Running head: DEPRESSION SCREENING 1

Depression Screening During Pregnancy and the Postpartum Period

Justin Burgett, Tessa Eckhardt, and Alyssa Matulich

University of Tennessee at Chattanooga

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Perinatal Depression Screening: Improving Patient Outcomes

Depression during pregnancy and the postpartum period, or perinatal depression, is

believed to impact as many as one in seven women in the United States (Gavin et al., 2005;

Shorey et al., 2018). While it is not uncommon for depression to occur in pregnant and

postpartum women, perinatal depression remains one of the most underdiagnosed obstetric

complications in the nation (Earls, 2010). Often symptoms of depression such as sleep, appetite,

and decreased energy may be attributed to the normal hormonal fluctuations of pregnancy and

postpartum states, making it easy for perinatal depression to go unrecognized (ACOG, 2018).

Not only may providers overlook the symptoms, but women may underreport their mood

changes because they attribute them to normal pregnancy or fear the stigma associated with

mental illness (ACOG, 2018). Although there is a general consensus among governing

healthcare bodies that perinatal depression screening is an important aspect of prenatal and

postpartum care, simplified, universal guidelines and protocols available for providers to

implement into their practice are lacking.

From our clinical experiences, we have identified a gap in practice surrounding

depression screening and treatment management in pregnant and postpartum women. More

specifically, we noted obstetrics and gynecology (OB/GYN) offices in both the Chattanooga and

North Georgia community fail to screen for depression. Providers and staff at these offices

admitted they did not have a current policy in place to guide perinatal depression screening and

its management following recognition. Based on our observations, we aim to develop a plan of

action that will allow providers at the aforementioned North Georgia office serving pregnant and

postpartum women to consistently and confidently screen and treat perinatal depression thereby

improving patient outcomes.

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Evidence and Guidelines

Literature Review

Much evidence has been collected to emphasize the importance of perinatal depression

screening. Researchers have identified several negative outcomes maternal depression can have

on the developing fetus, child, and the mother herself. In a review of literature, Szegda,

Markenson, Bertone-Johnson, and Chasan-Taber (2014) found evidence from multiple studies

supporting claims that depression during pregnancy can increase the risk for preterm birth, low

birth weight, and small for gestational age (SGA). Also, a history of depression has been linked

with an increased risk of pre-eclampsia when co-occuring with preterm delivery (Thombre,

Talge, & Holzman, 2015).

According to Gress-Smith, Lueken, Lemery-Chalfant, and Howe (2012), approximately

10-15% of new mothers experience postpartum depression in the United States, and a high

percentage report depressive symptoms at five and nine months postpartum. Additionally, low-

income minority females have a higher risk of postpartum depression but frequently remain

undiagnosed and under-treated. Infants born to low-income minority mothers with depression

gain weight at a slower rate and tend to have sleep disturbances and health issues later in life

(Gress-Smith et al., 2012).

Additional studies have investigated long-term impacts of maternal depression on

children and identified increased risk for impaired cognitive development and adverse behavioral

outcomes. A longitudinal study sought to identify a connection between maternal depression and

children’s cognitive development at ages five to six (Van der Waerden et al., 2017). The

researchers discovered children with mothers who had persistently high levels of depression had
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an average 6.7 point drop in IQ compared to children whose mothers were never depressed (Van

der Waerden et al., 2017). Netsi et al. (2018) found that children whose mothers experienced

severe postpartum depression were more likely to begin demonstrating behavioral problems by

age three and exhibit signs of depression themselves by sixteen to eighteen years of age.

Depression during pregnancy and the postpartum period is known to predispose women

to depression later in life (Abdollahi & Zarghami, 2018; Netsi et al., 2018). Factors such as

domestic problems, financial instability, lack of social support, unhealthy relationships, and

preexisting depressive or anxiety symptoms are known to increase the prevalence of perinatal

depression (McCall-Hosenfeld, Phiri, Schaefer, Zhu, & Kjerulff, 2016; Mukherjee, Coxe,

