Postpartum Depression Screening: Initial Implementation in a Multispecialty Practice With Collaborative Care Managers

Postpartum Depression Screening: Initial Implementation in a Multispecialty Practice With Collaborative Care Managers Journal of Primary Care & Community Health 1(3) 158 163 The Author(s) 2010 Reprints and permission: sagepub.com/journalspermissions.nav DOI: 10.1177/2150131910380055 http://jpc.sagepub.com Christina L. Wichman, DO 1, Kurt B. Angstman, MS, MD 2, Brian Lynch, MD 3, Denise Whalen 4, and Nathan Jacobson, DO 2 Abstract Postpartum depression (PPD) has emerged as an important issue for pediatricians and family practitioners because of detrimental effects on children. PPD occurs in 10% to 22% of women who have recently given birth, but fewer than half of cases are recognized. Despite the impact of PPD, many primary care clinicians do not have systemic screening approaches implemented. This paper will review the development of a screening protocol for PPD in a multispecialty clinic, with the implementation utilizing depression care managers and the preliminary results of our process. Of the 333 screened examinations during the 4-month study, 38.1% (n = 127) were performed for the 2-month well child examination; 33.6% (n = 112) were for the 4-month examination, with 28.2% (n = 94) being performed for the 6-month well child examination. Only 15 (4.5%) were positive for possible depression with a screening compliance rate of 47.9%. significant difference was noted in the timing of the well child visit with a positive screening test result, nor was there any difference in family medicine versus pediatric colleagues in the utilization of the screening or diagnosis of PPD. Implementation of PPD screening in a multispecialty clinic can be effective, given utilization of depression care managers. Keywords Postpartum depression, care management, primary care, practice improvement Postpartum depression (PPD) occurs in 10% to 22% of women who have recently given birth, but fewer than half of cases are recognized. 1-3 Many women will have depression symptoms during pregnancy and for the first year following delivery, and the terminology may be more appropriate as perinatal depression. 4 PPD has emerged as an important issue for pediatricians and family practitioners because of detrimental effects on children. 5,6 Maternal depressive symptoms are associated with fewer positive parenting behaviors and more negative interactions with young children. 7,8 Depressed mothers use pediatric services more and have children who are more likely to develop depression and other behavioral problems. 9-11 Treatment of PPD will improve outcomes for the infants. 12 Mothers of young children are more likely to have contact with a pediatrician or family physician than any other health care provider. Pediatrician inquiries about maternal mental health have been viewed as appropriate by mothers. 13,14 Pediatricians are encouraged to incorporate detection of parental depression into routine care of the child. Most pediatricians, like other primary care providers, have nonsystemic screening approaches 15,16 and low detection rates for maternal depression. 17 The vast majority of pediatricians (81%) rely on observation of symptoms, while only 8% of pediatricians ask routinely about maternal depression. 16 There have been a number of studies that have looked at the feasibility of maternal depression screening at well child examinations. 18-21 It was found that screening for PPD 1 Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA 2 Department of Family Medicine, Mayo Clinic, Rochester, Minnesota, USA 3 Division of Community Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA 4 Division of Preventive, Occupational, Aerospace and Executive Health, Mayo Clinic, Rochester, Minnesota, USA Corresponding Author: Kurt B. Angstman, MS, MD, Department of Family Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55906 Email: angstman.kurt@mayo.edu

