Improving Care for Postpartum Depression and Anxiety

Perinatal mood and anxiety disorders, including postpartum depression and pregnancy- related depression, are the most common complication of pregnancy and the postpartum period for both new mothers and fathers. Because successful navigation of the perinatal period lays the foundation for child well-being and healthy development, it's imperative to identify and treat these serious conditions. Developing postpartum depression treatment guidelines can help providers set moms and their babies up for success.

Here's what providers need to know:

• Difficulties can begin anytime during pregnancy or the first year postpartum, including after loss of pregnancy.
• Mental health complications during the perinatal period may include depression, anxiety, obsessive-compulsive symptoms (including intrusive thoughts of harm), onset or exacerbation of bipolar disorder and, in rare cases, psychosis.
• Men and woman are both affected by perinatal mental health issues.
• About 80 percent of new mothers experience normal "baby blues" beginning in the first days after the baby arrives. This period typically lasts about two weeks and does not include suicidal ideation or intrusive thoughts.
• At least one in nine mothers and one in 10 fathers experience serious depression or anxiety during pregnancy or postpartum.
• Depression rates are typically much higher in teen mothers, mothers of preterm infants, and women with high levels of interpersonal conflict, limited partner or social support and lower income.
• One or two out of 1,000 women experience postpartum psychosis, which is a psychiatric emergency.

Untreated postpartum mental health conditions may lead to increased medical costs, earlier discontinuation of breastfeeding, delays in cognitive and emotional development and a higher risk for depression, anxiety, ADHD and learning disorders in childhood and adolescence.

Symptoms of postpartum depression

• Feelings of sadness, anxiety, worthlessness or hopelessness
• Anger
• Lack of energy for everyday tasks
• Trouble sleeping even when the baby is asleep
• Sense of stress that interferes with daily life
• Loss of interest in food or preoccupation with eating
• Loss of interest in self-care
• Loss of concentration
• Difficulty making decisions
• Lack of pleasure or interest in most or all activities
• Excessive anxiety about the baby
• Lack of interest in or feeling disconnected from the baby
• Fears of harm coming to the baby or thoughts of harming the baby
• Thoughts of suicide

Postpartum depression screening

Publication of the Adverse Childhood Experiences (ACE) Study 20 years ago increased awareness of the impact of psychosocial stressors and adverse life events on long-term health and wellness. The transition into parenthood is a vulnerable life stage and an important time for providers to support parental mental health and decrease the child's risk for negative health outcomes.

Self-harm (including suicide and overdose) was the most common cause of pregnancy-associated mortality in Colorado from 2004 to 2012, with most deaths occurring in the first year postpartum. Identification and postpartum depression care in the early perinatal period can decrease these risks.

In 2016, the U.S. Preventive Services Task Force recommended that all healthcare professionals who have contact with pregnant and postpartum mothers should screen for perinatal mood and anxiety disorders. The American College of Obstetrics and Gynecology recommends screening at least once during the perinatal period — ideally at the first prenatal visit, at least once in second and third trimesters and at the six-week postpartum obstetrical visit.

The percentage of mothers who attend the six-week follow-up visit is much lower than those who attend the baby's well visits. The American Academy of Pediatrics recommends screening at the one, two, four and six-month well-baby visits.

The most common screening tool used in primary care settings is the Edinburg Postnatal Depression Scale (EPDS). This free tool is validated in pregnancy and postpartum screening and is translated to many languages. The EPDS also identifies many symptoms of anxiety that are common in new mothers.

Starting the conversation about postpartum depression

Talking about postpartum depression or anxiety can require sensitivity and a gentle approach. When screening for or discussing postpartum symptoms in patients:

• Use EPDS questions as a springboard to start conversation with families.
• Explore the mom's birth experience, mood and support system.
• Be empathic and warm, and use nonjudgmental language.
• Be cautious not to say they're "normal," as parents may feel their concerns dismissed or that they will not get better.
• Offer strategies that promote movement towards healthier lifestyle and social support, even in the case of "baby blues." Early intervention can prevent progression to a full depression or anxiety disorder.
• Share Postpartum Support International's message of hope: "You are not alone. You are not to blame. With help, you will be well."
• Become familiar with referral options in the community, including Children's Hospital Colorado's Healthy Expectations Perinatal Mental Health Program.
• Offer patients support for connecting with family members and resources. For example, someone in your clinic could make calls to support organizations or resources along with the patient during the visit.
• Follow up with families about whether they connected with referrals and explore barriers that prevent them from accessing further supports.

