What is Postpartum Depression? Perinataldepressionisdefinedasaperiodofatleast2weeksduringwhichthereisdepressedmoodorlossofinterestorpleasureinnearlyallactivities,whichoccursduringpregnancyorwithinthefirst12monthsafterbirth.Postpartumdepressionusuallybeginsfrom3to14dayspostpartum,butcandevelopanytimewithinthefirstyearafterdelivery.Symptoms of postpartum depression include:
• Socialwithdrawal
• Deepsadness,cryingspells,hopelessness
• Excessiveworryingandfears
• Irritabilityorshorttemper
• Moodswings
• Feelingoverwhelmed
• Feelingveryemotional
• Difficultymakingdecisions
• Changesofappetite
• Sleepproblems
• Mixedemotionsaboutthebaby
Majordepressiontypicallypeaksatapproximately6weekspostpartumwithanotherpeakat6months1.Theaveragedurationofanepisodeofpostpartumdepression(withouttreatment)issevenmonths. Afteroneepisodeofpostpartumdepression,theriskofrecurrenceinsubsequentpregnanciesis50-
LA BEST BABIES NETWORKHealthy Babies. Our Future.
PolicyStatementJuly2011
Screening for Postpartum Depression at Well-Child Visits
P ostpartumdepression(PPD)isthemostcommoncomplicationofchildbirthwithanestimatedprevalenceof15-20%1.PPDhasdevastatingshort-andlong-termconsequencesforthemother,herpartner,andhernewborn.ThemostsevereadverseoutcomesofPPDincludeincreasedriskformaritaldiscordanddivorce,childabuseandneglect,and
evenmaternalsuicideorinfanticide2.Childrenofdepressedmothersareatincreasedriskforimpairedmentalandmotordevelopment,difficulttemperament,poorself-regulation,lowself-esteem,andbehaviorproblems3.Easy-to-use,reliable,self-administeredscreeningtoolsforPPDareavailable,asareeffectivetherapeuticmodalities.Nevertheless,PPDoftengoesunrecognizedandthereforeuntreated.PediatricianshaveauniqueopportunitytoscreenforPPDsincetheyseethemother/infantdyadatleast7timesduringthefirstyearoflife.ByincorporatingroutinescreeningforPPDintotheseearlywell-childvisits,pediatricianscouldhelpdepressedwomenandtheirchildrenbyidentifyingandreferringwomenforcare.
Box 1. Diagnostic Criteria for DepressionFormajordepression,atleastfiveofthefollowingsymptomsmustbepresentformostoftheday,nearlyeveryday,foratleast2weeks.Atleastoneofthefirsttwoboldedsymptomsmustbepresent.Symptoms:
◊ Depressed mood, often accompanied or overshadowed by severe anxiety
◊ Markedly diminished interest or pleasure in usual activities
◊ Sleepdisturbance–mostofteninsomniaandfragmentedsleep,evenwhenthebabysleeps
◊ Fatigueorlossofenergy
◊ Appetitedisturbance–usuallylossofappetitewithweightloss
◊ Physicalagitation(mostcommonly)orpsychomotorslowing
◊ Feelingsofworthlessnessorexcessiveorinappropriateguilt
◊ Decreasedconcentrationorabilitytomakedecisions
◊ Recurrentthoughtsofdeathorsuicide
Adiagnosisofmajordepressionalsorequiresadeclinefromthewoman’spreviousleveloffunctioning,andsubstantialimpairment.
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75%.Therefore,womenwithanypreviousepisodeofdepressionshouldbepromptlyreferredfortreatment. Anothermentaldisorderthatcanoccurintheperinatalperiodispostpartum psychosis.Unlikepostpartumdepression,postpartumpsychosisisarelativelyrareeventwithanestimatedincidenceof1.1-4.0casesper1,000deliveries4.Theonsetofpostpartumpsychosisisusuallyacute,withinthefirst2weeksofdelivery,andismorecommoninwomenwithastrongfamilyhistoryofbipolarorschizoaffectivedisorder.Itresemblesamanicpsychosiswithagitation,irritability,depressedorelatedmood,delusions,anddisorganizedbehavior,anditcarriesariskofinfanticideandsuicide,makingitapsychiatricemergency.However,withimmediatehospitalizationandtreatmentwithmoodstabilizers,womenwiththisdisordercandoverywell.Althoughitisanimportantdisorderinitsownright,itwillnotbefurtheraddressedinthisissuebrief.
