NATIONAL PERINATAL ASSOCIATION 2014 CONFERENCE Descriptive Assessment of Depression and Anxiety Symptoms in an Outpatient Obstetric Clinic Sample: Screening for Symptoms in the Context of Substance Use Histories: The participant will be able to: Describe psychiatric disorders during pregnancy/postpartum, comorbidities, frequent symptoms of depression and anxiety, a plan of care for women with past and/or current issues with chemical dependency and formulate recommendations for improving mental health screening during routine obstetric visits.

1. A Descriptive Assessment of
Depression & Anxiety Symptoms
in an Outpatient Obstetric Clinic Sample:
Screening for Symptoms in the Context of
Substance Use Histories
Teresa A. Lillis, M.A., ABI.1,2,
Stephen Lassen, PhD.2, & Erin Smith, B.S.2
1. Rush University Medical Center, Dept. of Behavioral Sciences, Chicago, IL.
2. University of Kansas Medical Center, Dept. of Pediatrics, Kansas City, KS.

2. ✔
Conflict of Interest Disclosures for Speakers
1. I do not have any relationships with any entities producing, marketing, re-selling, or
distributing health care goods or services consumed by, or used on, patients, OR
2. I have the following relationships with entities producing, marketing, re-selling, or
distributing health care goods or services consumed by, or used on, patients:
Type of Potential Conflict Details of Potential Conflict
Grant/Research Support
Consultant
Speakers’ Bureaus
Financial support
Other
3. The material presented in this lecture has no relationship with any of these potential conflicts, OR
4. This talk presents material that is related to one or more of these potential conflicts, and the following
objective references are provided as support for this lecture:
1.
2.
3.

3. Health Promotion in the Postpartum
• The birth of a child is a considered the greatest change in the
family life cycle (Nystrom & Ohrling, 2004).
• A time of excitement and joy as well as considerable stress.
• North American women receive a great detail of medical attention
and advice during pregnancy, but much less in the postpartum
(Ayoola et al., 2010).
• This shift can leave women vulnerable to psychological problems
arising in the postpartum.
• Adequate screening for postpartum psychological issues with
provision of appropriate treatment-related referrals may improve
the long-term health outcomes of both mothers and their babies.

4. Mental Health in the Postpartum
• Postpartum Depression (PPD)is the most common mental health
issue.
• Prevalence 10-20% of U.S. women and ~15% of women world-wide (Beck
et al., 2001; O’Hara et al., 2009).
• Diagnostic criteria for PPD are the same as for a Major Depressive Episode
• For the previous two weeks:
• Down/depressed mood nearly every day AND/OR loss of interest or pleasure in
previously enjoyable activities
• Five or more of the following symptoms present most days:
• Significant change in appetite or weight
• Insomnia or hypersomnia
• Psychomotor agitation/retardation
• Fatigue/loss of energy
• Feelings of worthless/guilt
• Difficulty concentrating/making decisions
• Suicidal thoughts/plans/intent/attempts
• Onset limited 2 weeks-12 months postpartum.
• Different from the “baby blues.”
• Birth-2 weeks postpartum; mildly depressed mood, tearfulness, fatigue.

5. Mental Health in the Postpartum Cont.
• Anxiety-related issues may also occur.
• 12-20% experience generalized anxiety symptoms (Farr et al., 2014;
Stuart et al, 1998; Wenzel et al., 2005; Vesga-Lopez et al., 2008)
• OCD symptoms in 11% (Miller et al., 2013)
• PTSD symptoms in 9% (Beck et al., 2011)
• Depression and Anxiety disorders are highly comorbid in perinatal
populations (Cohen & Pearlstein, 2010).
• Discrete symptom presentation is the exception rather than the rule.
• Precise etiology for psychiatric disorder manifestation in perinatal
populations is unclear.
• Likely a diathesis stress disorder.
• An existing predisposition or genetic vulnerability is triggered by stress of
pregnancy or labor/delivery.
• Risk Factors (Brockington, 2004):
• History of Depression/Anxiety/other mental disorder, especially during
pregnancy
• Poor social support
• Lower Age, SES, and minority status

6. Perinatal Maternal Substance Use
• The perinatal period is generally a time of reduced substance use
• Approximately 8-18% of childbearing women continue use of illicit
and licit drugs (Connelly et al., 2014).
• Deleterious health outcomes related to perinatal substance use:
• Prematurity, intrauterine/neonatal demise and poor long-term child
health outcomes (Bonello et al., 2014)
• In the general population, substance use is highly correlated with
mental illness
• Some studies have found perinatal substance use to be related to
worsening psychiatric symptoms severity in the perinatal period
(Connelly et al.; Chisolm et al., 2009)
• Relationship remains unclear as other studies have not
demonstrated this relationship (Forray et al., 2013).

