Identifying Postpartum Depression
During the Well-Child Visit:
Resources for Screening, Referral, and
Treatment
Pam Shaw MD
Disclosure Information
I have no relevant financial relationships with
the manufacturer(s) of any commercial
product(s) and/or provider of commercial
services discussed in this CME activity.
I do not intend to discuss commercial
products or services and
unapproved/investigative uses of a
commercial product/device in my
presentation.
Learning Objectives
Understand the difference between normal
“baby blues,” peripartum depression, and
postpartum psychosis.
Gain knowledge about the impact of
postpartum depression on children and
families.
Identify risk and protective factors for
maternal depression.
Become familiar with maternal depression
screening tools.
Learn referral procedures.
Implement culturally-appropriate care for
patients with postpartum depression.
Presentation Overview
Definition
and Impact
Screening
Identifying
the Problem
Treatment
Culturallyaffective
Care
Implementing
a Solution
Burden
Approximately 500,000 of the 4 million American
women giving birth each year experience
postpartum depression (PPD)
PPD is under detected and under treated
Many barriers exist to detection and treatment
In the United States, depression is the
leading cause of non-obstetric
hospitalizations among women aged 18-44.
In the year 2000, 205,000 women aged 18-44
were discharged with a diagnosis of
depression.
Maternal Mental Health
Maternal
Mental Health
“Baby Blues”
Postpartum
Depression
Postpartum
Psychosis
Perinatal Depression:
Prevalence
Pregnancy
Postpartum
Kumar & Robeson 1984
13.4%
14.9%
Watson & Elliott 1984
9.4%
12.0%
O’Hara et al., 1984
9.0%
12.0%
Cooper et al. 1988
6.0%
8.7%
O’Hara et al., 1990
7.7%
10.4%
Evans et al., 2001
13.6%
9.2%
Depression May Begin During
Pregnancy
Symptoms (e.g., sleep problems, fatigue, and
appetite changes) similar to those of normal
pregnancy
Depression differs from “baby blues” or
postpartum sadness, a normal condition that
does not require treatment
Untreated gestational depression is
associated with:
• Difficulty in self-care during pregnancy
• Poor diet and inadequate weight during
pregnancy
• Missed prenatal visits
• Use of tobacco, alcohol, or illicit drugs
• Delivery of an underweight baby or
premature infant
Postpartum Blues
Most common, 50-80%
Relatively brief
Few hours to several
days
Onset usually in first week
to 10 days PP
Typically remit
spontaneously
May represent the initial
stages of PPD/PPP
The “Baby Blues”
Normal condition in postpartum mothers
Occurs in 50-80% of new mothers
Symptoms include feelings of loss, anxiety,
confusion, fear, or being overwhelmed
Symptoms peak ~5 days after birth and
resolve within a few weeks
Does not disrupt function or daily routines
Source: Miller LJ. JAMA 2002;287:762-765.
Postpartum Psychosis
Rare: 1/1000 postpartum
women
Hallucinations and/or Delusions
Risk Factors:
History Bipolar Affective
Disorder/Psychosis
Family history of
psychosis
Having first child
Aggressive intervention
absolutely necessary
Postpartum Psychosis
Relatively uncommon (1-3 out of 1000
women)
Onset as early as 1 day after delivery,
through baby’s first year
Onset may be abrupt
Characterized by hallucinations, paranoia,
possible suicidal/infanticidal thoughts
Requires immediate treatment and possible
hospitalization
Source: Miller LJ. JAMA 2002;287:762-765.
Postpartum Depression
Not as mild or
transient as the
blues
Not as severely
disorienting as
psychosis
Range of severity
Often undetected
Postpartum Depression
Same diagnostic criteria as for clinical depression
Affects 8-20% of childbearing women
May negatively impact:
• Mother’s ability to be responsive to child
• Child’s behavior
• Other family members
Risk may be identified in primary care practice
Occurs any time during first 12 months postpartum,
but most often begins in the first 4 weeks.
Symptoms persists in half of untreated mothers one
year postpartum.
Symptoms last from 2 weeks to more than a year.
Patients undergo mental health evaluation and
treatment by primary caregiver or by referral
Source: Miller LJ. JAMA 2002;287:762-765.
Symptoms of Postpartum Depression
Loss of interest in daily activities
Sleep problems (e.g., insomnia, over
sleeping)
Loss of pleasure in normally-enjoyable
activities
Excessive guilt or feelings of
worthlessness
Decreased energy
Poor concentration
Changes in appetite and weight
Thoughts of harming self or child
Source: Miller LJ. JAMA 2002;287:762-765.
