SCREENING PROTOCOL FOR PERINATAL MOOD AND ANXIETY

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611

www.hmhb-mt.org

SCREENING PROTOCOL

FOR PERINATAL

MOOD AND ANXIETY

DISORDERS FOR

PRIMARY CARE

PROVIDERS

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

CONTENTS

Page 1 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Introduction.....................................................................................2

Making the Choice to Screen.............................................................2

Choosing a Screening Tool...........................................................................3

Electronic Medical Records...........................................................................3

Administering Screening Tools........................................................4

Establishing the Screening Workow..........................................................4

Who Gets Screened?.....................................................................................4

Addressing Screening Tools with Clients.........................................5

Responding to a Positive Screen......................................................6

Addressing Concerns of Suicidality.............................................................6

Open-Ended Probing Questions..................................................................7

Screening Schedule.......................................................................................8

Recommended Additional Screening Tools......................................9

Resource and Referrals...................................................................10

Special Considerations..................................................................11

High Risk Groups..........................................................................................11

Protective Factors..........................................................................................11

Risk Assessment...........................................................................................12

Screening Partners.......................................................................................12

Using the Algorithm.......................................................................12

Algorithm......................................................................................................13

Algorithm Narrative......................................................................................14

References.....................................................................................15

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

Introduction

In 2018, Healthy Mothers, Healthy Babies

(HMHB) facilitated a yearlong research and

vetting process in order to create a Montana-

made screening protocol for Perinatal

Mood and Anxiety Disorders (PMADs).

Contributors included:

• Dr. Cassie Belzer, APRN, CNM, DNP,

Bozeman Health

• Dr. Kristin Day, Pediatrician, Bozeman

Health

• Amy Emmert, Director of Quality and

Population Health, St. Peter’s Medical

Group

• Kate Girard, MHS, RD, CLC, State WIC

Director

• Dana Hillyer, PMHCNS, APRN, Private

Practice

• Kelsey Kyle, Nurse Care Manager, St.

Peter’s Medical Group

• Stephanie Morton, MSW, Program

Manager, Healthy Mothers, Healthy

Babies -The Montana Coalition

• Leslie Nyman, Director of Behavioral

Health Services, Kalispell Regional

Medical Center

• Brie Oliver, RN, IBCLC, Executive Director,

Healthy Mothers, Healthy Babies -The

Montana Coalition

• Ria Overholt, Mental Health Manager,

Ravalli Head Start Inc

• Dr. Tiffany Stensvad, APRN, CNM, DNP, St.

Vincent Midwifery and Women’s Center

• Sarah Webb, Young Child Wellness

Coordinator, Montana Project LAUNCH

Initiative

Page 2 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Making the Choice to Screen

Making the choice to implement a new

screening tool in your practice can be difcult

logistically, but the desire to meet client needs

often outweighs these hurdles. Screening for

perinatal mood and anxiety disorders (PMADs)

is part of complete perinatal care as depression

is the most common complication of pregnancy.

Approximately 20% of women experience

depression during the perinatal period, with

rates tripling for higher risk groups such as teens

and women with low-income (Lancaster, 2010;

Robertson, 2004).

We hope that this protocol will help to ease some

of the logistical hurdles, inform your screening

choices, and make improving the quality of

care in your ofce easier for your whole team.

This guide will touch on choosing a screening

tool, provide recommendations and resources

on how to administer the tools, recommend

additional screening tools, present an algorithm

and response protocol, and briey touch on

establishing outside resources and referrals. We

acknowledge there are many other excellent

resources available to deepen your screening

practice and knowledge of perinatal mental

health and wellness. We hope this protocol will

be a great starting point for your practice.

It is vital when making the choice to screen for

perinatal mental health, to also provide your staff

with education on perinatal mood and anxiety

disorders. Providing foundational knowledge

on the various types of experiences women may

have when affected by a PMAD, ensures that

your organization can provide the most sensitive,

informed care, ensuring safety. This resource

document provides some training options for

your staff. Contact Healthy Mothers, Healthy

Babies for further training opportunities and

information ([email protected]g).

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

Page 3 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Patient Health Questionnaire (PHQ-9)

• 9 items; takes less than 5 minutes;

Sensitivity 75%, Specicity 90%

• Greater familiarity within the medical

community given its wide use in settings

outside of perinatal care

• Asks about previous two weeks

• When used prior to perinatal period can

offer baseline

• Does not detect anxiety symptoms, which

are more common in depression in the

perinatal period than in other stages of life

(Kabir, Sheder & Kelly, 2008)

• We suggest supplementing the use of the

PHQ-9 with the EPDS-3 (Appendix C) to help

screen for anxiety if that is a concern

Edinburgh Postpartum Depression Scale (EPDS)

• 10 items; takes less than 5 minutes;

Sensitivity 59 - 100%, Specicity 49 - 100%

• Valid for use in both the pre and post-natal

periods

• Asks about past 7 days

• Asks about anxiety, a common element of

depression in the perinatal period

• Excludes constitutional symptoms such as

sleep pattern changes, which are common in

the perinatal period

Choosing a Screening Tool

After a review of many depression screening tools, our group recommends the use of either the

Patient Health Questionnaire (PHQ-9) (Appendix A) or the Edinburgh Postpartum Depression Scale

(EPDS) (Appendix B). Both of these screening tools are free, widely used, and validated for use

in the perinatal period, which we dene as pregnancy through the rst year of a child’s life. We

have highlighted some pros and cons of each tool to help you choose what will work best in your

practice.

Please note that no screening tool will detect all possible PMADs. While the EPDS and PHQ-

9 are clinically validated for detecting possible depression and anxiety, they are not validated

to detect other less common types of PMADs, such as Obsessive Compulsive Disorder (OCD)

or Bipolar Disorder (BD). While less common, these PMADs can have devastating impacts and

are not addresses in depth in this protocol. While we have included many additional screening

suggestions, expertise in administering and responding to these screens is not covered in this

document. One key additional screen is the Mood Disorder Questionnaire (MDQ). Please see

page 8 for an important note on Bipolar Disorder and the Mood Disorder Questionnaire as well

as the recommend additional screening tools.

Electronic Medical Records

If your electronic medical system already has the PHQ-9 or the EPDS embedded, this may affect

which screening tool you use. If your EMR can store screening results, it may be easier to assess

client scores across time, and providers may be more likely to access scores if easily available

electronically.

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

Page 4 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

WHO

• Gives it out? front desk, nurse, doctor, etc

– Ensure that whoever presents the

screen can provide information to every

client that:

– All clients are screened

– That a positive screen is NOT a

diagnosis

See Administering the Screening section

for helpful language

• Scores it? front desk, nurse, doctor, etc.

• Communicates the results of the screen

back to the provider? i.e. agged in

electronic record or scored tool placed

on top of client le retrieved by provider

upon entering the room

• Enters the screen back into the EMR? (if

applicable)

WHERE

• Given out at front desk to be done in

lobby? Given in room? Done while

waiting for doctor?

HOW

• Does the client complete the screen? Both

screening tools are recommended to be

lled out on paper by the client alone, but

in cases where language, literacy, sight

or other barriers may prevent this, verbal

screening can be done.

Note: If the EMR contains the screen, the

client should still get a paper copy to ll

out in private, and then results should be

translated back into the EMR

STORAGE

• Where does the paper copy go? How is it

electronically recorded/stored if it is?

BILLING

• Can providers bill for the screening?

Billing codes?

Administering Screening Tools

Establishing the Screening Workow

Each practice is distinct, and unfortunately there is no universal screening workow we can

recommend. Instead, we are offering a list of considerations for administering the screening tools.

We hope these questions can help you more quickly and thoroughly evaluate screening from the

patient perspective and develop a workow that is tailored for your practice.

Who Gets Screened?

We strongly recommend universal screening for all clients. Universal screening reduces stigma

and normalizes the inclusion of mental healthcare in routine medical care. It also decreases the

inuence of provider bias and increases the likelihood that those who are experiencing a perinatal

mood and anxiety disorder will receive the services they need sooner.

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

Page 5 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Addressing Screening Tools With Clients

Equally as important to the workow is the way a screening tool is presented, evaluated, and

addressed with the patient. Training on PMADs will help ensure your staff has condence in this

subject matter. This can decrease staff anxiety about asking questions about mental health and

lead to an increase in empathy and rapport. The use of soft skills, such as active and reective

listening, build rapport with patients and are essential to creating a space where people feel safe to

disclose and discuss their lives.

• Always address the screening tools a client has lled out regardless of the outcome.

Screening tools are just the start of the conversation about mental wellness, and no one

is without risk of experiencing a PMAD. Addressing the screening results is part of the

psychoeducation of all patients.

• Ensure that whoever hands the client the screening tool (reception staff, rooming nurse, etc.)

can address why the screening tool is important to their care. This can be a daunting task, so we

recommend having an answer ready to use. One script we would recommend is from People

Centered Screening and Assessment: Module 4 – EPDS:

“Having a new baby is an important and sometimes difcult change in any family. Sometimes

it’s hard to know if our feelings are normal or a possible problem. This screen will provide you

with valuable information. You will know whether or not it might be helpful to talk with your

provider about how you are feeling since giving birth. It will also help me (us) understand if

there are any additional resources I (we) should help you connect to.” (Lilly Irwin Viteta, MCRP

President, Common Worth, LLC)

• The Milwaukee Child Welfare Partnership offers a free online training in video format. The

48-minute video focuses on administering the EPDS and covers the logistics of screening and

also addresses the interpersonal skills that can make screening and follow-up conversations

more meaningful for patient and provider. This video is available at: https://uwm.edu/mcwp/

peoplecenteredassessment/

• The AIMS Center at The University of Washington has published a very helpful guide for

answering questions about presenting the PHQ-9 to a patient entitled, Using the PHQ-9: A

Guide for Medical Assistants, Front and Back Ofce Staff (Appendix D). While this guide speaks

directly to the PHQ-9, the information for speaking to patients about screening for depression

can be extrapolated to EPDS and other screening tools.

