“I thought the blues were all part of being a new mom,” said the woman who was screened and referred for treatment at her pediatrician’s office after the birth of her second child. She told a news outlet in Raleigh, N.C., that she was grateful for the screening. “I’m able to be the mother that both my kids deserve,” she said.
The story spotlighting postpartum depression (PPD) aired in February 2017, just after North Carolina Medicaid established payment for the new maternal depression screening code (96161), encouraging primary care clinicians to screen for PPD at infant visits. “If a mother is unhappy, having depression, she’s not going to interact with her baby the same way as a non-depressed mother,” said Christoph Diasio, M.D., FAAP, who performed the screening.
An AAP policy statement and technical report, titled Incorporating Recognition and Management of Perinatal Depression into Pediatric Practice, highlight the impact of PPD on the infant, the mother-infant dyad and the family, recognizing what we know about the effect of toxic stress on early brain development and the buffering effect of resilience. The documents, from the Committee on Psychosocial Aspects of Child and Family Health, update a 2010 clinical report. They are available at https://doi.org/10.1542/peds.2018-3259 and https://doi.org/10.1542/peds.2018-3260 and will be published in the January issue of Pediatrics.
The policy addresses the pediatric primary care clinician’s role in identifying PPD and referring the mother-infant dyad for treatment, along with advocacy opportunities. The technical report reviews the epidemiology of perinatal depression, including the need for recognition among fathers, and evidence regarding the effects of perinatal depression, screening and treatment.
Widespread problem, broad implications
Perinatal depression is the most common, and underdiagnosed, obstetric complication in the United States, affecting 15% to 20% of new mothers. The prevalence is nearly doubled for mothers living at low income, and the rate is 40%-60% for poor adolescent mothers.
PPD, included under perinatal depression, is an adverse childhood experience that can impact early brain development, and the health and well-being of the child, mother and family. However, PPD can be treated, and the stress on the infant buffered through support of the dyadic relationship by pediatricians, obstetricians, midwives, mental health professionals and other health professionals throughout the perinatal period. The American College of Obstetricians and Gynecologists, the U.S. Preventive Services Task Force and the Centers for Medicare & Medicaid Services recommend routine universal screening for perinatal depression to facilitate intervention and referral.
Pediatricians’ central concern is that PPD may interfere with parent-infant interaction and attachment, potentially leading to long-term effects on the child’s physical, social-emotional and cognitive development. Primary care screening, discussion, promotion and intervention for PPD exemplify the two-generational aspect of pediatrics. For the pediatrician, follow-up of the mother-infant dyad and the child’s social-emotional development is an important component of the implementation of screening.
The role of the pediatric medical home is to:
- coordinate care with prenatal providers for women with prenatally diagnosed depression;
- implement a process for PPD screening at the 1-, 2-, 4- and 6-month well-child visits;
- use community resources for treatment and referral for mothers with depression and for the dyad; and
- support the mother-infant dyad relationship, including providing breastfeeding support.
The prenatal visit with the pediatrician is an opportunity to discuss the family’s expectations and hopes for the new baby, as well as strengths, risks and social determinants.
Screenings for PPD at infant visits are an opportunity for engagement and promotion, even if results are not concerning. When a screen is positive, primary care intervention and support are effective, even if referral is planned. When depression is identified, follow-up includes screening of social-emotional development for the infant.
Before implementing PPD screening at infant visits, it is essential to have knowledge of support and referral resources, and a plan to link families to them. This includes mental health professionals who care for infants and young children, and who offer evidence-based dyadic therapies such as child parent psychotherapy.
Screening tools include the Edinburgh Postpartum Depression Scale, which also can be used with fathers, and the Patient Health Questionnarie-2/PHQ-9.
The prevalence of perinatal depression, its potential impact on the infant and family, and the challenges of obtaining resources for the mother and dyad present advocacy opportunities at the chapter and national levels. These include implementation of screening and payment by all state Medicaid programs; use of PPD screening as a quality metric for value-based payment; improved access to treatment for women who are pregnant or have given birth within the preceding 12 months (as per the 21st Century Cures Act of 2016); and workforce development for mental health professionals who care for young children and the parent-infant dyad.
Dr. Earls is a lead author of the policy statement and technical report. She is a former member of the Committee on Psychosocial Aspects of Child and Family Health and is chair of the Mental Health Leadership Work Group.