Screening patients for depression is just the beginning! It’s not enough to screen and then stop there, particularly if your patient screens positive for depression. Although a screening is just a screening and does not necessarily equate a diagnosis, it is still a good indicator that the patient could benefit from an evaluation by a trained mental health clinician.
The patient may be relieved to finally have someone ask her about it. She may be caught completely unaware and need some additional education and introduction to depression. Or, she may be resistant and require some encouragement to engage in a discussion about further steps. Regardless of the circumstances, if a screening results in a score indicating a risk of depression, and your clinical judgement leads you to believe that this screening is an accurate reflection of the patient’s mental state, the next step is a conversation with the patient about referral options, what she thinks is best, and what next step best marries her wants and willingness with your clinical judgement regarding the best care for the patient.
Some scripts to help you navigate that conversation are included below.
ACOG
Counseling Your Patients on Perinatal Depression
Clinical judgment is most important when counseling patients. Conversations with your patients about sensitive topics, such as perinatal depression, can be difficult and awkward. The following scripts about introducing the EPDS, counseling patients about perinatal depression and prescribing treatment options have been successfully used by other depression screening programs.
Introducing the EPDS to Your Patients
Patients may wonder why they are being asked to complete the EPDS. Pregnancy is supposed to be a joyous occasion. Some patients may feel that they are, or are going to be bad mothers, if they are depressed. It is important for apprehensive patients to understand what perinatal depression is, to know that many women experience similar feelings and to realize that untreated perinatal depression may have adverse effects on women’s health and their children.
The following suggested scripts have been used to reduce potential patient apprehension regarding the EPDS.
Prenatal Visit:
• …I’d like to check in with you to hear about how you are feeling since you’ve become pregnant. Please take a few minutes to fill out this short survey.
• …Since you are now in the third trimester of your pregnancy and getting closer to your delivery, I’d like to check in with you and hear about how you are feeling lately. Please take a few minutes to fill out this short survey.
Postpartum Visit:
• …Now that you have had your baby, I would like to know how you are feeling and how you have been coping lately. Please take a few minutes to fill out this short survey.
Counseling Scripts Based on a Total EPDS Score above Threshold
(See EPDS Instructions About Setting A Threshold)
Transition from EPDS Score to Counseling:
…From the survey you just filled out, it appears as though you are feeling down or depressed. I’d like to ask you a little more about your history and how you’re doing now.
• How do you feel about your pregnancy/motherhood?
• What concerns do you have about your pregnancy/motherhood?
• How is your relationship with the father of the baby? (Is your partner supportive?)
• Who are the friends or family who help you during this time?
• How is your living situation?
Transition from Counseling to Diagnosis Script:
…It is common for women during and after pregnancy to feel down or depressed. It is very important to address these feelings to ensure your health and your baby’s health…
Baby Blues
(feelings of sadness, fear, anger or anxiety that typically occur within 48 hours after birth and usually fade within 1-2 weeks):
Baby Blues Script 1 (No Treatment Needed):
…Some call these feelings the baby blues. Women may have feelings of sadness, fear, anger or anxiety that usually fade within 1-2 weeks. I’d like to give you some brochures and information about local resources. I can have the office call you in about one week to see how you are doing and you are welcome to call the office if you have questions or if your mood or anxiety becomes worse.
Baby Blues Script 2 (Treatment Needed):
…Some call these feelings the baby blues. Women may have feelings of sadness, fear, anger or anxiety that usually fade within 1-2 weeks. I would like to discuss different treatment options with you. (See Page 11-Counseling Scripts for Treatment Options).
Perinatal Depression (intense feelings of sadness, anxiety or despair before or after childbirth that interfere with the patient’s ability to function and do not go away after a few weeks):
Perinatal Depression Script:
…Some call these feelings post-partum or perinatal depression. Women may have intense feelings of sadness, anxiety or despair before or after childbirth that interfere with her ability to function. If these feelings are not going away, treatment is needed. Options for treatment include medication, talk therapy or counseling, or both, depending upon the severity. Increasing healthy life behaviors is also helpful, like getting enough sleep, eating healthier foods, time for walking, and so on. I would like to discuss these treatment options with you. (See Below-Counseling Scripts for Treatment Options).
Counseling Scripts for Treatment Options
Transition from Counseling/Diagnosis to Discussing Treatment Options:
…From talking with you, I think you would benefit from treatment for anxiety or depression. The two most common forms of treatment are talk therapy or counseling (psychotherapy) and medication. Let’s talk about the benefits, risks, and alternatives of the various treatment options.
