Improving maternal mental health: assessing the extent of screening and training about peripartum depression

Abstract

Objective

Peripartum depression (PPD) is a common mental health complication of pregnancy and increases risk for maternal mortality and poorer outcomes for children. Despite its importance, screening rates vary across organizations and care team members. The goal of the current study was to explore the perspectives from care team members in both behavioral health and acute care settings about how they screen and refer pregnant and post pregnant women for PPD, what training around PPD is currently offered by their organization, and if they could benefit from additional PPD training.

Methods

Data were collected from an online self-report survey of care team members from behavioral health and acute care settings in the US. Questions focused on (1) when/if the care teams had a screening protocol for PPD, (2) beliefs about the efficacy of their organization’s PPD screening, identification, and referral process, and (3) if their organization currently offered or needed training around the topic of PPD.

Results

A total of 794 care team members in behavioral health and acute care responded to the survey between December 2021 and May 2022. Nearly, all (96.7%) reported having a specific protocol for screening for PPD when they know a patient is pregnant; however, only 69.6% of respondents routinely screen regardless of symptoms being reported by the patient. While 93.3% of the sample believed their organization does a good job screening for and identifying PPD, gaps in the referral processes were described, especially in acute settings. 95.3% of the sample reported their organization currently gives training in screening, identifying, or treating PPD or in the process for establishing outpatient referrals for PPD care for care team members who have direct contact with pregnant patients; however, 96.5% also reported their organization would benefit from additional training in one or more of these areas.

Conclusion

High rates of self-reported PPD screening and training indicate that care team members in both behavioral health and acute care are aware of the importance of maternal mental health issues. However, other research indicates that high rates of screening may not lead to improved outcomes, and there are still high rates of maternal suicide and suicidal ideation in the US. It is possible that high self-reported screening rates may indicate a false sense of security such that care team members feel the issue is addressed while problems remain. Alternatively, many respondents felt their organizations would benefit from further training, perhaps indicating an awareness of this gap. Care team members in behavioral health and acute care settings should increase collaboration to ensure high rates of screening lead to improved maternal mental health care.

Keywords:

• Screening
• behavioral health
• maternal health
• acute care
• PPD

Introduction/background

Peripartum depression (PPD) is a common but underdiagnosed complication of childbirth that affects as many as 20% of women [1]. This term replaces postpartum depression acknowledging that depression can occur anytime during pregnancy or within 4 weeks after the birth (according to DSM-5 [2]); or during the first 12 months after delivery (American College of Obstetrics and Gynecology (ACOG) [3]). It is associated with pregnancy complications, impaired maternal-infant bonding, and a host of other negative consequences for both mother and child. Untreated PPD is associated with poorer physical health, lower quality of life, increased relationship difficulties, and an increased risk of suicidal ideation [4]. The suicide death rate has been estimated to be between 2.0 and 3.7 deaths per 100,000 live births [5] and is a leading cause of maternal mortality in the first 12 months postpartum. Similarly, infants have worse physical health, are more likely to be placed for sleep in risky positions, and show impaired motor, cognitive, social, emotional, and language development. Finally, PPD has a negative effect on maternal-child bonding, breastfeeding, feelings of maternal competence, and is associated with increased difficulty caring for an infant [4]. PPD often goes unrecognized because changes in sleep, appetite, and libido may be attributed to normal pregnancy and postpartum changes. In addition to health care providers not recognizing such symptoms, women may be reluctant to report changes in their mood. In one small study, phone interviews conducted with women 5–9 months after delivery found that of those who met criteria for probable PPD, only 28% had reported their symptoms to a health care provider [6].

Due to these risks, all pregnant and post-partum mothers should be screened for PPD and guidelines from several organizations including ACOG [3] and the US Preventive Services Task Force [7] suggest routine screening for PPD should be conducted at least once during pregnancy and again during the post-partum period. However, PPD screening practices are not standardized or conducted similarly across health systems [8]. A study by Sidebottom et al. [9] found that prenatal and postnatal screening occurred in less than two thirds of mothers. There was considerable variation associated with race and income level, with nonwhite patients and those on Medicaid/Medicare being less likely to be screened. In a large health system, two thirds of women were not screened until their third trimester, which led to delayed detection for 28% of women [10]. Another large obstetric practice implemented a PPD screening for all newly presenting pregnant mothers; however, of those who screened positive and were referred for behavioral health care, none pursued that follow up [11]. In this same practice, patients were also screened at their 6-week post-partum visit but only 17.9% referred for behavioral health care actually completed the follow up. Other reviews [12] suggest significant barriers exist to the treatment of PPD including lack of obstetric provider training and limited access to behavioral health treatment.