It is important to recall as a provider that the results of a screening tool are not a replacement

for clinical judgment. If you feel as though a person is struggling during the perinatal period,

you may still refer them to providers you feel are necessary. Remember that screening tools

are simply conversation starters in the important discussion of mental health.

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

Page 6 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Responding to a Positive Screen

“You are not alone, you are not to blame, and with the right help you’ll get better.”

First and foremost, when a person screens high for possible depression or anxiety, it is imperative

to provide warm, strengths-based support in a non-judgmental manner. Follow this with education

and referral to appropriate treatment if necessary.

• Emphasize that screening tools only measure risk and are not a diagnosis.

• Let them know that many people experience a PMAD.

• A PMAD is not their fault and does not reect on their ability to parent.

• PMADs are highly treatable, and they will get better with appropriate treatment.

• Emphasize that caring for themselves is caring for the baby.

Addressing Concerns of Suicidality

Montana’s suicide rate remains among the highest in the nation, and suicide is a leading cause of

death for women during the perinatal period. We strongly recommend your ofce have a protocol

in place to address suicidality that includes evaluation of the patient’s plan, intent and access

to suicidal means, and safety planning. Further, this protocol should trigger providers to seek

consultation with their peers and with resources outside of their ofce, including psychiatric care

and when necessary, emergency department care. Here are some resources to help you and your

practice build and strengthen these necessary emergency responses.

National Suicide Prevention Lifeline provides 24/7, free and condential support for people

in distress, prevention and crisis resources for you or your loved ones, and best practices for

professionals. They also provide several different ways to contact a crisis counselor:

Suicide Prevention Lifeline 1-800-273-TALK (8255)

En Español 1-888-628-9454

Deaf & Hard of Hearing 1-800-799-4889

Online Chat: https://suicidepreventionlifeline.org/

Zero Suicide is an organization with the foundational belief that suicide deaths for individuals

under the care of health and behavioral health systems are preventable. For systems dedicated to

improving patient safety, Zero Suicide presents an aspirational challenge and practical framework

for system-wide transformation toward safer suicide care. This resource can provide toolkits to help

your practice develop a strong response plan. https://zerosuicide.sprc.org/

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

Page 7 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Open-Ended Probing Questions

A screening tool is not the end of a discussion, but instead, the beginning of one. While someone

may screen as having a low risk of depression or anxiety, they may still be experiencing symptoms

that you are detecting. Conversely, you may encounter folks who screen as high-risk, but seem to

be managing well. Professional judgment is important in these situations, and we encourage all

providers to use their practice wisdom along with evidence-based tools. In our research we have

identied several open-ended questions that may help you to continue the discussion started with

a screening tool.

Screening for mental health by a trained member of your ofce staff is a critical component of

client care and education. When a provider presents the questions to the client in an open and safe

environment, it allows for a conversation about potential symptoms or experiences common in the

perinatal period. Universal screening reduces stigma and normalizes conversation about how the

client is feeling about their pregnancy or motherhood. Phrases such as, “You are not alone, you

are not to blame, and you can get help,” empower the client to provide honest responses to the

screening questions. Remember that screening is just the rst step in this conversation, and it often

takes many conversations before a client is ready to fully explore their mental health status.

It is not uncommon for new

mothers to experience

intrusive, unwanted thoughts

that they might harm their

baby. Have any such thoughts

occurred to you?

If you had eight

free hours and

a clean, quiet

place to sleep,

could you?

Use the phrase, “Tell me

more about…” in reference

to any of the questions on a

screening tool.

It seems you

are scoring

high on this

screening tool.

How do you

think you are

feeling?

What are

some of the

triggers that

make you feel

this way?

In those times,

what do you

think would

make you feel

better?

If you did not have an infant

and you were feeling sad or

anxious, what would you do to

help those feelings?

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

Page 8 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Screening Schedule

After a thorough review of screening schedule recommendations including those from The

American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP),

American Congress of Obstetricians and Gynecologists (ACOG), US Preventative Services Task

Force (USPSTF), Centers for Medicaid and Medicare Services (CMS), and Postpartum Support

International (PSI), we recommend screening frequently. See chart below for recommended

screening frequency.

Some Montana health insurance payors may cover your screening costs. Check with your

contracted payors for benets and reimbursement related to these services.

PRENATAL

Intake, 2nd and

3rd trimester

POSTPARTUM

2 week pp checkup

6 week pp checkup

PEDIATRIC

(Well child checks)

2 - 4 week visit

2, 4, 6, 9 , & 12 month visits

RECOMMENDED SCREENING INTERVALS

Postpartum Bipolar Disorder and the Mood Disorder

Questionnaire

Recent research has shown that the postpartum period carries the highest lifetime risk for

bipolar disorder (BD). Rates of BD in postpartum women with positive EPDS scores may be

more than 20%. It is vital to rule out BD prior to prescribing any antidepressants as these

may increase the risk of mania or psychosis, and thus hospitalization. As per the recent

recommendations of the American College of Obstetricians and Gynecologists (ACOG), we

recommend using the Mood Disorder Questionnaire (MDQ) (Appendix Q) in tandem with

either screening tool to identify possible Bipolar Disorder.

Patient Health Questionnaire (PHQ-9) (Appendix A)

or the

Edinburgh Postpartum Depression Scale (EPDS) (Appendix B)

RECOMMENDED SCREENING TOOLS

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

Recommended Additional Screening Tools

While this protocol is specic to perinatal depression, we recognize that there are a host of other

issues that may arise in the perinatal period. As a care provider, you will need more tools to

adequately meet these client needs. Below you will nd a list of evidence-based tools validated for

use in the perinatal period. See Appendices for copies of these tools.

• ANXIETY:

• Appendix E - Generalized Anxiety

Disorder 7 (GAD-7)

• Appendix F - Perinatal Anxiety Screening

Scale (PASS)

• INTIMATE PARTNER VIOLENCE:

• Appendix G - Hurt, Insult, Threaten, and

Scream (HITS)

• Appendix H - Abuse Assessment Scale

(AAS)

• SUBSTANCE ABUSE:

• Appendix I - CAGE-AID

• Appendix J - T-ACE

• Appendix K - The 4P’s

• Appendix L - TWEAK

• Appendix M - AUDIT-C

• Appendix N - AUDIT-C 2

• OCD:

• Yale Brown Obsessive Compulsive Scale

• SUICIDALITY:

• Appendix O - C-SSRS – Suicide Severity

• TRAUMA:

• Appendix P - Impact of Events Scale

Revised (IES-R)

• BI-POLAR DISORDER:

• Appendix Q - Mood Disorder

Questionnaire

Page 9 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

In addition to screening tools that focus on illness, we also recommend using tools such as

the Maternal Well-being Plan (Appendix R) or The Perinatal Wellness Worksheet from Perinatal

Support Washington (Appendix S) to ensure that health promotion and wellness are parts of all

conversations about mental health. Empowering a mother to focus on her strengths through a

lens of wellness and education can lead to feelings of competency and enable moms to detect

and communicate possible issues sooner.

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

Page 9 | The Montana Children’s Health Data Partnership Project

Postpartum Support International (PSI) has

been in existence for 30 years and is the leading

organization devoted to increasing awareness

about the prevalence and devastation of perinatal

depression and anxiety. PSI also has Montana-

based, regional coordinators that can help anyone

nd providers for perinatal mental health, including

but not limited to, private counselors trained in

perinatal mental health. In addition to a client

warmline for folks who need immediate help, PSI

also offers providers access to a reproductive

psychiatric consultation.

https://www.postpartum.net/locations/montana/

PSI Helpline: 1-800-944-4773

For patients: #1 En Espanol or #2 English OR

Text: 503-894-9453

For providers: #4 Perinatal Psychiatry

Consultation Service

The Seleni Institute has been a resource for

professional training and education specializing

in maternal mental health. They have regularly

updated online resources and offer trainings:

https://www.seleni.org/

2020Mom, founded in 2011 as the California

Maternal Mental Health Collaborative, has evolved

as a national organization with a mission: Closing

gaps in maternal mental health care through

education, advocacy, and collaboration.

https://www.2020mom.org/

The Postpartum Stress Center provides

support and treatment for the pregnant or

postpartum woman and her family as well as

guidance for her treating physician or therapist.

They are committed to providing excellent clinical

care and education to both our clients and

professionals who seek our expertise.

https://postpartumstress.com/

LactMed is a drug and lactation database that is

available both online and in an app format.

https://www.toxnet.nlm.nih.gov/cgi-bin/sis/

search2/f?./temp/~2nER5K:1

Resources and Referrals

No single ofce will be able to meet all of

the needs of every client, so it is important

that your practice has a list of trusted and

reputable resources that exist outside of

your ofce. This requires nding what

resources exist in your community and

establishing a relationship with those

providers whenever possible.

• Often, a good place to start is your

local health department, especially

if they have a Women Infant and

Children (WIC) Program.

• More personal, or “warm handoffs”

referrals, increase the likelihood that

a person will take advantage of the

resource. If possible, help your client

make the appointment in the ofce

that day. A referral from you, their

trusted provider, is a transfer of trust

from you to another provider.

• The best practice approach is to

“close the loop” on any referrals with

the other providers, ensuring that the

client was able to access that care, and

in cases when care is not accessed,

contact the patient to offer assistance.

• The US Prevention Services Task Force

recommends talk therapy as a rst line

approach to preventing and healing

from a PMAD.

• In addition, home-based supports

such as peer-to-peer mom groups,

home visiting services, or postpartum

doulas can provide social support that

is critical to mental health stability.

