Digital Repository Doctoral Projects Fall 2022 Improved Perinatal Depression Screening Maja Lusk Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Lusk, M. (2022). Improved Perinatal Depression Screeing. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. 1 Improved Perinatal Depression Screening by Maja Lusk A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 16, 2022 Maja Lusk_____ Maja Lusk, DNP-FNP, RN December 16, 2022 Date Kelley Trump December 16, 2022 DNP, MSN/ED, RN, CNE, COI DNP Project Faculty Date December 16, 2022 ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director IMPROVED PERINATAL DEPRESSION SCREENING 2 Improved Perinatal Depression Screening in the Clinic Setting Maja Lusk Weber State University Annie Taylor Dee School of Nursing Doctorate of Nursing Practice Project Faculty Project Lead: Kelly Trump, DNP, MSN/Ed, RN, CNE, COI Project Consultant: Amelia Parrett, MD, OB-GYN Project Team Member: Aaron Plant, MBA Date of Submission: October 01, 2022 IMPROVED PERINATAL DEPRESSION SCREENING 3 Abstract Purpose: In the United States, mood disorders are the number one complication of childbirth and increase the lifetime utilization of mental and physical health services. Early identification of depression in the birthing individual is an essential step in prevention and treatment. The purpose of this Doctor of Nursing Practice (DNP) project aimed to develop a standardized workflow model to ensure early intervention of universal depression screening for all birthing individuals in the obstetric clinic setting, improving health care provider knowledge and reducing bias. Methodology: The DNP project created a clinic workflow that implemented a standardized process for perinatal mental health screening using the Edinburgh Postnatal Depression Screening (EPDS). The EPDS clinic workflow model utilized an algorithm to identify birthing individuals who required further mental health evaluation. Additionally, staff education, training, and resources were developed to improve the recognition of depressive symptoms and reduce the bias of healthcare providers in the clinic setting. Results: Analysis of the knowledge and bias levels of the staff exposed gaps in clinical knowledge concerning universal screening and charting of the EPDS. The small team clinic workflow model implementation was successful, but the implementation process for the entire clinical staff revealed some areas that needed to be readdressed. In addition, the MICA-4 results were poorer than expected after training, indicating attitudes did not improve with education. Implications for practice: Efforts to educate staff and improve depression screening depend on staff turnover and accountability by leadership. When small teams were trained, completing the universal screening was successful. As a result, a second phase was implemented to educate staff on the workflow and decrease the stigma surrounding depression screening. Keywords: Edinburgh Postnatal Depression Score, MICA-4, postpartum depression IMPROVED PERINATAL DEPRESSION SCREENING 4 IMPROVED PERINATAL DEPRESSION SCREENING 5 Table of Contents Abstract …………………………………………………………………………………………...3 Background ............................................................................................................................... 7 Problem Statement.................................................................................................................. 10 Diversity of Population and Project Site ............................................................................... 10 Significance for Practice Reflective of Role-Specific Leadership ....................................... 11 Literature Review ......................................................................................................................... 12 Search Methods ....................................................................................................................... 13 Synthesis of Literature ........................................................................................................... 13 Risk factors .............................................................................................................................. 14 Mothers ................................................................................................................................. 15 Infant and Family .................................................................................................................. 16 Society................................................................................................................................... 16 Consequences of Untreated Perinatal Depression ............................................................... 16 Consequences for the Mothers .............................................................................................. 17 Consequences for the Infant.................................................................................................. 18 Consequences for the Partners .............................................................................................. 18 Cost to Society ...................................................................................................................... 19 Treatment of perinatal depression ........................................................................................ 19 Universal screening ............................................................................................................... 20 Counseling ............................................................................................................................ 20 Pharmacotherapy................................................................................................................... 21 Barriers to Perinatal Depression Reduction......................................................................... 22 Inadequate Screening and Depression Recognition .............................................................. 22 Stigma Reduction .................................................................................................................. 23 Inadequate Provider Education ............................................................................................. 24 Discussion................................................................................................................................. 24 Implications for Practice ........................................................................................................ 25 Framework and Project Application ........................................................................................... 26 Framework Application to Project........................................................................................ 27 Project Plan .................................................................................................................................. 28 Project Design.......................................................................................................................... 29 Needs Assessment of Project Site and Population ............................................................... 29 Cost Analysis and Sustainability of the Project ................................................................... 30 Project Outcomes .................................................................................................................... 32 Consent Procedures and Ethical Considerations ................................................................. 32 IMPROVED PERINATAL DEPRESSION SCREENING 6 Instruments to Measure Intervention Effectiveness ............................................................ 33 Project Implementation................................................................................................................ 34 Project Intervention ................................................................................................................ 35 Project Timeline ...................................................................................................................... 36 Project Evaluation........................................................................................................................ 37 Data Maintenance/Security .................................................................................................... 37 Data Collection and Analysis ................................................................................................. 38 Findings .................................................................................................................................... 42 Strengths ............................................................................................................................... 43 Weakness .............................................................................................................................. 44 Quality Improvement Discussion ................................................................................................ 45 Translation of Evidence into Practice ................................................................................... 45 Implications for Practice and Future Scholarship ............................................................... 46 Sustainability......................................................................................................................... 48 Dissemination ....................................................................................................................... 48 Conclusion ............................................................................................................................... 50 References .................................................................................................................................... 52 Apendices ...................................................................................................................................... 58 IMPROVED PERINATAL DEPRESSION SCREENING 7 Improved Perinatal Depression Screening in the Clinic Setting Perinatal depression is the number one complication of childbirth, affecting more than a half-million birthing individuals each year in the United States (Van Niel & Payne, 2020). As a result, over four hundred thousand infants are born to individuals experiencing perinatal depression (Alhusen & Alvarez, 2016). Birthing individuals often report enormous physical, mental, and social changes during pregnancy and after birth, which increases the prevalence of mental health disorders, including depression (O'Hara & Wisner, 2014). In addition, untreated depression during pregnancy or after childbirth increases the risk for long-term complications, which costs the economy an estimated twenty-two thousand dollars per mother and child dyad annually (Cox et al., 2016; Moore Simas et al., 2018). Standardized screening and intervention can diminish the prevalence of perinatal depression (Van Niel & Payne, 2020). However, barriers to effective treatment include inadequate education, coordination of care, and therapeutic follow-up (Moore Simas et al., 2018). The primary purpose of this project is to advocate for the early detection of perinatal depression during routine obstetric visits to reduce social and economic barriers to depression treatment by implementing universal screening, training of medical staff, and standardization of the workflow model. Background Perinatal depression can result from complex physical, environmental, genetic, and social factors. Dagher et al. (2021) suggest that diagnosis of perinatal depression requires five specific symptoms during pregnancy or four to six weeks up to one year after delivery. The symptoms include but are not limited to: (a) mood fluctuation, (b) depression, (c) anxiety, (d) sleep disturbances, (e) guilt, (f) hopelessness, (g) changes in appetite or weight, (h) poor concentration, or (i) suicidal thoughts. Perinatal depression should not be confused with postpartum blues, IMPROVED PERINATAL DEPRESSION SCREENING 8 defined as mood fluctuation in the first two weeks after childbirth (Howard & Khalifeh, 2020). Palladino et al. (2011) suggest that untreated depression and anxiety symptoms can escalate and lead to psychosis, suicide, or infanticide. Unfortunately, the rate of suicide after childbirth exceeds death from hemorrhage and infection in a postpartum individual (Howard & Khalifeh, 2020). Unrecognized and untreated perinatal depression affects not only the birthing individual but the infant and family over their lifespan (Dagher et al., 2021). Depression during pregnancy or after childbirth increases the occurrence of long-term physical, mental, and social complications. Bonding insecurity, difficult lactation, high blood pressure, uncontrolled blood glucose, poor weight management, behavior difficulties, and toxic stress are associated with untreated perinatal depression (Dagher et al., 2021). In addition, social stigma, economic insecurity, transportation concerns, childcare needs, unsupportive healthcare providers, and confusing treatment options are a few barriers to depression treatment (Kendig et al., 2017). One way to reduce the obstacles to effective treatment includes early recognition of depressive symptoms, so intervention can begin while attending routine obstetric appointments. Recognition of depressive symptoms during pregnancy or the weeks following childbirth can improve access, reduce stigma, and alleviate socioeconomic concerns (Dagher et al., 2021). The first step in recognizing