People with preexisting behavioral health disorders have significantly increased risk of developing chronic PPD and delayed PPD [13]. Specifically, having a history of depression prior to pregnancy significantly increases a person’s risk of developing PPD [14,15]. Other preexisting behavioral conditions that increase risk, independent of comorbid depression history, include anxiety and panic disorders, bipolar disorder, obsessive compulsive disorder, posttraumatic stress disorder, and eating disorders [14]. Therefore, behavioral health providers should also screen their pregnant patients for PPD.

The goal of the current study was to explore if and how health care professionals, referred to as care team members in behavioral and acute health care, screen, identify and refer for PPD, what training is available around the topic of PPD, and if care team members in both behavioral health and acute care settings feel more training is needed.

Materials and methods

Data were collected from a cross-sectional survey conducted online. Health care team members in the acute care and behavioral health settings who come into contact with pregnant or recently pregnant women were invited to participate. Respondents were recruited from a convenience sample in a variety of ways. Authors sent emails containing recruitment language and the survey link to colleagues, listservs, and posted on LinkedIn, Facebook, and Nurse.com. Participants were offered the option to enter their email addresses at the end of the study to be entered into a drawing to win 1 of 10 $50 gift cards. The self-report questionnaire contained 40 questions and took ∼7 min to complete online via Decipher and included informed consent before allowing access to the questionnaire. Demographic questions included: setting (behavioral health or acute care), type of community, US region, type of organization, and primary role in the care team. See Addendum for a full copy of the survey. For the current study we focused on questions regarding the following: (1) when/if care team members had a screening protocol for PPD, (2) beliefs about the efficacy of their organization’s PPD screening and identification process, and (3) if their organization currently offered or needed training around the topic of PPD. The study was approved by Principal IRB: PIRB202188.

Results

Sample description

While there were 839 total survey completions, 45 participants were identified as taking the survey twice, via the e-mail addresses provided. We only included an individual’s first survey completion for a final sample size of 794. Of the total sample, 558 reported that they primarily work in the behavioral health setting and 236 reported that they primarily work in the acute care setting (see Table 1). Most participants worked in either a large city or a suburb of a large city, 86.2%, and primarily in the Western Region of the US. For those working in behavioral health, 53.2% worked in a behavioral health department/service line as part of a healthcare system (e.g. inpatient psychiatry), while 33.0% worked for a behavioral health organization. For those working in acute care, 55.5% worked in an OB/GYN department. Among the behavioral health respondents, 43.7% reported their primary role as a clinical lead (i.e. director, manager, or supervisor), while 27.6% identified as clinicians (i.e. therapist, social worker, or licensed counselor). Among the acute care respondents, registered nurse was the most commonly reported primary role (53.4%), while physician, nurse practitioner, or physician’s assistant was the second most common response (30.5%).

Table 1. Behavioral health and acute care providers responses to the survey questions: Where do you provide care? and What is your primary role?  

Where do you provide care?—Behavioral health providers only	Percent	N
Behavioral health organization (e.g. CCBHC, CMHC, private practice)	33.0%	184
Behavioral health department/service line as part of a healthcare system (e.g. inpatient psych)	53.2%	297
Primary care—Behavioral health (e.g. FQHC)	10.6%	59
Freestanding substance use treatment center/opioid treatment program	1.1%	9
Other (specify): Behavioral health provider within NICU, Early Head Start program, Health Department, Health Plan, Neonatal ICU, newborn care/postpartum care private duty, Private practice, school health	1.5%	9
Non-clinical Administrator	14.9%	83
Clinical Lead (i.e. director, manager, supervisor)	43.7%	244
Clinician (i.e. therapist, social worker, licensed counselor)	27.6%	154
Physician, Nurse Practitioner, or Physician Assistant	12.0%	67
Other (please specify): Care Coordinator, clinical nurse specialist, newborn care/postpartum care of mom, Nurse, Registered Nurse, school nurse, Staff nurse, UR/Care Manager	1.8%	10
Emergency Department	12.3%	29
OB/GYN Department	55.5%	131
Pediatrician’s office	10.2%	24
Primary Care	6.4%	15
Midwifery Clinic	1.3%	3
Other (specify): Cardiac, clinical access center, Community Health (CHHA), Family healthcare facility, Family planning, Home Health/Home Health Care, Hospital, ICU, In home lactation consultant, Infusion Center, Inpatient Maternity/LDRP, Labor and delivery, Maternal Program Manager, Maternal/child unit, med surg, Mother Baby, NICU, PACU, Post-partum unit, Pre-Op Teaching and Testing Unit, Public Health-Maternity clinic, Public Health, Postpartum & Pediatrics, Reproductive endocrinology, Special needs assistance	14.4%	34
What is your primary role?—Acute providers only	Percent	N
Physician, nurse practitioner, or physician’s assistant	30.5%	72
Registered Nurse	53.4%	126
Midwife	8.9%	21
LPN	3.0%	7
Non-clinical Administrator	2.1%	5
Other (please specify): Lactation Consultant, RN Manager, Safety RN for OB	2.1%	5

