Patient Care.; http://www.prnewswire.com/news-releases/pfizer-to-offer-free-public-access-to-mental-health-assessment-tools-to-improve- diagnosis-and-patient-care-99025129.html. Published July 22, 2010. Accessed June 6, 2016.
3. Instruction Manual: Instructions for Patient Health Questionnaire (PHQ) and GAD 7 Measures website. https://phqscreeners.pfizer.edrupalgardens.com/sites/g/files/g10016261/f/201412/instructions.pdf. Published December 2014.
4. DoesResponseonthePHQ-9DepressionQuestionnairePredictSubsequentSuicideAttemptorSuicideDeath? http://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.201200587. Published December 2013.
5. Pinto-Meza A, Serrano-Blanco A, Penarrubia M, et al. Assessing Depression in Primary Care with the PHQ-9: Can it be Carried Out over the Telephone? JGIM, 2005, 20:738-742.
6. Torous J, Staples P, Shanahan M, et al. Utilizing a Personal Smartphone Custom App to Assess the Patient Health Questionnaire- 9 (PHQ-9) Depressive Symptoms in Patients with Major Depressive Disorder. JMIR Mental Health, 2015, 2:1-11.
7. US Preventive Services Task Force, Screening for Depression in Adults. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-in-adults-screening1?ds=1&s=Depression%20screening. Published January 2016.
8. Summary of Recommendations for Clinical Preventive Services. Available at: http://www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/cps-recommendations.pdf. Published June 2016.
9. Recommendations for Preventive Pediatric Health Care. Available at: https://www.aap.org/en-us/Documents/periodicity_schedule.pdf. Published January 2016.
10. US Preventive Services Task Force, Screening for Depression in Adults. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-in-adults-screening1?ds=1&s=depression. Published January 2016.
11. Depression and Mania in Patients with HIV/AIDS. Available at: http://www.hivguidelines.org/clinical-guidelines/hiv-and-mental- health/depression-and-mania-in-patients-with-hivaids/. Published October 2010.
12. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part II. Treatment and Ongoing Management. Available at: https://pediatrics.aappublications.org/content/141/3/e20174082. Published March 2018.
13. A System-Based Approach to Depression Management in Primary Care Using the Patient Health Questionnaire-9. DOI: https://doi.org/10.4065/82.11.1395.

Radiology Epidemiology Statement

A collaboration of radiology groups throughout Rochester agreed to include a Radiology Epidemiologic Statement with every MRI of the Lumbar Spine report. This table shows the percentage of asymptomatic patients of a particular age range that have that finding on MRI. This begins to put into perspective how common these findings are and how necessary it is to look at these findings in the context of the clinical situation. Showing the patient the prevalence of findings on an MRI, helps define the clinical relevance of the findings and helps set expectations for treatment.

Guidelines for Pharmacological Options

• They don’t speed recovery
• They can give comfort
• They often create side effects
• Go OTC whenever possible (Acetaminophen, Ibuprofen)
• Go generic when you can
• Discontinue when there is no improvement

Common Red Flags Associated with LBP