Universal-screening programs for depression continue to evolve (Venkatesh, 2016). At Parkland Hospital, mental illness screening is generally done at the irst prenatal visit using a brief risk-based query and again postpartum using a universalapplied screening tool for postpartum depression. Questions search for psychiatric disorders, related therapy, prior or current use of psychoactive medications, and current symptoms. Women with a history of sexual, physical, or verbal abuse; substance abuse; and personality disorders are also at greater risk for depression (man, 2007; Janssen, 2012). History of neglect and abuse are especially powerful antecedents of depression in adolescent pregnancy (Meltzer-Brody, 2014). Smoking and nicotine dependence and obesity also raise rates of all mental disorders in pregnancy (Goodwin, 2007; Molyneaux, 2014). Finally, because eating disorders may be exacerbated by pregnancy, afected women are followed closely (p. l1S0).
Several screening instruments shown in Table 61-1 are available and have been validated for use during pregnany and the puerperium. Use of one of these screening tools is encouraged because symptom-or risk-based screening alone may be insuficient (American College of Obstetricians and Gynecologists, 2016a). Cerimele and colleagues (2013) found that obstetricians and gynecologists failed to identiY 60 percent of depressed women in clinical practice. As mentioned earlier, at Parkland Hospital, all women are screened during their irst postpartum visit using the Edinburgh Postnatal Depression Scale (EPDS). In an analysis of more than 17,000 women, 6 percent had scores that indicated either minor or major depressive symptoms, and 12 women had thoughts of self-harm (Nelson, 2013). Similarly, Kim and coworkers (2015) assessed suicidal ideation in more than 22,000 women screened using the EPDS both during pregnancy and postpartum. They found rates of depression as high as 3.4 percent during the puerperium. A small fraction of those with thoughts of self-harm had a credible plan, intent, and means for attempted suicide. Obviously, suicidal ideation warrants prompt psychiatric consultation for evaluation and management.
Screening for perinatal depression without appropriate subsequent treatment is insuicient (American College of Obstetricians and Gynecologists, 20 16a). hat said, mechanisms to ensure adequate ensuing care can be problematic. In
TABLE 61 -1 . Depression Screening Toolsa
Time to Complete
Edinburgh Postnatal 10 <5 http://www.fresno.ucsf.ed u/ped iatricsl down loadsl edi nbu rg hsca Ie. pdf
Patient Health 9 <5 http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf
Center for Epidemiologic 20 5-10 http://www.perinatalweb.org/assets/cms/uploads/files/CES-D.pdf aAIl depression screening tools are also available in Spanish. bAvailable free online.