Making the Legal and Ethical Case for Universal Screening for Postpartum Mood and Anxiety Disorders in Pediatric Primary Care

Systematic Review of Barriers to and Facilitators of Screening for Postpartum Depression at Well-Child Visits in the United States

OBJECTIVE

To identify and evaluate barriers to and facilitators of screening for postpartum depression (PPD) during well-child visits in the United States. Additionally, to describe prior work on PPD screening tool evaluation and outcomes from PPD screenings conducted within the well-child setting.

DATA SOURCES

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Five databases (Pub Med, PsycINFO, Web of Science, CINAHL, and Cochrane Library) were searched.

STUDY SELECTION

Randomized controlled trials, case studies, cross-sectional studies, case-control studies, cohort studies, qualitative studies, and quasi-experimental studies conducted in the United States were included. The Standard Quality Assessment Criteria Tool (QualSyst) was used to assess the methodologic quality of each included study.

DATA EXTRACTION

Sample, setting, methods, screening tools used, location of study setting, intervention, and salient findings were extracted and summarized for further analysis and synthesis.

DATA SYNTHESIS

Quantitative studies were rated on 14 aspects, and qualitative studies were rated on 10 aspects, per QualSyst. Studies received a score of 2, 1, 0, or not applicable based on scoring criteria, with higher scores indicating greater methodologic quality.

CONCLUSION

We found that barriers to PPD screening included concerns regarding time for screening, adequate training, and limited ability for referral. Facilitators of PPD screening included electronic prompts for providers, as well as tool availability and familiarity. Our results indicate that education and training about PPD screening in the pediatric setting are important next steps in addressing the rising concern of PPD in the United States.

Increasing postpartum depression screening and resources in pediatric primary care: A quality improvement project to enhance provider confidence

BACKGROUND

Unidentified and untreated postpartum depression (PPD) can have a negative impact on children. This Quality Improvement (QI) project aimed to increase PPD screening through provider education and enhancing pediatric primary care provider (PCP) confidence in using the Edinburg Postnatal Depression Screening (EPDS) tool, discussing PPD with mothers, and providing resources.

DESIGN AND METHODS

PCPs and staff were educated on the project. Providers were surveyed prior to and after implementation to assess confidence with screening for and addressing PPD. Mothers of infants 0-6 months were screened using the EPDS at well-care visits. Discussion of PPD and resource support was provided if needed.

RESULTS

A total of 273 mothers met criteria for screening, and of those 65% (n = 178) had a documented score. 12.4% of mothers had a score of 10 or greater, indicating high risk for PPD. Results from PCPs were compared both pre- and post-project. Screening for PPD increased from 3 to 4.5, using the EPDS tool from 2.25 to 4.75, discussing PPD with mothers from 2.75 to 4.25, and providing resources from 2.25 to 4.25.

CONCLUSIONS

PPD screening increased, and provider confidence with using the EPDS, discussing PPD with mothers, and providing resources in pediatric primary care increased.

PRACTICE IMPLICATIONS

Educating PCPs on the importance of PPD screening and providing resources for at-risk mothers can increase identification of PPD in the primary care setting. Enhancing the confidence of providers to discuss PPD with mothers and offer resources to those in need can lead to better outcomes for pediatric patients and their families.

Maternal Postpartum Depression Screening and Referral in a Latinx Immigrant Population: A Quality Improvement Study

Postpartum depression (PPD) is the most underdiagnosed obstetric complication in the United States. Left undiagnosed and untreated, PPD can have lasting effects on the infant and the mother. A quality improvement project was conducted to improve rates of screening and referrals with postpartum Latinx immigrant mothers. Community health workers were designated to assist with PPD screening and referral for behavioral health services, at a pediatric patient-centered medical home, using a referral process algorithm (Byatt, N., Biebel, K. & Straus, J. Postpartum Depression Screening Algorithm for Pediatric Providers During Well-Child Visits, MCPAP for Moms: Promoting maternal mental health during and after pregnancy, N/A (2014)). Using chi analysis of pre and post implementation findings, results demonstrated a 21% increase in screening of eligible postpartum mothers. Referrals for behavioral health services also increased from 9 to 22% of patients that screened positive. Community Health Workers were an asset in increasing screening and referral practices for PPD in a Latinx immigrant population. Further research efforts will assist to remove further barriers to PPD screening and treatment.

Coffee and caffeine intake and depression in postpartum women: A cross-sectional study from the National Health and Nutrition Examination Survey 2007-2018

This cross-sectional study examines the association between coffee and caffeine consumption and depressive symptoms in postpartum women. In total, 821 postpartum women who met the study's inclusion criteria were interviewed. Data were extracted from the 2007-2018 National Health and Nutrition Examination Survey. Coffee consumption and 11 confounding variables were considered and analyzed as baseline data. Weighted logistic regression models were constructed by adjusting the variables, and the odds ratios of total coffee, caffeinated coffee, and decaffeinated coffee were assessed for their impact on depression status. In addition, subgroup analyses were conducted according to race, breastfeeding status, and postpartum period. The results show that generic coffee and caffeinated coffee intake have a potentially protective effect in postpartum women. Drinking more than three cups of caffeinated coffee may lower the risk of postpartum depression, particularly in the 1-2 year postpartum period and in non-breastfeeding women. The association between decaffeinated coffee consumption and postpartum depression remains unclear.

