A communication intervention to improve prognostic understanding and engagement in advance care planning among diverse advanced cancer patient-caregiver dyads: A pilot study.

OBJECTIVES: Accurate prognostic understanding among patients with advanced cancer and their caregivers is associated with greater engagement in advance care planning (ACP) and receipt of goal-concordant care. Poor prognostic understanding is more prevalent among racial and ethnic minority patients. The purpose of this study was to examine the feasibility, acceptability, and impact of a patient-caregiver communication-based intervention to improve prognostic understanding, engagement in ACP, and completion of advance directives among a racially and ethnically diverse, urban sample of patients and their caregivers. METHODS: Patients with advanced cancer and their caregivers (n = 22 dyads) completed assessments of prognostic understanding, engagement in ACP, and completion of advance directives at baseline and post-intervention, Talking About Cancer (TAC). TAC is a 7-session intervention delivered remotely by licensed social workers that includes distress management and communication skills, review of prognosis, and information on ACP. RESULTS: TAC met a priori benchmarks for feasibility, acceptability, and fidelity. Prognostic understanding and engagement in ACP did not change over time. However, patients showed increases in completion of advance directives. SIGNIFICANCE OF RESULTS: TAC was feasible, acceptable, and delivered with high fidelity. Involvement of caregivers in TAC may provide added layers of support to patients facing advanced cancer diagnoses, especially among racial and ethnic minorities. Trends indicated greater completion of advance directives but not in prognostic understanding or engagement in ACP. Future research is needed to optimize the intervention to improve acceptability, tailor to diverse patient populations, and examine the efficacy of TAC in a randomized controlled trial.

Associations of financial hardship with suicidal ideation among bereaved cancer caregivers.

PURPOSE: To examine associations between financial hardship and suicidal ideation among bereaved informal caregivers of cancer patients. DESIGN: Longitudinal cohort study. SAMPLE: 173 informal caregivers of advanced cancer patients. METHODS: Caregivers were interviewed a median 3.1 months before and 6.5 months after the death of the patient they cared for. Logistic regression models estimated associations between caregiver-perceived pre-loss and post-loss financial hardship due to the patient's illness and post-loss suicidal ideation. FINDINGS: Suicidal ideation was identified in 12% (n = 21) of the sample pre-loss, rising to 20% (n = 34) post-loss (p=.049). Pre-loss financial hardship (OR = 3.4, 95% CI = 1.5-7.4, p=.002) and post-loss financial hardship (OR = 3.7, 95% CI = 1.7-8.2, p=.001) were each bivariately associated with post-loss suicidal ideation. In multivariable models adjusting for pre-loss suicidal ideation, psychiatric diagnosis, and spousal relationship to the patient, post-loss financial hardship remained significantly associated with post-loss suicidal ideation (AOR = 3.6, 95% CI = 1.4-8.8, p=.006). CONCLUSION: Among a cohort of cancer caregivers followed from active caregiving into bereavement, post-loss financial hardship was associated with suicidal ideation in bereavement. IMPLICATIONS: Economic policies that financially benefit caregivers may represent promising strategies for preventing suicidal thoughts and behaviors.

Associations between Latino ethnicity and the use of emotional support and completion of advance directives.

OBJECTIVES: Latino patients have been shown to engage in advance care planning (ACP) at much lower rates than non-Latino White patients. Coping strategies, such as the use of emotional support, may differentially relate to engagement in ACP among Latino and non-Latino patients. The present study sought to examine the moderating effect of ethnicity on the relationship between the use of emotional support as a coping strategy and completion of advance directives. METHODS: The present study employed a weighted sample (Nw = 185) of Latino and non-Latino White patient participants in Coping with Cancer III, an National Institutes of Health-sponsored, multisite, longitudinal, observational cohort study of patients with advanced cancer and their informal caregivers and oncology providers designed to evaluate Latino/non-Latino disparities in ACP and end-of-life cancer care. Main and interaction effects of Latino ethnicity and use of emotional support on patient use of advance directives were estimated as odds ratios. RESULTS: Use of emotional support was associated with dramatically lower do-not-resuscitate (DNR) order completion to a greater extent among Latino as compared to non-Latino patients (interaction AOR = 0.33, p = 0.005). Interaction effects were not statistically significant for living will or health-care proxy form completion. SIGNIFICANCE OF RESULTS: Use of emotional support is associated with lower odds of completing DNRs among Latino than among non-Latino patients. Seeking and/or receiving emotional support may deter Latino patients from completing DNR orders. Research is needed to address both emotional needs and practicalities to ensure high quality end-of-life care among Latino patients with cancer.