Why Does Depression Matter? Withoutintervention,maternaldepressioncanhavelife-longrepercussionsforthechild,themother,andtheirrelationship.Herearewaysthatitmayhaveanegativeimpact.ForMother:
• Impairedcare-takingofselfandothers
• Alteredappetite/weight
• Sleepdisturbance
• Increasedriskofsubstanceabuse
• Increasedriskofsmoking
• Suicidalthoughtsoractions
• Long-termdepressionoranxiety
ForInfant:
• Increasedcryingandirritability
• Poorattachmenttomother
• Increasedriskofabuseorneglect
• Decreaseddurationofbreastfeeding
• Increasedriskoffailuretothrive
• Poorweightgain
• Physicaldysregulation
ForFamily:
• Maritalfrictionanddivorce
• Contributestofather’sfeelingsofhelplessnessanddepression
• Effectsonolderchildren(emotional,behavioral)
• Causesfeelingsoflossandgriefinfamily
ForChildren:• Developmentaldelays:
o Latewalkingandtalking
o Delayedreadinessforschool
o Learningdifficultiesandproblemswithschoolwork
o Attentionandfocusimpairment
• Emotionalproblems:
o Lowself-esteem
o Anxietyandfearfulness
o Increasedriskfordevelopingmajordepressionearlyinlife
• Behavioralandsleepproblems:
o Increasedaggression
o Actingoutindestructiveways
• Socialdifficulty:
o Problemswithestablishingsecurerelationships
o Difficultymakingfriendsinschool
o Socialwithdrawal
ImpactonEarlyParentingPractices5:• SafetyPractices:
o Decreaseduseofcarseatsandelectricaloutletcovers
o Decreaseduseofsmokedetector
o Lesslikelytoplacebabyonbacktosleep
o Increaseduseofcorporalpunishmentduringfirstyearoflife
o IncreasedriskforaccidentsnecessitatingEDvisits
• FeedingPractices:
o Lesslikelytobreastfeedorbreastfeedforshorterduration
o Morelikelytogivewater,juiceorcerealbeforeageof4months
• Behaviorsthatpromoteearlydevelopment:
o Lesslikelytotalkdailywhileinthehome
o Lesslikelytoplaydailywithinfant
o Lesslikelytoshowbooksdailytoinfant
o Lesslikelytobeaffectionatewithinfant
o Lesslikelytofollow2ormoreroutinesatmeals,naptimeandbedtime
o Lesslikelytomakepediatricappointmentsandfollowthroughonpediatricguidelines
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o Morelikelytodisplayangeranddisengagement
Theinteractionbetweenparentandinfantiscentraltotheinfant’sphysical,cognitive,social,andemotionaldevelopment,aswellastohisself-regulationabilities6.Maternaldepressioninterfereswiththemother’scapacitytobondwithherinfantandcanseriouslyimpairthebaby’semotionalandevenphysicalwell-beingbecauseofneglectoftheinfant’sneedsandlackofreinforcementoftheinfant’sengagementcues.Maternaldepressioncanalsoresultininsecureattachmentthatincreasestheriskforsubsequentexternalizingandinternalizingbehaviorsinthedevelopingchild.Thus,itiscriticaltodetectandtreatmaternaldepressionasearlyaspossibleinthelifeoftheinfant.
Who is at risk for Postpartum Depression? Nowomanisimmunetothedevelopmentofpostpartumdepression,butsomenewmothersareatincreasedrisk8.
Medicalorpsychiatricriskfactors:• Familyorpersonalhistoryofmooddisordersorother
mentalillness,historyofdepression,ordepressionoranxietyduringpregnancy.
• Priorhistoryoftraumaorloss,especiallylossof
one’smother.
• Stressfullifeevents–separation,divorce,jobloss,move,etc.
• Unplannedand/orunwantedpregnancy.
• Difficultorhighriskpregnancy.
• Birthtraumaorcomplications.
• Multiplebirth.
• Historyofinfertility.
• Chronicmedicaldisorder.
• Substanceabuse.
• Perinatalloss:miscarriage,stillbirth,neonataldeath,infantdeath.
• BabyinNICU.
• Babywithbirthdefectordisability.
• “Fussybaby”orbabywithdifficulttemperament.
• Adoptedbaby.
Socialriskfactors:• Povertyorfinancialhardship.
• Poororinadequatesocialsupport.
• Relationshipdissatisfactionand/orstress.
• Domesticviolence.
• Highlevelsofchildcarestress.
• Teenmotherhood.
• Singlemotherhood.
• Immigrantstatus.
• Militaryservice.
Why Pediatricians?AccordingtotheAmericanAcademyofPediatrics,pediatricianshaveuniqueopportunities“topreventfuturementalhealthproblemsthrough…timelyinterventionsforcommonbehavioral,emotional,andsocialproblemsencounteredinthetypicalcourseofinfancy,childhood,andadolescence.”9Thefamily-centerednessofthechild’smedicalhomeandthepediatrician’slongitudinal,trusting,andempoweringtherapeuticrelationshipwiththefamilyrepresenttheperfectframeworkforimplementingroutinescreeningformaternaldepression.Moreover,pediatricians,unlikeobstetriciansormidwives,havetheopportunitytoseethemother/infantdyadcontinuallyduringthefirstyearoflife10.Obstetriciansandmidwivestypicallyonlyhaveonepostpartumvisitwiththenewmotherandrarelyseeherbeyond6to8weeks
Box 2. Signs of Possible Problems with Emotional Well-Being in Infants of Depressed Mothers8
◊ Excessivecryingandirritability,withdifficultycalming
◊ Dysregulationinsleep
◊ Physicaldysregulation(e.g.vomitingordiarrhea)
◊ Poorweightgain
◊ Pooreyecontact
◊ Lackofbrighteningonseeingparent
◊ Notturningtosoundofparent’svoice
◊ Lackofvocalizations
◊ Extremelylowactivitylevelortone
◊ Lackofmouthingtoexploreobjects
◊ Sadorsomberfacialexpression(evidentby3monthsofage)
◊ Wariness(evidentby4monthsofage)
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postpartum,atthepointwhenmanylow-incomemotherslosetheirinsurancecoverage.Sincemostdepressedmothersdonotrecognizetheirsymptomsasdepression,theyareunlikelytobeunderpsychiatriccare.Thus,thepediatricianmaybetheonlyproviderthemotherseesonaregularbasisduringthefirstyearofachild’slife.
