By Raymond Sturner, MD -
While studies vary, postpartum depression affects up to 22% of women who have recently given birth. Since less than 15% will seek help on their own, the use of formal screening as a part of an overall child well-visit and screening plan will help make clear that the focus is on the care of the family as a whole.
Why is screening for maternal depression important?
Parental depression can interfere with the quality of parenting and puts children at risk for adverse outcomes including:
Increased risk of childhood mental health problems: major depression, conduct disorder, substance abuse, and anxiety disorder.
Poorer family functioning and decreased marital satisfaction
Poorer cognitive outcome in toddlers due to mother-infant disturbances
Altered infant attachment
Impact on child health: More ED visits and hospitalizations and less well child visits More health/mental health expenditure for children
A reduced “buffer” or source of safety for children that experience adversity resulting in “toxic stress” and long term adverse outcomes as demonstrated in the ACE study.
Depression can have many impacts on parenting and children. Depressed parents are less likely to be attentive and responsive to their infant’s need which can impair learning, safety, attachment and bonding. The parent may more likely become frustrated with the infant and use corporal punishment. The parent may also have a difficulty establishing routines needed to help regulate emotions and sleep and they are less likely to talk or read to their children.
The consequences of maternal depression on children are many and include, but are not limited to:
Prenatal Inadequate prenatal care, poor nutrition, preeclampsia, spontaneous abortion, preterm birth rates, lower birth weights
Infant Heightened arousal, poor self-regulation, dysregulation, passivity, lower cognitive performance, attentional weaknesses
Toddler Noncompliance, less mature expression of autonomy, internalizing and externalizing problems, lower rate of social interaction, delayed speech, less creative play, lower cognitive performance, attentional weaknesses
School age Impaired adaptive functioning, internalizing and externalizing problems, affective disorders, anxiety disorders, conduct disorders, socialization difficulties, attention deficit/hyperactivity disorders, lower academic achievement
Adolescent Depression, anxiety disorders, phobias, panic disorders, conduct disorders, increased substance abuse and alcohol dependence, attention deficit/hyperactivity disorders, learning disorders
What are the Types of Postpartum Depression?
Postpartum “Baby Blues”; Very common occurring about day 3-4 in roughly 70% of mothers; peaks at about day 5 and last usually 10 days. Doesn’t interfere with baby care and usually requires reassurance and support.
Postpartum Depression Common, but serious. Occurring in about 10%-20% mothers and 6% fathers. Increased likelihood in low income (48%), teen moms (40%-60%).
Postpartum Psychosis Very rare, occurs is the first month, especially if there is a history of bipolar disorder. Symptoms include: paranoia, delusions (fear of being alone with baby and fear of dying), agitation, hallucinations, suicidal thoughts, homicidal thoughts.
Postpartum Obsessive-compulsive Disorder (OCD) Prevalence is 3% presenting with heighten anxiety and agitation; obsess about cleanliness or safety; engage in rituals, e.g., handwashing, checking on the baby. Prevalence 11% including mild intrusive thoughts and/or repetitive behaviors
Postpartum Post Traumatic Stress Disorder (PPTSD) Prevalence is 9% and occurs in women with past trauma or traumatic labor/delivery. Symptoms include: anxiety, depression and triggered trauma. Inability to stop thinking/reliving the traumatic event, nightmares, numbness, difficulty relaxing, a need to talk about the event.
When to Screen?
The US Public Health Service Taskforce and the AAP suggests screening each visit during the 1-month – 6-month well-child visits and the American College of Obstetricians and Gynecologists recommends screening between 4-6 weeks after giving birth.
How to Screen?
Studies have found that mothers are highly compliant when provided with electronic cues for depression screening. In fact, one study showed 100% compliance prior to their well-child visit. In addition, it’s important to remember that screening by itself is insufficient to improve clinical outcomes and must be coupled with appropriate follow-up and treatment when indicated.
Very popular screens: PHQ-2, PHQ-9, or Edinburgh Postnatal Depression Scale
CHADIS offers tools to help doctors and parents screen for postpartum depression including the PHQ-2, PHQ-9, or Edinburgh Postnatal Depression Scale. www.chadis.com See CHADIS Behavioral Tools
CHADIS is a unique screening, decision support and patient engagement system designed to streamline and optimize healthcare by providing clinicians with evidence-based data that improves diagnosis and management of health, emotional, developmental and behavioral concerns.
References
Gaynes BN, Gavin N, Meltzer-Brody S, et al. Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes. Evidence Report/Technology Assessment No. 119. Rockville, MD: Agency for Healthcare Research and Quality, February, 2005. AHRQ Publication No. 05-E006-2.
Jeanelle Sheeder, Karolyn Kabir, Brian Stafford. Screening for postpartum depression at well-child visits: is once enough during the first 6 months of life? Pediatrics. 2009 Jun;123(6):e982-8. doi: 10.1542/peds.2008-1160.