Survey responses

Survey responses are summarized in Table 2; 96.7% of respondents utilized a specific protocol for screening for PPD when they know a patient is pregnant. All patients were screened for depression regardless of symptom presentation for 69.6% of the sample, while 27.1% of the sample screened for PPD only upon symptoms of depression being presented. Further, 93.3% of the sample believes their organization does a good job screening for and identifying PPD. With regard to actions taken after a mother screens positive for PPD, 96.5% of behavioral health and 92.2% of acute care respondents reported that a subsequent care protocol was activated. When a referral was made for treatment 9.3% of behavioral health and 25% of acute care respondents did not have processes in place to ensure that follow up had occurred.

Table 2. Behavioral health and acute care providers responses to the survey questions regarding peripartum depression screening and training.

	Total		Behavioral		Acute
	Percent	N	Percent	N	Percent	N
When you know a patient is pregnant, what is your practice for screening for PPD?
Upon symptoms being presented	27.1%	215	32.3%	180	14.8%	35
Every pregnant person	51.0%	405	53.4%	298	45.3%	107
All patients regardless of pregnancy status	18.6%	148	12.9%	72	32.2%	76
No specific screening protocol	3.3%	26	1.4%	8	7.6%	18
Do you believe your organization does a good job at screening for and identifying PPD?
Yes	93.3%	741	97.3%	543	83.9%	198
No	6.7%	53	2.7%	15	16.1%	38
What kind of training in screening, identifying, and treating PPD or other PPD related topics does your organization currently give staff who have direct contact with pregnant patients?
Training in screening for PPD	50.8%	403	47.5%	265	58.5%	138
Training in identifying PPD	68.9%	547	74.9%	418	54.7%	129
Training in treating PPD	47.4%	376	53.2%	297	33.5%	79
Training in the process for establishing outpatient referrals for care	21.3%	169	22.0%	123	19.5%	46
None	4.7%	37	1.4%	8	12.3%	29
Other	1.0%	8	0.4%	2	2.5%	6
Would your organization benefit from more training in screening, identifying, and/or treating PPD?
Yes, screening	52.6%	418	52.3%	292	53.4%	126
Yes, identifying	64.5%	512	64.5%	360	64.4%	152
Yes, treating	42.6%	338	39.1%	218	50.8%	120
Yes, the process for establishing outpatient referrals for care	24.4%	194	18.5%	103	38.6%	91
No	3.5%	28	2.3%	13	6.4%	15

Additionally, 95.3% of the sample reported their organization currently gives training in screening, identifying, or treating PPD or in the process for establishing outpatient referrals for PPD care for care team members who have direct contact with pregnant patients. 50.8% of the sample reported receiving training in screening for PPD, while 68.9% reported receiving training for identifying PPD, 47.4% reported receiving training for treating PPD, 21.3% reported receiving training in the process for establishing outpatient referrals for care, and 1% reported receiving other training related to PPD. Despite almost all of the sample reporting their organization currently gives training related to PPD, 96.5% also reported their organization would benefit from more training in either screening, identifying, and/or treating PPD. 52.6% of the sample reported their organization would benefit from receiving more training in screening for PPD, while 64.5% reported their organization would benefit from receiving more training in identifying PPD, 42.6% reported their organization would benefit from receiving more training in treating PPD, and 24.4% their organization would benefit from receiving more training in the process for establishing outpatient referrals for care.

Discussion

Our survey results showed that care team members in behavioral health and acute care who interact with pregnant or recently pregnant women, report that they have an effective protocol for screening and identifying PPD, despite only 69.6% of respondents screening for PPD without a patient reporting symptoms. Acute care settings are more likely to screen all patients (32.2%) than behavioral health (12.9%) regardless of pregnancy status. This may reflect the implementation of routine depression screening in acute care settings rather than specifically targeting PPD. If this is the case then it not surprising that acute care staff would desire more training in screening for PPD in particular along with treatment and establishing outpatient referrals. The absence of universal screening of all patients represents a significant gap.