7. Screeningfor PostpartumMental Health
• Mental health screening integration into obstetric and well-child visits
has improved (Olson et al., 2002; Guirguis-Blake et al., 2003).
• Most common screener, Edinburgh Postnatal Depression Scale (EPDS; Cox
et al., 1987).
• Beck Depression Inventory (BDI-II; Beck, 1996), CES-D, Postpartum
Depression Screening Scale (PDSS; Beck & gable, 2000), Patient Health
Questionnaire-9 (PHQ-9; Spitzer et al., 1999), etc.
• The stigma of reporting emotional distress in the postpartum persists
• Many at-risk postpartum women continue to missed by their
healthcare providers.
• Systematic screening with treatment referral and follow-up needed to
improve maternal/child health outcomes (Gjerdingen & Barbara, 2007).

8. Current Study
• A sample of 84 women from a Midwest Academic Medical Center
Obstetric Clinic completed the Brief-Patient Health Questionnaire
(B-PHQ; Sptizer et al., 2000) at their 6-week postpartum visit.
• Brief-PHQ was chosen for its:
• Brevity
• Assessment of depression and anxiety symptoms
• Comprehensive coverage of psychosocial stressors
• Items pertaining to women’s health issues
• Limited/targeted EMR chart review conducted to confirm:
• Ethnicity
• Obstetric history
• Characteristics from most recent delivery
• Substance use history

9. Purpose of Study
• Describe frequency/severity of depression
and anxiety symptoms reported in the
obstetric sample.
• Assess the relationship between
depression/anxiety symptoms and substance
use history.
• Inform recommendations for postpartum
mental health screening.

10. Brief Patient Health Questionnaire

11. Sample Demographics (N = 84)
White
67%
African
American
21%
Latina
10%
Asian
1%
Other
1%
Ethnicity • Mean Age = 27.01 years
• SD = 4.72
• Range = 16-38

12. Obstetric Sample Characteristics
30
9
15
22
6 5
2 1
0
5
10
15
20
25
30
35
First Baby (P1) Second Baby (P2) Third Baby (P3) Fourth Baby (P4)
#ofparticipants
G1
G2
G3
G4
G6
*Sample = 84: Mothers of Singletons = 80, Mothers of Twins = 4

13. Most Recent Delivery/Birth Characteristics
Delivery Type Term Below Weight Normal Overweight TOTAL
SVD preterm 3 1 0 4
early term 1 7 1 9
full term 1 28 5 34
late term 0 3 1 4
TOTAL 5 39 7 51
LTCS preterm 2 2 0 4
early term 2 6 0 8
full term 2 10 2 14
late term 0 1 0 1
TOTAL 6 19 2 27
Other preterm 2 0 2
early term 0 1 1
full term 0 1 1
TOTAL 2 2 4
TOTAL preterm 7 3 0 10
early term 3 14 1 18
full term 3 39 7 49
late term 0 4 1 5
TOTAL 13 60 9 82

14. EMR Substance Use History
• Current/former use information obtained via EMR review.
• Matched updated information to the date of the 6-week visit/Brief-
PHQ completion
• Not possible to verify whether former substance use occurred during most
recent pregnancy or prior to pregnancy.
• Severity Classification for former/current use:
• Smoking:
• Mild = < 1 pack/week
• Moderate = 1-2 packs/week
• Heavy = > 3 packs/week
• Alcohol:
• Mild = “occasional” - 1-2 drinks/week
• Moderate = 3-5 drinks/week
• Heavy = > 5 drinks/week
• Drugs:
• Mild = < 1/year
• Moderate = “occasional” - 1-2x/month
• Heavy = > 1/week