perinatal depression is administering an evidence-based universal screening tool during routine obstetric clinic visits. The American College of Obstetricians and Gynecologists (ACOG) recommends screening for depression and anxiety at least once a trimester for the antepartum individual and then again during the postpartum period (ACOG, 2018). In addition, the U.S. Preventative Services Task Force (USPSTF) updated depression screening guidelines to include pregnant individuals or giving birth in the last year (Dagher et al., IMPROVED PERINATAL DEPRESSION SCREENING 9 2021). The Edinburgh Postnatal Depression Scale, PHQ-2, or PHQ-9 screening tools allows a qualified healthcare provider to evaluate individuals during routine obstetric care, during early pregnancy, the second trimester of pregnancy, and after delivery of the infant (Dagher et al., 2021). Several validated depression screening tools are available for public use. Systematic intervention models that initiate screening, diagnosis, and treatment show favorable remission rates for postpartum depression. However, depression screening is inconsistently administered in healthcare systems, leaving an estimated fifty to seventy percent of perinatal depression undetected and untreated (Dagher et al., 2021). Universal depression screening should be the first step in a clinic workflow model for an individual positive for perinatal depressive symptoms during an obstetric visit (Cox et al., 2016). The USPSTF recommends screening individuals at risk of perinatal depression, but only if a collaborative treatment plan is available within the health system (Reynolds & Frank, 2016). ACOG states that screening may impact the detection rate but strongly encourages appropriate diagnosis and intervention after screening by a trained professional for optimal treatment results (ACOG, 2018). A health system should utilize a validated depression screening tool to adequately determine if common somatic changes in pregnancy may be associated, with depression, such as fatigue and appetite changes (Dagher et al., 2021). After screening and diagnosis, an individual experiencing perinatal depression can begin supportive pharmacological and psychological interventions with the direct support of a trained medical provider (Alhusen & Alvarez, 2016). Interventions for individuals diagnosed with perinatal depression should include cognitive and behavior therapy, pharmacologic treatment, and follow-up visits with mental health screening (Cox et al., 2016). In addition, healthcare providers must address any positive screening for suicidal ideation with an emergency protocol IMPROVED PERINATAL DEPRESSION SCREENING 10 and initiation of immediate care (Palladino et al., 2011). Reduction of undiagnosed perinatal depression includes universal screening, appropriate medical diagnosis, and intervention. In addition, research supports that a collaborative team of obstetric, pediatric, and psychiatric medical providers can affect the function of the individual experiencing depressive symptoms twelve months after birth (Cox et al., 2016). Problem Statement Perinatal depression is often unidentified, underestimated, and untreated (Kendig et al., 2017; O'Hara & Wisner, 2014). As a result, women may receive inadequate provider-initiated assessment and intervention for perinatal mental health in the obstetric clinic setting (ACOG, 2018). Unfortunately, undiagnosed mental health disorders contribute to pervasive long-term maternal depression and anxiety, dysfunctional infant bonding, and poor maternal health outcomes, including death by suicide (Howard & Khalifeh, 2020). Therefore, improved universal screening, clinical education, and appropriate treatment guidelines for maternal mental healthcare will reduce perinatal depression for women in the clinic setting (Kendig et al., 2017). Diversity of Population and Project Site The project focuses on several populations: mothers, infants, partners, society, and health care providers. The project site is an obstetric clinic within Intermountain Healthcare's Medical Group. Intermountain Obstetrics and Gynecology Specialist is a large, urban obstetric clinic that annually cares for approximately twelve hundred perinatal individuals in the Salt Lake City region. In this setting, nine obstetricians, four advanced practice providers, registered nurses, medical assistants, and patient service representatives care for the perinatal population. Members of the clinical staff are ethnically diverse, including Caucasians, Hispanics, Asians, Blacks, and other nationalities. Staff education can improve stigma and discomfort by openly discussing IMPROVED PERINATAL DEPRESSION SCREENING 11 mental health, which is prevalent in culturally diverse individuals (House et al., 2020). In addition, universal screening in language-specific EPDS tools is available and validated in several languages (Montazeri et al., 2007). Therefore, healthcare providers must eliminate cultural bias and language barriers when screening patients for equitable mental health intervention. Significance for Practice Reflective of Role Specific Leadership Healthcare systems are aware of the medical, financial, and social burdens that mental health disorders place on society when women are affected by perinatal depression, yet still have not fully implemented the federally mandated cognitive screening (Rhodes & Segre, 2013). Universal screening for perinatal depression using evidence-based tools, including the EPDS, PHQ-2, and PHQ-9, is recommended (ACOG, 2018). The lack of standardized screening for all perinatal patients is a significant barrier to identifying perinatal depression (Cox et al., 2016). Sambrook Smith et al. (2019) found that women reported the process of mental health screening validating in many instances. Individuals screened for depression reported feeling recognized and taken seriously by the health care providers. However, poor implementation of the screening results made women feel like providers were ticking off the box and not examining their real feelings. The Doctor of Nursing Practice (DNP) and Family Nurse Practitioner (FNP) leader will develop education for all obstetric staff that uses evidence-based information to reduce the stigma surrounding the diagnosis of depression. Legere et al. (2017) acknowledge that stigma prevents women from expressing concerns, asking for help, and seeking medical care for signs and symptoms of depression. Negative attitudes projected by the healthcare provider may contribute to social stigma and shame in an individual experiencing perinatal depression. In IMPROVED PERINATAL DEPRESSION SCREENING 12 general, many healthcare providers do not possess the skills necessary to deliver high-quality, evidence-based mental health care to women experiencing perinatal depression due to inadequate training and education (Sambrook Smith, 2019). The obstetric clinical staff will receive education and training to improve the recognition of mental health disorders in the perinatal population. The DNP-FNP leader will institute a standardized practice change, including universal depression screening, electronic charting, and educational training in the obstetric clinic. Instruction will be developed for staff and individuals in the community to raise awareness of perinatal depression by the DNP FNP leader. Providers, registered nurses, medical assistants, and patient service representatives will implement a universal depression screening and workflow model intervention to identify individuals with perinatal depression in the obstetric clinic. The DNP FNP nurse leader will demonstrate the successful implementation of universal depression screening in the obstetric clinic setting to leaders in the Maternal Mental Health committee for the Utah State Legislature. Currently, leaders are working to validate evidence that screening improves depression identification. This additional evidence will support ongoing state-wide standardized screening policies, reimbursement for providers, and assistance programs for individuals experiencing perinatal mental health disparity in Utah. Federal legislative initiatives have provided funding for mental health access, treatment, and research, and various States have successfully implemented standardized perinatal depression screening guidelines to reduce disparity in depression treatment (Dagher et al., 2021). Literature Review The literature review intends to define perinatal depression, identify barriers to equitable mental health evaluation, and provide supporting evidence for evidence-based mental health IMPROVED PERINATAL DEPRESSION SCREENING 13 screening in individuals experiencing perinatal depression. Perinatal depression is the number one complication of childbirth. Predominant risk factors are a history of mental health disorders, lack of social support, and relationship insecurity. Evaluation at the obstetric clinic is an optimal time to screen for depression. Unfortunately, barriers exist to depression screening and intervention, including (a) provider stigma, (b) inadequate screening and assessment, (c) inadequate provider education, and (d) poor access to medication and therapeutic intervention. Implementing universal mental health screening specific to the perinatal population is critical. Recommendations for women with positive screening results include developing a management algorithm, executing provider-initiated intervention, and referring to psychiatric resources (Kendig et al., 2017). Universal screening, education for healthcare providers, and established care models improve women experiencing temporary mood disorders in the perinatal period (Cox et al., 2016; Muzik & Borovska, 2010). Search Methods The author used a combination of search methods to compile evidence supporting screening and workflow model intervention for individuals experiencing perinatal depression. The search methods include Cinhal, Cochrane Library, GoogleScholar, and PubMed. The key terms used for the search were cost to society, depression screening, Edinburgh Postnatal Depression Scale, woman, infant, partner, violence, perinatal depression, PHQ-2, PHQ-9, social determinants of health, and treatment. Synthesis of Literature Perinatal depression is a major or minor episode of depression occurring during pregnancy or within four weeks to one year after childbirth (Dagher et al., 2021; O'Hara & Wisner, 2014). The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders IMPROVED PERINATAL DEPRESSION SCREENING 14 (DSM‐V) does not recognize postpartum depression as an independent diagnosis. However, subclassification includes the diagnosis of “peripartum onset” of major depressive disorder with an onset during pregnancy or up to four weeks to one year after birth (Alhusen & Alvarez, 2016). Other definitions of perinatal depression include the classification of depression based on symptoms including decreased happiness, fatigue, excessive worry, anhedonia, and thoughts of suicide (Hutchens & Kearney, 2020). Symptoms of depression can include: (a) mild to moderate mood fluctuations, (b) sadness, (c) irritability, (e) crying, (f) anxiety, (g) anger, (h) worry, (i) insomnia, (j) excessive sleepiness, (k) emotional lability, and (l) numbness (Alhusen & Alvarez, 2016). Individuals can manifest one symptom or a combination of symptoms simultaneously but must have two symptoms simultaneously for two weeks to be diagnosed with major depressive disorder. Depression can occur during pregnancy, persist after delivery, or develop postpartum. The healthcare provider classifies perinatal depression by the length of time the symptoms persist and the intensity of the symptoms (Alhusen & Alvarez, 2016). Risk Factors The World Health Organization determined that depression is the leading cause of disability worldwide (World Health Organization, 2020). Furthermore, the prevalence of depression rises two-fold for women during the reproductive years (Alhusen & Alvarez, 2016). Variables increasing the risk of perinatal mental health conditions include relationship insecurity, including (a) low income, (b) unplanned pregnancy, (c) general lifestyle stress, (d) poor social support, (e) previous stillborn or miscarriage, (f) prior mental health conditions, (g) genetics, (h) premenstrual dysphoric disorder, (i) lower levels of oxytocin during pregnancy, and (j) breastfeeding status (O'Hara & Wisner, 2014; Stuart-Parrigon & Stuart, 2014). Predominant risk factors for perinatal depression include a history of psychiatric illness, life stressors, or IMPROVED PERINATAL DEPRESSION SCREENING 15 suboptimal social relationships. These risk factors are easily identifiable by healthcare providers in the clinic setting, and vulnerable women could benefit from education, social, cognitive, psychotherapy, and pharmacologic support (O'Hara & Wisner, 2014). Mothers Perinatal depression influences physical and mental health outcomes for the mother, infant, and partner over a lifetime. On average, four million infants are born annually in the United States (Hutchens & Kearney, 2020). Depression during pregnancy and after birth can trigger overwhelming feelings of hopelessness, shame, and humiliation for an individual. Individuals experiencing perinatal depression display poor problem-solving skills and may not initiate proper self-care, infant care, and mental health care intervention (Hutchens & Kearney, 2020). Severe perinatal depression is an associated risk for substance misuse, suicide attempts, and suicide. Suicide continues to be the leading cause of death in the perinatal period, accounting for five to twenty percent of maternal death