Below is a list of nationally available and

reliable resources that both providers and

clients may nd useful. These resources

can be sources of immediate help,

such as medication interactions or self-

screening tools, but can also be sources

of education and training that is necessary

to effectively identify and treat PMADs.

Page 10 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

Page 11 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Special Considerations

High Risk Groups

Please note that there are certain clients in the perinatal period who are at higher risk of

experiencing a PMAD due to social, economic, and health concerns. It is important to keep these

groups in mind as you provide care. While this list is expansive, and we recommend universal

screening, it may help you to better target education of clients and inform your clinical judgments.

• Adoption

• Breastfeeding difculties

• Certain personality traits, including

perfectionist tendencies or difculty

handling transitions

• Changes in thyroid function

• Complications of pregnancy, labor, or

infant’s health

• Endocrine-related disfunction such as

Polycystic Ovarian Syndrome (PCOS)

• Family history of PMAD

• High risk pregnancies

• History of a mental health diagnosis

• History of current or past substance use

• History of severe PMS

• Intimate partner / Domestic violence

• Low income

• Pregnancy loss/ Infertility

• Sleep disturbances

• Social isolation

• Teen mothers

• Trauma (IPV, childhood abuse and neglect,

PTSD, death in family)

• Unwanted / Unplanned pregnancy

• Veteran / Service member in family

• Balanced nutrition, physical activity or

healthy sleep

• Family Planning for an intended pregnancy

• Perceived & intact social and maternal

support

• Parenting condence

• Recognition of traditional postpartum

cultural practices

• Positive parenting role models

• Support of breastfeeding decision

• Healthy co-parent involvement

Protective Factors

Equally as helpful as focusing on risk, is promoting protective factors. Protective factors can lessen

the impact, or even prevent a PMAD. Further, while many of the risk factors listed above are based

on client history, many protective factors are actionable. For example, while we cannot change

past history of trauma, we can help to increase social and breastfeeding supports and build

parenting skills and condence.

318-20 N. Last Chance Gulch, Ste. 2C

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Page 12 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Risk Assessment

Some providers are beginning to include risk assessments as part of their standard of care. The

Postpartum Stress Center’s PPD Risk Assessment During Pregnancy Screening (Appendix T) is an

example of reaching beyond the screening tools to ask about possible risk of a PMAD. This can be

an integral part of psychoeducation between the provider and client, and can empower clients and

their support networks to understand their risk level and navigate preventative measures, including

how to increase protective factors.

Screening Partners

The perinatal period is a time of great change for all involved. Perinatal mood and anxiety

disorders impact the entire family unit, and about 10% of new dads experience a PMAD when the

mother of their baby has a PMAD. Notably, this may also occur in the absence of a maternal PMAD.

Screening partners is an essential part of understanding how the entire family unit is coping

with this time of change. The use of the three-question abbreviated Edinburgh, the EPDS-3, is

appropriate for this purpose, but also note that the full EPDS is validated for use in partners. The

PHQ-9 would also be appropriate in this setting.

Using the Algorithm

The following pages are an algorithm for perinatal mood and anxiety disorders and a companion

narrative. We envision the algorithm as an at-a-glance resource for use in daily practice. The

narrative provides a more detailed description of the algorithm and presents the same information

and processes in an alternate format that may be more useful to others. We recommend you place

this algorithm in exam rooms, at nurses stations, or where ever rooming, nursing or provider staff

can have easy access for reference when needed.

318-20 N. Last Chance Gulch, Ste. 2C

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Pregnancy Related Depression Screening

For those providing care from pregnancy through 1 year postpartum

EPDS OR PHQ-9

SCORE & CHECK

RED FLAGS

LOW RISK

“AT RISK FOR PMAD”

• RESCREEN AT NEXT

RECOMMENDED

INTERVAL

• PROVIDE EDUCATION

ABOUT PMADS &

WELLNESS PLANNING

PROVIDE VERBAL

EDUCATION INCLUDING:

• SIGNS AND SYMPTOMS

OF PMADS

• TREATMENT OPTIONS

GIVE THEM A BLANK

SCREENING TOOL WITH

SCORING

HIGH RISK

“LIKELY EXPERIENCING

A PMAD”

• ADMINISTER MDQ TO

SCREEN FOR BIPOLAR

• MAKE REFERRAL/

ARRANGE

APPOINTMENT FOR

MENTAL HEALTH

EVALUATION WITH

PRIMARY CARE/OB

PROVIDER ASAP

• REFER TO MENTAL

HEALTH SERVICES

PROVIDE VERBAL

EDUCATION INCLUDING:

• SIGNS AND SYMPTOMS

OF PMADS

• DISCUSS TREATMENT

OPTIONS

• COVER POINTS

OF EDUCATION

& ENCOURAGE

COMPLETION OF

WELLNESS GUIDE

GIVE THEM A BLANK

SCREENING TOOL WITH

SCORING

FOLLOW UP

• ENSURE CLIENT RECEIVED CARE WITHIN 3 DAYS

• HELP COORDINATE ONGOING SUPPORT NEEDS

• REFER TO FAMILY SUPPORT SERVICES, SUCH AS

HOME VISITING SERVICES IF AVAILABLE

• DOCUMENT

RED FLAG Q’S

EPDS #10 >2 & PHQ-9 #9 >1

“INDICATES RISK OF SELF HARM”

• DO NOT LEAVE CLIENT/BABY

ALONE

• REFER TO YOUR OFFICE

SUICIDE RISK RESPONSE

PROTOCOL

• COLLABORATE WITH CLIENT

TO FIND SUPPORTIVE ADULT

TO JOIN THEM AND SECURE

CHILDCARE

• CONTACT PRIMARY CARE

PROVIDER

• CREATE SAFETY PLAN

• IF NO CRISIS SERVICES

AVAILABLE, COORDINATE

WITH EMERGENCY

DEPARTMENT CALL 911

• CONTACT CPS IF NECESSARY

• MAKE CRISIS MENTAL HEALTH

APPOINTMENT

• DOCUMENT

SCORE

IS 10 OR

GREATER

SCORE

IS 9 OR

LESS & RED

FLAGS ARE

NEGATIVE

PRENATAL

Intake, 2nd and

3rd trimester

POSTPARTUM

2 week pp checkup

6 week pp checkup

PEDIATRIC

(Well child checks)

2 - 4 week visit

2, 4, 6, 9 , & 12 month visits

RECOMMENDED SCREENING INTERVALS

Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

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Page 14 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Algorithm Narrative

This section of the document is s screen

algorithm that presents a process and

response protocol for administering screening

tools.

STEP 1: ADMINISTER

Administer the EPDS or PHQ-9 at

recommended screening intervals

STEP 2: SCORE

Score the screening tool

STEP 3: RESPOND

Talk to the client about their screening

results. Use the following guidelines to tailor

response to the patients needs

LOW RISK RESPONSE: Response to Negative

Screen (Score less than 10 and Red Flags are

negative)

• Rescreen at next recommended interval

• Provide education about perinatal mood,

anxiety disorders and wellness plan

• Wellness Plan

HIGH RISK RESPONSE: Response to a

Positive Screen (Score 10 or greater)

• Likely experiencing a PMAD

• Administer MDQ to screen for Bipolar

• Make referral for mental health evaluation

with primary care provider/OB within 2

weeks

• Provide verbal education including:

• Signs and symptoms of PMADS

• Discuss treatment options

• Cover points of education and

encourage completion of wellness guide

• Give them a blank screening tool with

scoring

RED FLAG RESPONSE:

Red Flag Question responses (EPDS Q#10 ≥ 2

and PHQ-9 Q#9 ≥ 1)

• Both of the screening tools have a

question that specically addresses

suicidality and self-harm

• On the EPDS is question #10, positive

response = 2 or greater

• On the PHQ-9 is question #9, positive

response = 1 or greater

• Indicates a risk of self-harm

• Do not leave client/baby alone

• Make crisis mental health appointment

• Collaborate with client to nd

supportive adult to join them and secure

childcare

• Contact primary care provider or OB

• Decide on safety and treatment plans

• If no crisis supports or services

available, coordinate with Emergency

Dept, call 911 and/or contact CPS if

necessary

• Document

STEP 4: FOLLOW UP

• A positive response to either of these

questions triggers an emergency response

to ensure safety of mom and baby

• This is where an established protocol is

most helpful

• Asking questions about suicidality and self-

harm is uncomfortable for some providers,

but try to recall how uncomfortable it may

be for your client to share this information

• This discomfort, in addition to the urgency

of the situation, are reasons why a clear

self-harm risk protocol is essential

• Document

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Page 15 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

References

Accortt, E. E., & Wong, M. S. (2017). It Is Time for Routine Screening for Perinatal Mood and Anxiety

Disorders in Obstetrics and Gynecology Settings. Obstetrical & Gynecological Survey, 72(9)

American College of Obstetricians and Gynecologists. (2018) Screening for perinatal depression.

ACOG Committee Opinion No. 757. American College of Obstetricians and Gynecologists.

Obstet Gynecol 2018;132:e208-12.

Basile KC, Hertz MF, Back SE. (2007). Intimate Partner Violence and Sexual Violence Victimization

Assessment Instruments for Use in Healthcare Settings: Version 1. Atlanta (GA): Centers for

Disease Control and Prevention, National Center for Injury Prevention and Control.

Bennet, S. Ph.D. and Indman, P. EdD, MFT. (2015) Beyond the Baby Blues: Understanding and

Treating Prenatal and Postpartum Depression & Anxiety. Untreed Reads Publishing. San

Francisco, CA 94107.

Bodenlos, K., Maranda, L., & Deligiannidis, K. (2016). Comparison of the Use of the EPDS-3 vs.

EPDS-10 to Identify Women at Risk for Peripartum Depression [3K]. Obstetrics & Gynecology,

127, 89S-90S.