Screening for Postpartum Depression Studiesexploringthefeasibilityofscreeningformaternalpostpartumdepressionusingastandardizedtool11-13havefoundthattheintroductionofscreeningduringwell-childvisitsiswellreceived,withfewpatientsdeclining.Sincethestandardizedtoolsareself-administered,theycanbecompletedbythemotherwhilesheisinthewaitingroom,andthenscoredbythenurseormedicalassistant.Cliniciantimedemandsaremodest,withmostscreeningsrequiringnoadditionaldiscussion,20-30%requiringbriefdiscussions(lessthan3minutes),andonly4-5%requiringalongerdiscussion13. Thetwomostwidelyused,validatedscreeningtoolsarethePatientHealthQuestionnaire(PHQ-2orPHQ-9)andtheEdinburghPostpartumDepressionScale(EPDS-10).1Bothareavailableatnocost.14,15ThePHQ-2asksaboutthetwofundamentalsymptomsofdepression,diminishedmoodandanhedonia,andrequestssimpleyes/noresponses.MostcliniciansstartbyadministeringthePHQ-2andiftherespondentanswers“yes”toeitherorbothquestions,thePHQ-9isthenadministered.16ThePHQ-9hasbeenvalidatedformeasuringdepressionseverityandcanbeself-administered,administeredtelephonically,orreadtothepatient.Inaddition,ithasbeenvalidatedinAfricanAmerican,ChineseAmerican,Latino,andnon-HispanicwhitepatientgroupsandisavailableinEnglish,Spanish,andChinese. TheEPDS-10,a10-item,self-administeredquestionnairespecificallydevelopedfortheassessmentofpostpartumdepression,focusesonthepsychologicalratherthanthesomaticaspectsofdepression.Patientsrespondtoitemsona4-pointLikertscale.Anxiety is a more prominent feature of postpartum depression17thanofdepressionthatoccursatothertimesinlife,andforsomemotherswithPPD,anxietywillbetheonlysymptom.Therefore, if the pediatrician elects to use the PHQ-9 screening tool over the EPDS-10, we strongly recommend that the EPDS-3 (the 3-item anxiety subscale of the Edinburgh Postpartum Depression Scale18) be used concurrently (See Box 6.)
Box 4. Scoring the PHQ-9 Depression Assessment14
For initial diagnosis
1. PatientcompletesthePHQ-9QuickDepression
Assessment
2. Questions#1and#2areansweredaseither2or
3.
3. Ifthereareatleast5✔sinthetworightcolumns
(includingQuestions#1and#2),consideramajor
depressive disorder.Addscoretodetermine
severity.
4. Functional impairmentisansweredas“somewhat
difficult”orgreater.
Severity Determination
TotalScore DepressionSeverity
0-4 None
5-9 Mild
10-14 Moderate
15-19 Moderatelysevere
20-27 Severe
Box 3. Screening Protocol for Postpartum Depression at Well-Child Visits
◊ Who Allmothers
◊ When Ateachwell-childvisitthefirstyear
oflife
◊ Where Waitingroom(self-administered)or
inprivateroomifpatienthaslow
healthliteracyandneedsMAto
readittoher
◊ Whoscores Nurseormedicalassistant
◊ How PHQ-2,followedbyPHQ-9if
answer“yes”toeitherquestion,
PLUSEPDS-3
◊ Why Earlydetection
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Is the Patient Unsafe to Self or Others? Onceyouhavedeterminedthatthemotherisdepressed,itiscriticaltoassesssuicidaltendencies.14AskingquestionsaboutsuicidewillNOTmakeamothermoreorlesssuicidalthanshealreadyis.Infact,theopportunitytodiscusshersuicidalthoughtsisoftencathartic.Thefirstclueisifthemotheransweredyestoquestion#9onPHQ-9–“Overthepast2weeks,howoftenhaveyoubeenbotheredbythoughtsthatyouwouldbebetteroffdead,orofhurtingyourselfinsomeway?”Consideraskinganddocumentingthefollowingprogressionofquestions:
1.Doyoufeelthatlifeisworthliving?
2.Doyouwishyouweredead?
3.Haveyouthoughtaboutendingyourlife?
4.Ifyes,haveyougonesofarastothinkabouthowyouwoulddoso?
5.Doyouhaveaccesstoawaytocarryoutyourplan?
6.Whatkeepsyoufromharmingyourself?
Manypatientswillnotanswer#4directlyorwilladd,“ButI‘dneverdoit.”Givethempositivefeedback(e.g.,“I’mgladtohearthat”)butdonotdropthesubjectuntilshehastoldyouthespecificmethodsconsidered(e.g.,gun,medicationoverdose,motorvehicleaccident). Itisimportantforeachhealthcareofficeorclinic
Box 6. 3-Item Anxiety Subscale of Edinburgh Postpartum Depression Scale18
PleaseunderlinetheanswerthatcomesclosesttohowyouhavefeltINTHEPAST7DAYS,notjusthowyoufeeltoday.