yearly (Howard & Khalifeh, 2020). Woolhouse et al. (2014) developed a prospective cohort study to examine women pregnant with their first child. One in three women reported depressive symptoms during pregnancy and up to four years postpartum. The strongest predictors of depression at four years postpartum were previously reported depression in pregnancy, young maternal age, and low income. In the first twelve months postpartum, partner abuse increased the risk of depression four-fold at four years. As a result, the author suggests that postpartum depression does not end after one year. Women can be affected for years after giving birth. Furthermore, socioeconomic status can determine an increased risk for depression. The study finding suggests that intervention must begin in the clinic during pregnancy to give mothers access to care while on public insurance programs. Early intervention should include IMPROVED PERINATAL DEPRESSION SCREENING 16 screening, education, and early access to mental health resources, including medication and counseling for all perinatal patients. Infant and Family Experts agree that depression during pregnancy is associated with low-birth-weight infants and long-term psychological and physical infant development (Muzik & Borovska, 2010). Pilkington et al. (2016) report that the family unit, including fathers and same-sex couples, can experience a higher rate of depression than the average population during their partner's pregnancy and childbirth. The definition of a partner is anyone having an intimate relationship with the infant and mother dyad. Fifty percent of individuals diagnosed with perinatal depression have partners who experience depression. Musik & Borovska (2010) reported that depressed partners provide reduced support for mothers and infants during care. Society Poor social determinants of health compound disadvantages for mothers, infants, and families over a lifetime. Healthcare providers and clinical staff should screen for perinatal depression, social issues, and economic concerns during the obstetric visit (ACOG, 2018; Musik & Borovska, 2010). The United States Preventive Services Task Force (USPSTF) recently evaluated rates of perinatal depression. The United States' overall burden for the untreated mother-child dyad is an estimated 14.2 billion dollars (Siu et al., 2016; USPSTF, 2019). Medical, educational, and social burdens exponentiate when perinatal depression remains untreated in society. Consequences of Untreated Perinatal Depression Untreated perinatal depression leads to significant household dysfunction and reverberates throughout the family. Complications of perinatal depression include (a) IMPROVED PERINATAL DEPRESSION SCREENING 17 disintegration within the family unit, (b) long-term psychiatric illness, (c) substance use, (d) poor growth of the fetus, (e) pre-term delivery, (f) developmental delays for infants and toddlers, (g) poor bonding and relationship insecurity, and (h) increased utilization of health care resources for physical and mental health (Śliwerski et al., 2020). According to Hutchens & Kerney (2020), the number of individuals affected by perinatal depression is significant, estimated from 520,000 to 760,000 annually. Often, perinatal depression leads to a decline in self-care, inversely affecting the family unit. Consequences for the Mothers Depression during pregnancy and after birth can trigger overwhelming feelings of hopelessness, shame, and humiliation. In a systemic review, Howard and Khalifeh (2020) found clear evidence of adverse pregnancy outcomes when individuals have a severe mental illness, including an increased risk of pre-eclampsia, abruption during pregnancy, postpartum hemorrhage, and stillbirth. Traumatic birth experiences further potentiate mental health disorders after childbirth and subsequent pregnancies. Women who struggle with thoughts of self-harm may also display poor problem-solving skills and may not initiate self-care, infant care, and mental health care (Hutchens & Kearney, 2020). Severe perinatal depression is an associated risk for substance misuse, self-harm in pregnancy, suicide attempts, and suicide. Self-harm is not routinely evaluated and is considered a significant risk factor for suicide in the obstetric clinic. Suicide continues to be the leading cause of death in the perinatal period, accounting for five to twenty percent of maternal death yearly (Howard & Khalifeh, 2020). Additionally, screening for domestic violence and a history of abuse is essential in the perinatal population. The health care provider should evaluate for the presence of partner violence because it is a strong predictor of perinatal depression (Biaggi, 2016). IMPROVED PERINATAL DEPRESSION SCREENING 18 Consequences for the Infant Hutchens & Kearney's (2020) research suggests untreated maternal depression will lead to extended adverse infant outcomes. The chronic nature of depression can lead to bonding insecurities and parenting deficits. Depressed women have poor coping skills and ambivalent, disorganized, or withdrawn interactions with their infants. Individuals experiencing perinatal depression report being overwhelmed with basic infant care, which leads to failure to thrive, poor growth, and long-term health outcomes for infants (Cox et al., 2016). Dagher et al. (2021) report that children with depressed mothers have increased eating disorders, sleeping problems, and behavioral difficulties. Infants of depressed individuals also are at increased risk for developmental delays and future depression. In a randomized control trial, individuals diagnosed with perinatal depression had lower scores for sensitivity to infants during free play. Infants need positive maternal feedback to grow. Furthermore, maternal withdrawal behavior in early childhood was a strong predictor of future adolescent psychopathology, including suicide, borderline, antisocial, and dissociation (Lyons-Ruth et al., 2013). Consequences for the Partners Pilkington et al. (2016) reported that fifty percent of individuals diagnosed with perinatal depression have partners who experience depression. A systematic study suggests that partner support can be a protective factor for developing perinatal depression (Pilkington et al.,2016). Furthermore, depressed partners provide reduced support for mothers and infants during care. Engqvist & Nilsson (2011) completed an explorative qualitative internet search to examine the influence of depression on the support partner. They reported that individuals with partners diagnosed with postpartum depression feel their days include increased stressful reactions, lifestyle changes, acceptance of more responsibility, and disruptive feelings. The American IMPROVED PERINATAL DEPRESSION SCREENING 19 College of Obstetricians and Gynecologists suggests that partners' depression assessments are essential in women's health assessments. Concurrent assessment, education, and treatment of both mother and father may improve the family's health (ACOG, 2010). Cost to Society The burdens that perinatal depression places on society are enormous. The medical, educational, and social burdens on society increase exponentially when an individual with perinatal depression is left untreated. However, in terms of actual costs to society, treatment for depression costs an estimated twenty-three billion dollars annually in the United States (Siu et al., 2016). The United States Preventive Services Task Force (USPSTF) recently evaluated the cost burden of perinatal depression. Each mother-child grouping affected by perinatal depression costs $32,000 over a lifetime (USPSTF, 2019). As a result, the USPSTF increased its focus on perinatal depression and issued the Healthy People 2020 Initiative, emphasizing screening for major depression at least once during pregnancy (Hutchens & Kearney, 2020). Treatment of Perinatal Depression During pregnancy, frequent clinic visits are routine expectations of care. Obstetric clinic visits are ideal for assessing, recognizing, and treating mental health disorders (O'Hara & Wisner, 2014). The healthcare professional utilizes standardized screening tool scores, clinical assessments, or interviews to diagnose perinatal depression (Stuart-Parrigon & Stuart, 2014). When a patient is diagnosed with perinatal depression, the provider must decide on an appropriate course of care, including cognitive behavior training, individual or group psychotherapy, and pharmacotherapy (Siu et al., 2016). Cox et al. (2016) completed a systemic review concluding that treatment models that utilize several modalities increased the remission IMPROVED PERINATAL DEPRESSION SCREENING 20 rate for perinatal depression. However, initiation of treatment is challenging for individuals diagnosed with perinatal depression. Universal Screening Screening is an essential first step to decreasing perinatal mental health disparity (Muzik & Borovska, 2010). Women screened for depression show a reduction in mental health symptoms, reinforcing the universal benefit of screening for all perinatal women. The American College of Obstetrics and Gynecology (ACOG) recommends that individuals be screened at least once during pregnancy and postpartum for depression. ACOG also recommends using the Edinburgh Postpartum Depression Screening (EPDS) or a validated screening tool to identify postpartum depression (ACOG, 2018). The EPDS is a sensitive, ten-item self-report scale that reliably and quickly identifies women at high risk of developing depression (O'Connor et al., 2019). Bergink et al. (2016) compared the EPDS screening tool to similar proven depression screening methods. The authors concluded that the EPDS is a convenient and effective indicator used by a healthcare professional for the initial evaluation of postpartum depression. The PHQ-2 and PHQ-9 are two other validated tools to screen for depression. General depression screening questions are asked initially on the PHQ-2. A score above three on the PHQ-2 indicates positive results and further evaluation with the PHQ-9. The PHQ-2 has a ninety-seven percent sensitivity and can rule out but not diagnose depression. The PHQ-9 has a sixty-one percent sensitivity and ninety-four percent specificity for depression, allowing providers the option to eliminate additional depression screening if a negative PHQ-9 is obtained (Maurer, 2012). Screening tools are useful identification tools but do not replace diagnosis by trained providers during the assessment (ACOG, 2018; Rhodes & Segre, 2013). Counseling IMPROVED PERINATAL DEPRESSION SCREENING 21 The ACOG recommends psychotherapy for perinatal depression. In addition, the governing body recommends implementing a collaborative care model, including social workers working under mental health specialists' supervision in obstetrics and gynecology offices to improve perinatal depression outcomes (ACOG, 2018). Furthermore, assessing therapy preferences, offering treatment options, and including patients in decision-making will improve therapy acceptance. Ninety-two percent of pregnant women are likely to endorse individual therapy preference, and sixty-two percent of women accept group therapy (Muzik & Borovska, 2010). Individuals experiencing perinatal depression preferred psychotherapy in the obstetric office or the home over the psychiatric treatment setting. Women indicate that comfort and familiarity with the clinic and staff are essential factors that decrease treatment barriers (Flynn et al., 2010). Pharmacotherapy Pharmacotherapy is a personal decision made by the patient and family. Muzik and Borovska (2010) found that seventy percent of women who are not pregnant or breastfeeding endorse pharmacologic treatment for depression. However, an overwhelming majority of women reject the idea of antidepressant therapy while pregnant or breastfeeding. Meltzer-Brody & Jones (2015) suggest that many medical practice settings endorse antidepressant medication as the quickest and most common treatment for depression. In the United States, antidepressant use has doubled in the last fifteen years and nearly one in twelve women on Medicaid report using an antidepressant perinatally. Despite its increased use in the perinatal population, literature is still conflicting regarding safety and efficacy. Cox et al. (2016) defined the rate of depression remission as undetected depressive symptoms of diagnostic criteria by the DSM-5. The authors found that pharmacological therapy IMPROVED PERINATAL DEPRESSION SCREENING 22 improved remission rates for forty-eight percent of individuals experiencing perinatal depression. Muzik and Borovska (2010) advocate for medication therapy initiated by the obstetric provider. Interestingly, the authors report that women familiar with the medication with previous experience taking the drug are more willing to utilize antidepressant pharmacotherapy in pregnancy or postpartum. The authors feel that the healthcare provider's education, integration, and flexibility will increase a women's willingness to embrace a pharmacologic treatment plan. Barriers to Perinatal Depression Reduction Perinatal depression continues to be a pervasive issue because of the barriers surrounding screening and intervention, including (a) lack of universal mental health screening, (b) treatment cost, (c) insurance, (d) ineffective screening utilization, (e) lack of psychiatric resources, (f) staff stigma, and (g) inadequate social systems (Cox et al., 2016; Flynn et al., 2010). Furthermore, perinatal mental health diagnoses burden society and increases social awareness; only one-third of pregnant women receive the necessary treatment after