The ambulatory treatment of postpartum psychosis in Israel.

Postpartum psychosis is a severe psychiatric disorder that occurs following childbirth. Due to its severity, postpartum psychosis is generally treated in an inpatient hospital setting. In this original contribution, we present the ambulatory treatment of postpartum psychosis and advocate that an ambulatory setting can be feasible under the right circumstances. In this article, we provide an overview of the Israeli legal system and its implications when treating maternal mental illness. We present the process by which we treat a woman with postpartum psychosis in an ambulatory setting. We provide a case example of the successful treatment of postpartum psychosis in an ambulatory setting and list general strategies to utilize. We demonstrate that an ambulatory approach to postpartum psychosis is not only possible, but also has significant benefits. We suggest that the ambulatory treatment of postpartum psychosis was developed in Israel as a direct result of its liberal legal system. Specifically, because of the legal system's value on patient autonomy, acute psychiatric illnesses such as postpartum psychosis are at times treated in outpatient settings. Additionally, we posit that Israel's unique culture provides the framework to support its implementation. We review the challenges of the treatment in the case example as well as other anticipated challenges that may arise with a broader application of this approach. Our hope is that this novel presentation will lead to more nuanced and holistic treatment of postpartum psychosis.

Adding perinatal anxiety screening to depression screening: is it worth it?

BACKGROUND: Screening for peripartum depression is widely recommended and should now be the standard of care. However, little research exists on peripartum anxiety screening. OBJECTIVE: The purpose of this study was to assess whether adding perinatal anxiety screening would increase the identification of women who would benefit from mental health support. STUDY DESIGN: The existing practice at our clinic was depression screening via the Patient Health Questionnaire-2 at all prenatal visits; screenings were prospectively tracked for 3 months in women presenting for visit at 24-28 weeks gestation (Patient Health Questionnaire-2-only group). We then added Generalized Anxiety Disorder 2-item validated anxiety scale assessment to prenatal visits at 24-28 weeks gestation (Patient Health Questionnaire-2+Generalized Anxiety Disorder 2-item group). Our primary study outcome was the rate of positive depression and anxiety screens during pregnancy; secondary outcomes included referral rates to mental health services and obstetric and medical outcomes. RESULTS: A total of 100 women with visits at 24-28 weeks gestation were eligible to be screened during the Patient Health Questionnaire-2-only period; 125 women were eligible for screening during the Patient Health Questionnaire-2+Generalized Anxiety Disorder 2-item period. In the Patient Health Questionnaire-2-only group, 51 women were screened, with 2 positive depression screens. In the Patient Health Questionnaire-2+Generalized Anxiety Disorder 2-item group, 40 women were screened, with 5 positive screens for depression and 4 for anxiety. Three women who were anxiety-positive had been negative via depression screening. Mental health referral was not different between the 2 groups (odds ratio, 1.75; 95% confidence interval, 0.76-4.97), but a significant increase in referral was noted for Patient Health Questionnaire-2+Generalized Anxiety Disorder 2-item subgroups with a history of mental health diagnosis (odds ratio, 14.9; 95% confidence interval, 5.6-39.7) or substance abuse (odds ratio, 26.7; 95% confidence interval, 4.6-155.0). CONCLUSION: Screening for perinatal anxiety may increase referral rates to mental health professionals who can then diagnose and treat women who experience mood and anxiety disorders. Anxiety screening may be particularly useful in populations with a history of mental health diagnoses or substance abuse. Further research is necessary to understand how perinatal anxiety screening should be best implemented.

The best perinatal depression screening: Is self-administered PHQ2 more feasible than a nurse-administered one?

PURPOSE: To assess perinatal depression screening via self-administered PHQ2 (SAP) vs nurse-administered PHQ2 (NAP). DESIGN AND METHODS: NAP screening was performed for 3 months, followed by SAP. Data were gathered from visits at 24 to 28 weeks gestation. FINDINGS: One hundred twenty-seven patients were in NAP arm, 100 in SAP arm. SAP had higher rates of screening (odds ratio [OR], 3.25; 95% confidence interval [CI], 1.63-6.49), but no difference in positive PHQ2 screens. The SAP rate of therapeutic action for positive screens was lower (OR, 0.24; 95% CI, 0.12-0.50). PRACTICE IMPLICATIONS: SAP provided higher perinatal depression screening rates compared to NAP, but decreased therapeutic action.