#PTonICE Daily Show – Monday, October 9th, 2023 – Postpartum depression, part 2: screening & what to say to a client

In today’s episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick  continues with part 2 of her series on postpartum depression. In this episode, she discusses how rehab providers can screen for postpartum depression. She also offers tips for communicating with clients who we suspect have postpartum depression with scripted suggestions and responses to support a client in the moment.

Take a listen to learn how to better serve this population of patients & athletes.

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What’s up PT on Ice Daily Show fam? My name is Dr. April Dominick, and today I’ll discuss how to screen for postpartum depression and share tips and scripted phrases that you can practice saying to get comfortable supporting someone you suspect has postpartum depression. In the ice pelvic division, updates and course offerings are going to be that we are on the road October 13th and 14th in Milwaukee, Wisconsin. And your next opportunity after that will be with myself and Dr. Christina Previtt. We will be tackling all things pelvic health in the Pacific Northwest in Corvallis, Oregon, and that’s gonna be October 21st and 22nd. So head over to PTOnIce.com and grab your seat. Our final courses for the fall are still listed, and you still have a few chances to catch us live. So in episode 1553, that was the last episode I did of this postpartum series, depression series, we talked about prevalence rates, we defined postpartum depression, and we talked about risk factors for postpartum depression. Since then, I ran across another systematic review from 2017 that cited worldwide greater than 10% of pregnant and immediate postpartum women are having depressive episodes, greater than 10%. That number is still astounding to me. While screening for PPD or postpartum depression is one thing, if someone is sharing that they’re struggling and you sense they have some signs and symptoms of postpartum depression, we as providers may feel empathy for the person in front of us, but we may be at a loss of words for how to communicate that with another individual. So in the second half of today’s episode, I’ll go through a few key phrases that you can build off of in response to someone you suspect having postpartum depression, with the ultimate goal, of course, being referring them to the appropriate mental health provider and or medical provider.


But first, let’s chat about how we can screen for postpartum depression. Just a quick definition of postpartum depression, it is going to be someone with moderate to severe depressive symptoms. That can arise around post childbirth whenever that occurs, all the way up to four weeks post childbirth. And then that can also last for up to a year or more postpartum. Postpartum depression, it affects daily functions. So someone has some struggles with chores or daily childcare tasks compared to the baby blues, which is a more mild form of depression. Postpartum depression does require medical intervention as well. So pregnancy and postpartum, as we all know, is a time of psychological vulnerability, especially in those first few weeks when there’s so much transition happening after delivery, which is why early identification and screening for treatment is key. So we want to ask the questions, whether that’s verbally or in a paper or outcome measure form. So ACOG recommends that patients be screened for postpartum depression at a few certain timeframes. At the first OB visit, at 24 to 28 weeks gestation, and there was a study in 2013 by Wisner et al that suggested for a majority, depression begins prior to delivery. So this is why we have those checkpoints during pregnancy. And then the other times that they suggest that we screen for postpartum depression is at the comprehensive postpartum visit, whether that’s at six weeks, four weeks, eight weeks. And then also I loved this at pediatric visits well into the first postpartum year, because pretty much after that six week visit, um, most women are not seen by their OB until the next year for their annual. So those are some timeframes that we as PTs are likely seeing these individuals maybe during pregnancy, postpartum, so we can also help with this screening process. In terms of outcome measures, there are a number of outcome measures out there that are used to screen for postpartum depression. We are going to go over two of the most common evidence-based tools. The first is the Edinburgh Postpartum or Postnatal Depression Scale, and then the Patient Health Questionnaire. They’re both two scales that are recommended by ACOG and by the Postpartum Support International Group, which is a really cool resource, and we’ll talk about it more in my next episode, but it’s going to be a resource available for those in that perinatal mental health space period kind of combines those two things. So the two outcome measures, the Edinburgh Postnatal Depression Scale and the Patient Health Questionnaire, we love them because they are available in many languages and they are quick to administer and they’re free. Who doesn’t love free stuff? They are validated also for the perinatal population. which I think is something important that while we can give someone a major outcome measure that’s for general depression, it’s even really more helpful to have someone go through an outcome measure that is specific to the time and space that they’re in. And then scoring, the lower the score for both of the outcome measures is going to indicate lower or more mild depressive symptoms. The cutoff value of 11 or higher out of 30 for the Edinburgh scale is going to maximize the combined sensitivity and specificity.