diagnosis (Muzik & Borovska, 2010). Bennett et al. (2007) used a grounded theory study to evaluate women diagnosed with depression during pregnancy. Women experience challenges when diagnosed with depression, including recognizing depressive symptoms, social stigma, supportive health care providers, and management of treatment options. Successful interventions include counseling and medication. Unfortunately, fewer than seven percent of individuals experiencing perinatal depression receive adequate treatment (Cox et al., 2016). In conclusion, healthcare providers need additional training to support individuals struggling with mental health conditions during pregnancy and after childbirth. Inadequate Screening and Depression Recognition IMPROVED PERINATAL DEPRESSION SCREENING 23 Baumann et al. (2020) used the Center for Disease Control 2018 Pregnancy Risk Assessment Monitoring System (PRAMS) to evaluate the effectiveness of depression screening in the clinic setting. The authors conclude that one in eight women with a live birth did not receive an adequate mental health evaluation during the postpartum clinic visit. In addition, one in five women did not have mental health evaluation during a prenatal visit. Sambrook Smith et al. (2019) found that women reported the process of mental health screening validating in many instances. In addition, individuals reported feeling that healthcare providers recognized and acknowledged symptoms of mental health conditions. However, positive screening results did not increase the healthcare provider's initiation of mental health evaluation. As a result, poor implementation of treatment interventions made women feel like providers were ticking off the box and not examining their real feelings. In addition, individuals experiencing perinatal depression experienced a lack of knowledge, resources, and treatment options on the referral pathway after the screening (Sambrook Smith et al., 2019). Obstacles in identifying perinatal depression in the clinic setting begin with a failure to utilize screening tools. In 2010, the Patient Protection and Affordable Care Act (ACA) included comprehensive clinical services and research legislation. The ACA requires adult screening for depression in a healthcare setting, but only three states have mandatory screening for perinatal patients despite increased awareness. Healthcare systems are aware of the medical, financial, and social burdens that mental health disorders place on society, yet still have not implemented federally mandated cognitive screening for all adults, including perinatal patients (Rhodes & Segre, 2013). Stigma Reduction IMPROVED PERINATAL DEPRESSION SCREENING 24 The stigma surrounding the diagnosis of depression is prevalent in society. Pregnancy, birth, and motherhood are joyful times in life in many cultures, creating additional concerns about expressions of sadness, worry, or depression for pregnant mothers. Biaggi et al. (2016) used a systemic literature review to identify the risk factors for depression and pregnancy anxiety and concluded that women experiencing perinatal depression have pervasive thoughts, worries, and fears that affect daily living. Stigma prevents women from expressing concerns, asking for help, and seeking medical care for signs and symptoms of depression. In addition, personal bias among healthcare providers can influence the interventions provided for mental health. Research suggests that healthcare providers do not have adequate education and training to treat perinatal depression without bias (Legere et al., 2017; Sambrook Smith, 2019). Inadequate Provider Education Education and training are essential in recognizing mental health disorders in the perinatal population. Legere et al. (2017) acknowledged that negative attitudes might contribute to indifference and stigma exuded by the healthcare provider and create additional shame. A systematic review of seventeen hundred ninety studies examining healthcare providers’ level of understanding regarding perinatal mental health concluded a lack of education, professional development, and poor identification of mental health concerns in perinatal women. The systemic review indicated that any education is optimal, including informal or formal professional development in quality healthcare services for mothers with perinatal depression signs and symptoms. In general, many healthcare providers do not possess the skills necessary to deliver high-quality, evidence-based mental health care to women experiencing perinatal depression due to inadequate training and education. Discussion IMPROVED PERINATAL DEPRESSION SCREENING 25 Perinatal depression occurring during pregnancy or the first year after delivery affects the woman, infant, and family over their lifespan. Healthcare providers identify risk factors in the clinic setting with training and education. In the clinic, vulnerable women could benefit from education, social support, cognitive and psychotherapy, and pharmacological treatment. Complications of perinatal mood disorders increase the utilization of health care resources for physical and mental health services, and severe perinatal depression is associated with suicide. Universal screening is an essential first step to decreasing perinatal mental health disparity but does not replace diagnosis by trained providers during the assessment. Also, interventions such as counseling and antidepressant medication have influenced the remission of perinatal depression. In the future, women may continue to face many challenges when diagnosed with depression, including recognizing depression and reducing stigma. However, implementing a universal screening tool by a supportive and educated healthcare provider will allow optimal evaluation and treatment through a standardized clinic workflow model, eventually improving recognition of the signs of perinatal depression. Implications for Practice Mental health screenings to address depression are a crucial first step to universal mental health care for perinatal individuals. The evidence suggests that routine screening and standardized mental health intervention reduce depression. Therefore, clinical staff will initiate routine perinatal mental health screening during obstetric visits and six weeks after birth for all individuals ages fifteen to forty-five at Intermountain Obstetrics Gynecology Specialists. Individuals will complete a perinatal depression screening using the PHQ-2, PHQ-9, or Edinburgh Postnatal Depression Scale. An individual's screening results for the PHQ-2, PHQ-9, IMPROVED PERINATAL DEPRESSION SCREENING 26 or EPDS will be adequately charted and tracked through electronic medical records. The healthcare professional will initiate screening according to federal mandates at each patient visit. Women disclose mental health concerns at obstetric and postpartum office visits, depending on the provider's comfort, training, and education. Depression and anxiety are addressed explicitly in the EPDS assessment. The patient service representative distributed the mental health screening tool to all postpartum patients at check-in for the appointment. Electronic medical record charting and alerts help providers know if they should assess patients for additional concerns. However, clinical staff lacks training on EPDS screening in the clinic setting. Furthermore, there is no standardized follow-up on the EPDS screening. The current electronic health record used at Intermountain Healthcare includes the EPDS, PHQ2, and PHQ-9, but the clinical staff lacks education on the scoring and ICENTRA. In addition, the providers would like an improvement to the electronic charting patient summary page to include mental health scores, trends, and alerts. Specific management policies for a positive screening obtained from the patient are inadequate. The clinical staff is uncertain about when to initiate a mental health assessment follow-up. Each provider chooses to assess and treat based on personal practice, not evidence. A clinic workflow model will address the above concerns and additional interventions for this patient population and setting. Framework and Project Application The DNP FNP leader will utilize Kotter's Theory of Change to develop and implement a workflow model for providers. The DNP FNP will organize the healthcare team to standardize the screening process and implement the workflow model. As a result, clinical staff will have the training to utilize the EPDS and improve charting and communication. The goal is to reduce IMPROVED PERINATAL DEPRESSION SCREENING 27 cultural and cognitive bias in the healthcare worker and provide supportive intervention for mental health screening for all perinatal individuals. Framework Application to Project First, the DNP-FNP leader will provide staff education on disparity and long-term results of untreated perinatal depression for the mother, infant, and family to create a sense of urgency. Then, the framework outlined by the Institute of Health will be utilized to develop team activities to reduce burnout experienced by healthcare workers (IHI, 2019). Next, a small team within the clinic will create a strategic vision and initiative for the workflow model, becoming a guiding coalition. Next, the small team will implement the clinic workflow model before the full clinic utilizes the algorithm. After one month, the small teams will use the plan, do, study, and act cycle to refine the depression screening clinic workflow model. Finally, training on the EPDS screening tool, perinatal depression rates, and barriers for mothers will be given to all staff through electronic presentation to reduce cognitive bias and enlist the team to implement the clinic workflow model. After complete staff education, the clinic workflow model will be implemented for one month for every postpartum appointment. During this time, the team will meet daily to share concerns and celebrate short-term wins in the screening process. Concerns will be addressed at the daily team meeting, and adjustments will be made as needed. The DNP-FNP leader will empower the staff to share stories, promote open communication, and reward teams for successful universal screening to sustain the momentum. Last, the depression screening process will be reevaluated with input from all team members and chart surveys (Kotter, 2021). The DNP FNP nurse leader will use a proactive change theory to institute evidence-based depression screening and a clinic workflow model to reduce perinatal depression in the clinic setting. IMPROVED PERINATAL DEPRESSION SCREENING 28 Project Plan The quality improvement plan aligned with the eight stages of Kotter's Theory of Change (1) creating a sense of urgency, (2) building a coalition, (3) forming a strategic vision and initiative, (4) enlisting a volunteer army, (5) enabling action by removing barriers (6) generate short term wins, (7) sustaining acceleration and (8) instituting change (see Appendix A). Initially, an interdisciplinary team of medical assistants, patient service representatives, and registered nurses identified gaps in the current depression screening process (Kotter, 2021). Administration of the EPDS in the clinic setting was not standardized; therefore, some perinatal individuals suffering from depression were not identified. Unidentified perinatal depression has a long-term effect on the mother, family, and society (Ellington, 2021). The team was educated on the consequences of unidentified perinatal depression to create a sense of urgency. In addition, the vision included standardization of depression screening and improved staff collaboration. The team developed a workflow model endorsed by the project consultant. Barriers included internal review board approval and small team implementation to identify problems in the workflow model. First, Intermountain Healthcare and Weber State University's internal review board analyzed and approved the quality improvement project. Next, a small team of two medical doctors, registered nurses, medical assistants, and patient service representatives were enlisted to trial the clinic workflow model (see Appendix B). Finally, the initial model was evaluated for areas of concern and changed based on suggestions by the collaborative team. According to Sambrook-Smith (2019), barriers to adequate mental health care include fear, social stigma, and lack of education for healthcare providers. Therefore, the first step of the quality improvement project was staff education. Knowing known risk factors and symptoms of perinatal depression increases the likelihood of depression recognition in the health care IMPROVED PERINATAL DEPRESSION SCREENING 29 professional (Sambrook-Smith, 2019). The clinic workflow model was implemented for all postpartum individuals receiving follow-up care in the clinic setting. A bulletin board was used for staff to post short-term successes. In addition, the daily team meeting was used to share positive and negative responses to the new clinic workflow and sustain the project's acceleration. One month after initiating the clinic workflow model, the DNP leader audited patient health information to determine the effectiveness of the quality improvement project. Project Design The project design focused on quality improvement of the perinatal depression screening process in the obstetric clinic. The goal was to increase staff education, decrease staff bias, and eliminate discrepancies in postpartum depression screening. The success of the project design was dependent on the team approach. The obstetric healthcare team had multiple perspectives on depression and many identified