Behavioral Health Screening
Postpartum Depression
I have no relevant
financial relationships with the
manufacturers of any
commercial products and/or
providers of commercial
services discussed in this
CME activity.I do not intend to
discuss an unapproved or
investigational use of a
commercial product/device in
my presentation.
Summary
– 1)Early childhood screening is indicated for adverse child hood
events which are highly correlated to long term problems
2)Toxic stress without buffering interventions leads to changes
in brain structure (hippocampus,amygdala,prefrontal
cortex),function,epigenetics,childhood and adult physical and
behavioral morbidity
3)Postpartum depression is one example of toxic stress– a
hidden time bomb: under identified and under treated with long
term morbidity
4)Screening and referral for postpartum depression by
pediatricians is valid, effective and feasible at well visits during
the first year of life. The standard of quality pediatric care (Bright
Futures) incorporates this as part of our broader assessment of
the ecology of children and their families
Perinatal/Postpartum
Depression(Pregnancy to 1 year
after birth)
Despite the frequency of depression among new
mothers and fathers,large numbers of affected
individuals may not be identified as having a treatable
condition,and only 15% obtain professional care.This
has long term adverse effects on both parents and
children,i.e. a hidden time bomb.
Spectrum
• Mothers:
1)postpartum blues (50-80%,first weeks):crying
sadness,mood swings,needs reassurance ,support
2)Major depression(1320%),400,000/year in US,1/11
infants,DSM4 diagnosis
3)Postpartum psychosis(1-3/1000,first
month),paranoia,hallucinations,
delusions,suicidality ,homicidal
Fathers:
limited data,6-10%, different
manifestations,i.e.substance abuse
Co-morbidity/Risk Factors
– Poverty (increased prevalence ¼ infants)
Substance Abuse
Domestic Violence
Family history depression
Personal history depression
Infant temperament (colic)
Isolation
Consequences: Parents,Parent
child interaction(hostile,intrusive
or disengaged,withdrawn),Child
and ?Adult
Children who experience maternal depression
early in life may suffer lasting effects on their
brain architecture and persistent disruptions
of their stress response systems
Consequences
– 1)ER visits, health costs
2)Delays in cognition,socio-emotional and
language development
3)At risk for later mental health
problems,aggression,school problems
4)Abuse and Neglect
5)Failure of Breast Feeding
6)Brain structure and stress
response:increased cortisol levels in
preschoolers associated with anxiety and
depression
Parent Infant Interaction at
3months
Screening instruments
• Edinburgh Postnatal Depression Scale
Patient Health Questionnaire 9
Patient Health Questionnaire 2
PHQ
• PHQ 2: 2 items ,takes 1 minute ,self
administered high sens,low spec in which
a pos PHQ2 is followed up with a higher
specificity PHQ9
PHQ 9: 9 items ,self administered
,sens75% spec 90%,free in public
domain,10 min,staff scored,cutoff typically
10
Pediatric Screening
• Feasible to screen, to support parents and
facilitate access to resources to optimize child
development (most pediatricians not
comfortable diagnosing and treating maternal
depression)
Barriers: time, training, reimbursement
,adequacy of referral services,legal and ethical
barriers-shred form or give to parent
BENEFITS OUTWEIGH RISKS
Billing codes:96110, 99420 Illinois, HCPCS
S3005
Treatment
• Reducing mother’s depressive symptoms alone
does not necessarily lead to improvements in
parenting and child development
Evidence suggests that
intensive interventions that focus specifically on
parent-child interactions have shown promising
results in recent studies;focussing on both
parents and young children together can
improve child outcomes
Treatment
• Parent Support groups
Referral to parents OB, PCP, mental
health resource, ER
Early intervention
DPH resource list
Online CBT
Models from Illinois, Virginia Bright Futures,
Pediatric implementation manual
www.cmwf.org,federal ,
Resource for parents
www.mchb.hrsa.gov/pregnancyandbeyond/depr
ession
Standard of Care Guidelines
1999 Surgeon General’s Report on Mental Health
AAP-Bright Futures Guidelines (ACCA)
USPSTF has endorsed both the Edinburgh
and the PHQ 2
28 states and AAP chapters,especially
Illinois ,
Commonwealth Fund and Natl Assn of State
Health Plans have web sites below with listings ;
www.abcdresources.org,www.nashp.org
Conclusion
• Postpartum depression is underidentified and
undertreated with short and long term morbidity
for parents and children
Pediatric postpartum depression screening
at well child visits during the first year of life is
valid ,effective and feasible and along with/or
part of other behavioral screens that Dr. Perrin
will now discuss should be part of the standard
of quality pediatric care.