15. Substance Use Characteristics
Substance Use History?
No = 54
Yes = 28
Smoking
No = 8
Yes = 20
Former Use = 12
Mild = 6
Moderate = 3
Heavy = 3
Current Use = 8
Moderate = 3
Heavy = 5
Alcohol
No = 19
Yes = 9
Former Use = 1
Mild = 1
Current Use = 8
Mild = 6
Moderate = 2
Drugs
No = 24
Yes = 4
Former Use = 2
Mild = 1
Moderate = 1
Current Use = 2
Mild = 1
Moderate = 1

16. Substance Use Characteristics
6
1 1
6
1 1
3 3
2
1 1
3
5
Past
Smoking
Current
Smoking
Past
Alcohol
Current
Alcohol
Past Drugs Current
Drugs
#ofrespondents
Mild
Moderate
Heavy
*Use of more than one substance: N= 5
•All 3 substances, N = 1
•Smoking + Alcohol, N = 1
•Smoking + Drugs, N = 3

17. Substance Use Severity
• Substance Use Severity:
• Calculated based on frequency of use, number of substances used and
whether the use was former or current
• Current use weighted more heavily than former use
4
14
7
0 2 4 6 8 10 12 14 16
Severe Use (Scores > 5)
Moderate (Scores 3-4)
Mild (Scores 1-2)
# of respondents
Severity Score
(Range 1-8)

18. Depression Symptoms

19. Depression Symptoms
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Nearly Every Day
More than Half the Days
Several Days
Not at All

20. Depression Total Scores
(Score Range 0-27)
28
35
17
4
1 0
#ofparticipants

21. Anxiety Symptoms

22. Anxiety Symptoms
9 9
12 12
5 5
2 2
0
2
4
6
8
10
12
14
Had a Panic
Attack Before?
Panic Attacks
come out of the
blue?
Worried about
having another
Panic Attack?
Experience typical
Panic Attack
symptoms (racing
heart, sweatiness,
etc.)?
No
Yes
Have you had a Panic Attack in the past 4 weeks?
No = 70
Yes = 14

23. Depression/Anxiety Interference
Not at All, 76
Somewhat, 20.6
Very Much, 4
Extremely, 1
How Much Have These Symptoms Interfered
in Your Daily Life?

24. Depression/Anxiety Symptom Summary
• Most commonly reported depression symptoms:
• 1. Fatigue/Low Energy
• 2. Trouble Sleeping
• 3. Feeling Down/Depressed
• Severity of symptoms reported:
• 33% experienced NO symptoms
• 61% minimal-mild symptom severity
• 6% moderate-severe symptom severity
• Only 14 respondents indicated a history of experiencing panic
attacks
• 75% of the respondents did not feel impaired at all by depression
and/or anxiety symptoms

25. Psychosocial Stressors

26. Pyschosocial Stressors
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bothered a lot
Bothered a little
Not at all

27. Psychosocial Stressors Total Score
(Score Range 0-20)
24
31
21
6
3
0
5
10
15
20
25
30
35
None (0) Minimal (1-2) Some (3-6) Moderate (7-11) Moderate-Severe
(12-20)
#ofrespondents

28. OpenedEndedResponsesAbout Stress
“What is the most stressful thing in your life right now?
• “My routine.”
• “Taking care of everything that has to do around the house.”
• “New baby and no sleep at night.”
• “Taking care of my dad and dealing with my brother and sister.”
• “Trying to lose weight.”
• “Going back to work, and who will be taking care of my baby.”
• “No car/money.”
• “I have three kids, 3 and under!”
• “Maintaining school work and handling 2 kids. [name] just found out
he will need surgery. Hard to accept.”

29. Opened Ended Response About Stress
Nothing
30%
Childcare
20%
Sleep
4%
Finances
12%
Work/Life
Balance
13%
Family Issues
6%
Health Issues
5%
Combination
of one or
more
stressors
11%
Most Stressful Thing in Your Life Right now?

