As a practicing physician, there is a lot to be mindful of right now. Today, COVID-19 is on the forefront in most healthcare settings, both in identifying and treating symptoms of the virus, and in inhibiting its community spread. In the multiple labor and delivery units where I work as an OB hospitalist, the culture change is clearly visible — an event that is usually filled with family members and friends is now a relatively isolated experience, moreover, with smiling faces hidden by masks and additional layers of personal protective equipment it becomes more difficult to physically interact with patients as we previously have.
Less visible is the emotional impact that the isolation and dearth of human contact can have on patients, all of which is further exacerbated by the concern of then pandemic itself.
According to a recent survey by the U.S. Census Bureau, over one-third of Americans show signs of clinical depression and anxiety. With a prevalence this high, one fully expects a significant co-existence of depression and pregnancy. In addition to the emotional impact of COVID-19, research from the Centers of Disease Control and Prevention (CDC) found that nationally, 13% (1 in 8) women experience symptoms of postpartum depression (PPD) — that is, dysphoria caused by the biological (primarily hormonal) changes of pregnancy, labor, parturition and the transitions between these. The good news is PPD is treatable; identifying women that are experiencing the symptoms associated with depression allows us to provide them with the tools and resources to feel better. Such management includes medication, counseling, or some combination of the two. However, according to the same CDC study referenced above, 20% of women are never screened for depression, and over half of those with depression are never treated.
Given the myriad of new precautions, testing, protocols, and requirements for patient treatment needed on a day to day basis, where does one start with addressing PPD? More good news: it is not nearly as onerous nor time-consuming as one might expect.
It starts with the physician. While not all hospitals require depression screening, many of us have tried to make it a personal best practice to ensure that patients are given the PHQ-9 (or Edinburgh Postnatal Depression Scale (my personal preference) depression screening questionnaire, even if the signs we might suspect to see indicating depression aren’t visible at first glance of a patient’s record (or the patient herself). The actual screening is quick. Starting from the time it’s given to the mother to complete, to the time it’s reviewed, scored, and assessed by the physician takes a total of about 5 minutes. Five minutes well spent that could potentially make a lifetime of difference for that particular patient.
Secondly, physicians should keep top of mind that depression is typically a silent illness. There are a variety of socioeconomic factors that make mothers more prone to depression, and it tends to be more prevalent among mothers with lower income and to mothers of babies admitted to the neonatal intensive care unit. However, that doesn’t mean it’s not something that also happens to mothers with the most uncomplicated pregnancies and deliveries. And, importantly, to those that are very compliant with all prenatal care management. In fact, these mothers might even be less likely to be screened. Taking the first steps towards addressing depression is dependent on self-assessment by the patient. Using the questionnaire as a first step can give mothers in need of help permission to acknowledge that perhaps they’re feeling dysphoric, and hopefully take the first steps in getting the care they need.
Finally, discussing depression and anxiety in a manner that minimizes the stigmatization of these common conditions is vitally important to mothers. Consider this scenario: An infant has APGAR scores of 8/9, the mother has great blood pressures, maybe even looks happy. There may even be some instances where the mother knows that her emotions have been somewhat “off,” but does not necessarily feel that her symptoms of depression warrant any intervention. Given this happy scenario, depression may not be Number 1 on the problem list. It is seldom that a patient would feel affronted by being asked to complete a depression screen; more likely, they will feel that their physician is being thorough. The patient also is given the sense that the ‘door is open’ to discuss more than their chief complaint. We make sure new moms have a smoke detector installed in their home and a car seat set up properly before we send them on their way. Depression screening and referral are just as important for the mother and child’s safety as these measures.
While physicians can take the lead role in helping link patients to resources, state leaders are also looking to develop solutions to ensure women needing help can be identified and assisted. States that presently have some form of legislation mandating some form of postpartum depression assessment are Texas, Oklahoma, Illinois, Virginia, New Jersey, Massachusetts, and Pennsylvania.
Most physicians want to do what’s best for their patients, though without knowing the thoughts and feelings of those in our care, it’s not always easy to link them to essential tools that can help them lead healthy, productive, and happy lives once they leave our care. By incorporating depression screening into our patient care routine, we can help shine a light on those that may need our help most, and provide them with a pathway towards their best tomorrows.
Dwight Hooper is an obstetrician-gynecologist.
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