Fennie, Madhivanan, & Trepka, 2017). Mukherjee et al. (2017) examined the impact twelve

antenatal stressful life events had on postpartum depressive symptoms when occurring during the

twelve months preceding delivery. The stressful life events included the following: 1) illness in a

close family member requiring hospitalization; 2) separation or divorce; 3) moving to a new

address; 4) homelessness; 5) husband or partner lost his job; 6) the woman lost her job; 7) the

pregnancy was unwanted by the husband or partner; 8) the woman and her significant other

argued more than usual; 9) inability to pay the bills; 10) involvement in a physical fight; 11) the

woman or her significant other went to jail; and 12) someone very close to her died (Mukherjee

et al., 2017). Women in the study were classified based on the type of experience the stressful

life event was – traumatic, emotional, financial, or partner related. Researchers found 34.5% of

women who experienced all four categories had postpartum depression and were five times more

likely to experience postpartum depression than those with fewer stressful life events (Mukherjee

et al., 2017).
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Some studies have found cortisol levels during pregnancy remain as high as levels

observed in depressed patients who are not pregnant, making women more vulnerable to

depression during pregnancy and postpartum states (Brummelte & Galea, 2015). Pregnant

women also experience a significant increase in levels of progesterone and estradiol (200-300

times more) followed by a sudden and significant drop after delivery of the placenta (Brummelte

& Galea, 2015). This “estradiol-withdrawal state” is hypothesized to contribute to postpartum

depression (Brummelte & Galea, 2015).

Because sex hormones and reproductive events play a major role in the etiology of

depression, Bhat, Reed, and Unutzer (2017) recommend screening all women in the OB/GYN

setting annually and especially during “windows of vulnerability,” which they define as

adolescence, pregnancy, postpartum, and menopause transition. The authors “argue that, given

the high prevalence and burden of depression in women, the influence that an OB/GYN might

have by identifying and treating depression early is substantial” (Bhat et al., 2017, p. 158). Not

only do Bhat et al. (2017) encourage regular depression screening, but they also advocate for the

integration of depression treatment programs into practice.

Olin et al. (2016) examined the management of postpartum depression in pediatric

primary care. It was found that 78.2% of children studied received six or more well child visits

within in the first year, making pediatric primary care an ideal setting for the identification and

management of maternal depression (Olin et al., 2016). Pediatricians often express concern about

maternal depression because it affects childhood development, parenting practices, and family

stability. However, issues with treating postpartum depression in the pediatric primary care

setting arise because it is considered a maternal condition, making pediatricians challenged by

legal, ethical and reimbursement issues (Olin et al., 2016).

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Knights, Salvatore, Simpkins, Hunter, and Khandelwal (2016) note the Edinburgh

Postnatal Depression Scale (EPDS) is the most widely supported and used screening tool for

postpartum depression, and although there is a mandate for universal screening, there is little

information available for optimal interval and frequency of screening. Knights et al. (2016)

aimed to investigate a potential association between early EPDS scores and later EPDS scores in

order to provide evidence in support of less frequent screening. The study found that depending

on risk factors and first-time score on EPDS, there was some correlation with the later EDPS

score. The authors proposed that women be screened within ninety-six hours of delivery, and

only women with a score of ten or greater on the EPDS should be rescreened later (Knights et al.,

2016).

National Guidelines

United States Preventive Services Task Force. The United States Preventive Services

Task Force (USPSTF) recommends annual screening for depression in all adults aged 18 and

older, including pregnant and postpartum women, as a category B recommendation (Sui, 2016).

They identified that a combination of screening and adequate support systems available to treat

depression greatly improved clinical outcomes in adults by reducing the severity of or inducing

remission of depressive symptoms (Sui, 2016). The types of treatment the USPSTF supports to

treat depression include antidepressants, cognitive behavioral therapy (CBT), or a combination

of both.

More recently, the Task Force announced a new recommendation statement specific to

the pregnant population. Providing or referring women at increased risk of perinatal depression

to counseling is now a category B recommendation as well (Curry, 2019). The USPSTF defined

the target population as pregnant women and women up to twelve months postpartum who are
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not currently depressed but are at an increased risk based on the following: a personal or family

history of depression, women currently experiencing stressful life events, an unplanned or

unwanted pregnancy, adolescent pregnancy, low socioeconomic status, intimate partner violence

or a history of abuse, gestational diabetes, and limited financial means or support (Curry, 2019).