Risk Factors for Postpartum
Depression
• Previous history/family
•
•
•
•
•
•
history of depression
Domestic violence
Lack of quality social
support
Environmental factors
(lack of food,
inadequate housing
and/or income)
Substance abuse
Stressful major life
events or traumatic
experiences
Immigrant status
Sources: Driscoll JW. J Perinatal Neonatal Nurs 2006;20:40-42; McCoy SJ, et.al. J Am
Osteopath Assoc 2006;106:193-198.
Effects of Perinatal Depression:
An Overview
Depression negatively effects:
Mother’s ability to mother
Mother—infant relationship
Emotional and cognitive development of
the child
Postpartum Depression:
Maternal Attitudes
–
Infants perceived to be more bothersome
–
Make harsh judgments of their infants
–
Feelings of guilt, resentment, and
ambivalence toward child
–
Loss of affection toward child
Behaviors of Depressed Mothers*
Less responsive to baby’s cues1,2
Less aware of baby’s needs1,2
Reduced ability to communicate range of
emotions1,2
Reduced care and stimulation of baby1,2
Less empathy1,2
Less interactive behavior3
Less likely to obtain preventive healthcare
for baby4
*In some instances, maternal depression has no effect on parenting.
Sources: 1Bonari L, et.al. Can J Psychiatry 2004;49:726-735; 2Mian AI. J Psychiatry Pract 2004;11:389-396;
3Paulson JF, et.al. Pediatrics 2006;118:659-668; 4Minkovitz CS, et.al. Pediatrics 2005;115:306-314.
Postpartum Depression:
Maternal Interactions
Flat affect, low activity level, and lack of
contingent responding
OR
Alternating disengagement and intrusiveness
Effects of Maternal Depression
Infants- lowered Brazelton scores,
frequent looking away, fussiness
Toddlers- poorer cognitive development,
insecure attachment
Children- cognitive development of low
ses boys
Adolescents-higher cortisol levels
Face-to-Face/Still-Face Paradigm
Studies parent-child relationship
Focuses on infant’s reactions during
structured interactions
Mothers asked to
• Engage spontaneously
• Turn away, return with still-face
• Turn away again, reunite/re-engage
spontaneously with infant
http://www.youtube.com/watch?v=apzXGEbZht0
Protective Factors Against Poor
Outcomes
Child’s disposition
Familial
cohesiveness and
warmth
Support from other
family members
Source: Burke L. Int Rev Psychiatry 2003;15:243-255.
Overview of Maternal Mental Health
Maternal
Mental Health
“Baby Blues”
•Prevalence:50-80%
•Usually resolves
without treatment
Postpartum
Depression
•Prevalence: 8-20%
•Clinically significant
•Requires treatment
Postpartum
Psychosis
•Prevalence: < 1% (0.1-0.2 %)
•Serious illness
•Treat immediately
•May require hospitalization
What Can Be Done?
ROUTINE SCREENING
REFERRAL TO TREATMENT
Why Screen for Perinatal
Depression?
Which Mother is
Depressed?
You can’t tell by
looking.
Perinatal
Foundation
Madison, WI
June 2003
Why Screen for Perinatal
Depression?
Screening is associated with increased
detection
Georgiopoulos et al., 1999, 2001
EPDS screening resulted in
increased chart-based diagnosis of
PPD from 3.7% to 10.7% after one
year of universal screening –
Rochester, MN
Barriers to Detection
Women will present
themselves as well
as they are ashamed
and embarrassed to
admit that they are
not feeling happy
Media images
contribute to this
phenomena
Reality for New Mothers
Tired
Alone at home
Lots of care for the baby
Often there are other young children who
need care
No time for self (can’t even fit in a shower)
Complete loss of control over time
Barriers to Detection (cont)
Lack of knowledge about range of
postpartum disorders
They don’t want to be identified with Andrea
Yeats
They may also genuinely feel better when
you see them (they got dressed, out of
house, lots of attention, not isolated)
Barriers that Limit Diagnosis and Management of
Maternal Depression
Survey of Primary Care Pediatricians (n=508)
Insufficient time:
Education/counseling
73%
Insufficient time:
Adequate history
70%
Insufficient knowledge:
Diagnosis
64%
Insufficient knowledge:
Treatment
0
48%
10
20
30
40
50
60
Response (%)
Source: Olson AL, et.al. Pediatrics 2002;110:1169-1176.
70
80
90
100
“I Was Depressed But Didn’t Know
It.”