Addressing Adverse Childhood Experiences in Primary Care: Challenges and Considerations

This article draws attention to the overlapping literature on social determinants of health and adverse childhood experiences, and the growing clinical interest in addressing them to promote children's and parents' health and well-being. We address important considerations and suggest solutions for leaders and practitioners in primary care to address social determinants of health/adverse childhood experiences. Priorities include: begin with a few prevalent conditions for which there are helpful resources; focus on conditions that are current or recent and where parents may be more apt to engage in services; focus initially on families with children aged <6 given the frequency of well-child visits and the especially strong relationships between primary care professionals and parents during this period; ensure training of primary care professionals and staff to help them play this role competently and comfortably; and have good referral processes to facilitate additional evaluation or help.

Postpartum fatigue and depression: A systematic review and meta-analysis

BACKGROUND

New parents are vulnerable to fatigue and depressive symptoms. Many studies have reported significant positive correlations between the two in postpartum parents, but the size of correlations varies considerably between studies. The relationship between postpartum fatigue and depression is yet to be systematically synthesized and meta-analyzed.

METHODS

A PROSPERO registered systematic review and meta-analysis (CRD42017065240) was conducted on the correlation between fatigue and depression within the first two years postpartum in parents. Moderation analysis was used to examine the influence of demographic and measurement factors on the effect sizes.

RESULTS

Thirty-five eligible papers were identified (34 on mothers, 1 on fathers). The meta-analytic summary effect size for simultaneously measured fatigue and depressive symptoms among women in the postpartum period was r = 0.52, 95% CI [0.45, 0.59], p < .001. There was a high degree of heterogeneity in the strength of the correlation between studies. This heterogeneity was not accounted for by demographic (e.g., infant age, maternal age, population type) or methodology (e.g., measurement) related moderators.

LIMITATIONS

Studies not reporting or providing correlation between fatigue and depression were not included. Unable to assess some moderators due to limited sample size.

CONCLUSIONS

There is a strong correlation between fatigue and depressive symptoms among women in the first two years after child-birth, but a high degree of heterogeneity in correlation strength exists between studies. Careful assessment of both fatigue and depression when either symptom is reported could facilitate accurate differential diagnosis and prioritizing treatment in postpartum women. Further implications for assessment, treatment, and future research are discussed.

Improving Identification and Child-Focused Collaborative Care for Children of Parents With a Mental Illness in Tyrol, Austria

Background: Children of parents with a mental illness (COPMI) are more likely to experience negative long-term adversities. However, interventions to support their needs early can significantly enhance adjustment and reduce negative outcomes. Approximately one in four children currently lives with a parent with mental illness worldwide. The lifelong impact for individuals, governments, and broader society is likely to be substantial. There are significant workforce barriers to the early identification of COPMI and addressing their needs, particularly within the adult mental health care system. The current study aims to reduce such barriers and to improve identification of COPMI in the current health care systems. Objectives: The project "The Village" is a multidisciplinary health and social care policy intervention and seeks to improve child development and well-being outcomes for children of parents with a diagnosed mental illness. This will be achieved through the co-development, implementation, and evaluation of a practice approach to the early identification and collaborative care for COPMI, through establishing child-focused support networks. This will be done with open innovation science (OIS) approaches engaging the public in Tyrol, a geographical region of Austria, throughout 4 years. As part of the co-development process, we will work with stakeholders to co-develop the practice approaches based on evidence-based approaches and determine the most appropriate study design to evaluate those, as well as the implementation processes we will undertake. Methods: The project is underpinned by theories from different disciplines (i.e., public health, psychology, sociology, linguistics, economic sciences) as well as drawing on different approaches (i.e., co-development, implementation science, symbolic interactionism, and realist evaluation). It is based on the seven content work packages (WPs): 1) management, 2) focusing on children and methods to understand their "voice," 3) scoping, 4) co-development, 5) implementation, 6) evaluating the practice approaches, and 7) knowledge dissemination. "Scoping" will involve exploring the existing evidence, practice, and current state of identification and collaborative care in Tyrol, Austria. "Co-development" involves the co-design of practice approaches to identify and support children in partnership with key stakeholders and service providers working in Tyrol. The "implementation" of practice approaches will be based on the results of the co-development phase and will involve working with organizations to develop support strategies that draw on known organizational drivers from the field of implementation science to support the rollout of the practice approaches. In "Evaluation" we will follow principles of a realist approach; this includes developing program theories and logic models for the practice approaches. Those will set out the outcomes hypothesized to achieve and the processes that are expected to lead to those changes. This will refer to changes in children, parents, and practitioners. We expect that the main focus will be on measuring child quality of life and mental health outcomes, and outcomes that are on the path to those (such as social support needs, resilience, mental health literacy, stigma, and help-seeking behavior) as well as costs. The "child voice" WP focuses on children's perceptions and needs as the importance of "assent" and support of children to develop their own "voice" in health care is increasingly recognized within child health research. The "dissemination" step focuses on reaching a broad public audience of different stakeholders, researchers, and families involved. Discussion: The research project aims to directly improve identification and support of vulnerable children across selected regions in Tyrol, Austria, and by doing so, improve the health and well-being of future generations, through breaking the cycle of intergenerational transfer of adverse childhood experiences.