Legal and ethical considerations: risks and benefits of postpartum depression screening at well-child visits

Analyzing Best Practices for Pediatric Well-Child Clinic Visits in the United States for Children Aged Three to Five Years: A Review

Inadequate routine healthcare check-up visits for children aged three to five years impose substantial economic and social burdens due to morbidity and mortality. The absence of regular well-child visits and vaccinations leads to avoidable diseases, underscoring the need for a renewed emphasis on childhood immunizations and check-ups. Out of 160 articles initially screened after removing duplicates, 45 were chosen for full-text review following initial title and abstract screening by two independent reviewers. Afterward, 20 studies met the predefined inclusion criteria during the final assessment of full-text articles, and data were systematically extracted from these selected studies using standardized forms to ensure accuracy and consistency. Well-child visits promote holistic development, health, and well-being in children aged three to five years. Following established guidelines and evidence-based practices, healthcare professionals provide assessments, vaccinations, and guidance for a healthy future. Despite challenges, well-child visits are vital for preventive care, empowering informed decisions for children's growth and development. The benefits of well-child visits encompass growth monitoring, anticipatory guidance, and preventive measures, crucial for children with chronic illnesses. Key components include comprehensive assessments, developmental screenings, vision and hearing evaluations, immunizations, health education, and counseling. In the case of juvenile diabetes, parental education is paramount. Parents need to understand the intricacies of insulin administration, including proper dosage calculation based on glucose measurements, meal planning, and the importance of timing insulin injections. Implementing guidelines and principles by organizations such as Bright Futures and the American Academy of Pediatrics ensures holistic care, parent involvement, and evidence-based practices. This review explores best practices and guidelines for such visits, emphasizing their role in monitoring and promoting children's development.

Postpartum depression screening in mothers and fathers at well-child visits: a feasibility study within the NASCITA cohort

OBJECTIVE

To assess the feasibility of the family paediatrician's (FP) role in identifying the signs of postpartum depression in parents in time to guarantee child well-being.

DESIGN, SETTING AND PARTICIPANTS

Data for this observational prospective study were collected within the NASCITA (NAscere e creSCere in ITAlia) cohort. During the first visit, paediatricians collected sociodemographic data regarding the parents and information about their health status, the pregnancy and the delivery. Whooley questions were administered during the first and second visits (scheduled 60-90 days after childbirth). Moreover, on the third visit (5-7 months after childbirth) the FP was asked to answer 'yes' or 'no' to a question on the parental postpartum depression, based on his knowledge and on the acquired information.

RESULTS

In 2203 couples who completed the assessment, 529 mothers (19.9%), 141 fathers (6.3%) and 110 (5%) couples reported any depressive symptomatology. Of these, 141 mothers (5.3% of the total sample) and 18 fathers (0.8% of the total sample) were classified as 'likely depressed'. An association was found between maternal postnatal depressive symptoms and having a diagnosed psychiatric disorder during pregnancy (OR 9.49, 95% CI: 3.20 to 28.17), not exclusively breastfeeding at hospital discharge (OR 1.76, 95% CI: 1.19 to 2.61) and the presence of child sleeping disorders at 3 (OR 2.46, 95% CI: 1.41 to 4.28) and 6 months (OR 2.18, 95% CI: 1.37 to 3.47). Another significant predictor of postpartum depression was being primiparous (OR 1.99, 95% CI: 1.31 to 3.02). Concerning the fathers, a significant association was reported only between likely depressed fathers and child sleeping disorders at 3 months (OR 7.64, 95% CI: 2.92 to 19.97). Moreover, having a likely depressed partner was strongly associated with depressive symptoms in fathers (OR 85.53, 95% CI 26.83 to 272.69).

CONCLUSIONS

The findings of this study support the feasibility of an active screening programme for parental postnatal depression during well-child visits as an integral part of postpartum care.

TRIAL REGISTRATION NUMBER

NCT03894566; Pre-results.

Maternal Perceptions of Infant Behavior as a Potential Indicator of Parents or Infants in Need of Additional Support and Intervention

The goal of the present study is to examine the relationship between early infant behaviors, which can be easily reported by parents, with parent-infant bonding and maternal mental health. It has long been established that child characteristics and behaviors have a significant impact on parent well-being and how parents respond to their infants. Examining parent perceptions of challenging infant behaviors may help health professionals identify high risk infants in need of intervention and mothers in need of additional support. Mothers of 73 infants between the ages of 3.5 weeks and 6 months filled out questionnaires. Infant stomach issues were positively correlated with bonding issues, maternal anxiety and maternal depression. Infant crying issues were also positively correlated with bonding issues, maternal anxiety and maternal depression. Potential clinical and research applications of the instrument include early identification of caregivers in need of support and screening for further clinical assessment and care.

Impact of an on-site perinatal mood disorders clinic in the diagnosis and management of perinatal mood disorders

Objectives To assess change in Edinburgh Postnatal Depression Scale (EPDS) scores in women treated at the Perinatal Mood Disorders Clinic (PMDC) as a measure of improvement in perinatal mood disorders (primary outcome), and treatment disposition at final visit. Methods Chart review was performed for all PMDC patients between March 1, 2017 and June 1, 2018 (n=120), as a self-controlled case series design. Two-tailed t-tests compared initial and final EPDS scores for all patients with >1 visit (n=64), where EPDS score of ≥13 indicated a positive screen for depression. A multivariable linear regression model with robust standard errors estimated the relationship between patient characteristics and final EPDS scores. Results Of 120 patients, n=56 had one visit and n=64 had >1 visit. Of these 64, mean final score (11.04) was lower than mean initial score (16.54; p<0.001). Additionally, certain patient characteristics were associated with higher final EPDS score, including history of mood disorder and treatment with both pharmacotherapy and psychotherapy. Conclusions Women treated at the PMDC showed improved EPDS scores when receiving at least two separate care visits. Therefore, the clinic may be filling a gap in access to timely care for women with perinatal mood disorders.

Disrespect and abuse towards women during childbirth and postpartum depression: findings from Birth in Brazil Study

BACKGROUND

Many women are victims of disrespect and abuse during childbirth period. In Brazil, the prevalence of these acts has varied between 11.3% and 18.3%. Despite the high prevalence and grave consequences of mistreatment of women during birth care, women's mental health during this period, and its determining factors, are still poorly understood. The main objective is to investigate the association between mistreatment of women during childbirth and postpartum depression.