Another important gap exists with the referral and follow-up process. It was also noted that 8% of acute care respondents did not report automatic activation of care protocols, for example, additional follow-up with a social worker as an example. In addition, no processes for following up on referrals was reported by 25% of acute care respondents, indicating there may be gaps in continuity of care for treatment of PPD. Together this implies that significant numbers of women with PPD are not receiving a diagnosis and/or treatment. Perhaps not surprisingly, 97.3% of behavioral health respondents, compared to 83.9% of those in acute settings believed their organizations did a good job with screening and identification. Additionally, almost all of the sample (95.3%) reported their organization provides training in screening, identifying, or treating PPD or was in the process of establishing outpatient referrals for PPD care for care team members who have direct contact with pregnant patients. However, while they report confidence in the effectiveness of their screening protocols, and have access to current training, almost all of the respondents (96.5%) reported their organization would benefit from additional PPD related training. This inconsistency may be related to social desirability bias where respondents did not want to state that they work for an ineffective organization. The anonymous and online design of the study would, however, be expected to limit this bias. Alternatively, certain respondent groups may be answering the training need questions thinking about their system workforce in general rather than their own group in particular.

One important consideration when reviewing these results is that the survey population was a convenience sample and participation was voluntary. The sample was likely biased by people choosing to participate who already think PPD is an important issue, and may be more likely than other providers to conduct PPD screening and receive training on this topic. Our sample also consisted of more behavioral health than acute care team members, who also may be more vigilant around behavioral health topics like PPD.

Despite the enthusiasm respondents showed for screening and identifying PPD as well as other recent studies reporting high levels of PPD screening [16], poor outcomes are still commonly reported in the US. Prevalence of suicidal ideation ranges from 2% to 10% among perinatal patients, and can even be as high as 14% among perinatal patients with preexisting behavioral health treatment [17]. Further, there has been a reported tripling of suicidality between 2006 and 2017, particularly among younger and non-Hispanic black perinatal women [17]. A recent study in California reported that drug-related deaths and suicide accounted for 18% of all maternal deaths in California in the 12 months after delivery [18] and 74% of these patients had at least one contact with healthcare services between their delivery and death.

There seems to be a disconnect, then, such that care team members think they are doing a good job of screening and identifying PPD among their patients; however, evidence suggests that these protocols may be insufficient. Care team members may be aware of this disconnect, which could explain why nearly all the respondants in both behavioral and acute care settings reported their organizations would benefit from more training around PPD, despite reported high levels of confidence in their current screening and identification processes and high levels of current training around PPD. Care team members may believe they are adequately caring for patients by screening and referring them; however, if the follow up is lacking, they may be unaware their care was insufficient. Further, access to behavioral health care after a positive PPD screening is likely another contributing factor, particularly for low income patients [19].

Future research should address the limitations of the current research such as a more balanced division between acute and behavioral health respondents, as well as endeavoring to recruit a more diverse/representative sample of care team members. Additionally, further research should explore the gap between high self-reported screening and referrals, which could be the result of “check the box” compliance in the medical record, and a lack of improvement in maternal behavioral health care outcomes. Improving the partnership and working relationships between behavioral health care and acute care could potentially help to bridge this gap.

A final caveat is that the incidence of PPD peaks around 3 months post-partum [20], a time when mothers are more likely to be seeing their pediatrician. For this reason, the American Academy of Pediatrics recommends screening new mothers at the 1-, 2-, and 4-month well baby visits [21]. Certainly, expanding the current research to focus on pediatric providers is important to have a comprehensive picture of the state of PPD screening, treatment, and outcome.

To address the gap between high rates of self-reported PPD screening and training, and the lack of improvement in maternal behavioral health outcomes, a stronger relationship needs to be built between acute care and behavioral health care team members. Behavioral health care team members may be more comfortable in addressing and treating PPD; however, acute care team members shoulder the responsibility through their pre and post-natal contacts to screen and refer women in need of evaluation and treatment of PPD. Further, all those who conduct screenings, identifications, and referrals should add quality checks and audits to their processes to ensure that those who are identified as needing help actually receive the help they need. High rates of screening may lead to a false sense of security that the issue is being addressed if screening for PPD is simply a check the box requirement instead of a standardized process based on evidence based best practices. High rates of screening and training for PPD are promising indications that clinicians are taking the issue of PPD seriously and are important part of the process of improving maternal behavioral health; however, further action needs to be taken to ensure these screenings lead to meaningful improvement in maternal behavioral health outcomes.

Disclosure statement

No potential conflict of interest was reported by the author(s).