Healing at Home: Screening for Postpartum Depression

Current screening tools for postpartum depression may have limitations, but a new texting service as part of the Healing at Home program may help clinicians detect postpartum depression earlier. ReachMD host Charles Turck, PharmD, BCCCP, is joined by OBGYN specialist Kirstin E. Leitner, MD, to discuss this program and its impacts.

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Announcer: You're listening to Medical Breakthroughs from Penn Medicine on ReachMD, advancing medicine through precision diagnostics and novel therapies. Here's your host, Dr. Turck.

Dr. Turck: According to the CDC, one in eight women experience symptoms of postpartum depression. And while these symptoms are common, they can be challenging to identify. But now a new tool may help us screen for and detect postpartum depression early.

Welcome to Medical Breakthroughs from Penn Medicine on ReachMD. I'm Dr. Charles Turck. And joining me today to discuss a new screening tool for postpartum depression is Dr. Kirstin Leitner, who's an Assistant Professor of Clinical Obstetrics and Gynecology at the Hospital at the University of Pennsylvania. Dr. Leitner, welcome to the program.

Dr. Leitner: Thank you for having me.

Dr. Turck: To start us off Dr. Leitner, are there any known warning signs for postpartum depression?

Dr. Leitner: Postpartum depression, as you mentioned, is relatively common. And there are a number of warning signs that patients may self-identify, or providers may identify in interactions with patients that could indicate postpartum depression.

One of the important things to point out, however, cis the period called baby blues, which can happen for the first two weeks postpartum, which does not necessarily qualify as depression if people have symptoms during this two-week period of time. So when we're really diagnosing patients with postpartum depression, we're looking for symptoms that are happening beyond that two-week timeframe. And those symptoms would include, for instance, feelings of hopelessness and guilt. Patients may express a lack of joy in parenting or interacting with their child. They may describe excessive worry with regards to their infant's health and development. And, importantly, they may describe conversely to what many people think of as being tired all the time and inability to sleep despite what we know to be the sort of, quote unquote, "natural sleep deprivation" that happens when you're taking care of a newborn. Many patients with postpartum depression and/or anxiety will have difficulty sleeping, despite having time for that sleep given to them by either their infant or their other family members who may be helping them care for the infant.

And then finally, of course, there are going to be patients who may even have suicidal thoughts as part of their postpartum depression all the way from passive thoughts of self-harm to more active thoughts and plans, depending on how severe their depression is.

Dr. Turck: You've described many of the symptoms that patients experience. How do we typically approach screening for the condition?

Dr. Leitner: So screening for postpartum depression really starts actually with screening for risk factors for depression or postpartum depression during pregnancy. So one of the important parts of screening is sort of determining a person's risk. And that can be done through screening them during their pregnancy for depression symptoms. So that's the first thing that we do in obstetrical care is we screen patients either for a history of depression. Or if they don't have a history, we may screen them with screening tools like the PHQ-2 or even the Edinburgh Postnatal Depression Screening, which we'll talk about further during pregnancy, and then do follow-up screenings after delivery.

So in the United States at this point, the common times to screen for postpartum depression would be usually at the time of delivery, and then at the routine postpartum visit, which for many patients is happening around four to six weeks after delivery. It's also recommended that if there is an appointment with a patient, let's say they come in for a short interval follow-up we do recommend screening during that time as well. However, it's certainly not standard of care yet at this point that every patient who delivers has a short interval follow-up at two to three weeks. I would say a majority of patients are doing that follow-up at four to six weeks.

The standard of care screening tool that we use at those visits is the Edinburgh Postnatal Depression screening, or the EPDS screen. And that is the tool that's been validated and designed to ask questions in a way that are appropriate for the postpartum population.

Dr. Turck: As a quick follow-up, does our current approach to screening have any limitations?

Dr. Leitner: I do think there's a number of limitations. I think the first I alluded to a little bit in that prior answer is that screening is not reaching all of our patients, because they're not all attending these routine follow-ups. There's also these large gaps in time, many patients may go six weeks before they see their OB/GYN or midwife or family medicine provider for follow-up. And so there may be a long period of time within which they're suffering from these symptoms and their provider doesn't know about it.

And then I think, the final thing to point out is there have been some thoughts around patients being able to, quote unquote, "answer" the surveys in a way that will not concern their clinician, because they don't want to bother their clinician, or they're not quite ready to share the way they're feeling with their clinician. So I've personally had patients describe to me, 'Oh, I know how to answer those questions so that I don't score high.' Right? And so, there is a question of privacy. And you know, whether or not people are in a place or a space that they want to share those symptoms with their providers. So those were some of the things that kind of prompted me to start thinking about other ways that we could possibly screen for postpartum depression.

Dr. Turck: Now, let's talk a bit about the Healing at Home program and the resources you've helped develop for postpartum care at Penn Medicine. Dr. Leitner, what can you tell us about those efforts?