1 Ihaveblamedmyselfunnecessarilywhenthingswentwrong.
Yes,mostofthetime
Yes,someofthetime
Notveryoften
No,never
2 Ihavebeenanxiousorworriedfornogoodreason.
Yes,veryoften
Yes,sometimes
Hardlyever
No,notatall
3 Ihavefeltscaredorpanickyfornoverygoodreason.
Yes,mostofthetime
Yes,sometimes
Hardlyever
No,notatall
Box 5. PHQ-9: Guide to Diagnosis and Treatment Options14
PHQ-9 Score Provisional Diagnosis Treatment Options
5-9 Minimalsymptoms Support,educatetocallifworse,returninonemonth
10-14Minordepression*Dysthymia**Majordepression,mild
Support,watchfulwaitingAntidepressantorpsychotherapyAntidepressantorpsychotherapy
15-19 Majordepression,moderatelysevere Antidepressantorpsychotherapy
>20 Majordepression,severeAntidepressantandpsychotherapy(especiallyifnotimprovedonmonotherapy)
*Ifsymptomspresent>1monthorseverefunctionalimpairment,considertherapy.**Ifsymptomspresent>2years,probablechronicdepression,warrantstherapy.
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Example Suicidality Screening Flow*
Adapted from Major Depression in Adults in Primary Care 14
*Note: A clear chain of responsibility within the clinic system needs to be established and distributed to all parties who may identify a suicidal patient. Well-defined follow-up procedures for contacting the patient for further evaluation need to be established. Events need to be well documented in the patient’s medical record.
Patient answers positive on question nine of PHQ-9
Patient volunteers thoughts about suicide
LEVEL OF RISK: Current thoughts? How often? For how long? Plan? Intent? Means? Preparations? Previous attempts? Family history of suicide? Current use of alcohol or drugs? Severe stressors? Marked coping difficulties? High-risk factors (psychosis, agitation, history of aggressive or impulsive behavior, hopelessness, high anxiety, comorbid physical illness, high-risk demographics
With intent, current lethal plan
IMMINENT RISK: 1. Call 911 or 1-800-854-77712. Notify primary physician
Chronic thoughts, no intent No plan No means No previous attempts No active substance use No family history
LOWER RISK: 1. Discuss with primary physician
within 24 hours 2. Offer patient information about
contact numbers and procedures if suicidal ideation returns or worsens
3. Explain to patient that other clinical staff may be contacting them for further assessment, and confirm how they can be reached in the next 24 hours if needed
Current/acute thoughts and: Plan with no means or intent or Previous attempts or Current substance use or Family history of suicide or High-risk factors
MODERATE TO HIGH RISK: 1. Discuss with primary physician within one hour 2. Explain to patient that other clinical staff will be
contacting them for further assessment, and confirm how they can be reached within the hour if not in clinic.
3. Offer patient information about contact numbers and procedures if suicidal ideation worsens
National Suicide Hotline1-800-SUICIDE or 1-800-782-24331-800-273-TALK or 1-800-273-8255L.A. County Mental Health Hotline1-800-854-7771
[divorced or separated, Caucasian or Asian race]
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todevelopitsownsuicideprotocol.Theofficeshoulddevelopaclearprocessforriskassessment,includingwhentoinvolveamentalhealthspecialist,useoflocalornationalhotlines,nextsteps,etc.SeealgorithmforSuicidality Screening Flowonpage6. Amotherdeemedtobeatimminentriskforsuicideshouldnotbeleftaloneforevenashortperiodoftime(notevenwhenshegoestothebathroom);someoneshouldstaywithheruntiltheLosAngelesCountyPsychiatricMobileResponseTeam(PMRT)arrivestoevaluateher,andifnecessary,involuntarilydetainher.PMRTrespondstorequestsformobilepsychiatricserviceswithin60minutesoftheinitialcallto800-854-7771.
Educating and Engaging the Depressed Mother Successfulcareofmajordepressionasamedicalillnessrequiresactiveengagementofeachpatientandherfamily,andongoingeducation,beginningatthetimeofdiagnosis.TheNationalResearchCouncilandInstituteofMedicine’s2009report19recommendsthatafocusonpositiveparentingandchilddevelopmentbepairedwithtreatmentofparentaldepressiontopreventadverseoutcomesinthechild,enhancetheparent’sinteractionswiththechild,andhelpengagetheparentintreatment.Keymessages14include:
• You are not alone.Maternaldepressioniscommonmedicalillnessandcanaffectanywomanregardlessofage,income,culture,oreducation.
• You did nothing to cause this.Thisisnotyourfault.
• Help is available.Thesooneryougettreatment,thebetter.
• Recovery is the rule, not the exception.
• Treatment is effective for most patients.Theaimoftreatmentiscompleteremission,notjustgettingbetter,butstayingwell.
Referring the Depressed Mother for Treatment Pediatricianscanreferthedepressedmothertoherprimarycareprovider,ordirectlytoamentalhealthspecialist,forinitiationoftreatment,dependingonthemother’spreference.Ideally,thepediatricianhasasocialworkerco-locatedathisofficeorclinic.Alternatively,thepediatricianhasaworkingrelationshipwithamentalhealthprofessional(MSW,MFT,PsyD,PhD,psychiatrist)inthecommunitytowhompatientscanbeeasilyreferred.
