Screening tools and procedures
Despite the risks to infants from maternal depression, less than half of pediatricians screen mothers for PPD, Dr. Bauer said. American Academy of Pediatrics surveys of 778 pediatricians in 2004 and 2013 found that the proportion of pediatricians screening or asking mothers about depression increased from 33% to 44% during that decade, driven partly by the “belief that family screening is in the scope of practice,” she explained. Physicians who asked about the child’s mood were more likely to ask mothers about their mood too, the surveys found (J Dev Behav Pediatr. 2016 Feb-Mar;37[2]:113-20).
Medical organizations differ in their screening recommendations, although all agree screening is important. The American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force recommend screening mothers at least once in the perinatal period (Obstet Gynecol. 2015;125:1268–71; JAMA. 2016;315[4]:388-406). The AAP advocates a more aggressive approach, recommending screening at each of the 1, 2, 4, and 6-month child well-visits (“Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents,” 4th Edition [Elk Grove Village, Ill.: American Academy of Pediatrics Publishing, 2017]).
The two preferred screening tools for PPD are the Edinburgh Postpartum Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ).
The former is fast and simple, requiring less than 5 minutes for mothers to answer 10 items about their symptoms in the previous 7 days. The EPDS has a maximum score of 30; anything above 12-13 should prompt further examination or referral. Women scoring a 10 should be reassessed 2 weeks later, unless they answer affirmatively to item 10 on suicidal ideation, in which case they should be referred immediately.
You also can use a shortened form of the EPDS as a first step, asking about the three EPDS items related to anxiety: “self-blame, feeling panicky, and [feeling] anxious or worried for no good reason,” Dr. Bauer said, explaining “the score should be multiplied by 10 and divided by 3, so the cutoff is greater than or equal to 10.”
The PHQ-9 asks about symptoms in the previous 2 weeks. Scores of 10-14 indicate minor depression or mild major depression, and scores of 15-19 indicate moderate depression. Mothers require intervention if they score at least 20, or in the case of teenage mothers, if they score at least 11 or have suicidal thoughts. Like the shortened EPDS-3, the PHQ has a shortened two-question option you can use as surveillance before fully screening mothers: 1. Have you felt down, depressed, or hopeless in the past 2 weeks? 2. Have you felt little interest or pleasure in doing things in the past 2 weeks?
If mothers have a positive screen, Dr. Bauer recommended that practices document it, according to protocols they’ve already set up.
“It’s not unlike domestic violence, maternal substance abuse, or parental smoking habits,” she said. “The score need not be noted, but [should] include details such as the name of the screener used, interpretation of the results, and when a referral was made.”
After making a referral to her ob.gyn. or a mental health professional, you can continue to help mothers by offering support and reassurance, reminding them that they are not alone and not to blame for depression, and that treatment can help them. Encourage parents to seek your advice and support as a pediatrician and use you as a resource to refer them to services that can help, such as lactation consultants and home-visiting programs.
Dr. Bauer offerred the following recommendations for clinical practice:
- Choose a validated screener for postpartum depression.
- Share the tool with everyone in your practice.
- Identify ways to integrate the screening tool into daily work flow.
- Collect data.
- Implement and assess how it went after a short time, using plan-do-study-act cycles.
Dr. Bauer advised consulting the following websites for information regarding postpartum depression:
- AAP Screening and Technical Assistance and Resource (STAR) Center. This AAP website recommends validated screening tools for maternal depression and has them available on the site ().
- Postpartum Support International (PSI). This website offers information and resources for women, family, and professionals (). PSI can also be reached by calling 800-944-4773.
- PSI Support Coordinator Network. This network can provide referrals for specialized support, such as for members of the military, for fathers, when there are legal concerns, or when psychosis is present, and serves all 50 states and 40 countries ().
- PostpartumDads. This website has recommendations for partners of women with postpartum depression, offering recommendations on how dads can help themselves and the mothers ().
Dr. Bauer said she had no relevant financial disclosures. She reported that her spouse is an employee of Anthem and holds Anthem stocks/bonds. No external funding was used for the presentation.