Depression and Bipolar Screening Essential for New Moms

Tara Haelle

April 30, 2018

AUSTIN — Perinatal and postpartum depression affect one in seven women in the United States, but healthcare resources and access to care can be inconsistent or nonexistent for many.

"Maternal mental health problems are one of the most common complications of pregnancy, and we as OBs have a real opportunity to affect their care in a positive way by addressing and treating them, said Tiffany Moore Simas, MD, from the University of Massachusetts Medical School in Worcester.

Perinatal mental health disorders affect not only mothers, but also their families, she told Medscape Medical News. For mothers, untreated mental health conditions can contribute to poor adherence to medical care, smoking and substance use, pre-eclampsia, and suicide. For children, risks are elevated for low birth weight, preterm delivery, cognitive delay, behavioral problems, and infanticide.

Maternal suicide exceeds hemorrhage and hypertensive disorders as a cause of maternal mortality.

"Maternal suicide exceeds hemorrhage and hypertensive disorders as a cause of maternal mortality," Moore Simas said here at the American College of Obstetricians and Gynecologists (ACOG) 2018 Annual Meeting.

Still, it is estimated that just one-quarter of women with perinatal mental health complications receive treatment, she reported.

Women need to be screened for perinatal mood and anxiety disorders at least twice: once during pregnancy and again after delivery, according to the US Preventive Services Task Force. The ACOG recommends screening for depression and anxiety at least once during the perinatal period.

The major validated screening tools for depression take no more than 10 minutes, and often less, to complete.

These include the Edinburgh Postnatal Depression Scale, a free depression and anxiety screen available in more than 40 languages; the Postpartum Depression Screening Scale; the Patient Health Questionnaire 9, which screens for depression in the general population; the Beck Depression Inventory and the Beck Depression Inventory II; the Center for Epidemiologic Studies Depression Scale; and the Zung Self-Rating Depression Scale.

All but the Zung scale are available in Spanish.

Integrating depression care into obstetric practices can be transformative for the women we serve.

The perinatal period is ideal for depression screening because providers have regular contact with women, Moore Simas explained. Obstetrician–gynecologists can decrease the stigma of mental health conditions and educate women so that they feel comfortable seeking care.

In addition, barriers to care at provider and practice levels — such as inadequate resources, lack of guidance and training for providers, and obstacles that prevent the performance of nonroutine screening within systems — must be removed, she said.

"Integrating depression care into obstetric practices can be transformative for the women we serve," she explained.

The Maternal Mental Health: Depression and Anxiety patient safety bundle — developed by the Council on Patient Safety in Women's Health Care (Moore Simas was a member of the interdisciplinary task force) — is designed to increase the ability of obstetrician–gynecologists to care for women with postpartum mood or other psychiatric disorders.

MCPAP for Moms — adapted from the Massachusetts Child Psychiatry Access Project (MCPAP) — enhances the ability of obstetric care and primary care providers who care for pregnant and postpartum women with mental health concerns. Programs in 32 states have now been modelled after MCPAP, and Moore Simas said she hopes to see a similar expansion of MCPAP for Moms.

"MCPAP for Moms is spreading, and it's being viewed as a national model," she pointed out. It offers obstetrician–gynecologists resources on consultation, care coordination, and education, and includes training on how and when to screen, what to do with positive screens, and the need to rule out bipolar disorder before prescribing medications.

Of the mothers who screen positive for perinatal depression, it is estimated that 23% have bipolar disorder.

Screening for Bipolar Disorder

Of women who experience postpartum psychosis, 70% have bipolar disorder. Postpartum psychosis is a psychiatric emergency that affects up to two in 1000 women overall and carries a 4% risk for infanticide.

When depression screening results are positive and antidepressants are indicated, providers can conduct a quick bipolar disorder screen.

The idea of adding a bipolar screening question when women screen positive for perinatal or postpartum depression was a revelation to Shamita Bansore, MD, from Good Samaritan Hospital in Downers Grove, Illinois, who attended the presentation.

In the past, Bansore has prescribed selective serotonin reuptake inhibitors immediately after learning that a patient needed support for depression or anxiety, but, as Moore Simas explained, patients with bipolar disorder can develop mania and are at increased risk for psychosis when taking unopposed antidepressants.

The addition of a bipolar question to screens is "quick and easy," although many obstetrician–gynecologists probably don't do it, Bansore told Medscape Medical News. "I'm going to apply that right away."

This presentation was "inspiring and hopeful," said Ella Speichinger, MD, from the University of Missouri in Columbia, who described a recent patient who had been prescribed antidepressants and went on to develop psychosis at 3 months postpartum.

"She was prescribed an antidepressant because she was anxious, but she never had a screen for bipolar," Speichinger told Medscape Medical News. "I wonder what her course would have been like had she had access to this kind of care."

Providers have to advocate for funding for programs similar to MCPAP for Moms, said Moore Simas, who noted that funds were recently allocated to the Bringing Postpartum Depression Out of the Shadows Act, consolidated into the 21st Century Cures Act, which was signed into law in 2016.

"Thinking politically, I need to be involved in my legislature to get something like funding for MCPAP programs pushed through," Speichinger told Medscape Medical News. "But on a more granular level, when I go to work tomorrow, I should feel like I can pick up the phone and call somebody for advice because doing nothing is basically worse than doing something."

Moore Simas reports serving on advisory boards, being a research consultant, and receiving speaker honoraria from Sage Therapeutics. Bansore and Speichinger have disclosed no relevant financial relationships.

American College of Obstetricians and Gynecologists (ACOG) 2018 Annual Meeting. Presented April 28, 2018.

Follow Medscape OBGYN on Twitter @MedscapeObGyn and Tara Haelle @TaraHaelle

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