METHODS

national survey in childbirth care carried out between 2011 and 2012. The sample was composed of 23,378 puerperal women. Disrespect and abuse was composed by seven indicator.We assessed postpartum depression using Edinburgh Postnatal Depression Scale screening questions. We applied multigroup structural equation modelling (childbirth payment source), considering different theoretical models for vaginal births and C-sections.

RESULTS

Disrespect and abuse towards women during childbirth were associated with postpartum depression both in the public and private sectors, for both vaginal births and C-sections. In the public healthcare sector, disrespect and abuse were associated with maternal hospitalization. Presence of fundal pressure manoeuvre, not be white, and not receiving the desired mode of birth (only for C-sections). In the private sector, for both vaginal births and C-sections, not having the desired mode of birth was the only characteristic associated with disrespect and abuse.

CONCLUSION

Disrespect and abuse towards women during childbirth may contribute to the development of postpartum depression. Identifying its causes may help prevent the problem and strengthen public policies that favor the good quality of childbirth care.

Postpartum Depressive Symptoms and Screening Opportunities at Health Care Encounters

Background: The American College of Obstetricians and Gynecologists recommends that providers screen women for depression at the postpartum checkup. If this checkup is the only screening opportunity, women who do not attend or whose depressive episode occurs at a different time may not be identified. We evaluated women's encounters with postpartum health care to identify screening opportunities for postpartum depressive symptoms (PDS). Materials and Methods: Pregnancy Risk Assessment Monitoring System (PRAMS) data for 2012-2015 from eight jurisdictions (n = 23,990, representing 1,939,865 women) were used to calculate percentage of women reporting attendance at postpartum checkups, well-child visits, or postpartum home visitation, by presence of PDS. PDS were assessed using a modified two-item Patient Health Questionnaire. Using Modified Poisson regression, adjusted prevalence ratios (aPR) and confidence intervals (95% CI) were calculated to compare health services by PDS, adjusted for sociodemographic characteristics. Results: Almost all women with or without PDS attended a postpartum checkup (85.1% and 91.4%; aPR: 0.96; 95% CI: 0.93-0.99) and their infants attended a well-child visit (97.3% and 98.9%; aPR: 0.99; 95% CI: 0.98-1.00); 13.7% and 10.9% received home visitation (aPR: 1.18; 95% CI: 1.02-1.35). Of women with PDS who missed their postpartum checkup, 13.5% reported infant attendance at well-child visits, and 2.0% received home visitation. Of women with PDS, 98.8%, 86.1%, and 11.2% attended 1, 2, or 3 health services. Conclusion: A large percentage of women with PDS may attend well-child visits or receive home visitation, representing opportunities for depression screening and referral for care.

Maternal Report of Outcomes of Chiropractic Care for Infants

OBJECTIVE

The purpose of this study was to investigate the report by mothers of their infants' condition before and after a trial of care provided by registered chiropractic clinicians in addition to ratings of satisfaction, cost of care, and reports of any adverse events or side effects. A second purpose was to report the demographic profile of infants who presented for care to 16 chiropractic clinics in the United Kingdom.

METHODS

This observational study prospectively collected reports by mothers of their infants' demographic profiles and outcomes across several domains of infant behavior and their own mental state using the United Kingdom Infant Questionnaire. Participating registered chiropractors were recruited through the Royal College of Chiropractors annual meeting in January 2016, and 15 clinics and the Anglo-European College of Chiropractic University College teaching clinic volunteered to participate.

RESULTS

In all, 2001 mothers completed intake questionnaires and 1092 completed follow-up forms. Statistically significant (P < .05) improvements were reported across all aspects of infant behavior studied, including feeding problems, sleep issues, excessive crying, problems with supine sleep position, infant pain, restricted cervical range of motion, and time performing prone positioning. Maternal ratings of depression, anxiety, and satisfaction with motherhood also demonstrated statistically significant improvement (P < .05). In total, 82% (n = 797) reported definite improvement of their infants on a global impression of change scale. As well, 95% (n = 475) reported feeling that the care was cost-effective, and 90.9% (n = 712) rated their satisfaction 8 or higher on an 11-point scale. Minor self-limiting side effects were reported (5.8%, n = 42/727) but no adverse events.

CONCLUSION

In this study, mothers reported that chiropractic care for their infants was effective, safe, and cost-effective. Although the observational design makes it impossible to determine efficacy, the study's findings indicate that, on average, the changes observed by mothers were positive and may be clinically relevant.

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

Postpartum depression (PPD), part of a larger spectrum of perinatal mood and anxiety disorders, affects up to 15% of women following the birth of an infant. Fathers may also be affected. PPD not only affects caregivers, but also impacts infants through mechanisms such as inadequate caregiver-infant interactions and non-adherence to safety practices. The negative impact on infants may extend across the life course through adulthood. This article seeks to move the needle toward universal screening for PPD using validated tools in pediatric primary care settings for new caregivers by making the legal and ethical case for this course of action in a manner that is both compelling and accessible for clinicians. Toward this end, we summarize current literature as it applies to provider responsibilities, liabilities and perspectives; and caregiver autonomy, confidentiality, and privacy. We then assess utility by balancing the benefits and burdens of this approach to practices, providers, and caregivers; and take the analysis one step further by looking across multiple populations to assess distributive justice. We conclude that there is a strong ethical case for universal screening for PPD in pediatric primary care settings using validated tools when informed consent can be obtained and appropriate follow-up services are available and accessible. Clinical considerations, practical resources, and areas ripe for future research are also addressed.

Beyond Screening: A Stepped Care Pathway for Managing Postpartum Depression in Pediatric Settings

The negative consequences of untreated postpartum depression (PD) for both the woman and her infant are well established. The impact of maternal depression has led to recommendations on systematic perinatal depression screening. Unfortunately, large-scale initiatives on PD screening have found no benefit unless systems are in place to facilitate appropriate interventions for women who screen positive. Pediatric primary care has been a focus of efforts to support screening and management of PD because pediatric providers, unlike adult healthcare providers, have the most frequent contact with postpartum women through well-child visits. Well-child visits thus present an unparalleled opportunity to detect and intervene with PD. Literature reviews suggest that specific strategies are feasible within pediatric settings and could benefit both the woman and her child. In this article, we present a stepped care approach for screening and managing PD, integrating common elements found in existing pediatric-based models. A stepped care approach is ideal because PD is a heterogeneous condition, with a range of presentations and hence responsiveness to various interventions. This care pathway begins with systematic screening for depression symptoms, followed by a systematic risk assessment for women who screen positive and care management based on risk profiles and responsiveness. This approach allows pediatric providers to be optimally flexible and responsive in addressing the majority of women with PD within the context of the family-centered medical home to improve child well-being. Challenges to managing PD within pediatrics are discussed, including strategies for addressing them. Implications for research, policy, and practice are discussed.