Following an extensive review of the current literature, the Task Force found evidence that

strongly supports the use of counseling interventions such as CBT or interpersonal therapy in

preventing perinatal depression (Curry, 2019).

American College of Obstetricians and Gynecologists. The American College of

Obstetricians and Gynecologists (ACOG) recommends women be screened for depression and

anxiety symptoms at least once during the perinatal period, a time frame that ranges from the

beginning of pregnancy through the first twelve months postpartum (ACOG, 2018). The most

recent ACOG (2018) Committee Opinion mandates providers need to complete a full “mood and

emotional well-being assessment” during the comprehensive postpartum visit that includes

screening with a validated tool such as the Edinburgh Postnatal Depression Scale (EPDS). If

women are screened during pregnancy, they still need a comprehensive screening at the

postpartum visit (ACOG, 2018). Additionally, the following patients should be monitored

closely throughout the perinatal period: women experiencing a current depressive episode or

anxiety, women with a history of a mood disorder during a previous pregnancy, and women with

risk factors for perinatal depression (ACOG, 2018). ACOG (2018) also encourages collaboration

between obstetric care providers and pediatricians when screening for and facilitating treatment

in postpartum women with signs of depression or anxiety that may be identified at newborn

visits.
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American Academy of Pediatrics. While obstetric providers frequently encounter

pregnant patients throughout prenatal visits, pediatricians are more likely to have multiple

encounters in the postpartum period during routine newborn visits. Because of this exposure,

pediatric offices may have more opportunity to identify postpartum depression that has a later

onset. The American Academy of Pediatrics (AAP) recognizes that maternal depression can have

negative effects on child development and supports screening with the EPDS at regular newborn

well-visits at 1, 2, 4, and 6 months (Earls, 2010). The AAP does not endorse treatment of the

mother by the pediatrician but encourages referral to her OB/GYN or primary care provider

(Earls, 2010).

American Academy of Family Physicians. The American Academy of Family

Physicians (AAFP) recognizes depression as both a significant source of disability worldwide as

well as an economic and healthcare burden costing more than $210 billion annually in the United

States (Maurer, Raymond, & Davis, 2018). The AAFP recommends screening of all individuals

using the two question Patient Health Questionnaire (PHQ-2) and pregnant patients with the

PHQ-2, PHQ-9, or EPDS at least once during the prenatal period (Maurer et al., 2018). The

AAFP does not provide a recommendation for timing of the screening during the prenatal period

(Maurer et al., 2018). Additionally, the AAFP notes the PHQ-2 and PHQ-9 have similar

sensitivities, but the sensitivity of each instrument varies respectively; it does not discuss these

aspects of the EPDS (Maurer et al., 2018).

Action Plan

Based on national guidelines and evidence-based practice, we propose a plan of action

that can support providers at an OB/GYN practice in North Georgia in their effort to offer better

screening and treatment of perinatal depression. We are using several aspects of the
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Massachusetts Child Psychiatry Access Program for Moms (MCPAP for Moms) to guide our

quality improvement project. MCPAP for Moms was created in 2014 to promote mental health

and well-being in women throughout pregnancy and the first twelve months postpartum

(MCPAP, 2014). The developers recognized that although several providers were following

national guidelines for depression screening, “screening alone does not improve treatment rates

or patient outcomes” and guidance regarding management once depression was identified was

needed (Byatt et al., 2018, p. 346). The program consists of three core components: training and

toolkits for providers and staff on mental health screening and treatment using evidence-based

guidelines, telephone consultation and referral with perinatal psychiatrists, and connections with

community resources for mental health support (MCPAP, 2014).

Due to the scope of our project, we will only use one of the core components of the

program: the MCPAP for Moms toolkit for providers. The toolkit is intended for use by

providers to assist with “prevention, identification, and treatment of depression and other mental

health concerns in pregnant and postpartum women” (Byatt et al., 2017). The toolkit contains the

following information: key concepts regarding assessment of maternal mood and depression;

definitions and descriptions of emotional complications that may be experienced in pregnancy

and the postpartum period from Baby Blues to postpartum psychosis; advice on how to screen

and interpret results of the EPDS; and algorithms that guide action based on EPDS scores and

what type of treatment, if necessary, should be considered (Byatt et al., 2017). Using this toolkit,

our goal is to make depression screening and treatment as routine as the physical exam.