Association between immigrant status and advanced cancer patients' location and quality of death.

BACKGROUND: Cancer patients often prefer to die at home, a location associated with better quality of death (QoD). Several studies demonstrate disparities in end-of-life care among immigrant populations in the United States. This study aimed to evaluate how immigrant status affects location and quality of death among patients with advanced cancer in the United States. METHODS: Data were derived from Coping with Cancer, a federally funded multi-site prospective study of advanced cancer patients and caregivers. The sample of patients who died during the study period was weighted (Nw  = 308) to reduce statistically significant differences between immigrant (Nw  = 49) and nonimmigrant (Nw  = 259) study participants. Primary outcomes were location of death, death at preferred location, and poor QoD. RESULTS: Analyses adjusted for covariates indicated that patients who were immigrants were more likely to die in a hospital than home (adjusted odds ratio [AOR], 3.33; 95% confidence interval [CI], 1.65-6.71) and less likely to die where they preferred (AOR, 0.42; 95% CI, 0.20-0.90). Furthermore, immigrants were more likely to have poor QoD (AOR, 5.47; 95% CI, 2.70-11.08). CONCLUSIONS: Immigrants, as compared to nonimmigrants, are more likely to die in hospital settings, less likely to die at their preferred location, and more likely to have poor QoD. LAY SUMMARY: Cancer patients typically prefer to die in their own homes, which is associated with improved quality of death. However, disparities in end-of-life care among immigrant populations in the United States remain significant. Our study found that immigrants are less likely to die in their preferred locations and more likely to die in hospital settings, resulting in poorer quality of death.

Validation of the prolonged grief scale (PG-13) and investigation of the prevalence and risk factors of prolonged grief disorder in Turkish bereaved samples.

The aim of this study was to validate the Turkish version of the Prolonged Grief Scale (PG-13) and to determine the prevalence and predictors of prolonged grief disorder (PGD). Data were gathered from two independent samples of 306 (Study 1) and 271 (Study 2) bereaved adults to determine if findings in one sample could be replicated in the other. The results supported the one-factor structure of PG-13. PGD prevalence rates were 11.4% in Study 1 and 10% in Study 2. Lower level meaning reconstruction and unnatural cause of death were found as risk factors for the PGD diagnosis in both studies.

Development and preliminary evaluation of EMPOWER for surrogate decision-makers of critically ill patients.

OBJECTIVE: The objectives of this study were to develop and refine EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), a brief manualized cognitive-behavioral, acceptance-based intervention for surrogate decision-makers of critically ill patients and to evaluate its preliminary feasibility, acceptability, and promise in improving surrogates' mental health and patient outcomes. METHOD: Part 1 involved obtaining qualitative stakeholder feedback from 5 bereaved surrogates and 10 critical care and mental health clinicians. Stakeholders were provided with the manual and prompted for feedback on its content, format, and language. Feedback was organized and incorporated into the manual, which was then re-circulated until consensus. In Part 2, surrogates of critically ill patients admitted to an intensive care unit (ICU) reporting moderate anxiety or close attachment were enrolled in an open trial of EMPOWER. Surrogates completed six, 15-20 min modules, totaling 1.5-2 h. Surrogates were administered measures of peritraumatic distress, experiential avoidance, prolonged grief, distress tolerance, anxiety, and depression at pre-intervention, post-intervention, and at 1-month and 3-month follow-up assessments. RESULTS: Part 1 resulted in changes to the EMPOWER manual, including reducing jargon, improving navigability, making EMPOWER applicable for a range of illness scenarios, rearranging the modules, and adding further instructions and psychoeducation. Part 2 findings suggested that EMPOWER is feasible, with 100% of participants completing all modules. The acceptability of EMPOWER appeared strong, with high ratings of effectiveness and helpfulness (M = 8/10). Results showed immediate post-intervention improvements in anxiety (d = -0.41), peritraumatic distress (d = -0.24), and experiential avoidance (d = -0.23). At the 3-month follow-up assessments, surrogates exhibited improvements in prolonged grief symptoms (d = -0.94), depression (d = -0.23), anxiety (d = -0.29), and experiential avoidance (d = -0.30). SIGNIFICANCE OF RESULTS: Preliminary data suggest that EMPOWER is feasible, acceptable, and associated with notable improvements in psychological symptoms among surrogates. Future research should examine EMPOWER with a larger sample in a randomized controlled trial.