Commonalities in the Experience of Nondepressed and Depressed Pregnant and
Postpartum Women
Changes in appetite
Changes in weight
Sleep disruption/insomnia
Fatigue/low energy
Changes in libido
My Patient is Poor, Not Depressed!
Myth
Not all women with limited economic
resources are depressed
Depression can make it difficult for all
women to cope
Importance of Screening:
Why Screen Mom during Well-Child Visits?
• Well-child care
providers see
mothers with
regularity in child’s
first year of life
• Mother’s mental
health affects wellbeing of baby and
family
• Child’s development
influenced by early
relationship history
What is Required for Effective
Screening?
A screening tool
A schedule for screening
A plan for implementation
1.
Who does the screening?
2.
Where is it done?
3.
How is the primary care health provider
informed of the results if not done in their
office?
What is Required for Effective
Screening?
What to do with a positive screen?
1.
Implement or refer for diagnostic
assessment
Arrange for treatment
1.
2.
Antidepressant medication
Psychotherapy (individual or group)
Arrange for follow-up
Screening
Who?
Primary health care professionals
Physicians/Nurses: Obstetrics,
Family Practice, Pediatrics
Case Managers/Social Workers
Maternal Depression Screening Tools
Edinburgh Postpartum Depression Scale
(EPDS)
Primary Care Evaluation of Mental Health
Disorders Patient Health Questionnaire
(PHQ-9)
Beck Depression Inventory (BDI)
Note: All of the above tools are available in
Spanish-language format and are eligible
for reimbursement.
What is the Edinburgh Postnatal
Depression Scale (EPDS)?
John Cox, Jenifer
Holden & Ruth
Sagovsky
10 item depression
screening tool
(reliable and valid)
Simple to
complete
Acceptable to
mothers and
health workers
The Edinburgh Postnatal Depression
Scale (EPDS)
10-item self-report
Source: Cox JL, et.al. Br J Psych 1987;150:782-786.
questionnaire
Identifies depressive
symptoms in
pregnant women/new
mothers
Does not diagnose
postnatal depression
Validated crossculturally
Available in 21
languages
EPDS Scoring
Each question ranked on four-point scale
(e.g., 0-3)
Maximum score = 30
Consider action/referral when score > 10
(indicates possible depression,)
A score > 13 indicates likely depression
Review answers to individual questions
Discuss items with high scores
The Edinburgh Postnatal Depression
Scale (EPDS)
Advantages:
• Easy to administer (usually requires 5 minutes for
patient to complete)
• Easy to score (“positive” cut-off 10 - 13 out of 30)
• Designed & well-validated for peripartum use
• Cross-cultural; available in 21 languages
Disadvantages:
• Not linked with formal (DSM-IV) diagnostic criteria
• Cannot be used for assessment or treatment
tracking
Bottom Line: Good choice for clinics that only serve
peripartum patients and those that follow “screen &
refer” model
Using EPDS to Determine Risk of
Harm
Any patient who
scores >1 on question
#10 (“The thought of
harming myself has
occurred to me”)
should be asked
about the following:
• Severity of depression
• Plans for self-harm
• Availability of support
systems
If EPDS Suggests Depression
Screen for suicide ideation, planning, or
previous attempts
Assess risk for ideation-positive patients
through office interview before referral
Determine immediate risk by asking mother
what will become of her fetus, child,
children if she kills herself
Ask about domestic violence or threat of
same
Discussing EPDS Results
When discussing EPDS results:
Reinforce how mother’s health impacts her
child
Recognize sensitivity of issue
Consider cultural attitudes toward
depression
Provide a supportive environment
Reinforce without increasing/promoting
feelings of guilt
When to Screen Using the EPDS
Recommendations
Screen all mothers
Develop practice guidelines for frequency
•
•
•
•
*Note:
At least once during pregnancy
At least twice postpartum
Initial screen when child is 4-6 weeks old
Subsequent screen(s) at 2-, 4-, or 6-month visits
The American Academy of Pediatrics have issued specific maternal
depression screening guidelines in 2010.
Primary Care Evaluation of Mental Health
Disorders Patient Health Questionnaire
(PHQ-9)
9-item self-report questionnaire
Screening tool for clinical depression (peripartum and
otherwise)
Advantages:
• Easy to score
• Items & scores linked to DSM-IV depression criteria
• Can use to assess & track treatment response
• Same tool can be used for all patients in clinic
Disadvantages:
• Not designed for PPD; less well-validated
peripartum
Bottom Line: Good choice for primary care clinics and
clinics that wish to treat onsite
Source: Kroenke K, et.al J Gen Intern Med 2001;16:606–13.