Postnatal depression screening in a paediatric primary care setting in Italy

BACKGROUND

Postnatal depression is a non-psychotic depressive disorder that begins within 4 weeks of childbirth and occurs in 13% of mothers and 10% of fathers. A prospective study with the aim to evaluate the prevalence of postnatal depression by screening parents with the Edinburgh Postnatal Depression Scale (EPDS) in the Italian paediatric primary care setting was performed.

METHODS

Mothers and fathers of infants born between 1 February and 31 July 2012, living in Italy's Milan-1 local health unit area, represented the target population of this pilot study. Parents attending well-child visits at any of the family paediatricians' offices between 60 to 90 days postpartum were asked to participate in the screening and to fill out the EPDS questionnaire. A cut-off score of 12 was used to identify parents with postnatal depression symptoms. Maternal and paternal socio-demographic variables and information concerning pregnancy and delivery were also collected. To investigate the association between screening positivity (dependent variable) and socio-demographic variables and factors related to pregnancy and delivery, a Pearson's χ2 test was used. Moreover, a stepwise multivariate logistic regression was carried out to evaluate the risk factors that most influence the probability of suffering from postnatal depression.

RESULTS

In all, 126 out of 2706 (4.7%, 95% CI 3.9-5.5%) mothers and 24 out of 1420 (1.7%, 95% CI 1.0-2.4%) fathers were found to be positive for depressive symptoms. Women with mood disorders and anxiety during pregnancy were at increased risk of postpartum depression (OR 22.9, 95% CI 12.1-43.4). Only 11 mothers (8.7%) positive to EPDS screening attended a psychiatric service, and for 8 of them the diagnosis of postnatal depression was confirmed.

CONCLUSIONS

The prevalence of postnatal depression was lower than previously reported. Routine screening resulted ineffective, since few mothers found positive for depression symptoms decided to attend psychiatric services.

Using clinical decision support as a means of implementing a universal postpartum depression screening program

A major barrier to the diagnosis of postpartum depression (PPD) includes symptom detection. The lack of awareness and understanding of PPD among new mothers, the variability in clinical presentation, and the various diagnostic strategies can increase this further. The purpose of this study was to test the feasibility of adding clinical decision support (CDS) to the electronic health record (EHR) as a means of implementing a universal standardized PPD screening program within a large, at high risk, population. All women returning to the Mount Sinai Hospital OB/GYN Ambulatory Practice for postpartum care between 2010 and 2013 were presented with the Edinburgh Postnatal Depression Scale (EPDS) in response to a CDS "hard stop" built into the EHR. Of the 2102 women who presented for postpartum care, 2092 women (99.5 %) were screened for PPD in response to a CDS hard stop module. Screens were missing on ten records (0.5 %) secondary to refusal, language barrier, or lack of clarity in the EHR. Technology is becoming increasingly important in addressing the challenges faced by health care providers. While the identification of PPD has become the recent focus of public health concerns secondary to the significant social burden, numerous barriers to screening still exist within the clinical setting. The utility of adding CDS in the form of a hard stop, requiring clinicians to enter a standardized PPD mood assessment score to the patient EHR, offers a sufficient way to address a primary barrier to PPD symptom identification at the practitioner level.

Addressing access barriers to services for mothers at risk for perinatal mood disorders: A social work perspective

This article identifies variables at the micro/individual, mezzo/partner/spouse and family, and macro/health care-system levels that inhibit mothers at risk for perinatal mood disorders from accessing health and mental health care services. Specific recommendations are made for conducting thorough biopsychosocial assessments that address the mothers' micro-, mezzo-, and macro-level contexts. Finally, the authors provide suggestions for how to intervene at the various levels to remove access barriers for mothers living with perinatal mood disorders as well as their families.

Can Postpartum Depression Be Managed in Pediatric Primary Care?

BACKGROUND

Postpartum depression is prevalent among women who have had a baby within the last 12 months. Depression can compromise parenting practices, child development, and family stability. Effective treatments are available, but access to mental healthcare is challenging. Routine infant healthcare visits represent the most regular contact mothers have with the healthcare system, making pediatric primary care (PPC) an ideal venue for managing postpartum depression.

METHODS

We conducted a review of the published literature on postpartum depression programs. This was augmented with a Google search of major organizations' websites to identify relevant programs. Programs were included if they focused on clinical care practices, for at-risk or depressed women during the first year postpartum, which were delivered within the primary care setting.

RESULTS

We found that 18 programs focused on depression care for mothers of infants; 12 were developed for PPC. All programs used a screening tool. Psychosocial risk assessments were commonly used to guide care strategies, which included brief counseling, motivating help seeking, engaging social supports, and facilitating referrals. Available outcome data suggest the importance of addressing postpartum depression within primary care and providing staff training and support. The evidence is strongest in family practices and community-based health settings. More outcome data are needed in pediatric practices.

CONCLUSION

Postpartum depression can be managed within PPC. Psychosocial strategies can be integrated as part of anticipatory guidance. Critical supports for primary care clinicians, especially in pediatric practices, are needed to improve access to timely nonstigmatizing care.

ABM Clinical Protocol #18: Use of Antidepressants in Breastfeeding Mothers

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

When It Is Not Postpartum Depression: Understanding the Postpartum Mental Health Needs of Mothers and How They Are Being Met

Although often overlooked, subclinical symptoms of postpartum depression, anxiety, or other mental health symptoms among new mothers increase the risk of more severe problems and can adversely affect maternal and infant health. We conducted focus groups with 92 new mothers and interviews with 20 healthcare providers to elucidate perceptions of mental health needs among first-time mothers and how healthcare providers address these needs. Our findings suggest that a tradition of focusing exclusively on severe presentations of mental health issues may limit maternal and provider ability to address the full spectrum of mental health needs.

Important determinants of newborn health: postpartum depression, teen parenting, and breast-feeding

PURPOSE OF REVIEW

The present article addresses recent research related to three important determinants of newborn health: postpartum depression, teenage parents and their offspring, and breast-feeding.

RECENT FINDINGS

Postpartum depression can impact the entire family unit, and fathers may be affected more than previously recognized. Teenage mothers and their infants are at risk of a number of poor physical and mental health outcomes. New research continues to support the benefits of breast-feeding infants, and hospitals have adopted policies to improve breast-feeding rates.