History and Status of Prolonged Grief Disorder as a Psychiatric Diagnosis.

Prolonged grief disorder (PGD) is a diagnostic entity now included in the International Classification of Diseases 11th Revision (ICD-11) and soon to appear in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR). A characteristic feature of PGD is distressing, disabling yearning that persists a year or more after the loss. Other characteristic symptoms include disbelief and lack of acceptance of the loss, emotional detachment from others since the loss, loneliness, identity disturbance, and sense of meaninglessness. In this review, we detail psychiatric views on grief and their evolution over the twentieth century. We then discuss the development of diagnostic formulations for disordered grief, which culminated in PGD's status as a mental disorder in the DSM. After summarizing recent evidence that may suggest that PGD is linked to the neural reward system, we suggest further areas of research. In particular, we note the need for studies that extend the evidence base concerning PGD across cultural and sociodemographic boundaries and that investigate novel treatments.

"My doctor says the cancer is worse, but I believe in miracles"-When religious belief in miracles diminishes the impact of news of cancer progression on change in prognostic understanding.

BACKGROUND: News of cancer progression is critical to setting accurate prognostic understanding, which guides patients' treatment decision making. This study examines whether religious belief in miracles modifies the effect of receiving news of cancer progression on change in prognostic understanding. METHODS: In a multisite, prospective cohort study, 158 patients with advanced cancer, whom oncologists expected to die within 6 months, were assessed before and after the visit at which scan results were discussed. Before the visit, religious belief in miracles was assessed; after the visit, patients indicated what scan results they had received (cancer was worse vs cancer was stable, better, or other). Before and after the visit, prognostic understanding was assessed, and a change score was computed. RESULTS: Approximately 78% of the participants (n = 123) reported at least some belief in miracles, with almost half (n = 73) endorsing the strongest possible belief. A significant interaction effect emerged between receiving news of cancer progression and belief in miracles in predicting change in prognostic understanding (b = -0.18, P = .04). Receiving news of cancer progression was associated with improvement in the accuracy of prognostic understanding among patients with weak belief in miracles (b = 0.67, P = .007); however, among patients with moderate to strong belief in miracles, news of cancer progression was unrelated to change in prognostic understanding (b = 0.08, P = .64). CONCLUSIONS: Religious belief in miracles was highly prevalent and diminished the impact of receiving news of cancer progression on prognostic understanding. Assessing patients' beliefs in miracles may help to optimize the effectiveness of "bad news" scan result discussions.

Underdetection and Undertreatment of Dyspnea in Critically Ill Patients.

Rationale: Dyspnea is a common and distressing physical symptom among patients in the ICU and may be underdetected and undertreated. Objectives: To determine the frequency of dyspnea relative to pain, the accuracy of nurses and personal caregiver dyspnea ratings relative to patient-reported dyspnea, and the relationship between nurse-detected dyspnea and treatment. Methods: This was an observational study of patients (n = 138) hospitalized in a medical ICU (MICU). Nurses and patients' personal caregivers at the bedside reported on their perception of patients' symptoms. Measurements and Main Results: Dyspnea was assessed by patients, caregivers, and nurses with a numerical rating scale. Across all three raters, the frequency of moderate to severe dyspnea was similar or greater than that of pain (P < 0.05 for caregiver and nurse ratings). Personal caregivers' ratings of dyspnea had substantial agreement with patient ratings (κ = 0.65, P < 0.001), but nurses' ratings were not significantly related to patient ratings (κ = 0.19, P = 0.39). Nurse detection of moderate to severe pain was significantly associated with opioid treatment (odds ratio, 2.70; 95% confidence interval, 1.10-6.60; P = 0.03); however, nurse detection of moderate to severe dyspnea was not significantly associated with any assessed treatment. Conclusions: Dyspnea was reported at least as frequently as pain among the sampled MICU patients. Personal caregivers had good agreement with patient reports of moderate to severe dyspnea. However, even when detected by nurses, dyspnea appeared to be undertreated. These findings suggest the need for improved detection and treatment of dyspnea in the MICU.

An examination of Latino advanced cancer patients' and their informal caregivers' preferences for communication about advance care planning: A qualitative study.

