Support and Training to Enhance Primary Care for Postpartum Depression

Assessment

The assessment should build on the screening tools, but it should further ascertain the severity and degree of impairment and specific symptoms. The assessment takes into consideration the physical and mental health history, family history, course of current and previous depressive episodes, current medications, and other factors. It also helps to determine whether the woman is presenting with subclinical depressive symptoms or an actual PPD episode. The majority of the assessment is conducted through a clinical interview.

Clinical Interview

The clinical interview includes asking questions about the woman’s overall mood and functioning since the birth of her baby and comparing these to PPD diagnostic criteria. This opportunity should be used to inquire about other medical and psychological considerations and to rule out other sources of the symptoms (refer to the text box below for other medical conditions that can mimic depression). The amount of time spent discussing PPD should correlate with the screening tool responses; higher scores or more positive responses indicate a higher risk for PPD and a greater need for a thorough assessment.

Ruling Out Other Causes of PPD Symptoms

It is imperative to address and rule out medical or other psychological sources of PPD symptoms, as this has a great impact on how you should proceed with treatment:

  • Bipolar disorder (requires close monitoring, and the treatment is more complicated)
  • Psychotic illness or schizophrenia spectrum disorders (i.e., schizoaffective disorder)
  • Thyroid disorders
  • Side effects of oral contraceptives
  • Side effects of anticonvulsant medications
  • Side effects of Reglan or other medications
  • Vitamin deficiencies or other irregularities found in laboratory blood or urine tests
  • Diabetes
  • Autoimmune or other medical disorders

The types of questions you ask a woman during the clinical interview will depend on her history, personal situation, and responses to the screening tools. Here are examples of the types of questions that can help determine if a woman has PPD. While asking these questions, compare her answers about symptom and impairment severity to the DSM-IV-TR diagnostic criteria (Click here for DSM-IV-TR Diagnostic Criteria for Mood Disorder, postpartum onset).

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Sample Clinical Interview Questions

  • What is your mood like most of the time since you had your baby?
  • What areas of your life bring you enjoyment (e.g., socializing, working, and exercising)? Have you been active in these areas since the birth of your baby?
  • when have you been able to feel pleasure or joy since you had your baby?
  • How would you describe being a mom (this time)?
  • Do you ever feel guilty or bad about how well you are caring for the baby?
  • Do you worry about the baby’s health? Have you ever taken the baby to the emergency room?
  • Are you able to rest or sleep when the baby sleeps?
  • When you sleep, are you still tired upon waking? Do you feel energized?
  • Do you feel as if it takes more energy than usual to move or do chores? Has anyone commented that you walk or talk more slowly than before you had the baby?
  • Are you eating enough? How much? Does the food taste appetizing to you?
  • Do you have difficulty concentrating or making decisions?
  • Have you ever experienced symptoms of depression or anxiety? Has anyone in your family?
  • Does anyone in your family have a history of alcoholism?
  • Many women have thoughts they find strange or frightening. Are you having any strange thoughts?
  • Are you afraid to be alone with the baby?
  • Do you worry that you might hurt the baby?
  • Have you had thoughts of harming yourself, wanting to die, or wanting to end your life?
  • Are you breastfeeding? If not, what led you to stop (or choose not to)?
  • What kind of help are you getting with the baby?
  • What kind of help are you getting with household chores?
  • Are there people in your life who have children? Have you talked with them about their experience?
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Assessing Suicidal Thoughts or Intentions

If at any point during the screening or assessment process, a woman indicates she has had thoughts of hurting herself or her baby, you should conduct a suicide assessment. The following questions will help you find out more about these suicidal thoughts and to assess the risk to mother her baby:

  • Tell me more about your thoughts of hurting yourself (or your baby).
  • Why do you think you have these thoughts to harm yourself (or your baby)?
  • Have you thought about how you might harm yourself (or your baby) (or end your life)?
  • How specific were those thoughts? Did you think about where or when?
  • How long have you had these thoughts? How often?
  • How likely is it that you might actually do something like that to hurt yourself (or your baby)?
  • Have you ever told anyone that you’ve thought of hurting yourself (or your baby)?
  • Have you ever done anything before to hurt yourself or try to kill yourself?
  • Have you given away any of your things to others or written a goodbye note?
  • Do you have the means to carry this plan out (e.g., if she thinks about taking an overdose, does she have the medication accessible to her)?