SUMMARY

Recognizing both maternal and paternal depression during outpatient visits is key to family well-being, as well as to infant development and attachment. Pediatric providers should address the unique emotional, socioeconomic, educational, and health needs of teen mothers. Hospital implementation of evidence-based policies may increase the number of mothers who are successful in establishing breast-feeding, and pediatric healthcare providers should be prepared to support mothers of breast-feeding infants.

Pediatric-based intervention to motivate mothers to seek follow-up for depression screens: The Motivating Our Mothers (MOM) trial

OBJECTIVE

To determine the initial effectiveness of a novel, pediatric office-based intervention in motivating mothers to seek further assessment of positive depression screens.

METHODS

In this pilot randomized controlled trial, English-speaking mothers (n = 104) with positive 2-question depression screens and presenting with children 0 to 12 years old for well-child care to a general pediatric training clinic received interventions from a trained research assistant. The Motivating Our Mothers (MOM) intervention included office-based written and verbal targeted depression education and motivational messages encouraging further depression assessment and a semistructured telephone booster delivered 2 days later. The control intervention included nontargeted written and verbal messages and 2 days later, an attention control telephone survey. Both groups received a list of depression care resources. The primary outcome was the proportion of mothers in each group who reported trying to contact any of 6 types of resources to discuss the positive screen at 2 weeks after intervention (ClinicalTrials.gov NCT01453790).

RESULTS

Despite 6 contact attempts, 10 MOM and 9 control mothers were lost to follow-up. More mothers in the MOM intervention tried to contact a resource compared to control (73.8% vs 53.5%, difference 20.3%, 95% confidence interval for difference -0.1 to 38.5, P = .052).

CONCLUSIONS

Mothers receiving the MOM intervention made more attempts to contact a resource for follow-up of positive depression screens. If found effective in larger studies, MOM may prove a promising approach for motivating depression screen-positive mothers identified in general pediatric settings within and beyond the postpartum period to seek further depression assessment and support.

Postpartum depression screening in the pediatric emergency department

PURPOSE

This study aimed to determine the prevalence of and risk factors for postpartum depression (PPD) in mothers of young infants presenting to the pediatric emergency department (PED).

METHODS

This was a prospective, observational study to evaluate the prevalence of PPD in a sample of mothers of young infants presenting to the PED of an urban, tertiary care children's hospital. A convenience sample of mothers with infants younger than 4 months who presented to our urban, tertiary care PED was surveyed in English or Spanish using the Edinburgh Postpartum Depression Scale (EPDS). Demographic information was collected. Members of the study team evaluated and counseled those mothers who screened positive on the EPDS (score ≥ 10). During the PED visit, social work consultation and mental health resources were also offered. Resource use and additional mental health needs were assessed, with a follow-up telephone call 4 weeks after the initial ED presentation. Performance characteristics of a brief, 3-question anxiety subset were compared using a positive EPDS as the reference standard. All study participants were given information about community resources for new mothers. Data were analyzed using t test or Χ (with Yates correction as necessary).

RESULTS

A convenience sample of 200 mothers was enrolled; 31 (16%) of these mothers had an EPDS score of 10 or greater. Mothers had a mean age of 27 years (range, 15-41); 45% were first-time mothers; 40% got pediatric care in a state-funded clinic; and 10% were Spanish speaking. There were no statistically significant differences in baseline demographic characteristics of mothers with and without PPD. Mothers who were depressed were more likely to report that they either strongly agreed or agreed with the statement "I feel that my child is always fussy" (P = 0.004). The anxiety subscale produced a sensitivity of 0.87 (95% confidence interval [CI], 0.69-0.96), a specificity of 0.70 (95% CI, 0.63-0.77), and a negative predictive value of 0.97 (95% CI, 0.91-0.99). The majority of participants (92%) reached at follow-up reported improvement in their mood. Fifty percent reported discussing their mood with someone else, although only 33% of these women did so with a medical provider.

CONCLUSIONS

Postpartum depression affects a significant number of mothers of young infants who present to the PED for medical care. There are no clear demographic identifiers of these at-risk mothers, making universal screening an advisable approach. Capture of at-risk mothers during PED visits may accelerate connection with mental health resources. Anxiety seems to be a significant contributor. Mothers with PPD often characterize their infants to have a "fussy" temperament. The most appropriate referral for these women in this setting merits further investigation.

MomMoodBooster web-based intervention for postpartum depression: feasibility trial results

Background

Postpartum depression (PPD)—the most common complication of childbirth—is a significant and prevalent public health problem that severely disrupts family interactions and can result in serious lasting consequences to the health of women and the healthy development of infants. These consequences increase in severity when left untreated; most women with PPD do not obtain help due to a range of logistical and attitudinal barriers.

Objective

This pilot study was designed to test the feasibility, acceptability, and potential efficacy of an innovative and interactive guided Web-based intervention for postpartum depression, MomMoodBooster (MMB).

Methods

A sample of 53 women who satisfied eligibility criteria (<9 months postpartum, ≥18 years of age, home Internet access and use of personal email, Edinburgh Postnatal Depression Survey score of 12-20 or Patient Health Questionnaire score from 10-19) were invited to use the MMB program. Assessments occurred at screening/pretest, posttest (3 months following enrollment), and at 6 months follow-up.

Results

All six sessions of the program were completed by 87% (46/53) of participants. Participants were engaged with the program: visit days (mean 15.2, SD 8.7), number of visits (mean 20.1, SD 12.2), total duration of visits in hours (mean 5.1, SD 1.3), and number of sessions viewed out of six (mean 5.6, SD 1.3) all support high usage. Posttest data were collected from 89% of participants (47/53) and 6-month follow-up data were collected from 87% of participants (46/53). At pretest, 55% (29/53) of participants met PHQ-9 criteria for minor or major depression. At posttest, 90% (26/29) no longer met criteria.

Conclusions

These findings support the expanded use and additional testing of the MMB program, including its implementation in a range of clinical and public health settings.

Trial Registration

Clinicaltrials.gov NCT00942721; http://clinicaltrials.gov/ct2/show/NCT00942721 (Archived by WebCite at http://www.webcitation.org/6KjYDvYkQ).

Screening parents of high-risk infants for emotional distress: rationale and recommendations

Having a baby hospitalized in a neonatal intensive care unit (NICU) is a potentially traumatic event for parents. This article summarizes research documenting heightened symptoms of depression and post-traumatic stress in these parents and reviews studies of the relationship of parental distress with impaired infant and child development. We describe an array of validated screening devices for depression and post-traumatic stress, along with research on risk factors for elevated scores. In making recommendations for screening both mothers and fathers for emotional distress in the NICU, we (a) present commentary on the pros and cons of screening, (b) propose a timetable for screening and (c) describe both supportive interventions for parents in the NICU and a variety of referral possibilities for parents most at risk.

