Posts Tagged ‘prenatal depression screening’

Mother’s Mental Health: Professional Perspectives and Childbirth Education Part I

December 6th, 2012 by avatar

By Walker Karraa

Regular contributor Walker Karraa has written an excellent three part series on Perinatal Mood and Anxiety Disorders (PMAD) and what the childbirth educator or birth professional can do to help women get the help they may need when dealing with mental illness during the prenatal and postpartum period.  Walker interviews experts in the field who all offer concrete steps, activities and resources so that educators and others can do to be more prepared to discuss this important subject with students and clients.  Recent press coverage of a British mother suffering from severe PMAD has made headlines and the topic is one that belongs in whatever childbirth class a woman chooses to take. – Sharon Muza, Community Manager.


Safety regarding the use of a specific type of antidepressant medication, selective serotonin reuptake inhibitor (SSRI’s), is an important topic as maternal health care providers address the prevalence and negative effects of depression and other mood disorders in pregnancy and postpartum. Recently, the study The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond (Domar, Moragianni, Ryley & Urato, 2012) has garnered tremendous attention from media, researchers and childbirth professionals. I had the opportunity to ask the study’s authors and other experts about the dangers of discontinuation in a piece for Giving Birth With Confidence. From that article, we hear the overwhelming agreement; including two of the study’s authors, that sudden discontinuation of SSRI antidepressant medications in pregnancy is not advisable.


A week later, I learned about the tragic case of Felicia Boots, a 35 year old woman in the United Kingdom who, fearing she was harming her baby by taking SSRI’s and breastfeeding, suddenly stopped. Shortly after, she took the lives of her 14-month old and 10 week old children. A special editorial published by The Lancet (November 10, 2012), noted: “She had stopped her prescribed antidepressants because she was convinced that the drugs would harm her baby through her breastmilk and feared that her children would be taken away from her”(p. 1621). The authors went on to state: “A society in which women know that they will receive empathy, understanding, and help might be one in which women seek advice more readily, and accept appropriate treatments” (Lancet, 2012, p. 1621).

This is a vision shared by the guiding principles of maternity care–as childbirth professionals have always worked for a society where women know they will be cared for, understood, and have access to appropriate interventions. Unfortunately, we have failed to include mental health. How might the childbirth education community better address these issues? Asking experts is a place to start. What is uniquely helpful here is that the same questions were given to all participants—shedding light on one commonality: education.

Today’s article features Julia Frank, MD. Dr. Frank is a Professor of Psychiatry and Behavioral Sciences at the George Washington University School of Medicine and Health Sciences, where she has been the Director of Medical Student Education in Psychiatry since 2000. A graduate of the Yale University School of Medicine and of the residency program in psychiatry at Yale, Dr. Frank is also the founder of `Five Trimesters Clinic, a service for women with mental health needs relating to pregnancy and childbirth. In this installment, Dr. Frank addresses how childbirth educators might address these complex issues.

WK: How might childbirth professionals integrate an understanding of postpartum psychosis (PP) and other perinatal mood disorders in classes? 

Dr. Frank: It is important to stress that the condition is rare but serious and treatment is generally quickly successful. Women with a family history of bipolar disorder or of postpartum psychosis in relatives should be told that they are at somewhat increased risk. Giving information in writing to them and their partners about what to look out for (especially profound sleeplessness and confusion) in the first couple of weeks postpartum might also be helpful.

WK: The recent Lancet editorial regarding the Felicia Boots tragedy stated: “Postnatal depression and, more broadly, perinatal mental health disorders, are among the least discussed, and most stigmatizing, mental health illnesses today” (p. 1621).   

How would you describe the stigma of perinatal mental health disorders and its impact?

Dr. Frank: I think the widespread publicity given to the sensational cases with terrible outcomes makes it hard for women to admit to any difficulty postpartum. The general public tends to conflate postpartum depression with psychosis. I have had women say to me “I don’t think I’m depressed, because I don’t want to hurt my baby”. We also overemphasize depression and neglect anxiety. I am not sure that is a factor of stigma, but it certainly contributes to under diagnosis.