However,ifthepediatricianneedstofindatherapistforadepressedmotherinLosAngelesCounty,hecancall2-1-1and/orPostpartumSupportInternational(PSI)at1-800-944-4PPD(www.postpartum.net). Tothegreatestextentpossible,itisimportantfortheretobea“warmhand-off”wherebytheprimarycareproviderdirectlyintroducestheclienttothementalhealthprovider.Thereasonforthisisbothtoestablishaninitialface-to-facecontactbetweentheclientandthementalhealthcounselorandtoconferonthecounselorthetrustandrapporttheclienthasdevelopedwiththeprovider.Manycliniciansreportthatthisface-to-faceintroductionhelpsensurethatthecounselingappointmentwillbekept.Nevertheless,supportandeducationintheprimarycaresetting,i.e.,thepediatrician’soffice,arecriticalandcontributetothelikelihoodofgoodfollow-throughontreatment. Theimpactofthemother’sdepressiononherolderchildrenandfamilyasawholeshouldalsobetakenintoconsiderationwhenmakingreferrals.Forexample,ifthemother’sdepressionhasbeenchronic,olderchildrenmightneedacomprehensivementalhealthevaluationand/orreferralforearlyintervention.
Patient Self-Management Alldepressedwomenneedpsychosocialsupportandshouldbeencouragedtoidentifyfamilymembersandfriendswithwhomtheycantalk.Ifnonecanbeidentified,itisimportanttoreferthemtoapostpartumsupportgroup.20Activityschedulingisastraightforwardbehavioralinterventioninwhichpatientsaretaughttoincreasetheirdailyinvolvementinpleasantactivitiesandtoincreasetheirpositiveinteractionswiththeirenvironment 21.Physicalactivity,atadoseconsistentwithpublichealthrecommendations(i.e.,30minutesofmoderate-intensityaerobicexercise,3to5daysaweek,forotherwisehealthyadults),canalsobehelpfulineasingthesymptomsofmajordepression.
Treatment Options Pharmacologicand/orpsychotherapyinterventionsarealsoeffectiveintreatingdepression.Factorstoconsiderinmakingtreatmentrecommendationsaresymptomseverity,presenceofpsychosocialstressors,presenceofco-morbidconditions,chronicityofsymptoms,andpatientpreferences.If the mother has mild to moderate depression, either an antidepressant or psychotherapy is indicated, or possibly both.Ontheother
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hand,ifthepresentingsymptomsofdepressionaresevereorchronic,acombinationofanantidepressantandpsychotherapyisoftennecessary. Itisimportanttoalsotakeintoaccountculturalbeliefsandtheavailabilityofresourcessuchastransportation,finances/insurance,andchildcarewhenmakingthedecisiontotreatwithmedicationand/orpsychotherapy.Resultsfromasystematicreview22showedclinicalbenefitswhenracialandethnicminoritywomenwereallowedtochoosetheirtreatmentandprovidedwithsupportandoutreachservices. Psychotherapyfordepressionincludesindividual,family,dyadic(motherandinfant),andgrouptherapy.Cognitive-behavioraltherapy,interpersonaltherapy,short-termpsychodynamicpsychotherapy,andproblem-solvingtreatmentallhavedocumentedefficacy.However,justbecauseamotherreceivestreatmentforherPPDdoesnotmeanherinfantwillexperienceimprovedoutcomes. Unhealthydyadicrelationshippatterns,establishedduringtheearlierstagesofthepostpartumdepression,maycontinue.23Thesearepatternsthattheinfantparticipatedinasawayofcopingwithor“normalizing”interactionwithadepressedcaretaker.Thus,manyexpertsrecommendinfant-motherpsychotherapy.24 Effectivenessofantidepressant medicationsisgenerallycomparablebetween,andwithin,classesofmedications.However,therearedistinctdifferencesinside-effectscausedbytheclassesofmedicationsandindividualagents.14,24,26Moreover,whentreatingpostpartumwomen,itisimportanttoconsiderwhetherthemedicationissafeforbreast-feedingorpregnantwomen.27Nortriptyline,paroxetine,andsertralinearethepreferredchoicesinbreastfeedingwomen14.Foracompletelistofmedications,pleaseseewww.otispregnancy.org. Whenantidepressanttherapyislikelytobeprescribed,thefollowingkeyeducationalmessagesshouldbehighlighted:
• Sideeffectsfrommedicationoftenprecedetherapeuticbenefitandtypicallyrecedeovertime.
• Successfultreatmentofteninvolvesdosageadjustmentsand/ortrialofadifferentmedicationatsomepoint,tomaximizeresponseandminimizesideeffects.
• Mostpeopleneedtobeonmedicationatleast6-12monthsafteradequatealleviationofsymptoms.
• Patientsmayshowimprovementwithin2weeksbut
needalongerperiodoftimetoreallyseeresponseandremission.
• Continuetotakethemedicationasprescribedevenafteryoufeelbetter.Prematurediscontinuationofantidepressanttreatmenthasbeenassociatedwitha77%increaseintheriskofrelapse/recurrenceofsymptoms.
• Donotstoptakingthemedicationwithoutfirstcallingyourprovider.Sideeffectscanoftenbemanagedbychangesinthedosageordosageschedule.
• Mostimportantly,instructthemotherandheradultfamilymemberstobealertfortheemergenceofagitation,irritability,andothersymptoms.Theemergenceofsuicidalityandworseningdepressionshouldbecloselymonitoredandreportedimmediatelytoherhealthcareprovideror9-1-1.