A nurse-led initiative to improve obstetricians' screening for postpartum depression

Although up to 20 percent of women experience postpartum depression, screening is not standard practice. In a metropolitan area where only 1 of 30 obstetricians and two primary care clinics reported routine screening for postpartum depression, a nurse-led initiative to implement routine screening using the Edinburgh Postnatal Depression Scale was carried out. Twenty-two obstetricians (76 percent) agreed to consistently implement screening for 3 months. Of the 21 participating obstetricians, 71.4 percent indicated that postpartum depression screening would become their standard care. This article describes implementation strategies and lessons learned.

Maternal health needs and interest in screening for depression and health behaviors during pediatric visits

INTRODUCTION

Our aims were to assess postpartum health care barriers; health status (including depression and health behaviors); missed opportunities to discuss maternal health at health visits; acceptability of maternal screening in pediatric settings; and association of these variables with income level and race/ethnicity.

METHOD

A mail survey was used with names randomly drawn from birth files and balanced for race/ethnicity and income level.

RESULTS

The adjusted response rate was 27.6%, with 41% reporting one or more health care barrier(s), 22% screening positive for depression, and 30% screening positive for alcohol abuse. Women of lower income were eight times more likely than those of higher income to have health care barriers (adjusted odds ratio = 8.15; 95% confidence interval: 3.60, 18.44). Missed discussions of postpartum depression or behavioral health during pediatric or other health care visits ranged from 26% to 79%. Acceptability of discussing topics, including depression, smoking, and alcohol use at pediatric care visits generally exceeded 85%.

DISCUSSION

Postpartum women experienced income-associated barriers to health care and generally had favorable views about maternal screening in pediatric settings.

Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings

IMPORTANCE

The period prevalence of depression among women is 21.9% during the first postpartum year; however, questions remain about the value of screening for depression.

OBJECTIVES

To screen for depression in postpartum women and evaluate positive screen findings to determine the timing of episode onset, rate and intensity of self-harm ideation, and primary and secondary DSM-IV disorders to inform treatment and policy decisions.

DESIGN

Sequential case series of women who recently gave birth.

SETTING

Urban academic women's hospital.

PARTICIPANTS

During the maternity hospitalization, women were offered screening at 4 to 6 weeks post partum by telephone. Screen-positive women were invited to undergo psychiatric evaluations in their homes.

MAIN OUTCOMES AND MEASURES

A positive screen finding was an Edinburgh Postnatal Depression Scale (EPDS) score of 10 or higher. Self-harm ideation was assessed on EPDS item 10: "The thought of harming myself has occurred to me" (yes, quite often; sometimes; hardly ever; never). Screen-positive women underwent evaluation with the Structured Clinical Interview for DSM-IV for Axis I primary and secondary diagnoses.

RESULTS

Ten thousand mothers underwent screening, with positive findings in 1396 (14.0%); of these, 826 (59.2%) completed the home visits and 147 (10.5%) completed a telephone diagnostic interview. Screen-positive women were more likely to be younger, African American, publicly insured, single, and less well educated. More episodes began post partum (40.1%), followed by during pregnancy (33.4%) and before pregnancy (26.5%). In this population, 19.3% had self-harm ideation. All mothers with the highest intensity of self-harm ideation were identified with the EPDS score of 10 or higher. The most common primary diagnoses were unipolar depressive disorders (68.5%), and almost two-thirds had comorbid anxiety disorders. A striking 22.6% had bipolar disorders.

CONCLUSIONS AND RELEVANCE

The most common diagnosis in screen-positive women was major depressive disorder with comorbid generalized anxiety disorder. Strategies to differentiate women with bipolar from unipolar disorders are needed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00282776.

Maternal perinatal depression in the neonatal intensive care unit: the role of the neonatal nurse

The onset of depressive symptoms during pregnancy or the first year postpartum, termed perinatal depression, occurs in approximately 15 percent of women. Perinatal depression can have a significant negative impact on health outcomes for the mother and her infant including maternal emotional distress and parenting difficulties and infant behavioral and developmental problems. Nurses caring for patients in the neonatal intensive care unit (NICU) are in a key position to affect positive change in the lives of families affected by perinatal depression. An overview of antepartum and postpartum depression is provided that has been tailored to the educational needs of the neonatal nurse. A discussion of the role of neonatal nurses in the identification and treatment of perinatal depression follows in order that neonatal nurses may improve both short- and long-term outcomes for mothers, infants, and families in the NICU affected by perinatal depression.

Postpartum depression and intimate partner violence in urban mothers: co-occurrence and child healthcare utilization

OBJECTIVE

To assess the prevalence, timing, and co-occurrence of positive screens for maternal postpartum depression and intimate partner violence and examine their relationships with children's healthcare utilization from birth to 2 years.

STUDY DESIGN

Between February and March 2008, mothers bringing newborn, 2-, 4-, or 6-month-old children to an urban primary care clinic were screened for postpartum depression and intimate partner violence. A retrospective chart review abstracted demographic data, maternal responses on the postpartum depression/intimate partner violence screen at the initial and subsequent visits, and, from the child's birth to second birthday, adherence with well-child care and use of pediatric acute care and emergency department visits. Descriptive, bivariate, and multivariate analyses were conducted.

RESULTS

A total of 173 mothers completed at least one postpartum depression/intimate partner violence screening survey. Overall, 26% screened positive for postpartum depression and 7% screened positive for intimate partner violence; most positive screens occurred at the initial visit. About 60% of mothers with a positive intimate partner violence screen also had a positive postpartum depression screen. Well-child care adherence and acute care visit utilization were not associated with maternal postpartum depression/intimate partner violence screening. Children of women with a positive screen for postpartum depression had greater emergency department utilization.

CONCLUSION

The co-occurrence of postpartum depression and intimate partner violence is high in urban mothers. Primary care providers should routinely screen for both problems in this population and recognize the importance of screening for one problem if the other problem is identified.