Healthcare providers can also review the Colorado Department of Public Health and Environment Provider Resources for additional suggestions for postpartum depression care.

Postpartum depression initiatives

A former patient of the Healthy Expectations Perinatal Mental Health Program developed severe postpartum depression and anxiety following a traumatic delivery that resulted in her son being admitted to the NICU. After treatment and recovery, this new mother reflected on the missed opportunities to identify her illness and her struggle to access appropriate care before coming to our program. She contacted her state senator and representative and told them her story.

Last year, via a Senate Joint Resolution, Colorado declared the first week of May Maternal Mental Health Awareness Week. In addition, the state expanded funding for perinatal mood and anxiety disorder screening to three times per year for mothers with Medicaid and CHP+. More and more, patients are recovering and making their voices heard and transforming postpartum maternal care — paving the way for better access to treatment for future patients.

Many Colorado pediatric practices have been screening for perinatal mood and anxiety disorders at well-baby visits for a long time already. The Colorado Department of Public Health and Environment has made addressing perinatal mood conditions one of its top priorities, and many local and state-wide stakeholders have been involved in improving awareness and access to resources. A public awareness campaign was released in English and Spanish in the past year, and many resources are available to help practices implement screening protocols (see contact information for the Colorado Children's Healthcare Access Program below).

Postpartum programs offered at Children's Colorado care locations

Children's Colorado Anschutz Medical Campus, Aurora

• Mother-infant therapy group: A 12-week topic-based group that supports mothers and babies in their relationship. This group includes a weekly mothers-only portion, a weekly mother-baby portion, several individual sessions and some parenting partner's (i.e. father's and other partner's) involvement. We also offer medication consultation and management.
• Bearing Hope: A 12-week, topic-based group providing support to pregnant women experiencing distress and symptoms of a mood or anxiety disorder. We offer medication consultation and management.
• Mothers and Moods: A free drop-in support group for mothers experiencing distress during the postpartum period. Babies remain in the session with their mothers.

Children's Colorado South Campus, Highlands Ranch

• MAMAS Connect: A 12-week, topic-based group providing support for mothers and babies in the postpartum period. We offer medication consultation and management.

Healthy Expectations Perinatal Mental Health Program at Children's Colorado

We offer services designed to meet the needs of adult mothers experiencing emotional distress at our Anschutz Medical Campus in Aurora and our South Campus in Highlands Ranch. We accept most major insurance carriers, as well as Medicaid.

Providers, patients or family members can call our WarmLine at 303-864-5252 to leave a message, or email healthyexpecations@childrenscolorado.org for more information. Patients can call directly for an appointment.

Additional postpartum depression resources and programs

The Colorado Children's Healthcare Access Program

The Colorado Children's Healthcare Access Program, also known as CCHAP, is a statewide nonprofit that works with community pediatric providers to support, promote and sustain increases in pregnancy-related depression screening, referrals and practice transformation efforts.

We know the potential adverse impacts of maternal depression on a child's emotional, intellectual and social development. Pediatric primary care practices are well-positioned to administer screening during well-child visits, as they are often a mother's first and most frequent contact with the healthcare system after delivery. CCHAP offers coaching and technical assistance to providers for integrated behavioral health and links providers to community resources for practices based on their size, geographic location, available resources and capacity.

For behavioral health questions or support, visit CCHAP's website or call 720-330-2797.

Colorado Department of Public Health and Environment

Find downloadable materials and resources from the CDPHE pregnancy-related depression and anxiety public awareness campaign.

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1. Sit DK, Wisner KL. Identification of postpartum depression. Clinical obstetrics and gynecology. 2009;52(3):456-468.