Wichman et al 159 improved the rate of depressive symptom detection and increased the rate of mental health referrals 20 while requiring minimal clinician time. 18,19 Despite the understanding of the impact of PPD, many primary care clinicians do not have systemic screening approaches implemented. In 2010, the American College of Obstetricians and Gynecologists reviewed this topic and provided a committee opinion. 22 The recommendations include acknowledgment of the importance of this disease process to the mother and the infant but concluded that there is insufficient data to make recommendations on how often screening should be done. The opinion did recommend that screening should be considered and a process for follow-up and treatment be developed. In 2008, a care manager model of treatment for adult depression was implemented at our clinical sites. This was based on the IMPACT model, 23 which successfully integrates a care manager into the primary care practice with weekly psychiatry oversight. Patient contact by the care manager is dictated by the clinical scenario; some are contacted weekly, while other patients were contacted monthly. Other components of the collaborative care model include a systematic screening approach, appropriate diagnostic screening and standardized monitoring of improvement to ensure adequate therapy, the development of a patient registry, and the utilization of treatment guidelines. A metaanalysis by Gilbody in 2006 evaluated depression outcomes using a collaboration care model and demonstrated the significant improvements in treatment of adult depression over usual care. 24 Several smaller studies done at our institution have also shown significant improvement using this model over usual care. 25-27 Because of the success in the treatment of depression in primary care patients using a collaborative care model, expansion of the practice improvement process to other patient populations that were considered high risk was implemented. This paper will review the issues we encountered as well as discuss some of the resolutions in the development of a screening protocol for PPD with the implementation utilizing depression care managers and the preliminary results of our process. Methods Mayo Family Clinics are located in 2 locations in northern Rochester, Minnesota. The sites employ 31 physicians, who are board certified in family medicine, internal medicine, or pediatrics, and 5 nurse practitioners. There are 42,000 patients who receive care in this community-based practice, with approximately 50% being employees of the Mayo Clinic or their dependent children. A screening process for PPD with the Edinburgh Postnatal Depression Scale (EPDS) 28 was developed for mothers of infants who were presenting for a 2-, 4-, or 6-month well child examination. A team consisting of nurses, front desk staff, secretarial staff, and primary care and psychiatric physicians was charged with creating the workflow and an implementation strategy. The EPDS was new to many in the practice, so the form and scoring methods were shared with all staff. The protocol was implemented in June 2009, and the study period was through September 2009. The mother s name, date of birth, telephone number, her child s name, and primary care physician were documented on the form as this information was vital in documenting the outcome in the mother s medical record. The process began upon the patient s arrival for a 2-, 4-, or 6-month well child visit. This included visits that occurred exclusively with a nurse. The screening was initiated only if the birth mother accompanied the child. If the child was brought in by someone other than the mother, screening was not attempted by other means. There was no exclusion of visits if the child was not accompanied by the biological mother to the visit. This was a pilot study so questionnaires, administration, and collection were new duties for our desk staff, nurses, and providers (Figure 1). During the intake process, the nurse collected and scored the EPDS form, highlighting the total and the answer to question 10. A positive score was a total of 11 or more or a positive response to question 10, which raises concerns about suicide. The infant s provider determined if any intervention was necessary. Options for management of a positive screening included contacting the depression care manager. Depression care managers would coordinate the mother s care with internal and community resources or schedule regular follow-ups including telephone calls and/or nurse office visits. If the infant s physician was a pediatrician or not the mother s primary care provider, the care manager could schedule a return visit with the mother s primary care physician. If the mother was determined to be severely depressed or suicidal, then an emergency plan was developed. This included management arranged through the on-call psychiatry consultant along with a possible transfer of the patient to the emergency department. In addition, family medicine consultants were readily available for consultation of the adult patients for their pediatric colleagues. All EPDS forms were returned daily to the depression care manager, who would ensure that appropriate action was taken and documentation was entered into the mother s electronic medical record. The depression care manager was also responsible for notifying the primary care physician if not yet involved. The well child examinations were performed by physicians and nurse practitioners from family medicine and

160 Journal of Primary Care & Community Health 1(3) Receptionist adds EPDS form to all 2, 4, and 6 mo well child visit forms (including nurse appts.) Provider retrieves rooming packet Patient arrives Is mother checking in patient? Is mother here? further action necessary Provider enters and begins the well child exam Place paperwork in the following order: 1. Developmental 2. EPDS 3. Business Office Instruct individual checking in patient of the form to be completed by the patient s mother Provider reviews with mother and scores the form Has mother completed the EPDS? Is the EPDS score 11 or is the answer to #10 positive? Assess the severity of the situation and proceed with one of the following actions: o Contact a Care Manager (optimal) o Schedule urgent visit with primary care physician o Contact on-call psychiatry consultant Patient called by nurse o o Contact Psychiatry ED resident on-call Transfer patient to Emergency Department for psychiatric evaluation Patient taken to vitals room to be weighed and measured Place completed and initialed form in file Care Manager s office to document in mother s medical record Patient is escorted to exam room LPN returns to room to administer vaccinations Inbox primary (if Care Manager is involved, they will update Primary Physician via Inbox) Document in Clinical tes Nurse creates stub note, begins interview process, enters vitals into patient s medical record End Order return visit for child s immunizations or have LPN administer if appropriate Have forms been completed? Nurse scores the form and includes the total score and response to question #10 on EPDS then exits room leaving completed paperwork in rooming packet for Provider to review Ask mother to continue to work on Next step at top of page Place completed and initialed form in Care Manager office. Care Manager will document in mother s medical record End Figure 1. Implementation process for Edinburgh Postnatal Depression Scale (EPDS) screening. pediatrics at 2, 4, and 6 months. Some healthy infants had a registered nurse checkup at 6 months, which included immunizations, vital signs, screening EPDS, and education. Statistical analysis utilized χ 2 testing for the categorical data. All information was obtained from the patient s electronic medical record or from EPDS. The study was approved by the Institutional Review Board.