Outcomes from implementing systematic antepartum depression screening in obstetrics

This study was developed to evaluate the feasibility of implementing systematic depression screening in a large obstetric practice and to evaluate the degree that detection and referral led to linkage with behavioral healthcare. Depression screening was conducted using the Edinburgh Postnatal Depression Scale, administered at the initial pregnancy care appointment. Patients at or above a predetermined score of 14 were advised to seek further behavioral health assessment through the patient's behavioral healthcare coverage. Within 4 weeks of screening, those referred were contacted by telephone, by clinic staff, to determine whether they had pursued behavioral healthcare as recommended. Limited available data for newly established postdelivery screening were similarly evaluated. All 2,199 newly presenting pregnant women who were seen in our obstetric clinics from September 2008 to May 2009 were screened for depression, and 102 (4.6%) scored at or above an EPDS of 14. Follow-up calls revealed that none had pursued further behavioral health assessments. Of these 2,199, screening and follow-up data were available for 569 women at their 6-week postdelivery visit. Of these, 28 (4.9%) were above EPDS of 14, and 5 (17.9%) reported pursuit of further behavioral healthcare following screening and referral. Peripartum depression can be addressed with systematic screening, and the electronic medical record can readily be used to monitor results. Detection and referral at the beginning of pregnancy did not lead to intended linkage with behavioral healthcare, but detection and referral postdelivery had a modest influence. Barriers to pursuing behavioral healthcare need to be discovered and addressed.

South African Indian Women Screened for Postpartum Depression: A Multiple Case Study of Postpartum Experiences

Postpartum depression is a debilitating condition with negative psychosocial implications. Given a dearth of literature on prevalence or experiences of postpartum depression in South Africa, we sought to understand the experiences of South African Indian women screened for postpartum depressive symptoms. Ten low-income women screened using the Edinburgh Postnatal Depression Scale at primary health care clinics at two locations in KwaZulu-Natal were interviewed, using a multiple case study qualitative method, to understand their experiences within a biopsychosocial framework. The data were analysed thematically with the assistance of NVivo 8. In line with other studies on postpartum depression, the study revealed that interpersonal issues, abusive relationships, economic hardships, and a lack of adequate social support precipitated or aggravated depressive feelings in the postpartum period.

Perinatal depression screening and intervention: enhancing health provider involvement

OBJECTIVE

The authors of this study collaborated in the analysis of public health survey data in order to inform future statewide interventions that could systematically enhance depression screening and mental health service use for women of reproductive age. The primary objective of the study was to empirically inform and test the program theory components of a motivational interviewing intervention that we anticipate will guide statewide practice and policy priorities.

METHODS

Data were examined from a survey of healthcare practitioners statewide (n=1498) regarding their practices with and perceptions of perinatal depression care for women. Confirmatory factor analysis (CFA) was used to measure two latent constructs: health provider confidence in the ability to diagnose and treat and the importance placed on screening and treatment. Structural equation modeling (SEM) was used to test a program theory supporting motivational interviewing using a model implied relationship between confidence and importance on screening and treatment/referral practices.

RESULTS

The data fit the model; the model provisionally supports motivational interviewing as an intervention influencing provider attitudes and practices surrounding perinatal depression screening and treatment/referral.

CONCLUSIONS

Ultimately, study findings support statewide public health efforts to expand the role of health providers in recognizing and responding to perinatal depression and suggest that motivational interviewing techniques that augment importance and confidence may lead to enhanced screening and referral/treatment outcomes for pregnant and postpartum women.

Magnitude da depressão pós-parto no Brasil: uma revisão sistemática

OBJETIVOS: realizar uma revisão sistemática dos estudos sobre a magnitude da depressão pós-parto (DPP) no Brasil. MÉTODOS: a busca e seleção da literatura baseouse em artigos publicados em periódicos nacionais e internacionais, nas bases de dados eletrônicas Lilacs, SciELO e Medline. RESULTADOS: foram selecionados 14 estudos, sendo que 13 deles reportavam a prevalência de DPP e apenas um estudo de seguimento com limitada casuística (n=21) trazia estimativa da incidência do agravo (42,8%). A grande heterogeneidade em relação à população de estudo, método diagnóstico utilizado e período pós-parto focalizado dificultou a obtenção de uma estimativa agregada da prevalência de DPP no Brasil. Contudo, estudos conduzidos em unidades básicas de saúde, no âmbito da Estratégia de Saúde da Família ou em populações carentes apontaram uma prevalência entre 30 e 40% de DPP, enquanto pesquisas que incluíram amostras de base populacional e populações de unidades hospitalares terciárias revelaram uma prevalência de cerca de 20%. CONCLUSÕES: embora novos estudos sejam necessários para melhor caracterizar as peculiaridades que envolvem a magnitude da DPP no Brasil, as evidências disponíveis justificam uma atenção prioritária para os agravos à saúde mental materna no âmbito da saúde pública no país.

Psychosocial risk factors for postpartum depression and their relation to timing of onset: the Hamamatsu Birth Cohort (HBC) Study

BACKGROUND

The time frame for postpartum depression (PPD) defined in the literature differs among studies - either 4 weeks or 3 months after childbirth. To address potential difference in PPD in relation to onset of the illness, we investigated risk factors for early- and late-onset PPD using a representative birth cohort in Japan.

METHODS

We evaluated 675 women who completed the Edinburgh Postnatal Depression Scale (EPDS) for two to three times within 3 months after childbirth. Mothers with an onset of PPD (≥ 9 points on EPDS) within 4 weeks after childbirth were classified as having early-onset PPD, and those with PPD that occurred during the period of the 5th to 12th week after childbirth were classified as having late-onset PPD. We adopted multinomial logistic regression to investigate risk factors associated with each of early- and late-onset PPD, whilst simultaneously allowing for all risk factors a priori selected in the model.

RESULTS

The period prevalence of early- and late-onset PPD was 11% and 4%, respectively. Primiparity was associated only with early-onset PPD (OR=2.6, 95%CI 1.5-4.4). Younger (<25 years: OR=3.6, 95%CI 1.2-11.2) and advanced age (≥ 35 years: OR=2.5, 95%CI 1.1-5.8) of the participating women was significantly associated only with late-onset PPD. Lack of emotional support and a history of depression/anxiety appeared to increase risk both for early- and late-onset PPD.

LIMITATIONS

Moderate sample size and diagnosis of PPD without use of structured interviews may limit generalisability of the findings.

CONCLUSION

The finding that risk sets for early- and late-onset PPD differ suggests that these two types may have different aetiology.