Implementation

The first step in the process of implementing our plan of action involves educating the

providers and support staff, including medical assistants and front desk personnel. We propose
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two lunch and learn sessions lasting two hours each. On day one, we will discuss the importance

and relevance of screening using evidence-based research and national guidelines. On day two,

we will focus on implementation of routine screening and a treatment management plan. During

each session, we will provide education regarding Baby Blues, perinatal depression, and

postpartum psychosis as well as information on risk factors, as patients with one or more need to

be monitored more closely throughout pregnancy and the postpartum period. Providers will also

be instructed to bill for screening using the CPT code 96127 and include the ICD-10 diagnosis

code for “encounter for screening for perinatal depression,” or Z13.32, at each visit screening

with the EPDS occurs.

Our screening tool of choice is the Edinburgh Postnatal Depression Scale (EPDS), which

is validated to screen for both depression and anxiety (Ji et al., 2011; Zhong et al., 2014). Based

on the MCPAP for Moms recommendation, we will encourage screening at the initial obstetric

visit, the visit following the glucose tolerance test (approximately 27-28 weeks gestation), and at

the six-week postpartum visit (Byatt et al., 2017). Patients with a history of depression with or

without use of psychiatric medication, a positive EPDS screening, or those who are currently on

psychiatric medications are considered high-risk and will also be screened at two weeks

postpartum (Byatt et al., 2017).

We plan on utilizing the front desk staff to attach a paper copy of the EPDS on the

patient’s chart when she checks in so that it may be completed while the patient waits to be seen.

The patient will be informed she may complete the form in the privacy of her exam room rather

than the waiting room if she feels more comfortable there. Alternatively, the patient may

complete the EPDS at home via the online patient portal prior to arriving at her appointment. The

electronic health record (EHR) may be utilized to send a task to the patient to alert her of the
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screening. The front desk staff will be responsible for looking at the type of visit the patient is

scheduled for (initial OB visit, 27 to 28 weeks gestation, or six weeks postpartum) to ensure the

patients are being screened at the appropriate times. As a reminder and a guide, a laminated flyer

with the details of when to include the EPDS on the patient’s chart or when to determine if the

patient completed the screening at home using the patient portal will be placed at visible location

behind the front desk.

The medical assistants (MAs) will also be responsible for ensuring the patient has been

screened at the appropriate visit. They will also be instructed on how to correctly score the EPDS

and enter the results into the electronic health record. While the MAs will be encouraged to

inform the provider of the score before the visit, this may not always be feasible. Therefore, the

paper copy will remain on the chart for the provider to review prior to entering the exam room in

order to prepare for discussion and further evaluation if needed.

Based on the algorithm created by MCPAP for Moms, providers will use the EPDS score

as a guide for decision-making. An EPDS score less than ten suggests the woman is not

depressed, but she should still be educated on the importance of emotional health and well-being

and encouraged to express concerns or questions (Byatt et al., 2017). A score of ten or greater

suggests depression, and a more in-depth assessment of the severity of her symptoms and her

perception of her mood should is warranted. A positive score on question ten of the EPDS which

asks about the thought of self-harm suggests the patient could be at risk for suicide and requires

immediate intervention. The patient should not be left alone in the exam room until further

assessed and a plan is developed. The following questions should be asked: 1) “In the past two

weeks, how often have you thought of hurting yourself?” 2) “Have you ever attempted to hurt

yourself in the past?” 3) “Have you thought about how you could harm yourself?” (Byatt et al.,
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2017). It may be necessary to call the crisis hotline to arrange for further care for the patient and

her baby.

Following identification of risk, providers can then work with the patient to determine the

best treatment option for her. Regardless of the EPDS score, all patients should be counseled on

the benefits of self-care, physical activity, psychotherapy for mother and baby, community

support groups, and CAM therapies such as massage, acupuncture, Omega-3 supplementation,

and bright light therapy (Byatt et al., 2017). According to Byatt et al. (2017), mild symptoms of

depression may correlate with an EPDS score of 9 to 13, and consideration of medication for

treatment is appropriate. EPDS scores 14 to 18 correlate with moderate symptoms of depression

during which suicidal thoughts may be common; medication should be strongly considered and

assessment of need for hospitalization to prevent self-harm is important (Byatt et al., 2017).