Let’s go through a couple of differences, though, between what we’ll call the EPDS for the Edinburgh Postnatal Depression Scale. So for the EPDS, it’s got 10 questions. And not only does it address the depressive symptoms and suicidal thoughts, but it also has an anxiety component of perinatal mood disorders. And that anxiety piece is likely what contributes to it being the most widely used screening tool. The other interesting thing I came across is that the EPDS is actually reliable and a valid measure of mood in the supporting partner, whether it is a male or a female, which I think is great. Example of items from the EPDS. are as follows. The person is going to be answering whether or not they have been so unhappy that they have been crying, the thought of harming myself has occurred to me, or I have felt scared or panicky for no good reason. Moving to the patient health questionnaire, that’s going to be nine questions that assess for the depression component. It does include an item about suicidal ideation, but it doesn’t have an anxiety component that the EPDS does. Instead, it includes some of the somatic symptoms of major depressive disorders, such as fatigue, sleep disturbance, changes in weight, and these reflect what is also on the DSM categories. Here’s an aside for all these outcome measures. So in my research, I ran across a study from 2017 by Ukatu et al, reviewing about 36 articles that used PPD screening tools, and they investigated the outcome measures and their ability to detect maternal depression. So two of the conclusions from this review that looked at a bunch of articles that use PPD were, one, is that they found no recommendation could be made about the most effective tool for detecting PPD, which is, I guess the good side of that is you can use, there are a lot of tools out there and they will likely be capturing the depression component.


The other thing that they mentioned was there’s no recommended time duration in which to screen patients, again, from all of those reviews that they studied. So one of the reasons they suggest that the timing can be difficult to recommend is that For certain outcome measures that are administered at the two-week mark, the outcome measure may not be able to differentiate symptoms of baby blues, which commonly ends after about two weeks post-birth, versus postpartum depression that can have a much later onset. And that can be anywhere from post-birth up to three to four weeks for onset. So I just thought that was an interesting find from the screening side of things. But the two that we talked about are the EPDS and the patient health questionnaire. So outside of administering those two outcome measures, when it comes to screening, you’ll want to also use the power of your ears and your voice to catch anything that may have been missed in those outcome measures. Remember, some people won’t necessarily be honest on the outcome measures. They may be less likely to share that they’re struggling due to the feelings of shame, abandonment, maybe they have a lot of guilt about not being enough for their baby, or they may not even realize their current emotional state, even when asked right on the outcome measure. So be an active listener. Ask the person How are you doing? But don’t stop there. If you get a general response that’s like, I’m good or I’m okay, I think you should ask it again. Say, I’m going to ask you again, how are you doing? Then you should also be on the lookout for words or phrases that the person may use in their conversation, like dark, heavy, blue. And then we certainly also want to have screening out postpartum psychosis in the back of our minds. So hearing voices that tell me to drop my baby, if you hear that, that is very serious. It is a medical emergency. This postpartum psychosis is going to affect about one to 3% of moms. So that’s how to screen postpartum depression. How do we have the difficult conversation? How do we navigate the intricacies? when we suspect the person in front of us may be suffering from some postpartum depression. A few general tips. You’ll want to listen with compassion and empathy, particularly to the non-physical symptoms. As neuroscientist, Dr. Andrew Huberman said, says, use your body to shift the mind. An individual that’s not functioning at their usual physical capacity, or is in pain, or I don’t know, recovering from a human body coming out of their body, or they’re lacking sleep, right? This does not only affect the physical body, but it’s also going to affect the brain and the soul. So it is within our scope to chat about this as their mental status is linked to their physical healing and recovery and management of their condition. As a provider, ignoring their mental status is not an option. You’ll also want to avoid being dismissive. So someone may have been very vulnerable with you and they shared that, you know, they’re just struggling. They’re struggling to find the energy. They’re struggling to feed themselves. And then you as a provider, like, okay, moving on to range of motion of your leg, like absolutely not. That is not acceptable. So avoid being dismissive, hear them out. Then remind them that addressing their mental health now will be so much more beneficial than months or a year down the line. And then mentioning that you’d like to take an integrative approach and refer them to a medication provider or their OB or a PCP or a psychiatrist, right? We’ll talk in the upcoming podcast, but medications like antidepressants are also a good treatment option for them. So what are some specific responses that you can practice or just have in the back of your head when you suspect someone may be experiencing postpartum depression? I don’t know about you, but especially in the public health space, I tend to get, you know, we talk about intimate subjects and there are some times that someone will share something with me. And I mean, I am feeling so much for them, but I have a hard time putting into words the quote right thing to say. And I’m not saying that these things, these scripting phrases that I’m going to give you are the right thing, but it’s something to go off of if you’re just struggling in that way.