Depression screening for patients with epilepsy in a primary care setting using the Patient Health Questionnaire-2 and the Neurological Disorders Depression Inventory for Epilepsy

Depression among people with a diagnosis of epilepsy is under-recognized. General practitioner (GP) screening for depression using a new scale developed specifically for patients with epilepsy, the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), has not before been reported. The aims were to examine the process of GP screening for depression in patients with epilepsy employing the widely used Patient Health Questionnaire-2 (PHQ-2) and the NDDI-E; to determine the impact of screening on GP-recognized depression; and to ascertain depression predictors. Patients were screened via their GPs. A subset of participants underwent clinical interview to assess screener accuracy. Use of either instrument almost doubled the proportion of GP-recognized depression. Ninety-four percent of those interviewed found screening acceptable. More recent and frequent seizures predicted screening positive. The results suggest that screening for depression in patients with epilepsy via GPs improves detection of depression and is acceptable to interviewed patients.

Poor prepregnancy and antepartum mental health predicts postpartum mental health problems among US women: a nationally representative population-based study

PURPOSE

Mental health problems disproportionately affect women, particularly during the childbearing years. However, there is a paucity of research on the determinants of postpartum mental health problems using representative US populations. Taking a life course perspective, we determined the potential risk factors for postpartum mental health problems, with a particular focus on the role of mental health before and during pregnancy.

METHODS

We examined data on 1,863 mothers from 11 panels of the 1996-2006 Medical Expenditure Panel Survey. Poor postpartum mental health was defined using self-reports of mental health conditions, symptoms of mental health conditions, or global mental health ratings of "fair" or "poor."

RESULTS

Of the women included, 9.5% reported experiencing postpartum mental health problems, with over half of these women reporting a history of poor mental health. Poor prepregnancy mental health and poor antepartum mental health both independently increased the odds of having postpartum mental health problems. Staged multivariate analyses revealed that poor antepartum mental health attenuated the relationship between prepregnancy and postpartum mental health problems. Additionally, significant disparities exist in women's report of postpartum mental health status.

CONCLUSION

Although poor antepartum mental health is the strongest predictor of postpartum mental health problems, prepregnancy mental health is also important. Accordingly, health care providers should identify, treat, and follow women with a history of poor mental health because they are particularly susceptible to postpartum mental health problems. This will ensure that women and their children are in the best possible health and mental health during the postpartum period and beyond.

Treatment of postpartum depression: clinical, psychological and pharmacological options

Postpartum depression (PPD) is a common complication of childbearing, and has increasingly been identified as a major public health problem. Untreated maternal depression has multiple potential negative effects on maternal-infant attachment and child development. Screening for depression in the perinatal period is feasible in multiple primary care or obstetric settings, and can help identify depressed mothers earlier. However, there are multiple barriers to appropriate treatment, including concerns about medication effects in breastfeeding infants. This article reviews the literature and recommendations for the treatment of postpartum depression, with a focus on the range of pharmacological, psychotherapeutic, and other nonpharmacologic interventions.

Incorporating recognition and management of perinatal and postpartum depression into pediatric practice

Every year, more than 400,000 infants are born to mothers who are depressed, which makes perinatal depression the most underdiagnosed obstetric complication in America. Postpartum depression leads to increased costs of medical care, inappropriate medical care, child abuse and neglect, discontinuation of breastfeeding, and family dysfunction and adversely affects early brain development. Pediatric practices, as medical homes, can establish a system to implement postpartum depression screening and to identify and use community resources for the treatment and referral of the depressed mother and support for the mother-child (dyad) relationship. This system would have a positive effect on the health and well-being of the infant and family. State chapters of the American Academy of Pediatrics, working with state Early Periodic Screening, Diagnosis, and Treatment (EPSDT) and maternal and child health programs, can increase awareness of the need for perinatal depression screening in the obstetric and pediatric periodicity of care schedules and ensure payment. Pediatricians must advocate for workforce development for professionals who care for very young children and for promotion of evidence-based interventions focused on healthy attachment and parent-child relationships.

The obsessive-compulsive spectrum in the perinatal period: a prospective pilot study

This study aims to describe the phenomenology of obsessive-compulsive symptoms (OCS) and disorders (OCD) in perinatal women and to explore the relationship of OCS/OCD to postpartum depression. A prospective longitudinal study of 44 women screened with the Obsessive-Compulsive Inventory-Revised (OCI-R) and Edinburgh Postnatal Depression Scale (EPDS) between 30 and 37 weeks of pregnancy. Twenty-four women completed a diagnostic interview and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) before delivery and were contacted postpartum to repeat the EPDS and Y-BOCS. In the third trimester, 32% reported high levels of anxiety and/or depressive symptoms (EPDS ≥ 10 and/or OCI-R ≥ 15) and 29% of those who completed the diagnostic interview met criteria for OCD. At 1 month postpartum, 12.5% had new OCS (Y-BOCS ≥ 8) and 25% had new high levels of depressive symptoms (EPDS ≥ 10). OCS increased in intensity postpartum but did not change in character. OCD and OCS may be of greater prevalence during the perinatal period than previously recognized. The high rates provide new information and require replication in larger, more diverse populations. Research in the perinatal period must expand beyond the exploration of depression to include anxiety disorders and specifically OCD.

Can pediatricians accurately identify maternal depression at well-child visits?

BACKGROUND

The feasibility of a two-item screening tool for maternal depression in a pediatric setting was recently reported. We assessed whether the accuracy of pediatrician recognition of maternal depression during the one-month well-child visit could be improved by an educational intervention using the two-item screening tool.

METHODS

We conducted an educational intervention for pediatric residents in a suburban hospital in Tokyo, Japan, with outcome measurement before and after. Resident education included knowledge about postpartum depression and its impact on children, use of the two-item screening tool and available management strategies. Sixteen pediatric residents examined 267 mother-infant dyads during well-child visits. Residents documented the presence or absence of postpartum depressive symptoms on medical records. Depressive symptoms were also determined using the Edinburgh Postnatal Depression Scale (EPDS) survey; residents were not aware of the results. Using the EPDS as a "gold standard," improvement in sensitivity and specificity of resident recognition of maternal depressive symptoms was determined.

RESULTS

The overall prevalence of postpartum depressive symptoms based on the EPDS was 15.4%. The sensitivity of resident recognition was 8% and specificity 98% before intervention, and 12% and 96% afterwards, respectively. The difference was not statistically significant. Residents indicated fear of maternal stigmatization and mothers' receptiveness to discussing depressive symptoms, as well as lack of time and skills, as major barriers to the identification of maternal depression.

CONCLUSIONS

A simple educational intervention using a two-item screening tool did not improve the pediatrician's accuracy in detecting depressive symptoms in mothers. Additional strategies to address perceived barriers may be needed.