EPDS scores of 19 or greater correlate with severe symptoms which may include delusions,

panic, an inability to care for self or baby, and active suicidal ideation and preparation (Byatt et

al., 2017). Treatment with medication should be strongly considered, and inpatient

hospitalization may be required. Referral and collaboration with a psychiatrist may also be

warranted.

If treatment with medication is indicated, the provider will need to screen for bipolar

disorder prior to initiating antidepressants. A referral to psychiatry is indicated if screening

suggests the patient may have bipolar disorder, otherwise, she may be started on an SSRI. The

first-line treatment for perinatal depression is sertraline (Zoloft), but other medications that may

be used if sertraline fails include fluoxetine, citalopram, and escitalopram (Byatt et al., 2017).

The EPDS should be repeated in four weeks following initiation of medication to evaluate the

patient’s response and a potential need for increased dosage or medication change.
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Use of the electronic health record (EHR) will serve as an important part of the

implementation of the new screening and treatment protocol we are proposing. Updated EHRs

now offer use of alerts to “provide useful information to the clinician, shape clinician behavior,

and positively impact patient and safety outcomes” (Powers, Shiffman, Melnick, Hickner, &

Sharifi, 2018, p. 1557). There are three common types of alerts that can be used: a hard stop,

which prevents further action without external override from a third party; a soft stop, which

allows a user to proceed against the recommendation if a reason is entered; and a passive alert

that informs the user of the recommendation but does not require action to advance (Powers et

al., 2018). We plan to create a soft stop in the EHR so that a chart may not be signed off on until

an EPDS score is entered or a reason is documented explaining why it has not been addressed.

We believe this will increase provider compliance without interfering with workflow or creating

“alert fatigue” (Powers et al., 2018).

Evaluation

The evaluation of our interventions will be a two part process. We will first conduct a

chart review of patient encounters in the six months prior to and six months following the

implementation of the intervention. In the chart review process, we will be looking at the use of

the ICD-10 code for depression screening, Z13.32, as well as the CPT code 96127. As previously

mentioned, the practice does not currently routinely screen for depression. As such, it is expected

that we will see an increase in the use of the ICD-10 and CPT codes for the screening

intervention. We will next look for the use of ICD-10 codes in the F01-F99 code block of the

ICD-10-CM as recommended by ACOG (2018). Codes other than F53, which is specifically

used for postpartum depression, will have to be further evaluated as to determine whether or not

they are pertinent to perinatal patient. It is expected that with the increase in the use of the
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screening tool, the use of ICD-10 codes within the code block mentioned above will also

increase.

We will also evaluate the ease of use of the EPDS and treatment protocol post-

implementation. For this process we will survey the frontline, clinical, and medical billing staff

using a combination of qualitative, short answer questions and a Likert Scale. Front line and

clinical staff will be evaluated for the ease of use, effectiveness, and willingness to continue the

intervention along with open-ended questions regarding any problems they have faced while

using the tool. The medical billing staff will be evaluated for challenges to billing and

reimbursement as well as similar open-ended questions evaluating their experience with the

policy change.

The last piece of the evaluation will look at patient outcomes. In order to evaluate patient

outcomes, we will need to look at repeat screenings after treatment or intervention has been

implemented to ensure that the intervention was successful. Because intervention and treatment

may take longer than six months, this portion of the evaluation will extend past the six month

time period when the chart review takes place.

Collaboration

Implementing change into an organization can be met with resistance even though the

recommendations and data discussed above support its use. The practice of implementing change

is typically difficult regardless of the practice or change being implemented (Gesme & Wiseman,

2010). The pace of healthcare advancements continues to progress rapidly, and providers

struggle with the continuous adoption of new guidelines, recommendations, regulations, etc.

(Lau et al., 2016). Lau et al. (2017) point out that, due to the overwhelming complexity,

challenge, and fear associated with implementing any type of change, adherence rates for
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evidence-based practice guidelines is approximately 33%. In order to promote an atmosphere

conducive to change, it is important to acknowledge the fears personnel at all levels of the

organization have rather than to dismiss them or mandate the change through force (Gesme &

Wiseman, 2010; Lau et al., 2016).