OBJECTIVES: Latino-advanced cancer patients engage in advance care planning (ACP) at lower rates than non-Latino patients. The goal of the present study was to understand patients' and caregivers' preferred methods of communicating about ACP. METHODS: Patients and caregivers were interviewed about cultural, religious, and familial beliefs that influence engagement in ACP and preferences for ACP communication. RESULTS: Findings highlighted that Latino patients respect doctors' medical advice, prefer the involvement of family members in ACP discussions with doctors, hold optimistic religious beliefs (e.g., belief in miracles) that hinder ACP discussions, and prefer culturally competent approaches, such as using their native language, for learning how to discuss end-of-life (EoL) care preferences. SIGNIFICANCE OF RESULTS: Key cultural, religious, and familial beliefs and dynamics influence Latino engagement in ACP. Patients prefer a family-centered, physician informed approach to discussing ACP with consideration and incorporation of their religious medical beliefs about EoL care. Promising targets for improving the communication of and engagement in ACP include integrating cultural and religious beliefs in ACP discussions, providing information about ACP from the physician, involving family members in ACP discussions and decision-making, and giving instructions on how to engage in ACP discussions.

A scale to assess religious beliefs in end-of-life medical care.

BACKGROUND: Studies postulate that certain religious beliefs related to medical care influence the end-of-life (EOL) medical decision making and care of patients with advanced cancer. Because to the best of the authors' knowledge no current measure explicitly assesses such beliefs, in the current study the authors introduced and evaluated the Religious Beliefs in EOL Medical Care (RBEC) scale, a new measure designed to assess religious beliefs within the context of EOL cancer care. METHODS: The RBEC scale consists of 7 items designed to reflect religious beliefs in EOL medical care. Its psychometric properties were evaluated in a sample of 275 patients with advanced cancer from the Coping With Cancer II study, a National Cancer Institute-funded, multisite, longitudinal, observational study of communication processes and outcomes in EOL cancer care. RESULTS: The RBEC scale proved to be internally consistent (Cronbach α, .81), unidimensional, positively associated with other indicators of patients' religiousness and spirituality (establishing its convergent validity), and inversely associated with patients' terminal illness understanding and acceptance (establishing its criterion validity), suggesting its potential clinical usefulness in promoting informed EOL decision making. The majority of patients (87%) reported some ("somewhat," "quite a bit," or "a great deal") endorsement of at least 1 RBEC item and a majority (62%) endorsed ≥3 RBEC items. CONCLUSIONS: The RBEC scale is a reliable and valid tool with which to assess religious beliefs within the context of EOL medical care, beliefs that frequently are endorsed and inversely associated with terminal illness understanding.

How much time is left? Associations between estimations of patient life expectancy and quality of life in patients and caregivers.

PURPOSE: It is unclear whether life-expectancy estimates of patients with advanced cancer and their caregivers are associated with patient existential, social, or emotional quality of life (QOL) or caregiver emotional QOL. METHODS: Patients with advanced cancer and their caregivers (n = 162 dyads) reported estimates of the chance the patient would live for 2 years or more from 0% (most pessimistic) to 100% (most optimistic). They also completed self-report measures of QOL. RESULTS: Adjusting for sociodemographic confounds and multiple comparisons, more pessimistic caregiver and patient life-expectancy estimates were associated with worse caregiver emotional QOL and worse patient existential QOL. Discrepancies between patient and caregiver estimates were not associated with patient or caregiver QOL. CONCLUSIONS: Pessimistic life-expectancy estimates are associated with worse existential QOL in patients and worse emotional QOL in caregivers. Prospective research to establish causal relationships is needed, and interventions to address the relationship between beliefs about life expectancy and existential and emotional QOL should be considered. Providing these interventions to patients and caregivers receiving information on life expectancy may mitigate the negative impact of life-expectancy information on patient existential quality of life.

Advanced cancer caregiving as a risk for major depressive episodes and generalized anxiety disorder.

