"I should be happy but I feel nothing right now" Nadiya thought to herself. She had a brand new beautiful boy that looked like her husband but Nadiya felt none of the joy or excitement that she heard other mothers describe. She worried that her feelings would negatively affect her son and lead to future problems. Nadiya kept her feelings to herself and even acted upbeat during the pediatric medical visits. After several weeks, she began to wonder if she would ever feel normal again.
Nadiya's story is familiar to medical providers who work in primary care, especially pediatricians. Studies show that nearly 1 in 5 women experience postpartum depression (PPD) and that many go undiagnosed. PPD negatively affects a mother's ability to engage with her family and child at an emotional and cognitive level, placing the child at greater risk for impaired development. Despite these consequences, early detection and management can make a significant difference for mothers who suffer from PPD.
The American College of Obstetricians and Gynecologists (ACOG) recommends that clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms and then provide close follow-up and treatment for qualifying mothers. However, it's one thing to make recommendations and another thing to actually implement these guidelines. A recent literature review found that although most pediatricians felt a responsibility for identifying PPD, pediatricians were the least likely of the three provider groups included to use a screening tool to assess for PPD, at 7%, compared with 31% for family physicians and 36% for obstetrician-gynecologists.1 Pediatricians were also the least confident in their skills to recognize PPD yet were the most likely to rely on their own clinical judgment rather than a screening tool to detect PPD.
So, how can pediatricians, who work at the forefront of child primary care, increase screening rates for PPD? A new study on clinical decision support provides a helpful algorithm (see graph below) to guide pediatricians.2 Using a validated depression screening tool (e.g., PHQ-2, PHQ-9, EDS), pediatricians can use specific cut-off scores to determine if a mother qualifies for no referral, a referral to mental health, or immediate emergency services. This quick and simple decision tree easily guides pediatricians through the evidence-based process of decision-making.
In addition, the authors conclude that a warm handoff with a behavioral health provider is ideal and shows that the pediatrician cares about what happens to the mother and child after the medical visit. The next step in this line of research is to disseminate this algorithm and help practices quickly implement these evidence-based guidelines. There are many mothers like Nadiya out there that deserve to talk with a health professional about postpartum depression.
1. Evans, M. G., Phillippi, S., & Gee, R. E. (2015). Examining the screening practices of physicians for postpartum depression: implications for improving health outcomes. Women's Health Issues, 25(6), 703-710.
2. Waldrop, J., Ledford, A., Perry, L. C., & Beeber, L. S. (2018). Developing a Postpartum Depression Screening and Referral Procedure in Pediatric Primary Care. Journal of Pediatric Health Care.
||Matt Martin, PhD, LMFT is Clinical Assistant Professor at the Arizona State University Doctor of Behavioral Health Program. He serves as the CFHA Blog Editor.