The staff in the healthcare setting, clinical and non-clinical alike, have a unique duty to

their clientele that is not mirrored in other service industries (Gesme & Wiseman, 2010). In

addition to fears common throughout any organization regarding how change will impact the

provider and his or her job, pay, and revenue, the healthcare field also faces the fear that a

change may bring harm to the health or well-being of a patient (Gesme & Wiseman, 2010).

Providing evidence that the implementation is both feasible and beneficial for the patients and

the practice will encourage participation by the staff and lessen resistance (Gesme & Wiseman,

2010; Lau et al., 2016). Additionally, identifying staff champions to help promote the process,

identify successes and failures promptly, and assist with modifications as needed help promote

smoother transitions throughout the process (Lau et al., 2016). It is almost inevitable that

complications will occur when implementing change. All staff must be informed of the

anticipated goals, processes, expectations, and their roles in implementation of the project in

order to mitigate resistance to continuation of the quality improvement project (Gesme &

Wiseman, 2010; Lau et al., 2016).

As indicated above, it is important we have support and a willingness to participate from

the frontline and clinical staff for this project to be effective. Identification of which patients

need to complete the form either in person or via the patient portal is the responsibility of the

frontline staff. The MAs will be responsible for determining the score of the EPDS and

communicating it with the provider prior to the visit. Finally, the provider will be responsible for
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initiating a discussion with the patient regarding her score and determine severity of her

symptoms in order to provide safe and effective care.

Sustainability

Continuation of implementation of the project is key to the future success of improving

patient care. Although numerous studies provide evidence of the benefits of screening, there are

few policies at the state or local level that mandate or incentivize its use (Rhodes & Segre, 2013).

Currently, three states (New Jersey, Illinois, and West Virginia) mandate screening for pregnant

and postpartum women, and twelve states have some form of state-sponsored education or

awareness program (Rhodes & Segre, 2013). The MOTHERS Act (formerly the Melanie Blocker

Stokes Act) is a subsection of the Patient Protection and Affordable Care Act with funding

available to provide support to health initiatives. However, as of yet, the funds approved for use

of this act have not been made available for disbursement (Rhodes & Segre, 2013).

Kozhimannil, Adams, Soumerai, Busch, and Huskamp (2011) analyzed the effects of one

state’s efforts in implementation of mandatory screening and found no impact on the initiation of

treatment, follow-up, or continued care for those women found at risk based upon the screening

results with the Medicaid population. Byatt, Levin, Ziedonis, Simas, and Allison (2015) found a

similar result in settings in which screening was performed (whether mandatory or not) without

interventions in place. However, after three and a half years of implementation, the MCPAP for

Moms program we have based our action plan on has led to increased surveillance and treatment

of perinatal mental health disorders (Byatt et al., 2018). It is being utilized in OB/GYN offices

throughout Massachusetts with positive responses from both patients and providers (Byatt et al.,

2018).
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Further studies are needed to assess the process by which providers utilize the data

obtained from depression screenings, but previous research indicates practice and patient-level

intervention plans have the potential to improve patient outcomes. We believe the

implementation of screening alone in the OB/GYN practice in North Georgia is a positive first

step in developing a comprehensive assessment and treatment protocol that has the potential for

legitimate patient improvement. We expect that evaluation of our action plan following its

implementation will show an occurrence of depressive episodes similar to the national statistics.

Therefore, we will encourage the providers to continue implementing mandatory depression

screening and strengthen the treatment protocols outlined above in order to provide safer and

more effective care. Based on the size of this practice, we believe utilization of a memo or staff

email as notification of policy change will suffice over an official, signed policy document. With

further advancement of the practice-level policy, our depression screening and treatment policy

can be implemented as the standard of care in other practices in the area, thereby improving

patient outcomes throughout the Chattanooga and North Georgia community.

Project Summary

Impact on Patients

Depression in the perinatal and postpartum periods can compromise parenting practices,

child development, and family stability. Olin et al. (2016) found that breastfeeding, infant sleep,

and adherence to well-child visits and vaccine schedules are affected by maternal depression.