Brandes, M., Soares, C., & Cohen, L. (2004). Postpartum onset obsessive-compulsive disorder:

Diagnosis and management. Archives of Women’s Mental Health, 7(2), 99-110.

Center for Quality Assessment and Improvement in Mental Health. (n.d.) Standards for Bipolar

Excellence (STABLE) Resource Tool Kit Retrieved from: https://www.integration.samhsa.gov/

images/res/STABLE_toolkit.pdf

Challacombe, Fiona L. (2013). A hidden problem: Consequences of the misdiagnosis of perinatal

obsessive compulsive disorder. British Journal of General Practice. 63(610), 275-276.

Choi, K., & Sikkema, K. (2016). Childhood maltreatment and perinatal mood and anxiety disorders:

A Systematic review. Trauma, Violence, & Abuse. 17(5), 427-453.

Deshpande, NA and Lewis-O’Connor A. (2013) Screening for Intimate Partner Violence During

Pregnancy. Reviews in Obstetrics and Gynecology. 6(3-4):141-148. Accessed at https://www.

ncbi.nlm.nih.gov/pmc/articles/PMC4002190/.

Horst, Karen, MD (2018) Perinatal Mood and Anxiety Disorders. Presentation available at:

https:/vimeo.com/261343372.

Kabir, Sheeder, Kelly, & Stevens-Simon. (2007). Identifying Postpartum Depression: 3 Questions Are

As Good As 10. Journal of Pediatric and Adolescent Gynecology, 20(2), S135-S136.

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

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Kauffman, G. MA, LPCC, BC-DMT, NCC. (2018) Perinatal Depression and Anxiety: Why Universal

Screening is Critical. Presentation available at: https://vimeo.com/265598028

Lancaster CA, G. K. (2010). Risk factors for depressive symptoms during pregnancy: a

systematic review. Am J Obstet Gynecol, 202, 5-14.

Milwaukee Child Welfare Partnership. (n.d.) People Centered Screening and Assessment. Retrieved

from: https://uwm.edu/mcwp/peoplecenteredassessment/

Robertson E, G. S. (2004). Antenatal risk factors for postpartum depression: a synthesis of recent

literature. Gen Hosp Psychiatry, 26, 289-95.

Seleni Institute. (n.d.) PMAD Screening Training. Retrieved from: https://www.seleni.org/pmad

screening-training/

Sharma, Verinder, & Sommerdyk, Christina. (2015). Obsessive-compulsive disorder in the

postpartum period: Diagnosis, differential diagnosis and management. Women’s Health, 11(4),

543-552.

Soeken KL, McFarlane J, Parker B, Lominack MC. The abuse assessment screen: a clinical

instrument to measure frequency, severity, and perpetrator of abuse against women. IN:

Campbell JC, editor. (1998). Empowering Survivors of Abuse: Health Care for Battered Women

and Their Children. Thousand Oaks, CA: Sage Publications; 1998. pp. 195–203. In Deshpande

and Lewis-O’Connor, 2013.

Sokol RJ, Martier SS, Ager JW. (1989). The T-ACE questions: Practical prenatal detection of risk

drinking. American Journal of Obstetrics and Gynecology 160 (4).

US Preventive Services Task Force. Interventions to Prevent Perinatal Depression: US Preventive

Services Task Force Recommendation Statement. JAMA. 2019;321(6):580–587. doi:10.1001/

jama.2019.0007

Wright, Terplan, Ondersma, Boyce, Yonkers, Chang, & Creanga. (2016). The role of screening, brief

intervention, and referral to treatment in the perinatal period. American Journal of Obstetrics

and Gynecology, 215(5), 539-547.

Page 16 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

This project was made possible by a Healthy Kids, Healthy Families Grant

from BlueCross, BlueShield of Montana

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Page 17 | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Appendices

DEPRESSION:

Appendix A - Patient Health Questionnaire (PHQ-9)...........................................................Page 18

Appendix B - Edinburgh Postpartum Depression Scale (EPDS)........................................Page 20

Appendix C - Edinburgh Postpartum Depression Scale-3 (EPDS-3).................................Page 22

Appendix D - Using the PHQ-9: A Guide for Medical Asst, Front and Back Ofce Staff......Page 23

ANXIETY:

Appendix E - Generalized Anxiety Disorder 7 (GAD-7)......................................................Page 25

Appendix F - Perinatal Anxiety Screening Scale (PASS) .....................................................Page 26

INTIMATE PARTNER VIOLENCE:

Appendix G - Hurt, Insult, Threaten, and Scream (HITS) ....................................................Page 27

Appendix H - Abuse Assessment Scale (AAS)......................................................................Page 28

SUBSTANCE ABUSE:

Appendix I - CAGE-AID...........................................................................................................Page 30

Appendix J - T-ACE..................................................................................................................Page 31

Appendix K - The 4P’s..............................................................................................................Page 32

Appendix L – TWEAK Tes........................................................................................................Page 33

Appendix M – Alcohol Use Disorders Identication Test (AUDIT).....................................Page 34

Appendix N - Alcohol Use Disorders Identication Test (AUDIT-C).................................Page 35

SUICIDALITY:

Appendix O – Columbia-Suicide Severity Rating Scale (C-SSRS)......................................Page 37

TRAUMA:

Appendix P - Impact of Events Scale Revised (IES-R)..........................................................Page 39

BI-POLAR DISORDER:

Appendix Q - Mood Disorder Questionnaire (MDQ)..........................................................Page 40

WELLNESS

Appendix R- My Maternal Wellbeing Plan, Minnesota Department of Health.................Page 41

Appendix S – Creating a Wellness Plan, Perinatal Support Washington...........................Page 43

Appendix T – PPD Risk Assessment During Pregnancy, The Postpartum Stress Ctr........Page 45

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Page 19 - App A | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

PHQ-9 Patient Depression Questionnaire

For initial diagnosis:

1. Patient completes PHQ-9 Quick Depression Assessment.

2. If there are at least 4 3

s in the shaded section (including Questions #1 and #2), consider a depressive

disorder. Add score to determine severity.

Consider Major Depressive Disorder

- if there are at least 5 3

s in the shaded section (one of which corresponds to Question #1 or #2)

Consider Other Depressive Disorder

- if there are 2-4 3

s in the shaded section (one of which corresponds to Question #1 or #2)

Note: Since the questionnaire relies on patient self-report, all responses should be verified by the clinician,

and a definitive diagnosis is made on clinical grounds taking into account how well the patient understood

the questionnaire, as well as other relevant information from the patient.

Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment of social,

occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, a

history of a Manic Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as the

biological cause of the depressive symptoms.

To monitor severity over time for newly diagnosed patients or patients in current treatment for

depression:

1. Patients may complete questionnaires at baseline and at regular intervals (eg, every 2 weeks) at

home and bring them in at their next appointment for scoring or they may complete the

questionnaire during each scheduled appointment.

2. Add up 3

s by column. For every 3: Several days = 1 More than half the days = 2 Nearly every day = 3

3. Add together column scores to get a TOTAL score.

4. Refer to the accompanying PHQ-9 Scoring Box to interpret the TOTAL score.

5. Results may be included in patient files to assist you in setting up a treatment goal, determining degree of

response, as well as guiding treatment intervention.

Scoring: add up all checked boxes on PHQ-9

For every 3

Not at all = 0; Several days = 1;

More than half the days = 2; Nearly every day = 3

Interpretation of Total Score

Total Score Depression Severity

1-4 Minimal depression

5-9 Mild depression

10-14 Moderate depression

15-19 Moderately severe depression

20-27 Severe depression

trademark of Pfizer Inc.

A2662B 10-04-2005

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Page 20 - App B | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

* If you scored a 1, 2 or 3 on question 10, PLEASE CALL YOUR

HEALTH CARE PROVIDER (OB/Gyn, family doctor or nurse-

midwife) OR GO TO THE EMERGENCY ROOM NOW to ensure your

own safety and that of your baby.

If your total score is 11 or more, you could be experiencing

postpartum depression (PPD) or anxiety. PLEASE CALL YOUR

HEALTH CARE PROVIDER (OB/Gyn, family doctor or nurse-

midwife) now to keep you and your baby safe.

If your total score is 9-10, we suggest you repeat this test in one

week or call your health care provider (OB/Gyn, family doctor or

nurse-midwife).

If your total score is 1-8, new mothers often have mood swings

that make them cry or get angry easily. Your feelings may be

normal. However, if they worsen or continue for more than a week

or two, call your health care provider (OB/Gyn, family doctor or

nurse-midwife). Being a mother can be a new and stressful

experience. Take care of yourself by:

 Getting sleep—nap when the baby naps.

 Asking friends and family for help.

 Drinking plenty of fluids.

 Eating a good diet.

 Getting exercise, even if it’s just walking outside.

Regardless of your score, if you have concerns about depression

or anxiety, please contact your health care provider.

Please note: The Edinburgh Postnatal Depression Scale (EPDS) is a screening tool

that does not diagnose postpartum depression (PPD) or anxiety.

TOTAL YOUR SCORE HERE 

7. I have been so unhappy that I have had difficulty

sleeping:

Yes, most of the time ____

(3)

Yes, sometimes ____

(2)

No, not very often ____ (1)

No, not at all ____ (0)

8. I have felt sad or miserable:

Yes, most of the time ____

(3)

Yes, quite often ____ (2)

Not very often ____ (1)

No, not at all ____ (0)

9. I have been so unhappy that I have been crying:

Yes, most of the time ____

(3)

Yes, quite often ____ (2)

Only occasionally ____ (1)

No, never ____ (0)

10. The thought of harming myself has occurred to me:*

Yes, quite often ____

(3)

Sometimes ____ (2)

Hardly ever ____ (1)

Never ____ (0)

Below is an example already completed.