So the first phrase, and I think it’s probably one of the most impactful, your feelings are validated. I’m in a group text with a few moms and one of them, they’ve all been recently pregnant and recently postpartum. Some of them have been going through some tough times when it comes to emotions. And one of them said, my OB put her hand on my arm and told me how brave I am for asking for help and really realizing that I need to be my best self for my family. And she told me I could call her office anytime to talk to her. And that meant so much. So just letting the person in front of you know your feelings are validated. Number two, early identification. So if you’ve got someone who is pregnant and you suspect that they’re going through some tough times from an emotional standpoint, you can say, you don’t have to feel this way for the next eight months of your pregnancy. There are resources available. Number three, highlight and celebrate the person’s abilities. Say, look at what you’re doing. All of this is very impressive given the circumstances and all the stress that you’ve been under. Bring it back to a potential or current bond with the baby. And you know, if the baby’s in the room with you, even better, have a little side conversation before the appointment starts with the baby. When I point to you, look at your mother with loving eyes. I’m just kidding. But definitely show the person or show the mother, look at how you’re learning what your baby needs, right? For comfort, for snuggles, for food, for diaper changes. So remind her of the role she’s playing. And then number four, remind her your health is a priority just as much as the baby’s is. So often, as soon as labor and delivery is over, maybe we have that six week, postpartum visit, the rest of the visits are not for the mother, they’re for the child. So just reminding her that her health is definitely linked and just as important to her baby’s health. And then number five, say this happens. There’s a fine line though between normalizing that this happens a lot, but also it’s not so normal that you don’t need to address, that we can’t have you not address it. So there was a resource that is, was in the deep dive realms of the ACOG website and the title, the title just gives me chills. It says, how do you talk about mental health conditions in a strength-based way? Love that. Here were their suggestions. Say mental health conditions are common. Mental health conditions are like medical conditions or like diabetes. They need to be treated. Medical conditions are, or mental health conditions are treatable. And that reminding the client that the aim is that every woman who is pregnant or postpartum or every person who’s pregnant and postpartum is screened for mood disorders. They also recommended that their clinical support office staff needs to be skilled in talking to patients in a strength-based way, as they may be the first to encounter a postpartum person. And I wholeheartedly believe that because the face of the first person you encounter can really and truly change the trajectory of your care. So let’s sum things up. If you’re a healthcare provider, interacting with someone In the pregnant and postpartum period, you are in a unique position to be screening for postpartum depression. We covered using two outcome measures such as the Edinburgh Postnatal Depression Scale or the Patient Health Questionnaire. If we suspect PPD, we as rehab providers can be confident in having these early conversations early on and during the client’s pregnancy and then again in the early postpartum period. Using tips and verbal responses, the scripting phrases that I mentioned, can help support and validate the client’s concerns in a strength-based way. Reminding them that their health is equally as important as their baby’s. Reminding them of what they’ve accomplished under these incredible circumstances. And telling them, hey, this condition is treatable, just like we would treat a shoulder injury. This awareness can decrease stigma, it can normalize screening and detection, and encourage women to discuss any mental health concerns with you. Join us next time for specific treatments, resources, and ways to support a person with postpartum depression. Cheers, y’all.


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