Obstetricians and pediatricians may not recognize or discuss a postpartum psychiatric disorder for fear of offending the affected mother. Other aspects of stigma that apply to professionals are the belief that psychiatric disorders are overwhelmingly time consuming to address, that women who have them lack insight, that treatment is generally no better than passage of time.

WK: What do you see as the most significant barriers to treatment for women with perinatal mood and anxiety disorders (PMAD)? 

Dr. Frank: In the US, the disconnection between mental health care and medical care, written into our insurance systems, is a major barrier. Also, the way pediatricians are trained to deal only with the child, and not to assume any responsibility for the health of the mother, keeps them from screening appropriately. Obstetricians also maintain an overly narrow focus on the woman’s organs, and they tend to have very little contact with mothers after delivery, nor do most of them see mental health as within their sphere of interest or expertise. Fears of liability from the effects on the fetus of treating the mother are another barrier, especially in the US, where medical injury to an infant can bring astronomically high damage awards. This is a particular barrier to some psychiatrists being willing to initiate or maintain treatment related to pregnancy.

WK: How would you respond to media-based concerns regarding the safety of SSRI medication in pregnancy? 

Dr. Frank: There is no pregnancy without risk, and the risks of not treating a serious psychiatric disorder are as important to consider as the risks associated with treatment.  When we bypass maternal suffering out of concern for the safety of a fetus, we are making a misguided moral judgment that privileges “innocent” life over life as lived. The risks of these drugs are important and should be weighed carefully, but it has taken literally decades and the review of the experience of tens of thousands of women to identify the risks. Absolute and percentage risks remain acceptable, when weighed against the known benefits of taking medication when necessary. Over fifty percent of pregnant women take something during pregnancy, and treating a mood disorder is as important as treating a UTI, or diabetes, or heartburn or any of the conditions that are typically addressed.

WK: What are your thoughts regarding discontinuation of medication in pregnancy? 

Dr. Frank: Depends on the medication, the woman’s history, and the illness being treated. Certainly, discontinuing a medication should not be an automatic response to a woman becoming pregnant.

WK: What suggestions do you have regarding how childbirth organizations can encompass perinatal mental health into training curriculum and practice? 

Dr. Frank: Widespread education in the use of efficient screening methods, particularly the PHQ 9 or the Edinburgh Postnatal Depression Scale would be a first step.  Educators  also need to develop routines for referring women to mental health services—the postpartum depression self-help  community , embodied in organizations like Postpartum Support International, is pretty well organized and can help bridge the gap between screening and referral . Ideally, these organizations could reach out to women postpartum, rather than waiting for them to come in. Routine phone calls two and four weeks after delivery, providing encouragement for everyone while also identifying and facilitating referrals for women in difficulty, might be quite effective in both preventing and intervening in postpartum mood problems. This is an area that merits systematic study. Finally, organizations that include mothers themselves might consider urging women who have been identified and treated to write thank you notes to the health care providers who contributed to them getting help. I think this would counter the fears that providers have about giving and offense and doing harm.


Dr. Frank contributes to the broadening conversation regarding how childbirth educators might better address perinatal mental health. How do her suggestions resonate with your practice? In what ways could you use her information?  Will you consider adding this information to your classes and new mother contact? And how could your certifying or professional organization become a source of support and education?

The second post in this series, scheduled for Thursday, features Nancy Byatt, D.O., MBA–Assistant Professor of Psychiatry and Obstetrics & Gynecology;  Psychiatrist, Psychosomatic Medicine and Women’s Mental Health UMass Medical School/UMass Memorial Medical Center.


