The recent HealthStream Webinar, “Maternal Mental Health Risk Assessment and Intervention Before, During, and After Pregnancy,” featured Susan Kendig, an attorney and nurse practitioner with more than 35 years of experience in the healthcare industry. This blog post is the first in a series based on this webinar that will focus on maternal mental health.
Here’s some advice for incorporating maternal mental health issues into your clinical practice. These are things you'll want to think about, beginning with what screening tools are you going to use—a consistent screening tool which will give you trending information on the patients and established your response protocol because once you have a woman who is at significant risk. In addition, when you have identified a complex mental health condition or someone is suicidal, that's not the time to try and figure out where to send her. Having all of that thought through ahead of time and making sure the staff knows about it is really important.
Standardize Your Screening Tools
One of the first things that you want to think about is what standardized screening tools to use. You're looking for five different elements. Essentially, you want them to be readily available and inexpensive, and there are several that are free and validated for use in pregnancy and postpartum, easy and efficient to administer, validated within the population, and increase the likelihood of detection. For example, two screening tools to consider are the Edinburgh and the PHQ-9—both have been validated in pregnancy. They are both free and easy to use and can be self-administered. They take a patient about three to five minutes to complete. A couple of things to remember about those: The Edinburgh does actually have two questions that include anxiety symptoms. If you're using the Edinburgh, in addition to the score it's helpful to look at those questions, to see if perhaps there's an emerging anxiety issue as well.
Identify Community Resources
The other thing to think about is what are your community resources? Many times, we hear that women's healthcare providers don't screen or they are concerned about incorporating screening protocols because they don't know where to send women. There often is a dearth of psychiatric resources, and we do know that. You need to have a handle on where your community resources are located, and if there are any available moms support groups. Are there peer support phone lines? Is there a hotline number where there are counselors who can talk to a woman and help her find a counselor who takes her insurance? What's available within your own health system? Do you need to think about referring out? All of those things can be thought through ahead of time. If you are in a remote, rural area and you have actually no behavioral health support, is there telephonic support for maybe your level three or level four perinatal center? If you are the level three or level four center, how are you working with other areas to also include mental health consultation and availability within the package of services? A lot of things can be thought about early on during that readiness phase.
Establish Screening Occurrence Timeframe and Process
Moving then into the recognition and prevention phase, thinking about when you are going to be doing your screening. Every individual and family history should include a mental health history at intake, which with review is updated. Again, if you are an inpatient provider, are you thinking about how do you incorporate this when the woman comes into labor and delivery? Do you have a prenatal record accessible? If nothing else, is her Edinburgh score accessible? So that if somebody has scored high during the prenatal period, that's giving you a clue as to risk. Certainly, many hospitals will incorporate mental health screening prior to discharge, and that's really important. We may not see these symptoms, but I think this is prior, and they may have a normal screen at that time and may have their occurrence, sometimes post discharge or prior to the comprehensive postpartum visit. But, at least you would have that baseline.
Consider Special Stressors for NICU Families
The other group I would ask you to consider here are your NICU families. Often, when women are discharged from the postpartum unit, we may provide the screen, but the baby stays in the NICU or the special care nursery for a number of weeks for whatever reason. That may be an additional stressor. We know families that have a child who has a NICU stay or special care nursery stay; they have additional stressors and may develop situational depression or postpartum adjustment disorder. Thinking about how families can also access screening in the NICU is extremely important.
Look For Medical Complexity with Mental Health Complications
For those of you who have level threes or level four—certainly you're dealing with a lot of medically complex patients. Likewise, in our level ones and level twos, you may have patients who come in with a surprise high-risk condition. When women have a severe maternal event such as a postpartum hemorrhage or severe hypertensive disorder, and they survive that event, there may be mental health implications that will emerge down the road during the postpartum period. It’s important to do a handoff and talk with women about some of their risk factors and resources they can access after they leave the hospital. Likewise, if there is a death due to an untoward event during the pregnancy or labor and delivery, families may also experience similar trauma. It’s recommended that you remember the mental health implications when a severe medical complication occurs.
Access the full webinar recording here.
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