Edinburgh Postnatal Depression Scale (EPDS)

1. I have been able to laugh and see the funny side of

things:

As much as I always could ____

(0)

Not quite so much now ____ (1)

Definitely not so much now ____ (2)

Not at all ____ (3)

2. I have looked forward with enjoyment to things:

As much as I ever did ____

(0)

Rather less than I used to ____ (1)

Definitely less than I used to ____ (2)

Hardly at all ____ (3)

3. I have blamed myself unnecessarily when things went

wrong:

Yes, most of the time ____

(3)

Yes, some of the time ____ (2)

Not very often ____ (1)

No, never ____ (0)

4. I have been anxious or worried for no good reason:

No, not at all ____

(0)

Hardly ever ____ (1)

Yes, sometimes ____ (2)

Yes, very often ____ (3)

5. I have felt scared or panicky for no good reason:

Yes, quite a lot ____

(3)

Yes, sometimes ____ (2)

No, not much ____ (1)

No, not at all ____ (0)

6. Things have been getting to me:

Yes, most of the time I haven’t been able to

cope at all ____

(3)

Yes, sometimes I haven’t been coping as well

as usual ____

(2)

No, most of the time I have coped quite well ____ (1)

No, I have been coping as well as ever ____ (0)

Edinburgh Postnatal Depression Scale (EPDS). Adapted from the British Journal of Psychiatry, June, 1987, vol. 150 by J.L. Cox, J.M. Holden, R. Segovsky.

I have felt happy:

Yes, all of the time ____

(0)

Yes, most of the time ____ (1)

No, not very often ____ (2)

No, not at all ____ (3)

This would mean: “I have felt happy most of the time” in

the past week. Please complete the other questions in the

same way.

✔

Date: Clinic Name/Number:

Your Age: Weeks of Pregnancy/Age of Baby:

Since you are either pregnant or have recently had a baby, we want to know how you feel. Please place a CHECK MARK (✔) on

the blank by the answer that comes closest to how you have felt IN THE PAST 7 DAYS—not just how you feel today. Complete all

10 items and find your score by adding each number that appears in parentheses (#) by your checked answer. This is a

screening test; not a medical diagnosis. If something doesn’t seem right, call your health care provider regardless of your score.

See more information on reverse. 

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Page 21 - App B | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

ABOUT THE EPDS

Studies show that postpartum depression (PPD) affects

at least 10 percent of women and that many depressed

mothers do not get proper treatment. These mothers

might cope with their baby and with household tasks, but

their enjoyment of life is seriously affected, and it is

possible that there are long term effects on the family.

The Edinburgh Postnatal Depression Scale (EPDS) was

developed to assist health professionals in detecting

mothers suffering from PPD; a distressing disorder more

prolonged than the “blues” (which can occur in the first

week after delivery).

The scale consists of 10 short statements. A mother

checks off one of four possible answers that is closest to

how she has felt during the past week. Most mothers

easily complete the scale in less than five minutes.

Responses are scored 0, 1, 2 and 3 based on the

seriousness of the symptom. Items 3, 5 to 10 are reverse

scored (i.e., 3, 2, 1, and 0). The total score is found by

adding together the scores for each of the 10 items.

Mothers scoring above 12 or 13 are likely to be

suffering from depression and should seek medical

attention. A careful clinical evaluation by a health care

professional is needed to confirm a diagnosis and

establish a treatment plan. The scale indicates how the

mother felt during the previous week, and it may be useful

to repeat the scale after two weeks.

INSTRUCTIONS FOR USERS

1. The mother checks off the response that comes closest

to how she has felt during the previous seven days.

2. All 10 items must be completed.

3. Care should be taken to avoid the possibility of the

mother discussing her answers with others.

4. The mother should complete the scale herself, unless

she has limited English or reading difficulties.

5. The scale can be used at six to eight weeks after birth

or during pregnancy.

Edinburgh Postnatal Depression Scale (EPDS) Scoring & Other Information

Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale.

British Journal of Psychiatry, 150, 782-786. The Spanish version was developed at the University of Iowa based on earlier Spanish versions of the

instrument. For further information, please contact Michael W. O’Hara, Department of Psychology, University of Iowa, Iowa City, IA 52245, e-mail:

mikeohara@uiowa.edu.

Please note: Users may reproduce this scale without further permission providing they respect the copyright (which remains with the

British Journal of Psychiatry), quote the names of the authors and include the title and the source of the paper in all reproduced copies.

Cox, J.L., Holden, J.M. and Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal

Depression Scale. British Journal of Psychiatry, 150, 782-786.

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Page 22 - App C | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Edinburgh Postpartum Depression

Screening Tool

The Edinburgh Postnatal Depression Scale (EPDS) is the screening instrument most

commonly used to identify women with postpartum mood disorders.

This is a 10-item questionnaire which has been validated in many different populations

and is available in almost every language.

On this scale, a score of 10 or greater or an affirmative answer on question 10

(presence of suicidal thoughts) is suggestive of postpartum depression.

(Setting the cut-off score of 12 improves the specificity of the EPDS for identifying major

depression; however, the sensitivity falls off significantly, making it less useful for

screening.)

Most importantly it should be emphasized that an elevated score on the EPDS does not

necessarily confirm the diagnosis of postpartum depression; this requires a more

thorough diagnostic evaluation.

EPDS–3

A recent study indicated that the EPDS may be further abbreviated to a three question

version which can be used to screen for postpartum depression.

Given the prevalence of anxiety symptoms among women with postpartum depression,

the authors chose a screening tool using the 3 items which comprise the anxiety

subscale of the EPDS:

 I have blamed myself unnecessarily when things went wrong

 I have been anxious or worried for no good reason

 I have felt scared or panicky for no very good reason

The Edinburgh Postpartum Depression Scale-3 exhibited the best screening performance characteristics,

with sensitivity at 95% and negative predictive value at 98%. It identified 16% more mothers as

depressed than the Edinburgh Postpartum Depression Scale did. “Identifying Postpartum Depression:

Are 3 Questions as Good as 10?” Karolyn Kabir, Jeanelle Sheeder, Lisa S. Kelly

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Page 23 - App D | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Using the PHQ-9:

A Guide for Medical Assistants, Front and Back Office Staff

What is the Patient Health Questionnaire (PHQ-9)?

The PHQ-9 is a simple, nine question form used to screen depression and monitor changes in

signs/symptoms of depression. The patient’s PHQ-9 score should be recorded at the beginning of a visit,

like blood pressure or other vitals.

Depression screening workflows often include front office staff, medical assistants, and other care team

members who might not be used to tracking depression in the same way as other vitals.

It is important

that the patient sees that all staff feel just as comfortable administering the PHQ-9 as any other vital

sign, creating a welcoming environment.

Screening with the PHQ-9

The PHQ-9 can be filled out two ways; directly handing a copy to the patient to complete on their own

or being administered verbally by staff as part of the rooming process. Studies have shown that patients

can successfully fill out this form by themselves and do not always require assistance. If the PHQ-9 is

being administered verbally, it is crucial that the administrator

asks the question to the patient exactly

as it is written on the form to ensure accurate data.

Once a patient fills out the PHQ-9, the person administering the scale should immediately enter the

numbers into EHR and/or registry.

Do NOT enter “0” on the PHQ-9 if the patient did not complete the

form. Instead, a note should be made in the EHR and/or registry outlining why PHQ-9 scores are not

available. Entering a score of “0” falsely shows improvement in the patient’s symptoms.

Common Questions When Presenting PHQ-9 to Patients

The following Q&A is intended to help staff feel more comfortable answering the questions they may be

asked by patients about the PHQ-9.

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Page 24 - App D | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Example Questions from Patients Regarding the PHQ-9

Patient

Question:

Why do I need to fill this out?

Answer

SCREENING

Much like taking your blood pressure or temperature, we’re also focused on your overall

health and well-being over the past 2 weeks.

FOLLOW-UP (already in treatment)

Your provider wants to know more about your overall health so that we can properly gauge

if the treatment is working the way it should.

Patient

Question:

If I don‘t feel like I have these problems, should I still fill this out?

Answer

Absolutely, it’s just as vital as tracking your blood pressure or temperature to properly

assess your overall health and well-being. Like other factors, this metric is particularly useful

when tracked over time.

[Ask the patient if they have concerns. If they do then say I’ll tell your provider you would

like to talk about it.]

Patient

Question:

Do I have to fill this out even if I’m not comfortable answering these questions?

Answer

You never have to fill out a form or answer questions that you’re not comfortable with, but

we strongly recommend you do to help us provide better care.

Patient

Question:

I would rather just talk to my provider about these questions instead of filling this out. Is

that OK?

Answer

Yes, of course.

Patient

Question:

I don’t understand some of these questions. Can you help me?

Answer

If you have questions about the specific items on the form and how they apply to you, it

would be best to talk about that with your provider.

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Page 25 - App E | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

GeneralizedAnxietyDisorder7-item(GAD-7)scale



Overthelast2weeks,howoftenhaveyoubeen

botheredbythefollowingproblems?

Notat

allsure



Several

days

Overhalf

thedays

Nearly

everyday



1.Feelingnervous,anxious,oronedge

0 1 2 3

2.Notbeingabletostoporcontrolworrying

0 1 2 3

3.Worryingtoomuchaboutdifferentthings

0 1 2 3

4.Troublerelaxing

0 1 2 3

5.Beingsorestlessthatit'shardtositstill

0 1 2 3

6.Becomingeasilyannoyedorirritable

0 1 2 3

7.Feelingafraidasifsomethingawfulmi ght

happen

0 1 2 3

Addthescoreforeachcolumn +





TotalScore(addyourcolumnscores)=    



Ifyoucheckedoffanyproblems,howdifficulthavethesemadeitforyoutodoyourwork,take

careofthingsathome,orgetalongwithotherpeople?