Accuracy of depression screening tools for identifying postpartum depression among urban mothers

OBJECTIVE

The goal was to describe the accuracy of the Edinburgh Postnatal Depression Scale (EPDS), Beck Depression Inventory II (BDI-II), and Postpartum Depression Screening Scale (PDSS) in identifying major depressive disorder (MDD) or minor depressive disorder (MnDD) among low-income, urban mothers attending well-child care (WCC) visits during the postpartum year.

METHODS

Mothers (N = 198) attending WCC visits with their infants 0 to 14 months of age completed a psychiatric diagnostic interview (standard method) and 3 screening tools. The sensitivities and specificities of each screening tool were calculated in comparison with diagnoses of MDD or MDD/MnDD. Receiver operating characteristic curves were calculated and the areas under the curves for each tool were compared to assess accuracy for the entire sample (representing the postpartum year) and subsamples (representing early, middle, and late postpartum time frames). Optimal cutoff scores were calculated.

RESULTS

At some point between 2 weeks and 14 months after delivery, 56% of mothers met criteria for either MDD (37%) or MnDD (19%). When used as continuous measures, all scales performed equally well (areas under the curves of > or =0.8). With traditional cutoff scores, the measures did not perform at the expected levels of sensitivity and specificity. Optimal cutoff scores for the BDI-II (> or =14 for MDD and > or =11 for MDD/MnDD) and EPDS (> or =9 for MDD and > or =7 for MDD/MnDD) were lower than currently recommended. For the PDSS, the optimal cutoff score was consistent with current guidelines for MDD (> or =80) but higher than recommended for MDD/MnDD (> or =77).

CONCLUSIONS

Large proportions of low-income, urban mothers attending WCC visits experience MDD or MnDD during the postpartum year. The EPDS, BDI-II, and PDSS have high accuracy in identifying depression, but cutoff scores may need to be altered to identify depression more accurately among urban, low-income mothers.

Childbirth and mental disorders

This review approaches the topic of childbirth and mental illness using a model of perinatal health which takes into consideration the multiple determinants of health, approached from a lifespan perspective. The paper seeks to answer four broad questions using this model and available literature: (1) What is the relationship between childbirth and mental disorders? (2) How common are mental disorders during childbearing, and what is the perinatal course of illness? (3) What are the effects of mental illness during childbearing on foetal and infant developmental outcomes? (4) How do you approach the detection and treatment of mental disorders during the perinatal period?

Ethical issues in perinatal mental health

The principles of autonomy, beneficence, nonmaleficence, and justice can guide clinicians in finding ethical approaches to the treatment of women who have psychiatric disorders during preconception, pregnancy, and postpartum. Table 1 summarizes some clinical dilemmas in perinatal mental health care, the ethical conundrums posed by these situations, and guiding principles or tools that can help clinicians resolve ethical conflicts. The concept of relational ethics helps resolve apparent mother-offspring ethical conflicts, and the practice of preventive ethics helps anticipate and reduce the risk of ethical dilemmas and adverse clinical outcomes. These central principles suggest the following guidelines in caring for perinatal women: In situations that seem to pit the needs of a pregnant or postpartum woman against the needs of her fetus or baby, reframe the problem to find a solution that most benefits the mother-baby dyad while posing the least risk to the dyad. In evaluating a pregnant woman's ability to make autonomous, informed decisions about medical care, assess her ability to decide on behalf of both herself and her fetus. When explaining the risks of treatments such as psychotropic medication during pregnancy, avoid errors of omission by also explaining the risks of withholding the treatments. Apply the principle of justice to ensure that women are not stigmatized by having psychiatric disorders or by being pregnant. When screening for maternal psychiatric symptoms, ensure that the benefits of screening outweigh the ethical costs by designing effective follow-up systems for helping women who have positive screens. When treating women of reproductive age for psychiatric disorders, proactively discuss family planning and, when appropriate, the anticipated risks of the illness and the treatment during future pregnancies. Offer preventive interventions to reduce these risks.

Screening for postpartum depression at well-child visits: is once enough during the first 6 months of life?

OBJECTIVE

Screening for maternal depression is gaining acceptance as a standard component of well-child care. We tested the feasibility of this policy and determined the prevalence and incidence of maternal depression at well-child visits during the first 6 months of life.

METHODS

Providers in an adolescent-oriented maternity program were cued electronically, when they opened the electronic medical records of 0- to 6-month-old infants to conduct well-child visits, to ask the mothers to complete the Edinburgh Postpartum Depression Scale. Incident cases represented mothers who crossed the referral threshold (score of > or =10) after the first screening.

RESULTS

Mothers usually brought their infants to the clinic, and none refused screening. Providers could act on 99% of the 418 screening cues; they administered the Edinburgh Postpartum Depression Scale 98% of the time and always referred mothers with scores of > or =10. Overall, 20% of the mothers scored > or =10. Scores were unstable at < or =3 postpartum weeks (kappa = 0.2). Thereafter, the prevalence and incidence of scores of > or =10 decreased from 16.5% at 2 months to 10.3% and 5.7%, respectively, at 4 months. Prevalence increased to 18.5% at the 6-month visit, and incidence decreased to 1.9%. Repeat screening detected only 2 mothers (5.7%) with scores of > or =10.

CONCLUSIONS

Electronic cueing improved compliance with the detection and referral phases of screening for maternal depression at well-child visits. Screening 2 months after delivery detects most mothers who become depressed during the first 6 postpartum months, and screening at the 6-month well-child visit is preferable to screening at the 4-month visit.

Postpartum Depression: An Update

Postpartum depression occurs in at least one in seven new mothers, usually within the first 6 months after delivery. By the time of onset of postpartum depression, the mother has usually long since been discharged from the maternity hospital. Early identification and treatment of these mothers reduces both maternal and infant suffering. Careful risk–benefit decision-making regarding various treatment options in the postpartum should be discussed with the mother. Risks of untreated depression include poor bonding with the infant, lack of self care, infant neglect and infanticide.

Postpartum depression

Postpartum depression (PPD) affects up to 15% of mothers. Recent research has identified several psychosocial and biologic risk factors for PPD. The negative short-term and long-term effects on child development are well-established. PPD is under recognized and under treated. The obstetrician and pediatrician can serve important roles in screening for and treating PPD. Treatment options include psychotherapy and antidepressant medication. Obstacles to compliance with treatment recommendations include access to psychotherapists and concerns of breastfeeding mothers about exposure of the infant to antidepressant medication. Further research is needed to examine systematically the short-term and long-term effect of medication exposure through breastmilk on infant and child development.