Dr. Leitner: So the Healing at Home Program is a program that's been under development for probably the past three or four years here at Penn, supported by our Penn Center for Healthcare Innovation. The primary, part of the program is a postpartum chatbot that we developed along with a company called Memora Health. And that is a texting program, bidirectional, that provides support for patients after discharge for the first six weeks. Now, depression screening is a part of that. But it is certainly not the only part of that texting program.

The way that we have designed the program allows for patients to ask us questions and also for us to ask questions of patients. And finally, we provide anticipatory guidance at the correct times during their recovery as to what to expect with both their physical recovery or their baby's development or feeding or sleep patterns.

So part of that program, what we did was we decided to incorporate postpartum depression screening through a text-based Edinburgh Postnatal Depression Screen. So what we do for our patients in the program is, at the time of enrollment, which is usually around one to two days after delivery, they receive a text message that starts the EPDS. And it's a single question with a single answer that the patient provides. So question one is asked and then they respond, question two is asked, and then they respond. And that's done at, like I said, around enrollment in the program at three weeks postpartum. And then at six weeks postpartum at this sort of conclusion of the program.

Now, what we do is we are able to calculate the scores that the patient texts in. And as a clinician who is monitoring the program, I can receive an alert to let me know if a patient has an elevated screen. Or very importantly, especially if a patient has an elevated or abnormal answer to this question of self-harm, I can get an immediate alert to my cell phone as a text message. And so that allows us to detect these thoughts early. And it also allows us to change the screening interval. So when patients have an elevated screen we repeat that screen in one week, to follow how they're doing as they progress through the program up till six weeks.

Dr. Turck: For those just tuning in, you're listening to Medical Breakthroughs from Penn Medicine on ReachMD. I'm Dr. Charles Turck, and today I'm speaking with Dr. Kirstin Leitner, about screening for postpartum depression.

Now, Dr. Leitner, you've been describing a texting service that was part of this program to help patients keep in touch with their care providers. How else has this texting service affected clinician's ability to detect postpartum depression?

Dr. Leitner: So I think one of the things that was fortunate in many ways was that this program was being rolled out at the very beginning of the COVID-19 pandemic. And so the ability for us to screen patients more frequently and then utilize telehealth as the follow-up for that elevated screening, improved our ability to connect patients back with their clinicians. So prior to telehealth, you know, it was quite challenging often to schedule a patient for an in-person appointment, especially with a one or a two week-old at home to talk about their mood symptoms. So telehealth both through phone and video really allowed us to connect patients with their clinicians much more quickly in a way that was less burdensome, both to the patient and to the provider but still provided with a sufficient modality to assess for those symptoms, potentially start treatments. And again, since we were doing with screening before six weeks, we could start those treatments or help that patient get connected with therapy well before we were doing this previously at the four to six-week mark.

Dr. Turck: And finally, are there any other ways that you see the integration of technologies like this impacting postpartum care in the future?

Dr. Leitner: Yeah, I mean, I think there are almost endless sort of opportunities for integrating remote type monitoring into our postpartum care, not only for depression screening, but in many other aspects of postpartum recovery.

Maternal morbidity and mortality is a huge concern of all of us in this country. And we are doing our very best to try to, change that. And about 50% of maternal mortality occurs postpartum. So the postpartum time is really a place where we need to start focusing on some critical interventions to screen patients, whether it's for depression, or for hypertensive disorder, or cardiac disease, so that we can try to move that metric and improve the care that we provide.

So as a part of our Healing at Home Program, in addition to the depression screening we've also integrated blood pressure screening, both for low-risk patients without any prior hypertensive disorder. And we've been able to detect patients with postpartum preeclampsia through this program. And I also think this has the ability to potentially impact the way that we provide care in the sense that if patients are receiving 24/7 access to information, answering their questions from a medical standpoint, it's a resource they can reach out to that's more accurate than Googling something or asking our girlfriend. And has the potential with all of those questions allowing providers to really focus on patients who need more critical attention for significant signs or symptoms of complications.

So those are some of the things that we're continuing to work through and try to optimize through this program, which sort of expands definitely beyond the depression screening. I think depression screening is a great example of a way in which we've started to do this. But there are sort of infinite opportunities, I think in this technology.

Dr. Turck: Well, with those forward-looking thoughts in mind, I want to thank my guest, Dr. Kristin Leitner, for sharing her insights on screening for postpartum depression. Dr. Leitner, it was great having you on the program.

Dr. Leitner: Thank you so much, it was a pleasure.

Announcer: You've been listening to Medical Breakthroughs from Penn Medicine. To download this podcast or to access others in the series, please visit ReachMD.com/Penn and visit Penn Medicine Referring Provider resources, an exclusive program that helps referring physicians connect with Penn. To learn more, visit www.pennmedicine.org/for-health-care-professionals. Thanks for listening!