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Postpartum-Depression Questions Should Be Routine for Pediatricians

Neither problems nor solutions are lacking when psychiatrists and pediatricians consider the need to screen mothers for postpartum depression.

Linda Chaudron, M.D., M.S., wants to see some clarity out in the gray zone between pediatrics and psychiatry. She and other researchers see a medical problem—postpartum depression—getting lost too often at the hazy jurisdictional boundaries between the two specialties, and she would like both sides of the divide to strengthen the still-shaky bridge across the gap.

Chaudron, an assistant professor of psychiatry and obstetrics and gynecology at the University of Rochester Medical Center and director of Strong Behavioral Healthcare for Women, and her colleagues made a case in a report in the January Pediatrics for routine screening by pediatricians of mothers in the first year after giving birth.

That practice makes good sense at first glance. About 14 percent of new mothers have postpartum depression. As long as the mother is in the office, why not ask her a few questions about how she's feeling? Ideally, a brief screening test in the pediatrician's office could help identify and refer women who need treatment for an illness that affects their ability to care for their children. Yet a look below the surface reveals myriad questions that must be answered before asking about depressive symptoms.

"There's just not enough research on how to identify maternal depression and who, when, and where to get mothers to appropriate care," said Chaudron in an interview with Psychiatric News.

Pieces All Need to Fit

All the pieces need to be in place to make the system work, she said— recognition of the problem, valid screening tools, and effective treatment. Alone, each component works fine. Putting them together is the tricky part.

The first stop in the gray zone lies in the fact that pediatricians, pediatric nurse practitioners, or physician assistants provide care for the baby, not the mother. (An exception may lie with family practitioners, but there isn't much research on their role in screening for postpartum depression, said Chaudron.) These pediatric clinicians have several options if the mother of one of their patients screens positive for depression. They can refer the mother back to her primary physician or at least help educate her about postpartum depression and its effects on children.

At present, wrote Chaudron and colleagues, "a standard of care does not yet exist that would obligate a pediatric provider to conduct a screening." That lack of a clear standard opens the door to liability issues, they said.

Some physicians are concerned about what might happen if a mother finds questions about depression inappropriate. They fear she might feel insulted or stigmatized and not bring the baby back for further care. Nonetheless, if a pediatrician fails to screen, a depressed mother's impaired ability to parent well may continue. By couching the need for screening as being in "the best interests of the child," pediatricians can validate their efforts and convey to mothers that seeking help enhances the child's well-being by improving their ability to care for their children.

Clinicians Get Better at Screening

Pediatricians may also worry about the added time needed to screen and consult with mothers. One recent study conducted in private practices, however, found that over the six-month study period, clinicians screened for postpartum depression during 70 percent of well-child visits and grew more efficient in the process, taking less time to screen the same number of women. The screening flagged mothers at risk for depression but did not formally diagnose them.

"Screening did not require discussion at most visits and usually did not result in prolonged visits," wrote Ardis Olson, M.D., of the departments of pediatrics and community and family medicine at Dartmouth Medical School, and colleagues in the July 2006 Pediatrics. Parents told clinicians that they welcomed help and chose from a range of medical, social, pastoral, and personal resources for further help.

"We believe that from both clinical and legal perspectives, the benefits of screening for postpartum depression outweigh the risks," argued Chaudron and her coauthors.

"Pediatricians recognize screening as important but will need our help," she told Psychiatric News. There are many ways to begin, she said. These might include adding a component in residency training and using continuing medical education methods for pediatricians in practice.

Many elements of the child's environment are open to inquiry from the child's doctor—smoking, domestic violence, and substance abuse. Screening for postpartum depression falls into the same category. "Pediatricians have to identify it as part of their role," she said. "If they make it standard practice, it will not seem so unfamiliar to the doctor or the mother."

Olson's study was part of only a small body of knowledge available on outcomes, practice patterns, clinicians' views, and mothers' opinions. More research is needed in all these areas, said Marlene Freeman, M.D., director of the Women's mental Health Program and an associate professor of psychiatry, obstetrics and gynecology, and nutritional sciences at the University of Arizona Health sciences center.

"We don't know the best way to use screening tools in the pediatric clinic," said Freeman. "However, I think it serves mothers well, reduces stigma, and makes it more routine to do so."

Nevertheless, the acceptability of screening will depend on how it is approached, said Chaudron. "It will work if the clinic and provider are trusted and not seen as intrusive," she said. "In our clinic, mothers appreciated being approached and are glad to have a chance to talk about themselves."

An abstract of "Legal and Ethical Considerations: Risks and Benefits of Postpartum Depression Screening at Well-Child Visits" is posted at <http://pediatrics.aappublications.org/cgi/content/abstract/119/1/123>.

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