Domar, A. D., Moragianni, V. A., Ryley, D.A., & Urato, A.C. (2012). The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond. Human Reproduction, Vol.0(0) pp. 1–12 doi:10.1093/humrep/des383

Bringing postnatal depression out of the shadows The Lancet – 10 November 2012 (Vol. 380, Issue 9854, Page 1621 ) doi: 10.1016/S0140-6736(12)61929-1

Other Resources: 

Department of Health and Human Services: Depression During and After Pregnancy: A Resource for Women, Their Families, & Friends

The Organization of Teratology Information Services (OTIS), (866) 626-6847



Babies, Breastfeeding, Childbirth Education, Depression, Giving Birth with Confidence, Guest Posts, Infant Attachment, Maternal Mental Health, Maternity Care, News about Pregnancy, Perinatal Mood Disorders, Postpartum Depression, Prenatal Illness, Research , , , , , , , , , , , , ,

There is No Greater Loneliness: Pregnancy and Suicidal Ideation

August 25th, 2011 by avatar

 There is no greater loneliness in the life of a human being than being alone with one’s own suffering; and no suffering is greater than the mental torture of impending agony from which there is no escape and of which there is no understanding.” Grantly Dick-Read, 1959, p.50

Grantly Dick-Read was right.  Suffering alone breeds a sense of inescapable despair for which there are few words, if any.  Lack of language is a kind of quintessential, ontological divide between a person’s experience and the observer’s understanding–what Biro (2011) noted as the starting point for change.  Language can “replace isolation with community” (Biro, 2011, p. 15).  This site is testimony to that!  Listening to mothers is both our privilege, our scientific premise (the landmark study by the same name), and our standard of practice as childbirth professionals.  In the spirit of listening to mothers, and learning to replace isolation with community–I would like to share a recent study regarding quite possibly the worst mental torture imaginable: suicidal ideation in pregnancy.

One of the first of its size and breadth, a recent study published in the Archives of Women’s Mental Health (2011) examined prevalence of suicidal ideation in a large sample of pregnant women.  Two objectives were presented: (1) examine the prevalence of suicidal ideation and comorbid psychiatric disorders during pregnancy; (2) identify the risk factors for suicidal ideation during pregnancy:

“Although our understanding of the prevalence and consequences of antenatal major depression has improved, our understanding of suicidal ideation—a common aspect of major depression—during pregnancy is limited.” (Gavin, Tabb, Melville, Guo & Katon, 2011, p. 244)

Comparing prevalence rates of suicidal ideation in a pregnant population with those in general, non-pregnant population could substantiate or refute the commonly held belief that pregnancy is a protective mechanism against thoughts of suicide (Zajicek, 1981; Kendell, Chalmers, & Platz, 1987), offering a fuller vocabulary regarding this rare, yet tragic suffering.  The authors built a strong rationale for their study by reviewing the scant literature that does exist, and its compelling evidence:

  • “Suicide is a leading cause of death among pregnant and postpartum women in the United States” (Gavin, et al., 2011 p. 239; Chang, et al., 2005).
  • The precursor to suicide in most cases is suicidal ideation, and the presence of major depression (Perez-Rodriguez, et al., 2008; Lindahl et al., 2005).
  • Women of childbearing years are at greatest risk for depressive disorders (Perez-Rodriguez, et al. 2008).
  • Pregnant women are less likely to be screened for suicidal ideation during pregnancy (Stallones, et al., 2007; Paris, et al., 2009; Gausia, et al., 2009; Copersino et al., 2005; Newport et al., 2007).
  • Adverse outcomes experienced by women who did report suicidal ideation in pregnancy (Stallones, et al., 2007; Paris, et al., 2009;  Gausia, et al., 2009; Copersino et al., 2005; Newport et al., 2007; Bowen, et al., 2009; Eggleston, et al., 2009;  Chaudron et al., 2001).
  • Suicidal ideation in pregnancy is a strong predictor for postpartum depression (Chaudron et al., 2001).
  • Pregnant women with depressive disorders are less likely to receive treatment for depression (Vesiga-Lopez et al., 2008).
  • Depressive disorders remain under-detected in prenatal settings because most women seeking prenatal care are not screened for depression (Kelly, et al. 2001).
  • Most patients fail to tell care providers of suicidal plans or attempts (Isometsa et al., 1994).