OBJECTIVE: Caregivers of advanced cancer patients provide extensive care associated with high levels of caregiver distress. The degree to which cancer caregiving increases caregivers' risk for a psychiatric disorder is unknown. The current study examines whether advanced cancer caregiving poses distinct risks for initial and recurrent major depressive episodes (MDEs) and generalized anxiety disorder (GAD) relative to the general population. METHODS: Caregivers of advanced cancer patients (N = 540) from Coping with Cancer were compared to general population controls (N = 9282) from the National Comorbidity Survey Replication. The general population comparison sample was propensity-weighted to be demographically similar to the caregiver sample. RESULTS: Caregivers of advanced cancer patients were more likely than individuals in the general population to have an initial MDE (OR = 7.7; 95% CI, 3.5-17.0; P < .001), but no more likely than the general population to have a recurrent MDE (OR = 1.1; 95% CI, 0.6-2.1; P = .662). Caregivers were also more likely than the general population to have GAD (OR = 3.0; 95% CI, 1.9-4.8; P < .001) and comorbid MDE and GAD (OR = 2.5; 95% CI, 1.1-5.9; P = .038). CONCLUSIONS: The increased risk of meeting diagnostic criteria for current MDE and GAD and comorbid MDE and GAD associated with advanced cancer caregiving highlights the degree of emotional burden among cancer caregivers. Clinical services that assess, prevent, and treat depression and anxiety in cancer caregivers are needed to reduce the burden of caregiving and improve the mental health of this growing population.

Prolonged, but not complicated, grief is a mental disorder.

The DSM and ICD have taken steps to introduce a grief disorder as a new diagnostic entity. Evidence justifies the inclusion of prolonged grief disorder, but not complicated grief, as a new mental disorder.

Impact of end-of-life discussions on the reduction of Latino/non-Latino disparities in do-not-resuscitate order completion.

BACKGROUND: Compared with non-Latino, white patients with advanced cancer, Latino patients with advanced cancer are less likely to sign do-not-resuscitate (DNR) orders, which is a form of advance care planning associated with better quality of life at the end of life (EOL). Latinos' completion of DNR orders may be more sensitive to clinical discussions regarding EOL care. The current study examined differences between Latino and white terminally ill patients with cancer with regard to the association between EOL discussions and DNR order completion. METHODS: A total of 117 participants with advanced cancer (61 of whom were Latino and 56 of whom were non-Latino white individuals) were recruited between 2002 and 2008 from Parkland Hospital (a public hospital in Dallas, Texas) as part of the Coping with Cancer study, which is a large, multiinstitutional, prospective cohort study of patients with advanced cancer that is designed to examine social and psychological influences on EOL care. In structured interviews, patients reported if they had EOL discussions with their physicians, and if they completed DNR orders. RESULTS: The association between EOL discussions and DNR order completion was significantly greater in Latino compared with white patients, adjusting for potential confounds (interaction adjusted odds ratio, 6.64; P = .041). Latino patients who had an EOL discussion were >10 times more likely (adjusted odds ratio, 10.91; P = .001) to complete a DNR order than those who had not, and were found to be equally as likely to complete a DNR order as white patients. CONCLUSIONS: Differences in the impact of EOL discussions on DNR order completion may explain Latino/non-Latino ethnic disparities in DNR order completion in EOL care, and point to a means to eliminate those disparities. Cancer 2016;122:1749-56. © 2016 American Cancer Society.

The lasting impact of the therapeutic alliance: Patient-oncologist alliance as a predictor of caregiver bereavement adjustment.

BACKGROUND: Caregivers of patients with advanced cancer provide extensive care and experience high levels of psychosocial distress. The patient-oncologist therapeutic alliance may be a modifiable factor that can prevent or reduce negative caregiver outcomes. METHODS: Coping with Cancer (CwC) was a prospective, longitudinal, multisite cohort study of terminally ill cancer patients (life expectancy ≤6 months) and their informal caregivers, who were followed into bereavement (n = 68). Trained raters interviewed patients and caregivers upon study entry and also interviewed caregivers 6 months after the patient's death. Patients answered quantitative questions assessing their perception of the patient-oncologist therapeutic alliance (The Human Connection scale), and caregivers completed a measure of health-related quality of life (Medical Outcomes Study Short Form-36). Interviewers rated caregivers' level of emotional well being. Associations between therapeutic alliance and caregiver outcomes were analyzed using univariate analysis of variance and logistic regression analyses, controlling for baseline caregiver measures and confounding sample characteristics. RESULTS: A strong patient-oncologist therapeutic alliance was bivariately associated with caregiver self-report of less role limitation because of emotional problems, better social function and mental and general health-related quality of life, and better interviewer-rated emotional well being after the patient's death. After controlling for baseline measures and confounding sample characteristics, the correlation between patient-perceived therapeutic alliance and bereaved caregivers' mental health and interviewer ratings of bereaved caregivers' emotional well being remained significant. CONCLUSIONS: The influence of the patient-oncologist alliance may generalize beyond the patient to positively impact the caregiver. By developing a strong relationship with the patient, the oncologist may benefit the caregiver and the patient. This caregiver benefit may extend into bereavement.

