Improved screening can benefit women with postpartum depression

Nurse education is the key to successfully screening women for postpartum depression, which affects some 15% of mothers, according to a new quality improvement (QI) study from Cedars-Sinai.

Training that helped nurses get comfortable with the topic of depression and to develop a non-judgmental attitude and openness to a patient's questions and concerns is critical."

Eynav Accortt, PhD, principal investigator of the QI review and director of the Reproductive Psychology Program at Cedars-Sinai

Depression and anxiety during pregnancy or in the first 12 months after delivery is one of the most common perinatal medical complications. Postpartum depression that sets in after childbirth is often characterized by persistent sadness, fatigue, feelings of hopelessness and worthlessness and trouble sleeping or eating. Some women find it hard to care for their new baby.

Hospitals have been urged to institute postpartum depression screening and referral programs to identify and help women struggling with their mental health. Effective programs and procedures for screening can be challenging to develop. A new quality improvement (QI) initiative by Cedars-Sinai investigators in the Department of Obstetrics and Gynecology identified nurse training and education as key to successfully screening women in their care.

"Our research also revealed that framing the screening as part of the medical center's commitment to family wellness, as opposed to only using the term 'depression,' was helpful. It allowed us to normalize the challenging transition to parenthood these patients often experience," said Accortt, a clinical psychologist and assistant professor in the Department of Obstetrics and Gynecology.

The initiative, Implementing an Inpatient Postpartum Depression Screening, Education, and Referral Program: A Quality Improvement Initiative, is published in the American Journal of Obstetrics & Gynecology–Maternal-Fetal Medicine.

Nurses are often on the frontlines of screening programs for postpartum depression, but nursing schools rarely require training in mental health screening or education. Reviewing data involving over 19,500 women who gave birth at Cedars-Sinai allowed investigators to evaluate the benefits of additional training for the nurses charged with accessing new mothers for depression.

"We recognized that we needed to do a better job identifying patients at risk before they went home from the hospital," said Sarah Kilpatrick, MD, PhD, senior author of the QI study, and the Helping Hand of Los Angeles Chair in Obstetrics and Gynecology at Cedars-Sinai.

"We learned that it is a complicated process requiring dedicated collaboration between nurses, physicians, and information technology personnel to make the system work. Our framework should be reproducible in other hospitals, thus helping even more families recognize and better manage postpartum depression," Kilpatrick said.

An important tool for evaluating a patient for postpartum depression is a special questionnaire designed to identify the presence and seriousness of a mood disorder. Because many nurses called on to administer the questionnaire within two days of a patient giving birth had concerns about doing it correctly, an important quality improvement measure was in-service training; nurses observed a clinical psychologist demonstrate the process with a staff member playing the role of the patient.

If the results of a new mother's questionnaire suggest she needs help before she leaves the hospital, a visit with a social worker can be scheduled.

"The social worker begins by being a caring, nonjudgmental, listening ear and provides support and resources based on the patient's needs. She might consult psychiatry if the woman seems unstable and in need of a full psychiatric evaluation. Otherwise, she might provide a referral to our Reproductive Psychology Program or to our patient navigator, who can help connect her to care in the community," said Accortt.

The postpartum depression screening program at Cedars-Sinai has expanded to include outpatient follow-up. A screening initiative for women who have experienced a stillbirth or who are in the obstetrics intensive care unit has also been implemented.

"If we care about our patients' mental health, screening must be made routine, just like we screen pregnant patients for diabetes. It must be done in such a way that patients feel comfortable answering the questions truthfully, and there must be consistent follow-up of patients at risk for postpartum depression once they leave us," said Kilpatrick.