Transition from Counseling/Diagnosis to Referring:
…I would like you to speak with someone more about your feelings. This referral will help you take care of your health and your baby’s health.
If patient is reluctant to take referral for counseling:
…Many women experience some anxiety or depression during or right after pregnancy. This referral does not mean that you are or will be a bad mother. However, not getting treatment could have adverse effects on your health and your child. I am concerned for your health and want you to speak with someone.
Transition from Counseling/Diagnosis to Prescribing Medications*
…I want to discuss medications that could improve your mood. Have you taken medication in the past for anxiety or depression?
If YES-
• Was the medication effective?
• From the conversation we just had, I’m going to prescribe for you. Let’s discuss this medication’s side effects, especially how it may impact your pregnancy and ability to breastfeed…
• Please remember that the medication you will be taking works gradually and may not take effect for several weeks.
If NO-
…There are many choices for medications. The medication I am going to prescribe that should effectively treat your depression. Most babies of mothers who required antidepressant medication during pregnancy and/or post-partum experience no ill effects.
I’d be happy to talk about rare effects some medications could have on your baby. However, it is important to remember that not treating maternal depression has a harmful effect on pregnancy and development of the baby. Mothers who require medication to treat depression can often safely and successfully breastfeed*. Please remember that the medication you will be taking works gradually and may not take effect for several weeks.
If patient is reluctant to take medication:
…I am concerned for your health. Many women experience some anxiety or depression during or right after pregnancy. Medication can help you cope and lessen the harmful effects of depression on you and your baby.
*See Provider Medication Information Chart on pages 14 & 15.
…Leaving your feelings untreated could have adverse effects on your health and your child. I can refer you to a mental health professional for treatment options. However, I want to make sure you do address your feelings.
Transition from Providing Treatment to Patient Follow-Up:
…I’d like to give you some brochures and information about local resources. I can have the office call you in a few weeks to see how you are feeling. In the meantime, you are welcome to call the office if you have questions or if your mood or anxiety becomes worse.
Counseling Scripts Based on an EPDS Score of 1 or More on Question 10
Question 10 assesses patient thoughts of harming themselves. Treatment decisions should only be made after a discussion with your patient.
This referral may require the assistance of the partner, a family member or friend to a company the patient to the emergency room or mental health professional’s office where a complete suicide risk assessment and treatment can be accomplished, generally within 24 hours. Alternatively, you may need to call the community mobile crises unit to come get the patient.
Transition from EPDS Score to Counseling:
…From the survey you filled out, you responded that you’ve had thoughts of harming yourself on question 10.
Immediate emergency referral to a mental health professional maybe the most
- Do you currently feel as if you do not want to live? Have you made a plan?
- Can you tell me what it is?
- Do you have the means (pills, a weapon, a car, etc.) to carry out that plan? Have you tried to hurt yourself in the past?
Appropriate next step if the patient has suicidal ideation
**If an emergency referral is needed, please take immediate action.**
- Please refer to above for Counseling Scripts for Treatment Options if patient needs some form of treatment other than or in addition to an emergency referral.
- Emergency Telephone Numbers
Mental Health Professional Referral List
Please list all mental health professionals whom your practice/institution refers patients to for perinatal depression and assistance with emergency referrals. Keep this completed list in a central location at your practice/institution and use as needed.
(Name, Organization, Address, Telephone, Fax, Email, Comments)
Reasons for Referral:
- EPDS Score:
- Answer on EPDS Question 10:
- Prior history of Perinatal Depression
- Prior history of Depression
Additional Comments:
- Due date or date of delivery
- Relevant Psychosocial Risk Factors:
- Barriers to Care
- Unstable Housing
- Unintended Pregnancy
- Communication Barriers
- Poor Nutrition
- Tobacco Use
- Substance Use
- Depression
- Lack of Safety
- Intimate Partner Violence
- Stress
- Pregnancy or delivery complication
- Other:
Date of Referral Signature of Referring Ob-Gyn
• • • • • •
To Referring Ob-Gyn: The above patient has been scheduled for perinatal depression counseling.
This appointment is scheduled with the following mental health professional:
on at AM/PM Location:
http://familydoctor.org/familydoctor/en/diseases-conditions/postpartum-depression/treatment/postpartum-depression-action-plan.html