Establish Follow-Up Plan Proactivefollow-upcontacts(inperson,bytelephone)significantlylowerdepressionseverity28.Theadditionofacaremanagercanhelpthebusypediatricianmakesurethemotherhasfollowedthroughonhisreferrals.
Legal and Ethical Considerations OnebarriertoscreeningforPPDhasbeenpediatricians’legalandethicalconcernsoverscreeningparentsduringapediatricvisit,foraconditionthatcanhaveseriousnegativeeffectsontheinfant.29Liabilityoftendependsonthe“standardofcare”inthecommunity.NowthatAAP’sTaskForceonMentalHealth(TFOMH)hasproposedthatpediatricians,aspartoftheirSurveillanceofEnvironmentforRiskFactors,“screenformaternaldepressioninthefirstyearoflifeofthechildandwhenpsychosocialhistoryindicates”30,thestandardofcareislikelytoshift.Withrespecttoethicalconsiderations,ifcliniciansknowthatatreatabledisorderisprevalentintheirpopulationandmayaffectthehealthoftheirpatient,i.e.,thechild,theyareindeedethicallyboundtoscreenandrefermothersforhelp.Whenscreening,pediatriciansshouldclarifythatscreensforPPDareperformedforthepurposeofenhancingthechild’swell-being.Moreover,pediatricprovidersshouldbecautiousaboutoversteppingtheboundsoftheirrole,andleaveongoingcareandtherapyoftheadulttoqualifiedprofessionals.31
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Coding TheAAPhasdevelopedacomprehensivetoolkittohelpprimarycarecliniciansmoreeffectivelyidentifyandmanageavarietyofmentalhealthissues,includingmaternalPPD.Thetoolkit,“AddressingMentalHealthConcernsinPrimaryCare,”releasedinJune2010,includesscreeningtools,step-by-stepcareplans,parenthandouts,andotherresources. Ofnote,itincludesaguidetohelpcodeforthespecificstepsinthementalhealthalgorithmsintroducedbytheAAPTFOMH.32,33ScreeningformaternalPPDfallsunderAlgorithmA.TheTFOMHprovidesavarietyofoptionsforcodingprimarycarevisits,somemightreflectthepossibilityofanextendedvisit(i.e.,multiplestepsinthealgorithmduringoneencounter),whileothersreflectacontactfocusedonaspecificstep.Theguidealsotakesintoconsiderationifthepediatricianhasaco-locatedlicensedmentalhealthprofessionalintheofficetoperformorassistwithsomesteps. TheAAPandtheAmericanAcademyofChildandAdolescentPsychiatryreleasedawhitepaperaddressingtheadministrativeandfinancialbarrierstoaccessingmentalhealthservicesaswellascollaborationbetweenpediatricprimarycareprovidersandtheirmentalhealthcolleagues.34Thepediatricianplaysacriticalroleinongoingcommunicationandco-managementtomonitorthechild’sprogress,supportthechildandfamily,andensurecarecoordination.Inthecontextofmaternaldepression,carecoordinationbecomesevenmorecomplex–oftenbringinginthemother’sprimarycareprovider,therapist,and/orpsychiatrist,aswellasthetherapistprovidingdyadiccare. ThePatientProtectionandAffordableCareActrequiresinsurerstocoverpreventivecareandscreeningswithoutanycostsharing,includingscreeningforpostpartumdepression.In2010theNationalInstituteforHealthCareManagementreleasedanimportantissuebrief 35highlightingwhathealthplanscandotoensureearlyidentificationofmaternaldepressionandcarecoordination.SomehealthplanssuchasWellPoint,Inc.andKaiserPermanentearealreadyaddressingthisissue,byencouragingobstetricians,pediatricians,andprimarycareproviderstoscreenformaternaldepression,byraisingawarenessofmaternaldepressionthroughpatienteducationinmaternityprograms,andbyprovidingfreeaccesstophysicianeducation.
Home Visiting Pediatriciansconcernedaboutthewell-beingofaninfantofaseverelydepressedmothershouldalsoconsiderreferringthefamilytoanevidence-basedhomevisitingprograminthecommunity,suchasEarlyHeadStart,HealthyFamiliesAmerica,Nurse-FamilyPartnership,HomeInstructionforParentsofPreschoolYoungsters,orParentsasTeachers.Thesehomevisitingprogramscanimproveoutcomesformothersandyoungchildreninavarietyofareas,includingpreventionofchildabuseandneglect,childhealth,maternalhealth,childdevelopmentandschoolreadiness,familyeconomicself-sufficiency,andpositiveparentingpractices.Unlikeaphysician,thehomevisitorhastheopportunitytoseethemotherinherreal-lifecontextandthetimetositandlistentoher.
They come to your home where you are comfortable. Because I’ll tell you right now, they don’t come out in suits. They come out dressed like whoever. They don’t make you feel uncomfortable… It’s not going into somebody’s office. It’s almost like sitting down talking to a friend.36
Therearealsosomehomevisitingprogramsspecificallydesignedtomeettheneedsofparentsofinfantsandtoddlersstrugglingwithmentalhealthproblems,suchasLosAngelesChildGuidanceClinic’sFirst Steps Program.Thisprogrampromotesastrongparent-childattachmentusingastructuredhome-basedinterventionmodel.Thismodelfacilitatesunderstandingandsupportforparentsinwaysthatleadtoabetterunderstandingofhowtheycanimproveoutcomesfortheirchildren,e.g.throughtalking,singingandreadingtoinfantsandtoddlers,playinginteractivegames,andinterpretinginfantandtoddleremotionalcues.Thisapproachtotreatmentincreasesparents’awarenessabouttheirchildren’sneeds,improveschildren’sdevelopmentalcourse,andexpandssafetyandstimulationinthehomeenvironment.