30. Summary of Psychosocial Stressors
• Most commonly reported stressors:
• 1. Concerns about weight/beauty
• 2. Financial Concerns
• 3. Stress/Demands of Childcare
• More variability in severity of stress:
• 28% report no stress
• 62% report minimal-moderate stress
• 10% report severe stress
• Most stressful thing in life right now?
• 20% = Childcare
• 13% = Work/Life Balance Issues
• 12% = Finances

31. Statistical Relationships:
Depression, Anxiety &
Substance Use

32. Demographic & Obstetric Correlates
Age
# of Live
Births
Infant Birth Weight
Gestational
Term
Substance Use
• Smoking -.396*
Depression/Anxiety Sx
• Sleep Changes
• Eating Changes
• Feeling depressed
• History of Panic Attacks
• Sx Interference
-.222*
-.236*
.252*
.230*
-.231*
-.233*
Stress Sx
• Partner difficulties
• Financial problems
• No social support
• Recent trauma
• Childcare stress
-.288**
-.247*
-.375**
-.245*
-.237*
-.374** -.365**
-.366**
(*p < .05, **p < .01)
• Ethnicity, # of pregnancies, and delivery type were not correlated with
substance use or depression/anxiety/psychosocial stressor symptoms

33. Substance Use & Psychiatric Sx
Smoking Alcohol Drugs
Substance
Use Severity
Depression/Anxiety Items
• Sleeping much less/more
• Fatigue
• Fear of Future Panic Attacks
• Symptom Interference .409*
.538*
.919**
.790**
.345**
.258**
.307**
Psychosocial Stressor Items
• Worries about weight/looks
• Childcare Stress .394*
.501** .221**
(*p < .05, **p < .01)
• Current/former substance use collapsed across individual substance categories

34. Predictors of Depression Total Scores
B SE β R2
Step 1
(Constant)
2.271 .382
Panic Attack History 3.657 .935 .396**
.157
Step 2
(Constant)
.537 .419
Panic Attack History 1.798 .834 .195*
Substance Use Severity .297 .150 .169*
Psychosocial Stressor Severity .452 .114 .396**
Symptom Interference Severity 1.708 .697 .232**
.450
Step 2 R2 Change = .293, p < .01(*p < .05, **p < .01)
• Age, ethnicity, obstetric history and most recent birth characteristics were not
significant predictors of depression total scores
• Single substance types were not significantly related to depression total scores

35. Summary of Statistical Relationships
• Demographic & Obstetric Relationships:
• Age:
• Younger respondents reported more sleep disruption, more psychiatric
symptom interference, more relationship and financial stress and low
social support
• Parity:
• women with more children were more likely to have had a recent panic
attack and report changes in their eating habits
• Women with fewer children reported more relationship stress
• Infant Birth Weight:
• lower infant birth weight was related to smoking history, feeling
depressed, greater psychiatric symptom interference, low social support
and recent trauma.
• Gestational Term:
• Shorter gestation was related to recent trauma and greater childcare
stress

36. Summary Cont.
• Substance Use & Psychiatric Symptom Relationships:
• Smoking and drug use history and overall substance use severity
were strongly, positively related to increased impairment from
psychiatric symptoms.
• Drug use and overall substance use severity were strongly related
to items reflecting exhaustion and fatigue and worries about
weight/looks.
• Current alcohol use was predominantly mild in this sample subset
and was only related to increased childcare stress.

37. Summary Cont.
• Although the sample as a whole generally appeared high-
functioning and with relatively low levels of reported distress,
variability in depression scores were related to a number of
psychosocial factors:
• A history of panic attacks predicted higher depression scores.
• After controlling for panic attack history, higher depression scores
were predicted by:
• greater psychosocial distress
• greater impairment from psychiatric symptoms
• Increased substance use severity

38. Limitations &
Recommendations

39. Limitations
• Small, homogenous sample
• Relatively high-functioning, non-distressed
• Cross-sectional assessment
• No ability for longitudinal follow-up of sample to
confirm/disconfirm onset of mental health problem with
appropriate diagnostic tools.
• Not able to confirm pre-existing mental health diagnoses.
• EMR review to assess substance use may have resulted in an
under/over-estimation of actual current/former substance use
• Brief-PHQ’s lack of assessment of anxiety disorders and
symptoms, outside panic attack history

