Mental Health Takeaways from the New VA/DoD Pregnancy Clinical Practice Guideline

Pregnant woman in fatigues. holding her belly.
U.S. Air Force courtesy photo
By Alia H. Creason, Ph.D.
May 29, 2018

Pregnancy can impact all aspects of a mother’s well-being. While it’s an exciting time for many women, it’s also an emotional time. It can bring on mood changes from physical stresses, fatigue, changes in metabolism and hormones, as well as worries, such as about the costs and new responsibilities that come with being a parent. For service women, there are unique military-related concerns such as caring for the new baby if one or both parents gets deployed and meeting physical readiness standards after the baby is born. Sometimes these stressors can lead to the development of mental health conditions. Pre-existing issues such as substance misuse or intimate partner violence (IPV) can similarly affect a mother’s well-being and can have detrimental effects on her and her growing baby. Therefore, screening, early detection, and intervention for mental health and substance use concerns are critically important during and after pregnancy.

According to the Military Health System (MHS) Data Repository, more than 180,000 female beneficiaries in the MHS sought care related to pregnancy in 2017. Last month the Department of Veterans Affairs (VA) and Department of Defense (DoD) released an updated version of the VA/DoD Clinical Practice Guideline for the Management of Pregnancy. This updated guideline includes evidence-based information on the management of pregnancy and is intended to assist health care providers in all aspects of care for pregnant women, including their mental health. For those of us in the field of mental health, it contains several relevant screening recommendations to facilitate detection of depression, substance misuse, and IPV. The guideline details key times during pregnancy when health care providers should complete these screenings and courses of action for patients who screen positive. Including these brief screenings into routine medical care for pregnancy may improve outcomes for both mothers and their babies.

While mental health providers may not always be involved in routine medical care for pregnancy, there are actually many ways that you can help promote these evidence-based screening recommendations:

  • Help other providers understand the rationale for these screenings.
  • If screening patients, always obtain informed consent and provide education on the purpose prior to screening.
  • Offer consultation to your non-mental health providers on best practices in mental health screening, as it may not be intuitive. Encourage providers to discuss their patients’ screening responses with them, rather than just offering referral to mental health specialty care if they screen positive.
  • Ensure your pregnant patients receive these screenings and provide education to them on the screening benefits, as well as the risks associated with substance misuse, depression, and IPV.

Relevant mental health pregnancy guideline recommendations:

Substance Misuse

We recommend screening for use of tobacco, alcohol, illicit drugs, and unauthorized use of prescription medication because their use is common and can result in adverse outcomes.

Why screen?

When to screen?

What to do for women who screen positive?

Antepartum use of alcohol, cigarettes, illicit drugs, or unauthorized use of prescription medication is not uncommon and may be associated with adverse effects.

  • At first visit

Complete additional evaluation and treatment (see VA/DoD Clinical Practice Guidelines for the Management of Substance Use Disorders)

Depression

We recommend screening for depression using a standardized tool such as the Edinburgh Postnatal Depression Scale or the 9-item Patient Health Questionnaire periodically during pregnancy and postpartum. 

Why screen?

When to screen?

What to do for women who screen positive?

There is a high prevalence of perinatal depression, adverse maternal and offspring effects of untreated perinatal depressive symptoms, and low rates of detection and treatment entry in the absence of screening.

Evidence suggests screening pregnant and postpartum women for depression using a validated screening tool is more effective in detecting depression and in reducing symptoms than through usual clinical assessment. 

  • At first visit
  • At 28 weeks gestation/third trimester
  • Postpartum

Obtain more information and refer to mental health if suicidal or has moderate/severe depression, unless patient already has established mental health care

Intimate Partner Violence

IPV is a high-prevalence and high-risk problem that may be first identified during pregnancy, therefore routine screening during pregnancy is indicated.

Why screen?

When to screen?

What to do for women who screen positive?

Risks of IPV during pregnancy include preterm birth, low birth weight, and decreased gestational age.

A history of IPV is associated with higher rates of chronic pain, neurologic disorders, gastrointestinal disorders, and psychiatric disorders.

  • At first visit
  • At 28 weeks gestation/third trimester
  • Postpartum

Complete an assessment and provide information, intervention, and/or referrals as needed

For more information on the pregnancy guideline and related resources:

Creason is a contracted licensed clinical psychologist on the evidence-based practice team at the Psychological Health Center of Excellence. She has a doctorate in counseling and human systems and a master of public health in maternal and child health.


The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.


Comments

  • Thank you for bringing attention to the benefits of healthcare professionals screening pregnant Mothers for mental health issues. I would like to promote awareness and participation in the New Parent Support Program (NPSP) and the benefits of ALL military beneficiaries contacting their local NPSP office for information on this program. NPSP Home Visitors are Registered Nurses, Licensed Clinical Social Workers and/or Licensed Marriage and Family Therapist (depending on the branch of service), who provide intensive home visitation services, office and hospital visits, classes, and workshops on topics such as self-care and body changes during pregnancy, newborn care, bringing baby home, Mommy and Daddy Bootcamp, breastfeeding assistance, formula preparation, obtaining a birth certificate if your child is born overseas, relationship changes during pregnancy, reading your infant's cues, how to calm a crying baby, bonding and attachment, and the importance of Father's in childrearing. Playgroups are facilitated by NPSP Home Visitors to promote social interaction and reduce social isolation. Each family completes an individual needs assessment so services can be tailored to the family's unique needs. Services are free and offered during the work day and after duty hours to accommodate working parents. Parents do not have to leave the comfort of their home to receive services. Most NPSP offices have a lending library of DVDs, books, and educational resources. TNPSP is an amazing program and I encourage all Active Duty families to learn more about the program.

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