knowledge levels. Research suggests that a collaborative team approach reduces unintended consequences of insufficient perinatal depression screening. In addition, training improves when different perspectives are recognized within the team (Cabrera & Cabrera, 2019; Ellington, 2021). The quality improvement project design was developed to ensure universal implementation by the entire staff regardless of education or previously held perspective. Needs Assessment of Project Site and Population In Utah, forty percent of all individuals experiencing a recent live birth report symptoms of depression or anxiety (PRAMS, n.d.). Perinatal depression risk factors are identifiable with validated mental health screening tools in the obstetric visit. Unfortunately, despite solid evidence favoring preventative screening, many perinatal individuals are not routinely assessed for depression in the obstetric clinic (Bauman et al., 2020). However, a standardized model IMPROVED PERINATAL DEPRESSION SCREENING 30 needed to be developed to coordinate the interrelated parts of the patient experience in the clinic setting. The DNP candidate evaluated the postpartum depression screening process at Intermountain Ob-Gyn Specialists and identified gaps. The direct population target in the quality improvement project was the healthcare worker at Intermountain Ob-Gyn Specialists at Intermountain Medical Center, Murray, Utah. The problem identified the need for additional training, education, and a standardized workflow model. The Doctor of Nursing Practice (DNP) quality improvement project standardized staff education and clinic workflow model and facilitated the detection of perinatal depression during routine obstetric visits. The indirect population in the quality improvement project design was the perinatal individual. Anokye et al. (2018) suggest that mothers are reluctant to share their symptoms of depression and anxiety with their healthcare providers. The prevalence of undetected postpartum depression may be as high as half of those individuals that self-identified as depressed during the postpartum period (Anokye et al., 2018). Trained and educated obstetric healthcare providers play a crucial role in depression screening and identification (Ellington, 2021). Cost Analysis and Sustainability of the Project Expenses for the quality improvement project were modest compared to the impact of untreated perinatal depression on society (Mathematica, 2019). Unfortunately, depression screening remains unfunded by many private and public insurance programs, despite strong evidence supporting early preventative measures to improve maternal outcomes and reduce costs (Wiles, 2019). The cost analysis of the project included printing, food, incentives for team building, and training certification (see Appendix C). Educational material was developed and disseminated with minimal printing cost. The registered nurse team revised a postpartum IMPROVED PERINATAL DEPRESSION SCREENING 31 handbook with materials from approved patient education. The condensed postpartum handbook was then submitted to Intermountain leadership as an improvement idea. Unfortunately, Intermountain Healthcare's Marketing team did not approve the cost of the handbook development. However, the Ob-Gyn Specialists registered nurse team created a clinic-specific card with a QR code link to postpartum topics in the current handbook or Intermountain Healthcare’s website. The Intermountain postpartum handbook and a clinic-specific card will be given to the antenatal patient around the beginning of the third trimester in a registered nurse visit after a scheduled obstetric appointment. Development of the card and printing costs are currently unknown. Training and education were conducted during pre-planned staff meetings and did not require overtime. However, perinatal mental health certification of the DNP leader costs $500.00 yearly. A scholarship from the Utah chapter of Postpartum Support International (PSI) covered the cost of the training for the project leader in 2022. In addition, the DNP student provided team-building activities and incentives at minimal personal expenses. A long-term sustainability expense plan to improve perinatal depression screening in the clinic includes printing, certification training, and costs for maintaining up-to-date material (See Appendix B). In addition, Intermountain Healthcare Medical Group will cover the printing costs for patient and staff education (see Appendix D). Certification of a medically trained team member must be initiated or renewed through PSI yearly. The cost incurred for initial training is $500.00 annually. However, the renewal of a previously certified staff member is $100.00 yearly, so the actual cost is variable. The health system will not cover the cost, and the certification must be obtained at the healthcare worker’s expense. Scholarships are available through PSI-Utah. A digital presentation was developed to standardize training in the future for all staff without cost. However, the presentation will need to be updated and improved yearly. IMPROVED PERINATAL DEPRESSION SCREENING 32 The hourly wage for the certified healthcare provider to update material will be included in the sustainability plan of the clinic workflow model. The registered nurse (RN) team will utilize mandatory weekly meetings to update the clinic workflow model quarterly and will not incur additional costs. Incentives will not be included in the long-term sustainability expense plan. Project Outcomes The outcomes of the quality improvement project measured the effectiveness of staff education and training, standardization of the depression screening clinic workflow, and the number of individuals screened using EPDS at the postpartum visit. The validated tool measured project outcomes with a pre-training and-post training evaluation staff survey (Appendix E). The PHI data collection tool was a self-developed checklist to obtain quantitative data from electronic medical records. The goal was to measure the delivery of the EPDS screening tool to postpartum individuals before and after the initial staff education and training. Consent Procedures and Ethical Considerations Intermountain Healthcare's Internal Review Board (IRB) and Weber State University IRB determined that no study component was more significant than minimal risk. Therefore, the DNP project, Improving Perinatal Depression Screening in the clinic, was approved by both institutions. The study retrospectively reviewed patients' medical records to measure utilization of the EPDS tool at the postpartum clinic visit. After IRB approval, patient health information was audited. The results were stored on the facility’s password-protected and encrypted internal information systems. Patient health information (PHI) identification was never collected or stored. Furthermore, the patient’s EPDS was not recorded at any time. The principal investigator viewed the PHI to measure the compliance and improvement of staff clinic workflow before and IMPROVED PERINATAL DEPRESSION SCREENING 33 after education. HIPAA compliance for the data collection was maintained. The data collected was not used to alter the patient care plan. In addition, a survey was administered to the staff at Intermountain Ob-Gyn Specialists measuring individual knowledge and bias toward depression. The pre-training and post-training staff surveys were administered with a validated tool: The Mental Illness Clinician Attitude -4 (MICA-4) (Appendix F). The staff survey measured changes in knowledge and bias, which could alter the success of the depression screening clinic workflow. The survey was optional for participating staff, and completion implied informed consent (Appendix F). The participant was notified before the survey was administered in writing. Completion or participation in the survey was not used as an incentive or reward. In addition, employment opportunity was not altered based on the completion of the survey. The staff survey was collected in a paper format without any employee identification. However, the training was mandatory for all staff at Intermountain Ob-Gyn Specialists. Inclusion criteria included the approximately fifty employees in the age range of eighteen to seventy years old employed by Intermountain Healthcare Medical Group. Exclusion criteria included staff members who did not desire to participate in the pre-and-post-education survey and all PRN staff members. Instruments to Measure Intervention Effectiveness Two data collection tools were used to measure the project intervention effectiveness: A self-developed Patient Health Information (PHI) data collection tool (Appendix E) and the validated MICA-4 (Appendix F). The PHI data collection tool is a self-developed checklist to review electronic medical records and obtain qualitative data and was used with specific inclusion criteria. Eligible records were identified by the perinatal individual's estimated date of delivery. Nominal Data collection measured the number of EPDS completed and charted for all IMPROVED PERINATAL DEPRESSION SCREENING 34 postpartum patients delivered at Intermountain OB-GYN Specialist in October 2021 and March 2022 (Appendix E). Identification systems were not used to collect the PHI. The primary investigator and employee at Intermountain OB-GYN Specialist, Maja Lusk DNP FNP-C, BSN, RN, completed the data extraction of approximately three hundred patient health records. The MICA-4 (Appendix F) is a short, self-administered instrument that measures the health professional's bias and knowledge regarding mental health. The MICA-4 tool has been validated for use with nurses and health service professionals. The tool measures attitude change with a six-point Likert-type Scale (Kassam et al., 2010). Quality improvement outcomes could only be validated if the number of EPDS tools completed by the patient were used as evidence for quality improvement in a depression screening model. Project Implementation Project implementation began with a review of patient health information, activities for team building, presentation of the new clinic workflow model (Appendix B), and completion of the staff survey (Appendix F). Initially, patient health information was accessed to determine the number of EPDS screenings completed in the obstetric clinic. Then team-building activities were implemented to build momentum. The interactive activities helped the team learn more about personal joy, strengths, and qualities. In addition to building momentum, the activities included additional education on perinatal depression screening. Finally, two detailed presentations were delivered to the specific clinical team members participating in a staff meeting via Microsoft Teams (Appendix G; Appendix H). Before the presentation, the team completed a staff survey to measure education and clinician bias regarding depression. After the staff completed the education and training at the staff meeting, the clinic workflow was implemented. IMPROVED PERINATAL DEPRESSION SCREENING 35 The clinic workflow model was implemented universally for individuals at the postpartum office visit at Intermountain Ob-gyn Specialists. In addition, continuing education, short-term wins, and screening challenges were shared at the daily staff meetings. The RN meeting’s quality improvement workflow model was refined and reevaluated weekly. At the end of the implementation period, patient health information for all individuals attending a postpartum visit in March 2021 was audited. Then, the chart audits and staff surveys were compiled into usable information. The information was presented at the medical provider's monthly meeting to demonstrate success with a standardized depression screening process and improve clinician bias and mental health education. Project Intervention Project intervention included (1) chart audits, (2) staff education, (3) clinic workflow model development, (4) patient education, and (5) screening implementation. Chart audits revealed gaps in depression screening for postpartum individuals in the clinic. Patient health information was audited for all individuals, with an estimated delivery date in October 2021. The DNP leader used a self-developed spreadsheet (Appendix E) to gather qualitative data on completing the EPDS chart and discussing mental health at the postpartum visit. After chart audits were complete, PowerPoint presentations were developed to educate staff on the signs of postpartum depression and outline the depression screening workflow in detail. The first presentation was specific to the registered nurse. It provided additional standardized information for a two-week follow-up phone call, patient education, and resource lists to send electronically to patients. In addition, each registered nurse received a folder with the depression screening algorithm (Appendix B), standard questions for the two-week RN phone call (Appendix I), updated resource lists (Appendix I), and standardized patient education (Appendix J). IMPROVED PERINATAL DEPRESSION SCREENING 36 The second presentation included general information on the clinic workflow model and was delivered to the RN team and staff on February 16 and 17, 2022. The staff survey (Appendix F) to measure bias and education on depression was distributed to the staff before each presentation. After the presentation, standardized patient education, resources, and EPDS forms were given to all staff, and the clinic workflow model was implemented. In May 2022, the postpartum handbook was sent to the Intermountain Marketing team. Revision of the current postpartum