40. Where Do We Go From Here?
• Women should continued to be screened for perinatal mental
distress.
• Risk factors to consider based on this study:
• Younger mothers, multiparous mothers, and mothers with a history
of shorter gestation and/or low infant birth weight
• Comorbid mental health problems
• History of substance use, especially the number of substances used
and the frequency of use
• Reported impairment from psychiatric symptoms
• Number and severity of psychosocial stressors

41. How Do We Get There From Here?
• Although any screener is better than no screener…
• Screeners with items that ask about “stress” in addition to face
valid depression/anxiety items may circumvent propensity for
underreporting
• Screening for postpartum substance use also prone to
underreporting (Magura & Kang, 1996; Osterea et al., 2001).
• Quasi-anonymous methods may increase perinatal substance use
disclosure (Beatty, Chase, & Ondersma, 2013).
• Chart review not ideal, but may provide a context for assessing
overall physical and psychological risk in the postpartum
• Good screening needs good follow-up.
• Treatment-related and follow-up referral decisions could be
conceptualized with Stepped Care Model.

42. Stepped Care Model
28
35
17
4
1
0
No Symptoms (0)
Minimal (1-4)
Mild (5-9)
Moderate (10-14)
Moderate-Severe
(15-20)
Severe (21-27)
Patients with few or no
presenting problems
=
Usual Care
Patients with potential
concerns
=
Treatment Referral Info
and/or Mental Health Consult
Intensive
&
Immediate Care
(*suicidal ideation)

43. Stepped Care Model

44. Stepped Care Model Decision Making:
Sample Language
Patients with few or no
presenting problems
=
Usual Care
• Usual Care:
• “Thanks so much for completing our
mental health screener. From the looks
of your responses, it sounds like you’re
doing pretty well, maybe just a little
fatigued?
*clarify any endorsed symptoms*
• “OK, well please keep an eye for any
major changes in your mood or if you
feel like the fatigue is starting to affect
your ability to function during day.”
*if needed, differentiate “normal” postpartum
physical/psychological symptoms from
potentially clinically significant symptoms*
• “You can always let your child’s
Pediatrician know when you go for well-
baby visits…
• Or feel free to call us back too, if you’re
not sure…”
• [We’ve got lots of good resources to help
with those symptoms if they persist or get
worse.]”

45. Patients with potential
concerns
=
Treatment Referral Info
and/or Mental Health Consult
• Potential Concerns:
• “Thank you so much for completing our
mental health screener. From your
responses, it sounds like you’ve been
feeling really down and are pretty
stressed about heading back to work.”
• *clarify any endorsed symptoms*
• “I’m concerned about your mood and
how much support you may or may not
have right now to manage the stress of
going back to work. I’d to share some
resources with you that I think might
help both of those things.”
• [“Would you be open to speaking briefly with
our mental health consultant?”]
• [medication/therapy/both]
Stepped Care Model Decision Making:
Sample Language

46. Intensive
&
Immediate Care
(*suicidal ideation)
• Intensive & Immediate Care:
• “Thank you for completing our mental
health screener. I really appreciate your
honesty and bravery in sharing how
extremely difficult the postpartum has been
for you.”
• *validate & clarify endorsed symptoms*
• “I’m very concerned for your safety and
want to get you set up with
[medication/therapy/both] today. You don’t
have to suffer through this alone.”
*instill hope, especially for patients with
suicidal thoughts*
*safety contract for suicidal ideation*
*hospitalization for acutely suicidal patients*
Stepped Care Model Decision Making:
Sample Language

47. Acknowledgments
• Dr. Stephen Lassen, Clinical Supervisor
• Ms. Erin Smith, Research Assistant
• University of Kansas Medical Center OBGYN Department & Staff
• Dr. Carl Weiner, Department Chair
• KUMED OBGYN Attending Physicians & Residents