Male-female patient differences in the association between end-of-life discussions and receipt of intensive care near death.

BACKGROUND: Patient gender plays a significant role in patient-physician communication, patients' understanding of illness, and the aggressiveness of end-of-life (EoL) care. However, little is known about the extent to which gender differences in the effects of EoL discussions on EoL care contribute to gender differences in EoL care. The current study was aimed at determining whether gender differences exist in the receipt of intensive care unit (ICU) care near death and in the association between EoL discussions and the receipt of EoL ICU care. METHODS: This was a multisite, prospective cohort study of patients (n = 353) with metastatic cancers who were identified as terminally ill at study enrollment and were interviewed at a median of 4.1 months before their deaths. Postmortem chart reviews and caregiver interviews documented ICU stays in the last week of life. RESULTS: Patients who received ICU care at the EoL were more likely to be male than those who did not (73% vs 52%, P = .02). After adjustments for potential confounders, male patients reporting an EoL discussion were less likely to have an ICU stay in the last week of life than male patients with no EoL discussion (adjusted odds ratio, 0.26, 95% confidence interval, 0.07-0.91; P = .04). There was no association between EoL discussions and ICU stays near death among female patients. CONCLUSIONS: Men with advanced cancers are more likely than women to receive aggressive, nonbeneficial ICU care near death. Gender differences in the effects of EoL discussions on EoL care likely contribute to and may even explain gender differences in the receipt of ICU care in the last week of life.

Advanced cancer as a risk for major depressive episodes.

OBJECTIVE: Major depression adversely affects health communication, quality of life, and survival in patients with advanced cancer. Prior research provides limited insight into how patients with advanced cancer differ from the general population in risk for developing a major depressive episode (MDE). This study aims to determine whether advanced cancer poses distinct risks for initial and recurrent MDEs. METHODS: Advanced cancer patients (N = 628) from Coping with Cancer were compared with propensity-weighted general population controls (N = 9282) from the National Comorbidity Survey Replication. RESULTS: Patients with advanced cancer were more likely than comparisons to have an initial MDE [OR = 27.3, 95% CI = (14.8-50.4); p < 0.001] but no more likely than comparisons to have a recurrent MDE [OR = 1.5, 95% CI = (0.9-2.6); p = 0.160]. Nearly two thirds (64.4%) of current MDEs in patients were initial onset; the vast majority (91.8%) of current MDEs in comparisons were recurrent. CONCLUSIONS: Advanced cancer increases risk of an initial MDE but appears not to enhance risk of a recurrent MDE. This suggests the importance of screening widely for depression in patients with advanced cancer as opposed to targeting screening to presumably high-risk subgroups of those with psychiatric histories.

Screening for bipolar disorder during pregnancy.

Bipolar disorder is a high-risk condition during pregnancy. In women receiving prenatal care, this study addresses the proportion screening positive for bipolar disorder with or without also screening positive for depression. This is a pilot study using chart abstraction of Edinburgh Postnatal Depression Scale (EPDS) and Mood Disorder Questionnaire (MDQ) scores from patients' initial prenatal visits. Among 342 participants, 289 (87.1 %) completed the EPDS, 277 (81.0 %) completed the MDQ, and 274 (80.1 %) completed both. Among EPDS screens, 49 (16.4 %) were positive. Among MDQ screens, 14 (5.1 %) were positive. Nine (21.4 %) of the 42 participants with a positive EPDS also had a positive MDQ. Of the 14 patients with a positive MDQ, five (35.7 %) had a negative EPDS. The prevalence of positive screens for bipolar disorder in an obstetric population is similar to gestational diabetes and hypertension, which are screened for routinely. Without screening for bipolar disorder, there is a high risk of misclassifying bipolar depression as unipolar depression. If only women with current depressive symptoms are screened for bipolar disorder, approximately one third of bipolar disorder cases would be missed. If replicated, these findings support simultaneous screening for both depression and bipolar disorder during pregnancy.