Notdifficultatall__________

Somewhatdifficult_________

Verydifficult_____________

Extremelydifficult_________



Source:SpitzerRL,KroenkeK,WilliamsJBW,LoweB.Abriefmeasureforassessinggeneralizedanxiety

disorder.ArchInernMed.2006;166:1092-1097.



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Page 26 - App F | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

PERINATAL ANXIETY SCREENING SCALE (PASS)



ANTENATAL



POSTNATAL

DATE:

Weeks pregnant (

)

Baby’s age (

)

OVER THE PAST MONTH, How often have you experienced the following? Please tick

the response that most closely describes your experience for every question.

Not at all

Some

times

Often

Almost

Always

1. Worry about the baby/pregnancy

2. Fear that harm will come to the baby

3. A sense of dread that something bad is

going to happen

4. Worry about many things

5. Worry about the future

6. Feeling overwhelmed

7. Really strong fears about things, eg

needles, blood, birth, pain, etc

8. Sudden rushes of extreme fear or

discomfort

9. Repetitive thoughts that are difficult to

stop or control

10. Difficulty sleeping even when I have the

chance to sleep

11. Having to do things in a certain way or

order

12. Wanting things to be perfect

12. Needing to be in control of things

14. Difficulty stopping checking or doing

things over and over

15. Feeling jumpy or easily startled

16. Concerns about repeated thoughts

17. Being 'on guard' or needing to watch out

for things

18. Upset about repeated memories, dreams

or nightmares

Not at all

Some

times

Often

Almost

Always

Continued on Back

Name:

DOB:

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Page 27 - App F | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Not at all

Some

times

Often

Almost

Always

19. Worry that I will embarrass myself in

front of others

20. Fear that others will judge me negatively

21. Feeling really uneasy in crowds

22. Avoiding social activities because I

might be nervous

23. Avoiding things which concern me

24. Feeling detached like you're watching

yourself in a movie

25. Losing track of time and can't remember

what happened

26. Difficulty adjusting to recent

changes

27. Anxiety getting in the way of being able

to do things

28. Racing thoughts making it hard to

concentrate

29. Fear of losing control

30. Feeling panicky

31. Feeling agitated

Not at all

Some

times

Often

Almost

Always

Global Score

Reference:

Somerville, S., Dedman, K., Hagan, R., Oxnam, E., Wettinger, M., Byrne, S., Coo, S., Doherty,

D., Page, A.C. (2014).

The Perinatal Anxiety Screening Scale: development and preliminary validation. Archives of

Women’s Mental Health, DOI: 10.1007/s00737-014-0425-8

Department of Health, State of Western Australia (2013).

belongs to the State of Western Australia, under the provisions of the Copyright Act 1968

(Commonwealth of Australia). Apart from any fair dealing for personal, academic, research

or non-commercial use, no part may be reproduced without written permission of the

Department of Psychological Medicine, Women and Newborn Health Service, WA

Department of Health. Please acknowledge the authors and the WA Department of Health

when reproducing or quoting material from this source.

Clear fields Print / Save PDF

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Page 28 - App G | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Hurt, Insulted, Threatened with Harm and Screamed (HITS)

Domestic Violence Screening Tool

Please read each of the following activities and place a check mark in the box that best indicates

the frequency with which your partner acts in the way depicted.

Date: ____________________

Age: _____________________

Sex: Male _____ Female _____

Ethnicity: Caucasian ______ Hispanic _____ African American _____ Asian _____ Indian _______

For more information, call

1.800.4BAYLOR or visit us online at

BaylorHealth.com/DallasTrauma.

Each item is scored from 1-5. Range between 4-20. A score greater than 10 signify that you are at risk

of domestic violence abuse, and should seek counseling or help from a domestic violence resource center

such as the following:

e Family Place Hotline– 214.941.1991

Genesis Women’s Shelter– 214.389.7700; Genesis Hotline– 214.946.HELP (4357)

Texas Council on Family Violence– 800.525.1978

National Domestic Violence Hotline– 1.800.799.SAFE (7233)

How often does your partner? Never Rarely Sometimes Fairly Often Frequently

1. Physically hurt you

2. Insult or talk down to you

3. reaten you with harm

4. Scream or curse at you

1 2 3 4 5

Tota l Sc ore:

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Page 29 - App H | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

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Page 30 - App I | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

CAGE-AID Questionnaire

Patient Name __________________________________ Date of Visit ___________________

When thinking about drug use, include illegal drug use and the use of prescription drug other

than prescribed.

Questions: YES NO_______

1. Have you ever felt that you ought to cut down on your drinking

or drug use?

…………………………………………………………………………………………………....

2. Have people annoyed you by criticizing your drinking or drug use?

……………………………………………………………………………………………............

3. Have you ever felt bad or guilty about your drinking or drug use?

……………………………………………………………………………………………............

4. Have you ever had a drink or used drugs first thing in the morning

to steady your nerves or to get rid of a hangover?________________________________

Scoring

Regard one or more positive responses to the CAGE-AID as a positive screen.

Psychometric Properties

The CAGE-AID exhibited: Sensitivity Specificity

One or more Yes responses 0.79 0.77

Two or more Yes responses 0.70 0.85

(Brown 1995)

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Page 31 - App J | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Screening Tests

everal hundred screening instruments are available

today to aid clinicians and others in identifying

patients with alcohol problems. Many of these tools

are presented in the guide, Assessing Alcohol Problems: A

Guide for Clinicians and Researchers,

available from the

National Institute on Alcohol Abuse and Alcoholism.

This issue of Alcohol Research & Health highlights some

of the most popular screening tools for identifying

hazardous or risky drinking. Two instruments in particular,

the AUDIT and the CAGE, are cited throughout this

issue—primarily because of their usefulness in a variety

of settings and with a range of target populations.

In contrast, the T-ACE is a test developed to ascertain

drinking in a very specific population—pregnant women.

The AUDIT, CAGE, and T-ACE are presented here

in their entirety. See the Assessing Alcohol Problems

guide for a full description of these and other instruments,

including their target audiences, reliability, clinical

utility, research applications, and source references,

as well as administrative issues such as scoring, time

requirements, training required to deliver the screening

tests, their costs, and copyright issues.

National Institute on Alcohol Abuse and Alcoholism. Assessing Alcohol Problems: A Guide for Clinicians and Researchers, 2d ed. NIH Pub. No. 03–3745. Washington,

DC: U.S. Dept. of Health and Human Services, Public Health Service. Revised 2003, may be accessed online at www.niaaa.nih.gov/publications/protraining.htm.

CAGE

T-ACE

C Have you ever felt you should

cut down on your drinking?

T Tolerance: How many drinks

does it take to make you feel

high?

A Have people annoyed you by

criticizing your drinking?

A Have people annoyed you by

criticizing your drinking?

G Have you ever felt bad or guilty

about your drinking?

C Have you ever felt you ought to

cut down on your drinking?

E Eye opener: Have you ever had

a drink first thing in the morning

to steady your nerves or to get

rid of a hangover?

E Eye-opener: Have you ever

had a drink first thing in the

morning to steady your nerves

or get rid of a hangover?

The CAGE can identify alcohol problems over the

The T-ACE, which is based on the CAGE, is valuable

lifetime. Two positive responses are considered a posi-

for identifying a range of use, including lifetime use and

tive test and indicate further assessment is warranted.

prenatal use, based on the DSM–III–R criteria. A score

of 2 or more is considered positive. Affirmative answers

to questions A, C, or E = 1 point each. Reporting tolerance

to more than two drinks (the T question) = 2 points.

Alcohol Research & Health 28

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Page 32 - App K | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

The 4Ps Plus has a cost associated with its use. This image is from a scholarly article providing evidence

for its use of screening for substance use in the perinatal period.

Chasnoff, IJ, McGourty, RF, Bailey, GW. (2005). The 4P's Plus screen for substance use in pregnancy:

clinical application and outcomes. Journal of Perinatology. 25(6), 368–374. Retrieved from:

https://www.nature.com/articles/7211266#ref27

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Page 33 - App L | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

TWEAK v1.1 05/09/2003 Page 1

UW ADAI Sound Data Source

TWEAK Test

Protocol Number: XXXXXXXX-XXXX

Do you drink alcoholic beverages? If you do, please take our “TWEAK” test.

T. Tolerance: How many drinks can you “hold”?

Record number of drinks on line at right.

__ __

W. Have close friends or relatives Worried or Complained about your

drinking in the past year?

Yes 1

No 0

E. Eye-Opener: Do you sometimes take a drink in the morning when you

first get up?

Yes 1

No 0

A. Amnesia (Blackouts): Has a friend or family member ever told you about

things you said or did while you were drinking that you could not remember?

Yes 1

No 0

K(C). Do you sometimes feel the need to Cut Down on your drinking? Yes 1

No 0

Scoring:

To score the test, a seven-point scale is used. The tolerance question scores two points if a

woman reports she can “hold” more than five drinks without passing out, and a positive

response to the worry question scores two points. Each of the last three questions scores one

point for positive responses. A total score of three or more points indicates the woman is likely

to be a heavy/problem drinker.

Completed by (Staff #): ___ ___ ___ ___ ___

Reviewed by (Staff #): ___ ___ ___ ___ ___

Entered by (Staff #): ___ ___ ___ ___ ___

Participant #: __ __ __ __

Name Code: __ __ __ __

Visit #: __ __ __

Form Completion Status: __

1=CRF administered

2=Participant refused

3=Staff member did not administer

4=Not enough time to administer

5=No participant contact e

6=Other (specify: ________________)

f g h

Visit Date: __ __ /__ __ /__ __ __ __

Node #: __ __

Site #: __ __ __ __

m m d d y y y y

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Page 34 - App M | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Vol. 28, No. 1, 2004/2005 29

Screening Tests

Alcohol Use Disorders Identification Test (AUDIT)

The Alcohol Use Disorders Identification Test

(AUDIT) can detect alcohol problems experienced

in the last year. A score of 8+ on the AUDIT generally

indicates harmful or hazardous drinking. Questions

1–8 = 0, 1, 2, 3, or 4 points. Questions 9 and 10 are

scored 0, 2, or 4 only.