48. References1.Ayoola, A.B., Nettleman, M.D., Stommel, M., & Canady, R.B. (2010). Time of Pregnancy Recognition and Prenatal Care Use: A Population‐based Study in the United States. Birth, 37(1), 37-43.
2.Beck, A. T., & Steer, R. A. (1993). Beck Depression Inventory Manual. San Antonio, TX: The Psychological Corporation. Harcort Brace & Company.
3.Beck, C. T., & Gable, R. (2001). Further validation of the Postpartum Depression Screening Scale. Nurs Res, 50(3), 10.
4.Beck CT, Gable RK, Sakala C, Declercq ER. (2011). Posttraumatic stress disorder in new mothers: results from a two-stage U.S. national survey. Birth,38:216–227.
5.Bonello, Michelle R, Xu, Fenglian, Li, Zhuoyang, Burns, Lucy, Austin, Marie-Paule, & Sullivan, Elizabeth A. (2014). Mental and Behavioral Disorders Due to Substance Abuse and Perinatal Outcomes:
A Study Based on Linked Population Data in New South Wales, Australia. International journal of environmental research and public health, 11(5), 4991-5005.
6.Chisolm, Margaret S, Acquavita, Shauna P, Kaltenbach, Karol, Winklbaur, Bernadette, Heil, Sarah H, Martin, Peter R, . . . Tuten, Michelle. (2011). Cigarette Smoking and Neonatal Outcomes in
Depressed and Non-Depressed Opioid-Dependent Agonist-Maintained Pregnant Patients. Addictive disorders & their treatment, 10(4), 180.
7.Connelly, C. D., Hazen, A. L., Baker-Ericzen, M. J., Landsverk, J., & Horwitz, S. M. (2013). Is screening for depression in the perinatal period enough? The co-occurrence of depression, substance
abuse, and intimate partner violence in culturally diverse pregnant women. J Womens Health (Larchmt), 22(10), 844-852. doi: 10.1089/jwh.2012.4121
8.Forray, A., Gotman, N., Kershaw, T., & Yonkers, K. A. (2014). Perinatal smoking and depression in women with concurrent substance use. Addict Behav, 39(4), 749-756. doi:
10.1016/j.addbeh.2013.12.008
9.Gjerdingen, Dwenda K, & Yawn, Barbara P. (2007). Postpartum depression screening: importance, methods, barriers, and recommendations for practice. The Journal of the American Board of
Family Medicine, 20(3), 280-288.
10.Hanusa, B. H., Scholle, S. H., Haskett, R. F., Spadaro, K., & Wisner, K. L. (2008). Screening for depression in the postpartum period: a comparison of three instruments. J Womens Health (Larchmt),
17(4), 585-596. doi: 10.1089/jwh.2006.0248.
11.Miller ES, Chu C, Gollan J, Gossett DR. Obsessive-compulsive symptoms during the postpartum period. A prospective cohort. (2013). J Reprod Med,58:115–122.
12.Nystrom, K., & Ohrling, K. (2004). Parenthood experiences during the child's first year: literature review. J Adv Nurs, 46(3), 319-330. doi: 10.1111/j.1365-2648.2004.02991.x JAN2991 [pii]
13.O'Hara, M. W., & Swain, A.M. (1996). Rates and risk of postpartum depression – A meta-analysis 8:37–54, 1996. International Review of Psychiatry, 8, 18.
14.Sohr-Preston, S., & Scaramella, L. (2006). Implications of timing of maternal depressive symptoms for early cognitive and language development. Clin Child Fam Psychol Rev, 9(1), 19.
15.Spitzer, Robert L, Williams, Janet BW, Kroenke, Kurt, Hornyak, Raymond, & McMurray, Julia. (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(3), 759-769.
16.Stuart S, Couser G, Schilder K, O’Hara MW, Gorman L. (1998). Postpartum anxiety and depression: onset and comorbidity in a community sample. J Nerv Ment Dis, 186:420–424.
17.Sword, W., Busser, D., Ganann, R., McMillan, T., & Swinton, M. (2008). Women's care-seeking experiences after referral for postpartum depression. Qual Health Res, 18(9), 1161-1173. doi:
18/9/1161 [pii].10.1177/1049732308321736
18.Wenzel A, Haugen EN, Jackson LC, Brendle JR. (2005). Anxiety symptoms and disorders at eight weeks postpartum. J Anxiety Disord,19:295–311.
19.Wisner, K. L., Parry, B. L., & Piontek, C. M. (2002). Clinical practice. Postpartum depression. N Engl J Med, 347(3), 194-199. doi: 10.1056/NEJMcp011542347/3/194 [pii].
20.Vesga-Lopez O, Blanco C, Keyes K, Olfson M, Grant BF, Hasin DS. (2008). Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry, 65: 805–815.