handbook was not approved, but the development of a clinic-specific card to be included with the current handbook given on the postpartum floor was initiated. A final chart audit for postpartum individuals was completed in April 2022, and the data from the chart audits and surveys were shared in May 2022 staff meeting. In addition, the results of the survey and chart audits were disseminated to the medical provider at a meeting in June 2022. Project Timeline The project timeline included (1) chart audits, (2) team-building activities, (3) small team implementation and reevaluation, (4) training on the clinic workflow model, (5) survey collection, (6) project implementation, and (7) approval of the postpartum depression screening toolkit. In December 2021, chart audits, staff education, and team-building activities were implemented. The following month small teams were organized to develop a clinic workflow model and refine the depression screening process. A standardized process algorithm was developed and approved by the small teams. In addition, the registered nurse team compiled educational material for a postpartum depression screening tool kit, which was submitted to the Senior Practice Director and Marketing for approval at the beginning of the year. The clinic workflow model was presented to the staff on February 16th and 17th, and implementation began on February 22, 2022. Weekly staff huddles discussed short-term wins and concerns with IMPROVED PERINATAL DEPRESSION SCREENING 37 the depression screening workflow. In April, patient health information was audited to determine whether the depression screening workflow improved. The same survey was distributed to the staff to measure bias and education on depression. The chart audits and surveys were presented to the medical providers, Intermountain Review Board, and Women's Service Line. Lastly, the results of the standardization process were disseminated to PSI Utah and the Maternal Mental Health Legislative Committee. Additional education on depression screening was prepared and given to individuals at mental health awareness community events in June 2021 and 2022 Project Evaluation The evaluation of the project consisted of two parts. First, a self-administered clinical staff survey measured bias and knowledge of depression for mid-level clinicians. Next, data collected from the electronic medical records of individuals expected to give birth in October 2021 and March 2022 were compared to determine how many EPDS tools were distributed and charted at the postpartum visit. The same data collection tool (see appendix E) measured the percentage of individuals with scores above ten, indicating that intervention was necessary and whether it was received. Next, the self-administered MICA-4 survey (see appendix F) was used to determine if education and training improved knowledge and bias about depression. Data collected from the electronic health records of individuals giving birth evaluated the completion and charting of the EPDS. Additional data were collected, including if the provider addressed mental health during the postpartum and the initiation of the clinic workflow process for an EPDS score above ten. Data Maintenance/Security Data attained by the student was recorded without any protected health information on an Excel sheet. The Excel spreadsheet was located on a password-protected, secure server within a IMPROVED PERINATAL DEPRESSION SCREENING 38 computer drive that requires permission for access by employees of Intermountain Ob-Gyn Specialists. The self-administered staff survey responses were placed in a sealed envelope after completion and in a secure lock box in the manager's private office. The envelopes remained sealed until the final tabulation of the results. The student later collected the envelopes, and the data was organized on an Excel spreadsheet in a secure location within the clinic office. No patient or staff identification was recorded in the collections or compiling process. Data Collection and Analysis Quantitative data collected from the electronic medical records were recorded and analyzed for comparison on an Excel spreadsheet manufactured by the student. Data was organized according to the number of scheduled deliveries by the individual provider for October 2021 and March 2022. The total number of charts audited completed in October 2021 was 113. The total number of charts audited in March 2022 was 115. Training and education on the EPDS and clinic workflow model successfully in a small team with six participants. However, the percentage of depression screening completed decreased when implemented for the entire clinic of approximately forty staff. Many factors may have played a part in the reduced rate of universal screening and are discussed below. Table 1 Electronic Medical Record Audit for Postpartum EPDS tool Utilization Variables Pre-training Post-training Small Team Implementation Completed EPDS 79% 69% 94% Charted EPDS 45% 69% 94% Mental Health Assessment at the postpartum visit 76% 88% 88% Score 10 or > 10% 14% 22% Intervention for Score 10 or > 100% 100% 100% IMPROVED PERINATAL DEPRESSION SCREENING 39 Note: The data collection consisted of several points, including (1) completed EPDS by the patient, (2) EPDS charted in the electronic health record, and (3) the EPDS score of 10 or greater. An EPDS score of 10 or greater indicates intervention and further assessment are necessary at the time of the appointment. The first component of the survey consisted of general questions concerning knowledge and comfort level administering the EPDS in the clinic setting. Before implementing the clinic workflow, the survey was completed to assess depression knowledge and bias. In addition, staff knowledge and comfort level with depression screening and charting were also measured in the same survey. Table 2 Pre-Training Staff Survey Variable Extremely Proficient Very Proficient Proficient Somewhat Proficient Not Proficient Knowledge of EPDS 8% 28% 24% 24% 16% Knowledge of EHR charting 24% 16% 12% 12% 36% Knowledge of viewing the EHR charting 16% 20% 12% 20% 32% Comfort with Providing additional resources 24% 28% 16% 4% 28% Note: Pre-Training Staff Survey to determine comfort level with the proposed changes to the clinic workflow on a five-point Likert Scale. .Pre-training Chart Audit of 113 patients is expected to deliver in October 2021.Post-training Chart Audit of 115 patients expected to deliver in March 2022. Pre-training: Patient Health Information for October 2021 Delivery at Intermountain Ob-Gyn Specialists Table 3 Post-Training Staff Survey Variable Extremely Proficient Very Proficient Proficient Somewhat Proficient Not Proficient Knowledge of EPDS 15% 36% 30% 11% 8% Knowledge of EHR charting 38% 26% 22% 12% 2% IMPROVED PERINATAL DEPRESSION SCREENING 40 Knowledge of viewing the EHR charting 33% 36% 26% 4% 1% Comfort with Providing additional resources 24% 30% 28% 12% 6% Note: Post-training Chart Audit of 115 patients expected to deliver in March 2022. Post-training and initiation of new clinic workflow: Patient Health Information for March 2022 Delivering at Intermountain Ob-Gyn Specialists. The second part of the staff survey was the mental illness clinician analysis (MICA-4) for mid-level healthcare providers. The MICA-4 was developed by Professor Graham Thornicroft, Aliya Kassam, and the Health Service and Population Research Department, Institute of Psychiatry, College London. It was administered with permission from the authors, wholly unchanged. The MICA-4 staff survey (Appendix F) was completed before the student began education and training on the new clinic workflow. An identical self-administered staff survey was administered after the clinic workflow had been established and implemented for one month by the entire healthcare team at Intermountain Obstetricians and Gynecology Specialists. A six-point Likert scale was utilized in sixteen questions included in the MICA-4 survey. Sums of the responses to the six-point Likert scale used in the study were recorded in an Excel spreadsheet. Numbers were assigned to the Likert scale according to directions established by the original authors. Score totals for each individual were recorded for every question in the MICA-4 tool. The sum of the individual score was also recorded. In addition, mean and standard deviations were measured for a particular question, individual total scores, and entire clinical staff scores. IMPROVED PERINATAL DEPRESSION SCREENING 41 The higher overall score indicates a more negative attitude toward mental health disorders. Therefore, the scores for each item are summed to produce a single overall score (Siddiqua & Foster). Additionally, the sums of the responses to the clinical knowledge and comfort level concerning the EPDS were organized with an identical six-point Likert scale for continuity in the survey process. Table 4 Mental Illness Clinician Attitude Scale-4 Pre-training Pre-training Post-training Post-training Mean SD Mean SD 1. I just learn about mental health when I have to and would not bother to read additional material on it 2.04 1.27 2.32 1.46 2. People with severe mental illness can never recover enough to have a good quality of life 1.8 1.04 1.84 1.30 3. Working in the mental health field is just as respectable as other fields of health and social care 1.44 1.08 1.47 1.17 4. If I had a mental illness, I would never admit this to my friend because I would fear being treated differently 1.96 1.06 2.26 0.99 5. People with severe mental illness are dangerous more often than not 2.44 1.5 2.37 0.96 6. Health/social care staff know more about the lives of people treated for mental illness than do family members or friends 3.44 1.26 3.73 1.15 7. If I had a mental illness, I would never admit this to my colleagues for fear of being treated differently 2.52 1.39 2.68 1.06 8. Being a health/social care professional in the area of mental health is not like being a real health/social care professional. 1.52 0.87 1.95 0.85 9. If a senior colleague instructs me to treat people with a mental illness in a disrespectful manner, I will not follow their instructions. 1.32 1.30 1.21 0.42 10. I feel comfortable talking to a person with a mental illness as I do talk to a person with a physical illness. 1.72 0.89 2.11 1.50 IMPROVED PERINATAL DEPRESSION SCREENING 42 11. It is important that any health/social care professional supporting a person with a mental illness also ensures that their physical health is assessed. 1.52 0.51 1.63 0.60 12. Public does NOT need to protect people from individuals with severe mental illness 2.84 0.89 3.11 1.24 13. If a person with a mental illness complained of physical symptoms, I would attribute it to the mental illness 2.48 1.19 2.42 1.17 14. PCP should not have to thoroughly assess mental health because they can be referred to a psychiatrist 1.84 0.8 2.05 0.85 15. I would use the term crazy, nutter, mad to describe to a colleague someone with a mental illness 1.4 0.65 01.79 1.15 16. If my colleague told me, they had a mental illness I would still want to work with them 1.2 0.41 1.21 0.42 Overall Score 31.48 6.50 34.16 7.23 Note: For items 3, 9, 10, 11, 12, and 16 items are scored as follows: Strongly agree = 1, Agree = 2, Somewhat agree = 3, Somewhat disagree = 4, Disagree = 5, Strongly disagree = 6. All other items (1, 2, 4, 5, 6, 7, 8, 13, 14, 15) are reverse scored as follows: Strongly agree = 6, Agree = 5, Somewhat agree = 4, Somewhat disagree = 3, Disagree = 2, Strongly disagree = 1. The scores for each item are summed to produce a single overall score. A high overall score indicates a more negative (stigmatizing) attitude. The overall score is between 16-96. The higher the score indicates less knowledge and more bias. Permission to use the MICA is granted on the condition that no changes are made to the MICA. (Minor word changes are acceptable when the MICA is used in contexts where these are the equivalent terms). Findings Overall, eighty percent of clinicians briefly charted addressing mental health in the postpartum visit. In the first data collection set, sixty-five percent of individuals saw an obstetrician, and twenty-seven percent saw an advanced practice provider. In the second data set, eighty-three percent of postpartum individuals saw an obstetrician, and seventeen percent saw an advanced practice provider. Rates of mental health screening did not appear to change based on professional education and training. However, obstetricians consistently provided mental health IMPROVED PERINATAL DEPRESSION SCREENING 43 evaluation and offered intervention, whereas advanced practitioners' evaluation was less consistent. Analysis of the knowledge and bias levels of the staff, including in the self-administered staff survey, exposed gaps in clinical knowledge concerning universal screening with the EPDS and charting within the electronic health record. At the end of the implementation process, minimal improvement in EPDS completion and charting occurred post-training. The small team implementation was successful, but the implementation process for the entire clinical staff revealed some areas that needed to be readdressed. In addition, the MICA-4 results were poorer than expected. The education and training utilizing the EPDS did not improve staff knowledge or bias. Some reasons may have been high staff turnover from October 2021 through April 2022, absenteeism with COVID, and lack of general accountability on job roles due to a new practice manager being hired in January 2022. As a result, a second phase was initiated to retrain the teams that needed additional