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Page 35 - App N | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

AUDIT-C

Please circle the answer that is correct for you.

1. How often do you have a drink containing alcohol? SCORE

Never (0) Monthly or

less (1)

Two to four times a

month (2)

Two to three times

per week (3)

Four or more times a

week (4) ______

2. How many drinks containing alcohol do you have on a typical day when you are

drinking?

1 or 2 (0) 3 or 4 (1) 5 or 6 (2) 7 to 9 (3) 10 or more (4) ______

3. How often do you have six or more drinks on one occasion?

Never (0) Less than

Monthly (1)

Monthly (2) Two to three times

per week (3)

Four or more times a

week (4) ______

TOTAL SCORE

Add the number for each question to get your total score.

______

Maximum score is 12. A score of > 4 identifies 86% of men who report drinking above

recommended levels or meets criteria for alcohol use disorders. A score of > 2 identifies 84% of

women who report hazardous drinking or alcohol use disorders.

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Page 36 - App N | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Screening Measure

Consider oering positive feedback and

educating patients who drink and use

cannabis about:

•

Recommended drinking limits

Screening Results Interpretation Clinical Guidance

AUDIT-C

(0-12 points)

Women: < 3 points

Men: < 4 points

Cannabis question

(0-4 points)

0-1 points

(0 or < monthly)

Other drugs question

(0-4 points)

1-4 points

(any use)

Negative Screen —

lowest risk (if no

contraindications

for drinking or

cannabis use)

Positive Screen —

drinks or uses

cannabis regularly,

at levels that can

impact health

High Positive Screen —

drinks, uses cannabis

and/or other drugs at

a level that is more

likely to impact health

and therefore needs

further assessment

Low-risk cannabis use.

Health risks of alcohol (e.g. cancers,

driving after drinking, pregnancy or

planning)

and cannabis use (e.g.

impaired driving, use disorder).

•

Brief counseling per

Key Elements in

a patient-centered manner consistent

with motivational interviewing:

Begin conversation, build rapport

Provide feedback on screening

Provide advice or recommendation

Support patient in setting a goal

and/or making a plan

•

Elicit symptoms (

Change #2)

Ongoing brief counseling (Change #3)

Manage alcohol and/or other drug use

disorders (

Change #4)

Follow-up monitoring of use and

symptoms and progress towards goal

(

Change #5)

•

Table 1.1 Interpreting AUDIT-C Plus 2 Screening Results

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Page 37 - App O | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

COLUMBIA-SUICIDE SEVERITY RATING SCALE

Screen Version

For inquiries and training information contact: Kelly Posner, Ph.D.

New York State Psychiatric Institute, 1051 Riverside Drive, New York, New York, 10032; [email protected]u

SUICIDE IDEATION DEFINITIONS AND PROMPTS

Past

month

Ask questions that are bolded and underlined. YES NO

Ask Questions 1 and 2

1) Wish to be Dead:

Person endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep

and not wake up.

Have you wished you were dead or wished you could go to sleep and not wake up?

2) Suicidal Thoughts:

General non-specific thoughts of wanting to end one’s life/commit suicide, “

I’ve thought about

killing myself”

without general thoughts of ways to kill oneself/associated methods, intent, or

plan.

Have you actually had any thoughts of killing yourself?

If YES to 2, ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6.

3) Suicidal Thoughts with Method (without Specific Plan or Intent to Act):

Person endorses thoughts of suicide and has thought of a least one method during the

assessment period. This is different than a specific plan with time, place or method details

worked out. “

I thought about taking an overdose but I never made a specific plan as to when

where or how I would actually do it….and I would never go through with it.

”

Have you been thinking about how you might kill yourself?

4) Suicidal Intent (without Specific Plan):

Active suicidal thoughts of killing oneself and patient reports having some intent to act on such

thoughts, as opposed to “

I have the thoughts but I definitely will not do anything about them

.”

Have you had these thoughts and had some intention of acting on them?

5) Suicide Intent with Specific Plan:

Thoughts of killing oneself with details of plan fully or partially worked out and person has

some intent to carry it out.

Have you started to work out or worked out the details of how to kill yourself? Do

you intend to carry out this plan?

6) Suicide Behavior Question:

Have you ever done anything, started to do anything, or prepared to do anything to

end your life?

Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note,

took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from

your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut

yourself, tried to hang yourself, etc.

If YES, ask:

How long ago did you do any of these?

Over a year ago? Between three months and a year ago? Within the last three months?

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Page 38 - App O | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

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Page 39 - App P | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Revised Impact of Event Scale (22 questions):

The revised version of the Impact of Event Scale (IES-r) has seven additional

questions and a scoring range of 0 to 88.

On this test, scores that exceed 24 can be quite meaningful. High scores

have the following associations.

Score (IES-r) Consequence

24 or more PTSD is a clinical concern.

Those with scores this high

who do not have full PTSD will have partial PTSD or at

least some of the symptoms.

33 and

above

This represents the best cutoff for a probable diagnosis

of PTSD.

37 or more This is high enough to suppress your immune

system's functioning (even 10 years after an impact

event).

The IES-R is very helpful in measuring the affect of routine life stress,

everyday traumas and acute stress

References:

1. Horowitz, M. Wilner, N. & Alvarez, W. (1979). Impact of Event Scale: A measure of subjective

stress. Psychosomatic Medicine, 41, 209-218.

2. Weiss, D.S., & Marmar, C.R. (1997). The Impact of Event Scale-Revised. In J.P. Wilson & T.M.

Keane (Eds.), Assessing Psychological Trauma and PTSD (pp.399-411). New York: Guilford.

3. Hutchins, E. & Devilly, G.J. (2005). Impact of Events Scale. Victim's Web Site.

http://www.swin.edu.au/victims/resources/assessment/ptsd/ies.html

4. Coffey, S.F. & Berglind, G. (2006). Screening for PTSD in motor vehicle accident survivors using

PSS-SR and IES. Journal of Traumatic Stress. 19 (1): 119-128.

5. Neal, L.A., Walter, B., Rollins, J., et al. (1994). Convergent Validity of Measures of Post-

Traumatic Stress Disorder in a Mixed Military and Civilian Population. Journal of Traumatic

Stress. 7 (3): 447-455.

6. Asukai, N. Kato, H. et al. (2002). Reliability and validity of the Japanese-language version of the

Impact of event scale-revised (IES-R-J). Journal of Nervous and Mental Disease. 190 (3): 175-

182.

7. Creamer, M. Bell, R. & Falilla, S. (2002). Psychometric properties of the Impact of Event Scale-

Revised. Behaviour Research and Therapy. 41: 1489-1496.

8. Kawamura, N. Yoshiharu, K. & Nozomu, A. (2001) Suppression of Cellular Immunity in Men

with a Past History of Post Traumatic Stress Disorder. American Journal of Psychiatry. 158: 484-

486

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Page 40 - App Q | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Mood Disorder Questionnaire (MDQ)

Name: Date:

Instructions: Check (

✓

) the answer that best applies to you.

Please answer each question as best you can.

1. Has there ever been a period of time when you were not your usual self and…

…you felt so good or so hyper that other people thought you were not your

normal self or you were so hyper that you got into trouble?

…you were so irritable that you shouted at people or started fights or arguments?

…you felt much more self-confident than usual?

…you got much less sleep than usual and found you didn’t really miss it?

…you were much more talkative or spoke faster than usual?

…thoughts raced through your head or you couldn’t slow your mind down?

…you were so easily distracted by things around you that you had trouble

concentrating or staying on track?

…you had much more energy than usual?

…you were much more active or did many more things than usual?

…you were much more social or outgoing than usual, for example, you

telephoned friends in the middle of the night?

…you were much more interested in sex than usual?

…you did things that were unusual for you or that other people might have

thought were excessive, foolish, or risky?

…spending money got you or your family in trouble?

2. If you checked YES to more than one of the above, have several of these ever

happened during the same period of time?

Please check 1 response only.

3. How much of a problem did any of these cause you — like being able to work;

having family, money, or legal troubles; getting into arguments or fights?

Please check 1 response only.

No problem Minor problem Moderate problem Serious problem

4. Have any of your blood relatives (ie, children, siblings, parents, grandparents,

aunts, uncles) had manic-depressive illness or bipolar disorder?

5. Has a health professional ever told you that you have manic-depressive illness

or bipolar disorder?

This questionnaire should be used as a starting point. It is not a substitute for a full medical evaluation.

Bipolar disorder is a complex illness, and an accurate, thorough diagnosis can only be made through

a personal evaluation by your doctor.

Adapted from Hirschfeld R, Williams J, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum

disorder: the Mood Disorder Questionnaire.

Am J Psychiatry.

2000;157:1873-1875.

Yes No

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Page 41 - App R | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

My Maternal Wellbeing Plan

SLEEP

It is often very hard to get rest or sleep when you have a new

baby, as a young baby is not meant to sleep through the night. It

is normal for them to sleep in 2-3 hour stretches. This will change

as baby grows. Sleep is important for your health. Your sleep will

probably change after the baby comes, but you can try these

things to help yourself get needed rest.

• You may need to sleep in 2-3 hour blocks at a time, strung

together to get you the 7-9 hours you need.

• During that time, don’t do anything except try to sleep. If you

need to get up for feeding, do it, change his diaper, but don’t

play with him, and then go right back to bed. Keep lights off,

low, or use a red bulb. Don’t start watching TV, turn music on,

or check your phone or other electronics.

• Create a healthy sleep environment—dark, quiet, comfortable,

with not a lot of distractions.

• In addition to the main sleep time, rest or nap when the baby is

sleeping. Don’t use that time for house chores or any work.