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ResourcesAAPMentalHealthToolkitPediatrics2010;Volume125Supplement#3EnhancingPediatricMentalHealthCare
Freeonlinetraining:www.step-ppd.com/step-ppd/home.aspx
Medications:www.otispregnancy.org
LACountyPerinatalMentalHealthTaskForce’sPerinatalDepressionToolkit:www.lacountyperinatalmentalhealth.org
PostpartumSupportInternational1-800-944-4773http://www.postpartum.net/
SuicideHotlines:National1-800-SUICIDEor1-800-784-2433LACounty1-800-854-7771
References1. GaynesBN,GavinN,Meltzer-BrodySetal.Perinatal
Depression:Prevalence,Screening,Accuracy,andScreeningOutcomes.AgencyforHealthcareResearchandQuality.EvidenceReport/TechnologyAssessment,Number119,2005.
2. McCoySJ.PostpartumDepression:AnEssentialOverviewforthePractitioner.SouthMedJ2011;104:128-132.
3. WisnerKL,ChambersC,SitDKY.PostpartumDepression:AMajorPublicHealthProblem.JAMA2006;296:2616-18.
4. YonkersKA,VigodS,RossLE.Diagnosis,Pathophysiology,andManagementofMoodDisordersinPregnantandPostpartumWomen.ObstetGynecol2011;117:961-77.
5. McLeanKT,MinkovitzCS,StrobinoDMetal.MaternalDepressiveSymptomsat2to4MonthsPostpartumandEarlyParentingPractices.ArchPediatrAdolescMed2006;160:279-284.
6. EarlsMF&TheCommitteeonPsychosocialAspectsofChildandFamilyHealth.ClinicalReport-IncorporatingRecognitionandManagementofPerinatalandPostpartumDepressionintoPediatricPractice.Pediatrics2010;126:1032-39.
7. HaganJF,ShawJS,DuncanPM,eds.BrightFuturesGuidelinesforHealthSupervisionofInfants,Children,and
Adolescents:PromotingMentalHealth,ThirdEdition,ElkGrove,IL:AmericanAcademyofPediatrics,2008.
8. PearlsteinT,HowardM,SalisburyA,etal.PostpartumDepression.AmJObstetGynecol2009;200:357-364.
9. AmericanAcademyofPediatricsCommitteeonPsychosocialAspectsofChildandFamilyHealthandTaskForceonMentalHealth.PolicyStatement-TheFutureofPediatrics:MentalHealthCompetenciesforPediatricPrimaryCare.Pediatrics2009;124:410-421.
10. ZuckermanBS,BeardsleeWR.MaternalDepression:AConcernforPediatricians.Pediatrics1987;79:110-117.
11. SheederJ,KabirK,StaffordB.ScreeningforPostpartumDepressionatWell-ChildVisits:IsOnceEnoughDuringtheFirst6MonthsofLife?Pediatrics2009;123:e982-e988.
12.ChaudronLH,SZilagyiPG,KitzmanHJ,etal.DetectionofPostpartumDepressiveSymptomsbyScreeningatWell-childVisits.Pediatrics2004;113:551-558.
13.OlsonAL,DietrichAJ,PrazarG,HurleyJ.BriefMaternalDepressionScreeningatWell-ChildVisits.Pediatrics2006;118:207-216.
14.InstituteforClinicalSystemsImprovement.HealthCareGuideline:MajorDepressioninAdultsinPrimaryCare.May2010.www.icsi.org.
15.AmericanAcademyofPediatrics.SupplementalAppendixS12:MentalHealthScreeningandAssessmentToolsforPrimaryCare.Pediatrics2010;125:S173-S192.
16.GjerdingenD,CrowS,McGovernP,etal.PostpartumDepressionScreeningatWell-ChildVisits:Validityofa2-QuestionScreenandthePHQ-9.AnnFamMed2009;7:63-70.17.RossLE,GilbertEvansSE,SellersEM,RomachMK.MeasurementIssuesinPostpartumDepression,Part1:AnxietyasaFeatureofPostpartumDepression.ArchWomen’sMentHealth2003;6:51-57
18.KabirK,SheederJ,KellyLS.IdentifyingPostpartumDepression:Are3QuestionsAsGoodas10?Pediatrics2008;122:e696-e702
19.NationalResearchCouncilandInstituteofMedicine.CommitteeonDepression,ParentingPractices,andtheHealthyDevelopmentofChildren,BoardonChildren,Youth,andFamilies,DivisiononBehavioralandSocialSciencesandEducation.2009.DepressioninParents,Parenting,andChildren:OpportunitiestoImproveIdentification,Treatment,andPrevention.Washington,DC:NationalAcademiesPress.
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20.http://www.postpartumprogress.com/weblog/postpartum-depression-support-groups.html
21. CuijpersP,vanStratenA,WarmerdamL.Behavioralactivationtreatmentsofdepression:ameta-analysis.ClinPsycholRev2007;27:318-26.