If the woman expresses any intent to hurt herself or her baby, or ambivalence about her ability to keep herself or her baby safe, immediate intervention is necessary. Furthermore, if she has developed a specific plan and has the means to carry out her plan, she should not be permitted to go home, and needs immediate crisis intervention.

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Immediate Crisis Intervention

When a woman indicates that she is having thoughts or feelings about harming herself and/or her baby and she cannot ensure she will not act on them (or your clinical judgment indicates you that she may still act on those feelings even if she states she will not), the woman should not be allowed to leave your office. You need to take immediate action to make sure the woman and her baby stay safe. In these cases, the woman should receive an immediate and complete suicide assessment by an experienced mental health professional. How and where this assessment is completed will depend on the situation and the resources your clinic has available; the list below highlights several effective ways to assure the evaluation is completed:

  • Contact a mental health provider to evaluate the woman at your office
  • Escort the woman to a mental health provider’s office or an ER (if in walking distance) for an immediate suicide assessment.
  • Ask a friend or family member of the patient to escort/drive the woman to a mental health provider’s office or emergency room
  • Call 911 or contact emergency services and allow them to escort the woman to the ER

Most importantly, do not leave the woman unattended. The chances are too great when there is a risk that she might cause harm to herself or her baby. If none of the options listed above are possible in your clinic, talk with your supervisor about crisis interventions that are appropriate for your setting.

If she says she can keep herself safe, does not have a plan for committing suicide, and seems to be thinking clearly, refer her to a mental health specialist for immediate treatment and monitoring. It is best to help her make the appointment before she leaves your office. Follow up within a few days to make certain she attended the appointment and is receiving the help she needs.

If there is any question as to whether the woman is at risk, err on the side of caution. Asking these questions will not lead a woman to start contemplating suicide, but will help you clarify her intent and take the necessary action to keep her safe.

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Diagnosis

If the mother reports (#1) a depressed mood and/or (#2) an inability to experience joy or partake in pleasurable activities, and, over the past 2 weeks, she consistently endorsed a total of 5 symptoms of depression (including #1 and/or #2) that significantly impair her functioning and are not attributable to other causes, she meets diagnostic criteria for depression.

PPD When you diagnose a woman with PPD, explain your concerns and discuss treatment options. Guidance on how to make the decision to treat or refer a woman with PPD is provided in the Treating PPD module, along with treatment strategies and options.

For women who do not appear to have PPD but rather have a subclinical level of depression, your recommendation will vary depending on their symptoms and the severity of the symptoms. You should use clinical judgment to determine what makes the most sense for each woman, given her level of risk. No matter what you decide, be sure to educate her about PPD and explain how she is at risk for developing depression. Provide her with literature on PPD (click here for the patient brochure) and tell her to call you (or give her the name of a mental health professional) if she develops any additional symptoms, or her symptoms worsen. For others, you may choose one or more of the following steps:

  • For some women with subclinical depression, it may be prudent to make a follow-up appointment within a few weeks to screen them again and reassess their symptoms.
  • For other women, it may make sense to refer them for more thorough assessment by a mental health professional to ensure they do not have depression.
  • For others, it may be more appropriate to refer them for treatment (counseling, therapy, support group) to provide support and help them to avoid developing depression.
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Billing Codes
When assigning a code for billing purposes, be sure to use the ICD-10 code for "mood disorder associated with pregnancy" (F53.X codes 137 ) and do not code as "Major Depression." This distinction may seem minor, but it has major ramifications on future insurance coverage, as the patient could wrongly be classified as having a pre-existing condition.

Making the Decision to Refer

Detailed information about how to determine which women to treat and which to refer to a mental health specialist is discussed at length in the Treating PPD module. However, as a rule, a woman should always be referred to a mental health specialist for assessment and treatment when she:

  • Appears to have other psychiatric symptoms or disorders along with the depression
  • Voices thoughts about harming herself or her baby
  • Shows signs of postpartum psychosis
  • Does not respond to treatment after two medication trials
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