encouragement. In addition, a centrally located information board addressed weekly progress and allowed the teams to see areas that could be improved within the team. Strengths The survey results indicate that education and standardization of the clinic workflow were successful with small teams. In addition, all postpartum individuals screened with the EPDS received intervention for mental health treatments, including psychotherapy or pharmacotherapy, from their medical provider. Results indicated that medical providers addressed mental health seventy-nine percent of the time before training and eighty-eight percent of the time after training. In October, nine percent of the birthing individuals had an EPDS score above ten, indicating intervention was required. All these individuals had interventions provided IMPROVED PERINATAL DEPRESSION SCREENING 44 and addressed in the same encounter. Interestingly, more individuals were identified with EPDS scores above ten after training, and all were offered interventions according to the clinic workflow model. The survey results indicate that small team implementation of the clinic workflow model was successful after training and standardization. Before training and education for the entire staff in October 2021, seventy-nine percent of birthing individuals completed the EPDS. However, only forty-two percent of the EPDS were charted in the electronic health record. The small team survey results indicated that ninety-four percent of postpartum individuals completed an EPDS, and ninety-four percent of the EPDS were charted in the electronic health record for the provider to review at the visit the same day. Weakness The implementation process for the entire clinical staff revealed some areas that needed to be readdressed. Weaknesses included training and knowledge gaps, problems with staff turnover, and compliance despite retraining and re-evaluation of the clinic workflow process. Sixty-nine percent of postpartum visits had EPDS scores charted after the clinic workflow model was implemented by the entire clinic. As a result of poor outcomes, training and knowledge gaps were identified, and the medical assistants and patient service representatives were retrained. Unfortunately, one obstetrician-medical assistant team did not complete any EPDS charting in the electronic medical record chart audit for March 2022, which lowered the overall percentage of the survey results. In addition, the MICA-4 results were poorer than expected after training, indicating attitudes did not improve with education. Efforts to educate staff and improve depression screening were found to be dependent on staff turnover and lack of accountability by leadership. IMPROVED PERINATAL DEPRESSION SCREENING 45 When small teams implemented the clinic workflow model, it was utilized ninety-four percent of the time, and universal screening was successful. A second phase was implemented to educate staff on the workflow and decrease the stigma surrounding depression screening. Quality Improvement Discussion The DNP improvement project introduced a standardized clinic workflow for postpartum depression screening using the EPDS. The Intermountain Ob Gyn Specialists clinical staff were educated on the importance of depression screening and the correct collection process for depression screening and charting in the electronic health record. The goal of a standardized clinic workflow model included universal postpartum depression screening to ensure birthing individuals were identified and provided additional assessment by a medical provider. The implementation phase of the project included team-building activities, education and training, and multiple process improvement phases to identify areas that needed to be changed in the clinic workflow process. Translation of Evidence into Practice The American College of Obstetricians and Gynecologists recommends depression screening for all postpartum individuals at the comprehensive visit after birth. Furthermore, the USPSTF recommends EPDS screening during pregnancy at the obstetric appointment, even before symptoms are identified by the clinician (ACOG, 2018; Felder, 2019). The clinic developed a standardized workflow using the EPDS to ensure the early identification of symptoms related to depression. The workflow model was implemented in two phases after education and re-evaluation with collaborative teams. Medical staff at the obstetric and gynecology clinic who participated in the new workflow process indicated that it was effective. Small team implementation of the clinic IMPROVED PERINATAL DEPRESSION SCREENING 46 workflow was successful. Results indicate that 94% of postpartum individuals were screened, and 100% of individuals were provided with additional assessment and resources for treatment. However, when the entire clinical staff initiated the clinic workflow, the results were not as favorable. Variables in the clinic staffing and compliance were significant factors in the electronic health record chart audit results. Additional compliance strategies were employed, identifying teams utilizing correct charting strategies and working on continuous improvement. Unfortunately, the large team implementation results did not show improvement in depression screening rates or clinician mental health attitude and bias measurements. Implications for Practice and Future Scholarship Research suggests that individuals that give birth are reluctant to disclose concerns related to postpartum depression for fear of social abandonment and support. There is also evidence that medical clinicians may have a bias or lack education concerning postpartum depression symptoms or risk factors. The DNP project established a standardized clinic workflow for postpartum depression screening for individuals giving birth who were patients at an obstetric clinic, as research supported. The clinic workflow was instituted with the collaborative team, which addressed discrepancies in the depression screening process. Additionally, staff training included education on the EPDS tool, rates of postpartum depression for birthing individuals in Utah, and poor projected societal outcomes for unidentified depression. The standardized training and clinic workflow sought to eliminate staff bias and improve education by emphasizing the importance of universal screening of postpartum patients with the EPDS tool. Staff members utilized the EPDS as a universal screening tool, which was necessary to identify individuals that needed further assessment by a trained medical provider while at the postpartum appointment. Early identification and diagnosis by a trained medical IMPROVED PERINATAL DEPRESSION SCREENING 47 provider after screening provided postpartum individuals who were experiencing signs and symptoms of postpartum depression with readily available resources, including individual and group psychotherapy and pharmacology. Despite the preparation, education, and collaboration, the quality improvement project outcomes were not as favorable as hypothesized. Project findings show that staff bias is challenging to change, even with team-building activities, multiple education and training sessions, and weekly motivation. Individual staff bias had an unfortunate effect on the number of individuals offered depression screening at the postpartum obstetric appointment. One medical assistant decided they did not want to complete the depression screenings for one provider's patient population. As a result, over thirty percent of postpartum individuals in one month were not screened. The implication of this staff member's personal decision based on bias or lack of training and education could have lasting effects on the birth individual that was afraid to discuss signs of depression with the provider. However, project findings show the positive results from universal screening when there was staff buy-in and reduced personal bias in depression screening. Even when the percentage of individuals screened was lower because of one staff member not offering the EPDS to their patient population, more individuals with depressive symptoms were identified overall in the screenings completed by staff members in compliance with the clinic workflow. This result emphasizes the importance of education and standardization of the clinic workflow. In addition, the survey results can be used in future practice and scholarship to help medical clinicians understand their responsibility in providing equitable health access to individuals at risk for depression. IMPROVED PERINATAL DEPRESSION SCREENING 48 Sustainability Sustainability includes standardized and ongoing training, tangible electronic and paper education materials, and incentives or corrective direction. The standardized clinic workflow and training material were provided to all clinical staff via electronic and paper packets. The training was recorded and made available for new staff members to watch when they began practicing in the clinic in the future. These resources can continue to be used as a starting point for future refinement of the standardized depression screening process in the clinic. Historically, healthcare providers lack adequate education and training about perinatal depression and depression screening tools. Unfortunately, the DNP project findings showed that standardizing the depression screening with a clinic workflow process and improved education did not increase the number of individuals screened for depression. However, it did improve the number of individuals identified with depressive symptoms. As a result, one hundred percent of those individuals identified as at risk for postpartum depression were provided with additional medication interventions, including pharmacological and psychological support. Sustainability may be linked with increased education on the depression screening tool and cognitive bias training for staff. The clinic decided that ongoing education and corrective guided training when the EPDS tool was not implemented universally would be a good formula for long-term success. Dissemination Dissemination of the DNP project included education and advocacy at community events, professional conferences, and media presentations. The DNP leader organized an annual community event to increase awareness of the sign and symptoms of postpartum depression. Postpartum Support International- Utah Chapter sponsored the Climb Out of the Darkness event. The DNP leader organized community leaders, therapists, the Utah Health Department, and IMPROVED PERINATAL DEPRESSION SCREENING 49 many other community businesses. The one-day event, held on the Saturday nearest to the long day of the year, represented an individual's climb out of the darkness of depression into the light. The purpose of the free community event was to validate feelings, reduce stigma, and provide a sense of community for individuals who have experienced postpartum depression or maternal mental health disorders at any time. Licensed clinical social workers, therapy groups, massage therapists, physical therapists, local healthcare organizations, and The Utah Department of Health sent representatives to set up booths for people to visit at the event. Education material, including the Sunshine handout and the EPDS tool, was disseminated to each family attending the event. The events took hours of planning and organization over six months preceding each occasion. As a result, the event held in the summer of 2022 donated seven thousand dollars of gift items for a raffle. The funds raised from the raffle will provide scholarships to healthcare providers for additional postpartum training and mental health certification specific to maternal mental health. In addition, the PSI-Utah board of directors has committed to continue the community event annually. Lastly, the DNP leader was invited to speak at a local radio talk show to discuss the Climb Out of the Darkness event and educate the public on the signs and symptoms of postpartum depression. The DNP leader has applied for oral dissemination to the Postpartum Support International Utah Conference to be held in November 2022 in Salt Lake City. In addition, written results will be disseminated to the Utah Maternal Mental Health legislative committee stating the areas of concern in the DNP project results, including professional bias. The Utah Health Department is currently implementing a toolkit like the DNP Project clinic workflow to standardize the postpartum depression screening process in four clinics in Utah. The evidence from the toolkit pilot program will be presented to the Utah State Maternal Mental Health IMPROVED PERINATAL DEPRESSION SCREENING 50 Legislative Committee for consideration in designing legislation regarding standardized depression screening for all postpartum individuals in Utah by all medical providers in association with such individuals. Conclusion Perinatal depression, defined as major or minor episodes of depression occurring during pregnancy or four to six weeks after delivery, affects the woman, infant, and family over their lifespan. Significant risk factors include a history of psychiatric illness, poor social determinants of health, or suboptimal social relationships and are identifiable by healthcare providers in the clinic setting with training and education. Birthing individuals could benefit from mental health education, social support, psychotherapy, and pharmacological treatment. Complications of perinatal mood disorders increased healthcare utilization for physical and mental health services. In addition, a lack of mental health intervention increases the