22.Ward,EC.Examiningdifferentialtreatmenteffectsfordepressioninracialandethnicminoritywomen:aqualitativesystematicreview.JournaloftheNationalMedicalAssociation2007;99:265-74
23.NylenKJ,MoranTE,FranklinCL,etal.MaternalDepression:AReviewofRelevantTreatmentApproachesforMothersandInfants.InfantMentHealthJ2006;27:327-343.
24.LiebermanAF,SilvermanR,PawlJH.Infant-ParentPsychotherapy.InCHZeanah,Jr(ed)HandbookofInfantMentalHealth,SecondEdition.2000.NewYork:GuilfordPress.
25.WisnerKL,ParryBL,PiontekCM.PostpartumDepression.NEnglJMed2002;347:194-199.
26.GelenbergAJandAmericanPsychiatryAssociation’sWorkGrouponMajorDepressiveDisorder.PracticeGuidelinefortheTreatmentofPatientswithMajorDepressiveDisorder.November2010.http://www.psychiatryonline.com/pracGuide/pracGuideChapToc_7.aspx
27.YonkersKA,WisnerKL,StewartDE,etal.TheManagementofDepressionDuringPregnancy:AReportfromtheAmericanPsychiatricAssociationandtheAmericanCollegeofObstetriciansandGynecologists.ObstetGynecol2009;114:703-13.
28.UnutzerJ,KatonW,CallahanCM,etal.Collaborativecaremanagementoflate-likedepressioninprimarycaresetting:Arandomizedcontrolledtrial.JAMA2002;288:2836-45.
29.ChaudronLH,SzilagyiPG,CampbellAT,etal.LegalandEthicalConsiderations:RisksandBenefitsofPostpartumDepressionScreeningatWell-ChildVisits.Pediatrics2007;119:123-128.
30.AmericanAcademyofPediatrics.TheCaseforRoutineMentalHealthScreening.Pediatrics2010;125:S133-S139.
31.AmericanAcademyofPediatrics.PrimaryCareReferralandFeedbackForm.Pediatrics2010;125:S172.
32.Foy,JM.EnhancingPediatricMentalHealthCare:AlgorithmsforPrimaryCare.Pediatrics2010;125:S109-S125.
33.AmericanAcademyofPediatrics.CodingfortheMentalHealthAlgorithmSteps.Pediatrics2010;125:S140-S152.
34.AmericanAcademyofChildandAdolescentPsychiatryCommitteeonHealthCareAccessandEconomicsandAmericanAcademyofPediatricsTaskForceonMentalHealth.ImprovingMentalhealthServicesinPrimaryCare:ReducingAdministrativeandFinancialBarrierstoAccessandCollaboration.Pediatrics.2009;123:1248-1251.
35.SantoroK,PeabodyH.IdentifyingandTreatingMaternalDepression:Strategies&ConsiderationsforHealthPlans.NIHCMFoundationIssueBrief.June2010.
36. GoldenO,HawkinsA,BeardsleeW.HomeVisitingandMaternalDepression:SeizingtheOpportunitiestoHelpMothersandYoungChildren.March2011.TheUrbanInstitute.http://www.urban.org/publications/412316.html
LA BEST BABIES NETWORKHealthy Babies. Our Future.
1401SouthGrandAvenue,PHRBuilding3rdFloorLosAngeles,California90015(213)250-7273
www.LABestBabies.org
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Sample Screening Form16
Depressionisacommonbuttreatableillnessthatoccursmoreoftenamongparents.Manypeoplewhosufferdon’trealizetheyhaveamedicalillnessandcouldbenefitfromtreatment.TheU.S.PreventiveServicesTaskForcerecommendsthatalladultsbecheckedfordepressionwhentheyseeadoctor.Parentsofchildrenwhoarecaredforinthispracticemayseeusmoreoftenthananyotherhealthcareprovider.TheTaskForceisconsideredtheauthorityonpreventivehealthcareandwebelieveitiswisetofollowtheiradvice.Itisourjobbecause,ifaparentisdepressed,theirchildisaffected.Thechilddoesbetteriftheparentgetshelp.
Forthisreason,pleasetakeaminutetorespondtothefollowingquestions.Wewillthentakealookatyourresponsestogetherduringthisvisit.
1. Overthepast2weeks,youhavefeltdown,depressed,orhopeless?(True or false)Iftrue,haveyoufeltthiswayfor:severaldays,morethanhalfthedays,ornearlyeveryday?
2. Overthepast2weeks,youhavefeltlittleinterestorpleasureindoingthings?(True or false) Iftrue,haveyoufeltthiswayfor:severaldays,morethanhalfthedays,ornearlyeveryday?
PleaseunderlinetheanswerthatcomesclosesttohowyouhavefeltINTHEPAST7DAYS,notjusthowyoufeeltoday.
1. Ihaveblamedmyselfunnecessarilywhenthingswentwrong.Yes,mostofthetimeYes,someofthetimeNotveryoftenNo,never
2. Ihavebeenanxiousorworriedfornogoodreason.Yes,veryoftenYes,sometimesHardlyeverNo,notatall
3. Ihavefeltscaredorpanickyfornoverygoodreason.Yes,mostofthetimeYes,sometimesHardlyeverNo,notatall
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