Wichman et al 161 Results Based on birth data, during the 4 months of this study, there were 695 potential well child examinations performed at our primary care clinics. Depending on the birth month, approximately a third of the potential well child examinations could have been screened twice. It was possible for the birth mother to not be present (and not documented) and to not complete the testing for any reason; there was a compliance rate of 47.9%. Of these 333 screened examinations, 38.1% (n = 127) were performed for the 2-month well child examination; 33.6% (n = 112) were for the 4-month examination, with 28.2% (n = 94) being performed for the 6-month well child examination. Of the completed EPDS form, only 15 (4.5%) were positive with a score of 11 or more. Of the positive test results, 8 (53.3%) were positive at the 2-month well child examination (n = 118), 2 (13.3%) at the 4-month well child examination (n = 112), and 5 (33.3%) at the 6-month examination (n = 94). There was no statistically significant difference in the number of positive screenings by the month of the examination (P =.21). Three positive examination findings (n = 78) were done while seeing a pediatrician, while 11 (n = 205) were documented while the patient was seeing a family medicine provider. There was no significant differences in the rates of positive examination results based on the specialty (P =.78). Two examination findings (n = 50) were scored positive at a 6-month nurse visit. Discussion Primary care research has demonstrated that the outcomes from depression screening are enhanced when utilized in conjunction with systems that ensure accurate diagnosis, treatment, and follow-up. 29,30 The collaborative care model system has been a successful part of our primary care practice since 2008 and has been reviewed in prior publications. 25-27 Implementation of PPD screening for mothers at their child s 2-, 4-, and 6-month visits with management of failed screens through collaborative care managers was successfully initiated into our primary care practice. The EPDS was completed at 47% of eligible visits, and 4.5% of mothers had positive screen results. Our screening rate of 47% is similar to other studies. 21 There is no consensus on the proper time intervals to screen for PPD, and some providers will screen women up to 1 year following a delivery. The utility of screening at multiple visits and at specific time frames will need to be evaluated with future studies. Although the EPDS was used for screening for PPD during this pilot study, it was determined to be a significant change in our process of the management of depression. The collaborative care model for adult depression utilizes the Patient Health Questionnaire-9 (PHQ-9) 31 for screening. There has been documented use and discussion of the use of the PHQ-9 for PPD. 20 Because of these reasons, after the pilot study, the primary clinics changed the instrument used for screening from the EPDS to the PHQ-9. Any woman with a positive PHQ-9 finding with a score of 10 or more was also screened with an EPDS by the depression care manager. The strengths of this pilot study demonstrate that initiation of a process of PPD screening in a multispecialty clinic is feasible and that the utilization of care managers improved the process flow. This study is limited by the small sample size; it was not a randomized study; there were no controls for medical comorbidity, age, and prior psychiatric care; limited positive screening results; and the narrow time window of the study. Generally, the patient population was not racially diverse and limited in insurance and employment characteristics. If a mother was positive for depression screening but was not a patient of our primary care clinics, the care managers could be utilized as a resource for coordinating initial follow-up, but no tracking mechanism was in place for these patients. Although the study was not designed to detect utilization differences between the specialties, there were no significant differences in the percentage of mothers screened, or mothers had positive screening results, or the outcomes of mothers referred to care management between family medicine and pediatric patients. Thus, a standardized screening and referral system can equalize the standard of care for depression screening among family medicine physicians, pediatricians, and nurse practitioners. Conclusions Screening and treatment of PPD can improve the health of both the mother and the infant. Although screening is recommended, consistent clinical use is not seen. Utilization of a depression care manager to help manage the positively screened mothers at the infants well child examinations can help the implementation of a clinical screening process, even in a multispecialty clinic. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the authorship and/or publication of this article. Funding The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: The funding for this paper was from internal department funds.

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Wichman et al 163 Dr. Kurt B. Angstman is an assistant professor of Family Medicine at Mayo Clinic. He was the medical director of Mayo Family Clinics from 2006-2010. Previously, he was in private practice in rural southwestern Minnesota for 15 years. His clinical interests are in practice management and quality improvement. Dr. Brian Lynch is an instructor of Pediatrics and Adolescent Medicine at Mayo Clinic. He has been on the medical staff at Mayo Clinic since 2007 and prior to this worked two years at a community health center in northeast Iowa. His clinic interests include developmental, autism and mental health screening in primary care as well as pediatric asthma. Denise Whalen is currently a Clinic Operations Supervisor in Preventive, Occupational, Aerospace Medicine and Executive Health at Mayo Clinic. Previously, she was the Clinic Operations Supervisor in Primary Care for 13 years. In this role, she made significant contributions to the primary care practices of FM, Int Med, and Peds leading multiple practice improvement efforts in areas such as influenza immunization planning, medication management, telehealth technology, and telephonic care/services. Dr. Nathan A. Jacobson is an assistant professor of Family Medicine at the Mayo Clinic in Rochester, MN. He did his residency in Family Medicine at the Mayo Clinic. His clinical interests are obstetrics, women s health and residency education.