Lack of prenatal depression screening, known risk factors for comorbid mood disorders and their adverse effects are noted:

“Given the risks associated with antenatal suicidal ideation to women and their offspring, identifying effective methods of detecting women with antenatal suicidal ideation is a paramount challenge.” (Gavin, et al., 2011)

Study Design

Authors employed a cross-sectional analysis design of data from a longitudinal study of 3,347 pregnant women receiving prenatal care at a single site university-based obstetric clinic (University of Washington) from January 2004 to 2010.   After exclusion, the final sample size was 2,159 women.  Study protocol mandated screening a minimum of two times, once in early second trimester, (16 weeks) and once in third trimester (36 weeks).  Suicidal ideation was measured using the Patient Health Questionnaire (PHQ-9)–a screening instrument that has demonstrated both high sensitivity (73%) and specificity (98%) for major depression (Spitzer, et al., 2009).   To examine suicidal ideation specifically, the authors measured women’s responses to item 9 of the PHQ-9:

“Over the last two weeks how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?  0 = not at all, 1= several days, 2 = more than half the days, and 3= nearly every day.” (Gavin, et al., 2011, p. 241)

Participants self-reporting a score of 1 or greater (suicidal ideation several days a week in last 2 weeks), were considered positive for suicidal ideation.  With the protocol in place, authors then applied multiple covariate logistic regression analysis.

Study Results

Results demonstrated 2.7% of the 2,159 sample scored positive for suicidal ideation–similar to the prevalence rates for general, non-pregnant populations recorded in both the National Comorbidity Survey 1990-1993 (NCS) 2.8% ; and the National Comorbidity Survey Replication 2001-2003 (NCS-R) rate of 3.3% in general, non-pregnant population:

“The prevalence of antenatal suicidal ideation in the present study was similar to rates reported in nationally representative non-pregnant samples.  In other words, pregnancy is not a protective factor against suicidal ideation”.  (Gavin, et al., 2011, p. 239)

Of the 2.7% prevalence rate:

  • 78.0% reported thoughts of suicide “several days” in last 2 weeks
  • 15.3% reported thoughts of suicide “more than half the days” in the last 2 weeks
  • 6.7% reported thoughts of suicide “nearly every day”
  • 52.5% experienced comorbid antenatal depression
  • 15.7% experienced comorbid antenatal panic disorder

Speak My Language

Consider for a moment a group of 2,159 women attending standard prenatal childbirth education classes at a local hospital over the course of several years.  Generalizing from this study and national statistics, 59 of them are having thoughts of ending their lives.  Of those 59:

  • 48 (78%) have considered killing themselves several days in the last two weeks.
  • 9 (15.3%) have considered suicide more than half of the week,
  • 4 (6.7%) of those moms have contemplated killing themselves nearly every single day.

And those are the women who admit it.  The mothers who speak it. What do we do?  Final recommendations put forth by the authors here included “efforts to identify those women at risk for antenatal suicidal ideation through universal screening” (Gavin, et al., 2011, p. 239).

I think it is pretty fair to say that the majority of childbirth educators and doulas are trained to screen for difficulties in breast feeding.  When problems or risk factors present themselves, or a mom suffers from the agony of mastitis, we use language to help.  We lean over the void of suffering and listen to our mothers.

We speak the language of lactation quite easily,
and have organizational support and training to do so.
Yet, how many of us feel comfortable with the language of suffering alone in major depression? Go to your certifying organization’s website and look for resources for moms, or family members who feel suicidal.  Anything?   For you as a professional certified by that organization to offer emotional support to your clients, are there resources there for you to access, to help your clients?  Consider writing your certifying organization and request they update training for prenatal courses to include screening for depression.  Ask them to post suicide prevention materials for consumers. Your organization(s) should offer assistance in learning how to screen, referral sources in your area, and after care resources for your own healing should you need it.  Not doing so, not having public position papers, not speaking the language, in my mind is tantamount to silencing women’s suffering, and perhaps contributing to the loneliness of those who feel misunderstood. As David Biro (2011) states: “The consequences of silence are unacceptable…if we wish to relieve pain, we must first hear it” (p. 14).
“Listening to Mothers”…I’m in.

