Postpartum depression is the most common and serious postpartum condition, affecting 10% to 20% of mothers within the first year of childbirth. Studies have found that up to 50% of women with PPD go undiagnosed. (Earls, MF and the Committee on Psychosocial Aspects of Child and Family Health American Academy of Pediatrics. Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice. (2010). Pediatrics. 2010; 126(5):1032-1039) Postpartum depression has been shown to be more common among women who are disadvantaged and is highly prevalent (25%) in low-income, black mothers. (Cutler CB, Legano LA, Dreyer BP, Berkule SB, Lusskin SI, Tomopoulos S, Roth M, Mendelsohn AL. Screening for maternal depression in a low education population using a two-item questionnaire. Arch Womens Ment Health.2007; 10:277-283) The American Academy of Pediatrics (AAP) recommends that pediatricians screen mothers at infant 1, 2, 4, and 6-month well-child visits.
Every year more than 400,000 infants are born to mothers who are depressed, making PPD the most underdiagnosed obstetric complication in America.Most women typically only have 1-2 postpartum visits with their obstetricians, where depression screening may not always occur. For low-income women, particularly minorities, the risk of undiagnosed and untreated depression is especially high because of below-average rates of postpartum follow-up visits with obstetricians.
Since a pediatrician can see a child up to six times within the first six months of life, they are probably in the best position to identify mothers suffering from postpartum depression. The nature and longevity of the pediatrician-patient relationship, coupled with the frequency of visits, allows mothers to develop a certain level of trust with their child’s pediatrician, making it more likely that the mother will speak to her pediatrician about other issues that may be affecting the child’s environment, health and well-being. The health status of a child is directly linked to and affected by the mother’s perceived sense of health, both mental and physical.
The adverse effects of postpartum depression are far-reaching. It can cause family dysfunction, prevent effective mother-baby dyad bonding, cause early cessation of breastfeeding, and can adversely affect infant growth and brain development. Postpartum depression can cause mothers and partners to neglect anticipatory guidance and health care advice, including safety and preventive measures such as car seat and home safety measures. Depressed mothers are more likely to engage in less healthy feeding and sleeping practices with their infant. Infants living in an environment with a depressed mother are likely to have delays in development, impaired social interactions and may be less likely to respond to interventional therapies.
Mothers who are depressed are less likely to read to, cuddle with, and interact with their child, leading to deficits in language acquisition. Infants of depressed mothers show less engagement and eye contact with their mother and are at risk for failure to thrive, attachment disorder, and development delay.
Depressed mothers are less likely to breastfeed, nurse for shorter durations, and have more negative emotions and experiences toward breastfeeding. New mothers experiencing breastfeeding difficulties may be more likely to be suffering from PPD, highlighting the importance of screening.
In addition, children of depressed mothers are less likely to attend well-child visits, have their children receive timely vaccinations, and use the emergency department more often.
Despite AAP recommendations that pediatricians should screen new mothers for postpartum depression at 1, 2, and 6 months only a small percentage of pediatricians are currently screening for PPD. Reasons include lack of time, education, and confidence with respect to mental health issues; inadequate reimbursement; lack of knowledge of resources; and fear of liability. These barriers are deterrents to screening within pediatric practice. Validated instruments must be used and not replaced with informal assessment, which does not comply with standard of care and is inefficient.
We struggle with the number of topics that need to be addressed at each well child visit in a short time. Although pediatricians can bill for maternal depression screening, many pediatricians note that inadequate knowledge, skills, and responsibility for follow-up care and liability are deterrents to screening. We receive no training in maternal depression during residency training. Since the mother is not the pediatrician’s patient, the provider may feel awkward and legally vulnerable. However, many pediatricians are open to modifying their practice and to interventions to increase their knowledge about maternal depression. There are many educational methods available to pediatricians to improve their knowledge and self-efficacy in recognizing PPD.
Before starting screening for PPD in a pediatric office, systems must be in place to allow for proper referral, appropriate case management, and follow-up. Understandably, many pediatricians are fearful to open ‘Pandora’s Box.’ Pediatricians are often unaware of mental health resources in the community. Social workers are a key component of the referral process. If a social worker isn’t available on site, collaborative working relationships need to be established between the pediatric practice and mental health providers in the community. Medical staff should be trained on how to do mental health referrals, especially for those screens that are positive and/or the mother is positive for suicidal ideation. If the mother declines an immediate referral or speaking with the social worker, the pediatrician can provide her with a list of print and online resources, local and national, so that she can access help when she’s ready. The pediatrician can ask to speak to a family member who might be able to offer some support. The pediatrician should schedule close follow-up to monitor any negative effects on the mother-baby dyad.
Maternal depression is an important public health issue and can be associated with comorbid conditions. If left untreated, PPD can worsen, adversely affecting the mother, her child(ren), and the family. All of these things can negatively affect the growth, development, and health of the infant.
The outpatient pediatric clinical setting may be the best opportunity to screen, identify, and refer a depressed mother for timely and appropriate mental health therapy. Taking care of a mother’s mental health needs is a professionally rewarding opportunity because we will be making a long-term, positive effect on our most vulnerable pediatric population.
Natasha K. Sriraman MD MPH FAAP FABM is a board-certified pediatrician and Associate Professor of Pediatrics in Norfolk, VA. She has specialized training in breastfeeding medicine and has published extensively on postpartum depression screening in pediatrics and speaks internationally on treating postpartum depression in breastfeeding mothers. She is the creator of www.NatashaMomMD.com where she blogs regularly about maternal and child health issues. Follow her on Instagram @Natasha.Mom.MD