risk of childbirth complications, including severe perinatal depression and suicide. As a result, women experience many challenges when diagnosed with depression, including recognizing depression, reducing stigma, and utilizing healthcare treatment options. The Doctor of Nursing Practice (DNP) and Family Nurse Practitioner (FNP) leader and a collaborative team developed training for the obstetric clinical staff utilizing evidence-based information designed to reduce the stigma surrounding the diagnosis of depression. Research strongly supports universal screening as an essential first step to decreasing perinatal mental health disparity, and it does not replace diagnosis by trained providers during the assessment. Furthermore, implementing a universal screening tool by a supportive and educated healthcare provider allows equality in evaluation and treatment. The DNP leader found that the standardized clinic workflow in the obstetrics clinical setting provided high rates of universal depression IMPROVED PERINATAL DEPRESSION SCREENING 51 screening when a small team implemented the standards but was not as successful with full clinic implementation. As a result, after project implementation with the entire obstetric clinical staff, evidence indicated improved depression screening and electronic charting knowledge. However, there was no improvement in rates of depression screening and no significant reduction in the clinical staff’s personal mental health bias. The DNP leader concluded that individual team member participation affected the project's success. Additionally, personal staff bias was the variable that affected the outcome of universal screening for individuals giving birth. A clinic workflow model standardized the EPDS screening to allow early recognition of depressive symptoms for individuals during pregnancy or the weeks following childbirth. Research suggests early identification of depressive symptoms can improve access to a mental health diagnosis, intervention, and community resources. However, many individuals are reluctant to disclose symptoms of depression without promotion from a medical provider. Depression screening is an essential step in recognizing depression in individuals giving birth. Notwithstanding the evidence surrounding poor personal disclosure of mental health concerns, some medical professionals did utilize the validated depression screening tools that are proven to increase the recognition of symptoms. The author concludes that cognitive bias in medical health professionals affects the utilization of the EPDS in the clinic setting despite education and training. The overall screening rates were contingent on the obstetric staff members' level of cognitive bias. However, medical providers consistently assessed the birthing individual for symptoms of depression at the postpartum obstetric visit, which improved the number of birthing individuals diagnosed and treated for postpartum depression. IMPROVED PERINATAL DEPRESSION SCREENING 52 References A Pregnancy Risk Assessment Monitoring System Report: Maternal mental health in Utah. (2021, January). 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From pregnancy to postpartum: The effects of maternal depression on mothers, infants, and toddlers. https://www.ncsl.org/research/human-services/from-pregnancy-to-postpartum-the-effects-of-maternal-depression-on-mothers-infants-and-toddlers.aspxIMPROVED PERINATAL DEPRESSION SCREENING 58 Appendix A IMPROVED PERINATAL DEPRESSION SCREENING 59 Appendix B IMPROVED PERINATAL DEPRESSION SCREENING 60 IMPROVED PERINATAL DEPRESSION SCREENING 61 Appendix C IMPROVED PERINATAL DEPRESSION SCREENING 62 Appendix D IMPROVED PERINATAL DEPRESSION SCREENING 63 Appendix E IMPROVED PERINATAL DEPRESSION SCREENING 64 Appendix F I. IMPROVED PERINATAL DEPRESSION SCREENING 65 II. IMPROVED PERINATAL DEPRESSION SCREENING 66 IMPROVED PERINATAL DEPRESSION SCREENING 67 Appendix G IMPROVED PERINATAL DEPRESSION SCREENING 68 IMPROVED PERINATAL DEPRESSION SCREENING 69 IMPROVED PERINATAL DEPRESSION SCREENING 70 Appendix H IMPROVED PERINATAL DEPRESSION SCREENING 71 IMPROVED PERINATAL DEPRESSION SCREENING 72 IMPROVED PERINATAL DEPRESSION SCREENING 73 IMPROVED PERINATAL DEPRESSION SCREENING 74 Appendix I RN EPDS Workflow Ensure that the MA is gathering and completing the full EPDS charting in ICENTRA, not just entering the score. Make a reminder for two weeks after delivery for RN phone calls when receiving the delivery message. Make the two weeks RN Phone call with the following script. If YES to Mental Health Concerns, complete an EPDS screening on the phone and alert MD through the Message log. HOT Text Standardization: Two-week RN Phone Call Hot text Script "Hi, this is (NAME ) RN from Intermountain OB GYN Specialists working with Dr. (OB/GYN NAME). We want to ensure that you adjust well to parenthood (Unless it is a SAB, Adoption, Other, HE/HIM, They/Their). Do you have a few minutes for some questions today to check on your health after delivery? 1. How did you choose to feed your baby? Breast or Bottle? -If breastfeeding? Are you having any breast pain or concerns with your breast milk supply? _▼ -Here is the number for a lactation specialist at Intermountain Medical Center. They can schedule outpatient appointments with you for additional support. (801)-507-7683 Videos on Breastfeeding Support https://intermountainhealthcare.org/locations/intermountain-medical-center/medical-services/women-and-newborn-care/women-and-newborn-services/breastfeeding-support/ 2. Are you concerned about housing, food, or diapers? __▼ - We have a resource called "211" available to you with phone numbers for contacting agencies that can help. www.211ut.org This phone resource is not just for right after birth. The United Way has programs to help mothers, children, and families with food, clothes, housing, and support. With a new baby, many (Women, Parents) are tired. Are you coping okay with the lack of sleep? __▼ Are you getting any help from your partner or other family members? __▼ IMPROVED PERINATAL DEPRESSION SCREENING 75 -Additional resources are available at; www.211ut.org Childcare and crisis options 5. How are you feeling physically? __▼ -If the patient had an SVD: Are you having any vaginal pain? __▼ If so, can you control your pain with peri care and Ibuprofen? __▼ -If the patient had a c/s: Do you have any drainage from the incision? __▼ Are you able to control your pain with the medications you received when you were discharged from the hospital? __▼ Using Ibuprofen? __▼ 6. Are you having any concerns with feeling down, anxious, or depressed in the past seven days? __▼ -YES: Please complete Edinburgh postnatal depression scale (EPDS-3) 1. I have blamed myself unnecessarily when things went wrong Yes, Most of the time (3) Yes, Some of the time, (2) Not very often (1) No, Never (0) 2. I have been anxious or worried for no good reason Yes, Most of the time (3) Yes, Some of the time, (2) Not very often (1) No, Never (0) 3. I have felt scared or panicky for no very good reason Yes, Most of the time (3) Yes, Some of the time, (2) Not very often (1) No, Never (0) TOTAL- TIMES BY 10 AND THEN DIVIDE BY 3 _____SCORE X 10/3 = -if EPDS > 3: May indicate depression – send resources and make a phone visit in one week -if EPDS > 6: schedule PP visit with provider/APC within one week *** If answers YES- please direct the patient to the nearest Emergency Room for immediate evaluation. ***** -NO: move on to the next question IMPROVED PERINATAL DEPRESSION SCREENING 76 Complete the phone call, confirm the time and date of the Postpartum visit, and ask them to call or send my health message with concerns or questions. ***Answers for charting ease back to MD (if this is your preference) 1. Feeding choice: Concerns- 2. Concerns for Food, housing, or Diapers: 3. Sleep and Support: 4. Physical Health after delivery: 5. Mental Health: EPDS QUESTIONS- LINK to an ONLINE CALCULATOR WITH THE QUESTIONS https://www.mdapp.co/edinburgh-postnatal-depression-scale-epds-calculator-412/ RESOURCE HOT TEXT Perinatal and postpartum depression is prevalent and can be caused by situational stressors, hormones, or both. I am glad you reached out, and I hope we can be helpful to you in finding the resources that you need. If you are considering hurting yourself or others, please call 911 or visit the nearest emergency room for additional support. The website below is an excellent resource for finding a therapist that takes your insurance in your area. Postpartum Support International- Utah Chapter https://www.psiutah.org/ for tips and resources. Postpartum Support International (PSI) http://www.postpartum.net Local Non-profit: The Emily Effect https://theemilyeffect.org/ Maternal Mental Health Resource (insurance and provider lists) https://mihp.utah.gov/maternal-mental-health Other Resources: Behavioral Health Access Center Located at LDS Hospital IMPROVED PERINATAL DEPRESSION SCREENING 77 324 9th Ave in SLC Walk-in Direct Care Center: Hours are 10 am- 10 pm The Healing Group thehealinggroup.com phone 801-305-3171 Reach Counseling 873 West Baxter Drive | South Jordan, UT 84095 admin@reachcounselingutah.com | voice: (801) 446-3515 text: (925) 876-4282 fax: (801) 601-1578 Please be sure to visit the following: Postpartum Support International (PSI) http://www.postpartum.net Postpartum Support International’s mission is to promote awareness, prevention, and treatment of mental health issues related to childbearing in every country worldwide. PSI’s vision is that every woman and family worldwide will have access to information, social support, and informed professional care to deal with mental health issues related to childbearing. PSI promotes this vision through advocacy and collaboration and by educating and training the professional community and the public. For a list of the local treatment programs or support groups in your area, please visit the following: U.S. and Canada http://www.postpartum.net/get-help/locations/united-states/ Please let us know if we can help you any further. IMPROVED PERINATAL DEPRESSION SCREENING 78 Appendix J SUNSHINE HANDOUT- HOT TEXT S – Sleep: Aim for four to six hours of sleep in a row, at least three nights a week. Ask a family member or friend to give the first feeding of the night so you can get enough rest. U – Understand: Counseling with a trained maternal mental health professional prevents and treats mental health issues. Learn more by calling Help Me Grow at 801-691-5322 or by visiting postpartum.net N – Nutrition: Take a prenatal vitamin through one year postpartum. Avoid caffeine and sugar when possible. Include protein and unsaturated fats in every snack and meal. Drink two large pitchers of water daily. S – Support: Share your feelings with a trusted friend or family or find a support group online. Ask for help with baby care – getting an hour each day to yourself is essential. H – Humor: Make time for silliness and joy each day. A funny movie, time with friends, or tickling your children can improve your mood. However, it is time to seek more support if laughing seems impossible. I – Information: Take the Edinburg Postnatal Depression Scale monthly for a year postpartum to track your mental health. Call your provider if your score is ten or above or if you marked anything other than “never” on question 10 about self-harm. N – Nurture: Care for yourself through nature, spiritual practices, music and art, meditation, dates with friends, etc. Schedule weekly time in your calendar to do things you enjoy outside of motherhood. E – Exercise: Walking 10-20 minutes daily can help your body, mind, and spirit heal and stay emotionally healthy. You can also try yoga or stretching if your provider gives you the go-ahead. NOTICE: This e-mail is for the sole use of the intended recipient and may contain confidential and privileged information. If you are not the intended recipient, you are prohibited from reviewing, using, disclosing, or distributing this e-mail or its contents. If you have received this e-mail in error, please contact the sender by reply e-mail and destroy all copies of this e-mail and its contents. IMPROVED PERINATAL DEPRESSION SCREENING 79 Appendix J IMPROVED PERINATAL DEPRESSION SCREENING 80 Appendix K Depression Screening Quality Improvement Project Timeline December 2021 Chart audits of EPDS data started and completed. Team building activities were implemented. Staff bulletin board for education implemented. January 2022 Small teams organized to develop a clinic workflow model The small team implemented the clinic workflow model and refined the screening The registered nurse team completed patient education materials into a booklet February 2022 Presentation to RN Team on February 16, 2022 Presentation to Clinical Staff on February 17, 2022 Implementation of Clinic Workflow Model March 2022 Daily Huddles to share short-term wins or concerns The postpartum handbook approval by the project consultant Sent postpartum handbook to the marketing team to work on the development April 2022 Approval and printing of the postpartum handbook Audit patient health information for March 2022 Repeat Staff survey Compile all data for medical provider meeting May 2022 Incorporated the postpartum handbook into the 36-week Perinatal clinic visit. Present Quality Improvement results to the medical providers June 2022 Climb out of Darkness Awareness Campaign for PSI- disseminated PPD material July-November 2022 Meet with Maternal Mental Health Legislative Committee to report on the Intermountain Standardized screening process. Disseminate information to Intermountain IRB and Woman's Service Line