Weissman (2018) found that mothers who met the criteria for moderate and severe postpartum

depression at 2 months and at 8 months postpartum were found to be more likely to experience

depression 11 years later. An association has also been found between postpartum depression

and cognitive, social, emotional and behavioral problems that can last well into adolescence
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(Netsi et al., 2018). Through our proposed quality improvement project, we are hoping that early

identification of depression will lead to more frequent implementation of effective treatment

thereby minimizing the negative impact depression can have on mothers and children.

Ethical and Cultural Considerations

The EPDS has been extensively validated for multiple languages. As a result, it is

appropriate to consider retrieval and dissemination of the tool with the appropriate language

translation as an intervention method for patients for whom English is not their primary

language. It is crucial to provide non-English speaking patients with an interpreter to assist with

the tool as it cannot be assumed that the patient can read or comprehend the tool without

assistance. The practice we have focused on can utilize their telephone/web-based interpreter line

for patients requiring these services.

Other socioeconomic and demographic factors also play into the reporting of depression

in patients. The Chattanooga and North Georgia community has a significant number of

immigrants and is racially diverse. Women from cultural backgrounds outside the U.S. may not

report depressive symptoms the same as their native U.S. counterparts (Di Fiorio et al., 2017).

Women with lower educational attainment are less likely to report crying and self-harm but are

more likely to report anhedonia than those with higher education (Di Fiorio et al.,

2017). Interestingly, Di Fiorio et al. (2017) did not find a difference between race or ethnicity in

the psychometric properties of the EPDS scores. They posit that the difference in disclosure of

symptoms between whites and minorities may be more akin to difference in socioeconomic

status (Di Fiorio et al., 2017). Clinicians need to be aware of the impact these factors can have on

the self-reporting of depressive symptoms and should continue to utilize their clinical judgement

regardless of EPDS score if they believe a woman is suffering from depression or anxiety.
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Patient safety and ethics are key considerations during any research. While we believe

our project will serve to improve patient outcomes, screening patients for depression has the risk

of causing distress. Patients may worry something is wrong with them even if the symptoms they

are feeling can be attributed to normal hormonal changes of pregnancy or normal adjustment to

becoming a mother. Depression is often accompanied with feelings of guilt and negative self-

worth, which may manifest as a patient’s concerns about being an adequate mother (Yonkers,

Vigod, & Ross, 2011). It will be the provider’s responsibility to be diligent when evaluating the

EPDS score and patient symptoms. Changes in sleep, energy, and appetite may occur in both

non-depressed and depressed patients during pregnancy and postpartum. However, patients who

are experiencing a depressive episode may exhibit anxiety regarding their infant’s health while

also appearing “despondent and strikingly uninterested in either their pregnancy or the activities

of their infants” (Yonkers et al., 2011, p. 962).

An additional safety concern is that the identification of a patient with bipolar can be

overlooked. Initiation of an SSRI in a patient with bipolar disorder may induce a manic state or

fail to improve the patient’s symptoms entirely. The provider must carefully monitor the

patient’s response to treatment and refer to psychiatry when necessary.

Limitations

As previously mentioned, staff willingness to participate is essential to effectively

implementing change. A major limitation our action plan is resistance from the staff to

consistently screen patients as indicated. The policy change will impact the entire office, from

the front desk employees to the MAs and practitioners. Adding another task on top of an already

heavy load may lead to failure of continuation of the project. In order to prevent unwillingness to
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adopt a new practice, proper education and understanding of the importance of perinatal

depression screening must be conveyed to the entire staff.

Conclusion

During our clinical experience, we observed OB/GYN offices in the Chattanooga and

North Georgia community were failing to screen for depression due to a lack of guidance and

policy. This gap in practice prompted us to develop a plan of action that would serve to

encourage providers and staff to consistently and competently screen and treat perinatal

depression. There is much evidence supporting the negative implications maternal depression

can have on a developing fetus and child as well as the future mental health of the mother

herself. Furthermore, a high prevalence of perinatal depression combined with a history of under

diagnosis in the United States justifies the need for a simple but comprehensive guide to

screening and managing depression for OB/GYN providers. Through the implementation of a

screening and treatment protocol, the overall health and well-being of pregnant and postpartum

women can be promoted in the Chattanooga and North Georgia community.

DEPRESSION SCREENING 21

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