Posted by: Walker Karraa, MFA, MA



The Suicide Prevention Life Line offers free buttons, logos and links to add to your websites, and free downloads to give clients/students. You can also call them yourself to ask them how to talk to a mom about her symptoms.

Edinburgh Postnatal Depression Scale (EPDS)


Postpartum Support International (PSI)




Biro, D. (2011). The language of pain: Finding words, compassion, and relief. NY: Norton.

Bowen, A., Stewart, N., Baetz, M., et al. (2009). Antenatal depression in socially high risk women in Canada. J Epidemiol Community Health, 63:414-416.

Brand, S. Brennan, P. (2009). Impact of antenatal and postpartum maternal mental illness: How are the children? Clinc Obstet Gynecol, 51:441-455.

Chang, J., Berg, C., Saltzman, L., et al. (2005). Homicide: a leading cause of injury and deaths among pregnant and postpartum women in the United States, 1991-1999. Am J Public Health, 95:471-477.

Chaudron, L., Klein, M., Remington, P., et al. (2001). Predictors, prodromes and incidence of postpartum depression.  Psychosom Obstet Gynecol, 22:103-112.

Copersino, M., Jones, H., Tuten , M., et al. (2005) Suicidal ideation among drug-dependent  treatment -seeking  inner-city women.  J. Maint Addict, 3:53-64.

Eggleston, A. Calhoun P., Svikis, D., et al. (2009). Suicidality, aggression, and other treatment considerations among pregnant, substance-dependent women with posttraumatic stress disorder.  Compr Psychiatry, 50: 415-423

Gausia, K., Fisher, C., Ali, M., et al. (2009). Antenatal depression and suicidal ideation among rural Bangladeshi women: A community-based study. Arch Womens Ment Health, 12:351-358.

Gavin, A., Tabb, K., Melville, J., Guo, Y., & Keaton, W. (2011). Prevalence and correlates of suicidal ideation during pregnancy. Arch Womens Ment Health 14(239-246).

Kelly, R., Zatzick, D., Anders, T. (2001). The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in osbstetrics. Am J Psychiatry, 158:213-219.

Kroenke, K., Spitzer, & Williams, J. (2001).  The PHQ-9: Validity of a brief depression severity measure. Gen Intern Med. September; 16(9): 606–613.

Lindahl, V., Pearson, J., Colpe, L. (2005). Prevalence of suicidality during pregnancy and postpartum. Arch Womens Ment Health, 8:77-87.

Newport, D., Levey, L., Pennell, P., et al. (2007).  Suicidal ideation in pregnancy: Assessment and clinical implications. Arch Womens Ment Health, 10:181-187.

Paris, R., Bolton, R., Weinberg, M. (2009) Postpartum depression, suicidality, and mother-infant interactions. Arch Womens Ment Health 12:309–321

Perez-Rodriguez M., Baca-Garcia E., Oquendo M et al. (2008).  Ethnic differences in suicidal ideation and attempts. Prim Psychiatry 15:44–58

Spitzer, R., Williams, J., Kroenke,  K.,  et al. (2000). Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD patient health questionnaire obstetrics-gynecology study. Am J Obstet Gynecol 183:759–769

Stallones,  L., Leff,  M., Canetto, S. et al. (2007). Suicidal ideation among low-income women on family assistance programs. Women Health 45:65–83

Vesga-Lopez,  O., Blanco, C., Keyes, K., et al. (2008). Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry 65:805–815


New Research, Patient Advocacy, Perinatal Mood Disorders, Prenatal Illness, Uncategorized , , , , , , ,

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