• You and your baby need time together. Take advantage of

offers for help by asking others to do household tasks.

• If you are feeling depressed or anxious, you may need to find

a way to get 5-6 hours of continuous sleep—research shows

this may make your depression or anxiety better. Have

someone else feed and care for the baby during that time.

EAT WELL

• Always have on hand: protein, veggies, fruit, whole grains.

• Prepack single-serve portions in baggies for easy eating.

• Keep healthy snacks where you sit to feed the baby.

• Drink water as you need it, have it easily available.

MOVE & Get Outside

• Aim for 30 minutes a day of movement. Start easy! Walk,

light housework or gardening, quick trip to the store or

errands or library.

• Try to get outside every day, even if just for a slow walk.

CONNECT

• Stay connected to supportive family and friends by phone,

email and text.

• Encourage short visits, and be very clear about “visiting

hours”.

• Accept offers of help. Ask for it if you need it!

Resources

Getting Good Sleep:

www.sleep.org

Baby Development:

www.helpmegrowmn.org

Nutrition for New Moms:

http://www.health.state.mn.

us/wic/nutrition/morenutinfo.

html

Places to find other parents/

new moms:

• Early Childhood

Family Education

• Family Home Visiting

• Community Parks or

Libraries

MATERNAL AND CHILD HEALTH SECTION

PO Box 64882, St. Paul, MN 55164-0882 651-201-3625 English July 19, 2016

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Page 42 - App R | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

My Maternal Wellbeing Plan

PLAN AHEAD

My best place for relaxing in my home is: ______________________________________

Healthy, easy foods I like to eat are: __________________________________________

People I can ask for help when I need it:

1. ________________________________ 2. _________________________________

Ways I like to exercise and connect with other people, which I could do with a small baby:

1. ________________________________ 2. _________________________________

JUST IN CASE

Having a new baby is a big change.

There are resources to help people figure

out how to adjust. You can find help to

keep you and your baby healthy,

mentally and physically. If it’s not going

well, it’s good to recognize that and get

help.

My early signs that I am feeling bad,

depressed, or too anxious:

• _____________________________

It can be difficult to talk about not doing

well. If you feel like this, who are 3

people you would talk with?

1.______________________________

______________________________________________

3. ______________________________________________

What will you say?

________________________________

GET HELP

If it is not an emergency, but I need

advice:

• Provider’s office daytime:

______________________________

• Provider/clinic after hours:

______________________________

• Pregnancy and Postpartum Support

warm help line: call or text:

612-787-7776

• Mother Baby Program: (warm line,

will call you back):

612-873-HOPE (4673)

If it is an emergency and I am scared I

will hurt myself or my baby:

* 911

* Crisis hot line: 866-379-6363

Please visit our webpage for more

information or printouts of this plan:

http://www.health.state.mn.us/divs/cfh/to

pic/pmad/

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

Page 43 - App S | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

Page 44 - App S | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Do I need therapy? How could a therapist or counselor help?

This might be exactly the question that a therapist could answer with you. There are so many things happening to you

right now--talking through them would be helpful. A therapist can also offer perspective on whether what you are

experiencing is postpartum depression/anxiety/traumatic response, etc. For parents experiencing these issues, a

specialist with training and experience is important. Find a therapist near you on our providers list:

www.perinatalsupport.org/providers.

What about medications? I’ve never used them before. Will I have to be on them forever? What if I am

breastfeeding?

First off, needing/wanting medication is not a weakness and it may not be the right choice for everyone. Medication is a

tool that can be helpful for some and may be needed for others. We highly encourage you to meet with a well-trained

provider on this issue, and to use the following sites to learn more: infantrisk.com or womensmentalhealth.org. You can

find more resources for medication management on our website, perinatalsupport.org.

I obviously want more sleep, but how? Can sleep deprivation really cause the feelings I am having?

Slleep dramatically impacts our mood, and can be the biggest risk factor for mental health symptoms. Often the very

first treatment intervention for depression or anxiety symptoms will be sleep--that’s how important it is. A sleep plan is

way more than “sleep when the baby sleeps.” It entails scheduling shifts and asking for help to ensure that you are

getting a minimum of 4-5 hours of sleep plus shorter stretches throughout the night and day.

A support group--really?

Support groups get a bad rap--maybe we should call them something else. The bottom line is that you will likely be

surprised by our groups. They are down-to-earth, refreshingly honest, and often bring some humor to an otherwise

difficult time. Also, they are a great way to meet other parents, and they are a great baby/parent-friendly place to go in

the first weeks when you just want to get out of the house but haven't mastered breastfeeding in public, are not sure

what to bring, etc. We have groups all around the state with times throughout the day and week. Social support is

crucial to reducing stress; meeting other parents going through the same life struggles can be the best medicine.

How am I supposed to eat healthy when I can’t even find time to eat, let alone cook?

Have you found yourself stuck holding a sleeping baby, without food or water for hours on end? Stash water bottles

and healthy snacks on the coffee table. Prepare hardboiled eggs, 12 at a time. Focus on eating high-protein and highly

nutrient-rich foods often. These will help balance your blood sugar. Have foods available that you can eat one-handed,

such as yogurt, meat, cheese, pre-cut veggies and fruit, or pre-made smoothies from the store. Aim for no cooking, no

plates, no utensils (well sometimes)--just open the fridge, grab, and put in your mouth. This phase won’t last forever

and usually when you’re not taking good care of yourself, you feel worse and vice versa. It seems small, but eating well

matters.

How can I possibly fit in me time? I’m feeding or attending to my baby all the time.

Taking care of yourself in the first weeks and months can seem like an impossible task, and taking care of your

relationship might seem even harder. We strongly encourage you (and your partner) to take time every few days to

yourself. This will look very different for each of us. And for many of us, the things we used to do to take care of

ourselves are not possible. It's important to think small and schedule time regularly. What brought you joy pre-baby?

Here are some ideas: hot shower by yourself, phone a friend, play music that makes you feel good, journal/jot down

your thoughts and feelings (sticky notes ok!), or listen to a mindfulness meditation or a podcast.

I’m overwhelmed by the state of my home, and it’s stressing me out. How can I get on top of things?

For household help, think of what you can delegate and what you can give up for now. Enlist everyone to do everything

you don’t want to do. Your job is to rest, heal, and take care of the baby. We mean it! If you don’t have someone to

ask, let things stay undone. You will get to it--at some point you will need clean dishes and you will do them.

What do you mean by a support team?

Is there someone in your life that you feel comfortable telling it like it is? A friend, a sibling, a parent, a partner? It's

important to share how you are really feeling and process this intense experience you have been through. These are

the people who you can ask for help, you can ask to just sit with you, or you can trust to take care of your baby.

People often want to help but are not sure how to navigate those first days and weeks of new parenting. If you don’t

want people over, definitely say no. But if you'd like help or company, please ask them to come over and bring a meal

on their way in and bring the garbage out when they leave! You can also find more information about support groups

and our warm line on our website, perinatalsupport.org.

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

Page 45 - App T | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers

Disclaimer:Thesematerialsaremadeavailableforpersonaluseprovidedthereisproperattribution,nochangesaremade,andnofeeischarged.

Page1

PPDRiskAssessmentDuringPregnancy

ImportantNote:

Thisassessmentisnotdiagnostic.Riskfactorsdonotcausepostpartumdepression.Ourintentionistohelp

youbecomeawareofthefactorsthatcanpotentiallymakeyouvulnerabletodepression,soyoucanmobilize

yoursupportnetworkandmakeuseoftheresourcesavailabletoyou.Thelistbelowarefactorsthatcan

increaseyoursusceptibilitytodepression.Checkallthatapplyanddiscusstheresultswithyourdoctor.

Infact,wewouldencourageyoutoprintitoutandtakethelistsoyourtreatingphysiciancanseeitandkeep

itinyourpatientfile.

• IwasnothappytolearnIwaspregnant.

• MypartnerwasnothappytolearnIwaspregnant.

• Ihavehadapreviousepisodeofpostpartumdepressionand/oranxietythatwassuccessfullytreated

withtherapyand/ormedication.

• Imighthaveexperiencedsymptomsofpostpartumdepressionfollowingpreviousbirths,butInever

soughtprofessionalhelp.

• Ihavehadoneormorepregnancylosses.

• Ihaveahistoryofdepression/anxietythatwasnotrelatedtochildbirth.

• Ihavelostachild.

• Ihavebeenavictimofthefollowing:

o Childhoodsexualabuse

o Childhoodphysicalabuse

o Physicalassaultbysomeyouknow

o Physicalassaultbystranger

o Physicalassaultduringthispregnancy

o Sexualassaultbysomeoneyouknow

o Sexualassaultbystranger

• Thereisafamilyhistoryofdepression/anxiety,treatedoruntreated.

• IhaveahistoryofseverePMS.

• Ihaveexperiencedsuicidalthoughtsorhaveconsidereddoingsomethingtohurtmyselfinmypast.

• IdonothaveastrongsupportsystemtohelpmeifIneedit.

• Ihaveahistoryofdrugoralcoholabuse.

• PeoplehavetoldmeI’maperfectionist.

• Duringthispregnancy,IhaveexperiencedsomeemotionsaboutwhichIamveryconcerned.

• Ifeelsad.

• MyrelationshipwithmypartnerisnotasstrongasI’dlikeittobe.

• MypartnerandIhavebeenthinkingaboutseparatingordivorcing.

• IamnotlikelytoadmititwhenIneedhelp.

318-20 N. Last Chance Gulch, Ste. 2C

Helena, MT 59601

406.449.8611 | www.hmhb-mt.org

Page 46 - App T | Screening Protocol for Perinatal Mood and Anxiety Disorders for Primary Care Providers







• 



• 

• 

• 

• 



• 

• 

• 

• 

• 

• 