PHQ-9 Scoring
Total PHQ-9 Score
1-4
Assessment of Depression
Level
Minimal
5-9
Mild
10-14
Moderate
15-19
Moderately severe
20-27
Severe
Source: Kroenke K, et.al J Gen Intern Med 2001;16:606–13.
Coding and Billing for Screening
Procedures
99240Administration and
interpretation of
health risk
assessment
instrument
99216Developmental
screening; limited
with interpretation
and report
The Role of the Provider
Increase awareness/recognition
Assess and determine referral needs
Discuss problem w/mother’s PCP (where
appropriate)
Mention treatment options (e.g.,
counseling, support groups, parenting
coaching, pharmacotherapy)
Discuss options for further
help/assessment:
Mental health provider
Community resources
Models for Treating Postpartum
Depression
Screen and Refer
• Screen using EPDS
• Refer to mental health services for assessment &
treatment
Screen and Treat
• Screen & assess using PHQ-9
• Identify onsite treatment candidates (those with
mild to moderate depression, not bipolar or
suicidal)
• Treat with medication; track with PHQ-9
• If response is inadequate, refer for mental health
care
Who ya gonna call?
Most doctors other than those in urban
settings don’t have ready referrals
Kansas Chapter of AAP recognizes this
problem
Developed a resource for clinicians:
KidLink which is an online resource to find
out who is available in their area
http://kansaskidlink.org/
Care Algorithm for “Screen and Treat” Model:
Screening Steps
Screening
PHQ<5
MDQ negative
PHQ 5-19
MDQ negative
No Intervention
Assessment
PHQ>19
and/or MDQ positive
Mental Health Referral
MD not confirmed and/or
medication not indicated
MD confirmed;
medication indicated
No intervention, case
management or mental health
referral per clinical judgment
Medication explained
and offered
Legend:
MD=Maternal depression
MDQ=mood disorder questionnaire
Source: Women’s Mental Health Program, University of Illinois at Chicago.
Endorses suicidal
thoughts
Urgent Intervention
Team evaluation &
disposition
Care Algorithm for “Screen and Treat” Model:
Treatment Steps
Medication explained
and offered
Patient accepts
Patient declines, but accepts
mental health referral
4-week PHQ
PHQ>5 and <5 points
lower than pre-treatment
PHQ<5 or at least 5 points
lower than pre-treatment
Mental Health Referral
8-week PHQ
PHQ>5 and 50% lower
than pre-treatment
PHQ<5 or at least 50%
lower than pre-treatment
Mental Health Referral
Maintenance treatment
Source: Women’s Mental Health Program, University of Illinois at Chicago.
Patient declines any
intervention
Antidepressant Use During Pregnancy or if
Breastfeeding:
Sertraline and fluoxetine believed to be
.
safest
Fluoxetine top choice for women not
planning to breastfeed
Sertraline preferred for breastfeeding
women
Fluoxetine may be considered for use
during pregnancy
Fluoxetine most well-studied concerning
effects of use during pregnancy
Antidepressant Use for Postpartum Depressed
Women who are not Breastfeeding
Surprisingly few studies directly addressing
medication efficacy for postpartum
depression
Clinicians lean toward serotonergic drugs
(SSRI's) because of the link between
serotonin and estrogen, and the possibility
that hormone/neurotransmitter flux may be a
contributory factor in postpartum depression
Consider starting with an SSRI's,
You could also use the antidepressant that
has worked best for depression in the
mother prior to her pregnancy
Considerations for Antidepressant Use During
Pregnancy
Consider combining with behavioral therapy
(counseling, support groups)
Evaluate each patient individually using
risk/benefit analysis
Consider risk of depression relapse if patient
who is being treated for depression wishes to
discontinue medication during pregnancy
• Risk of relapse among pregnant women who
discontinue medication may be five times
greater than among women who continue
use of antidepressants1
Source: 1Cohen LS, et.al. JAMA 2006;295:499-507.
Support Networks
Resource
Contact Information
Depression After Delivery
www.depressionafterdelivery.com
National Alliance for the Mentally Ill
www.nami.org; 800-346-4572
Postpartum Stress Center
www.postpartumstress.com
Postpartum Support International
www.postpartum.net
Postpartum Education for Parents
http://www.sbpep.org
The National Women’s Health
Information Center
http://www.4women.govpregnancy-after the baby is
born-PPD
http://www.kansasppd.org/
Why is Cultural Effectiveness Important?
People of color (Latinos, African-Americans,
Asian/Pacific Islanders, and American
Indian/Alaskan Natives) make up nearly onethird of the US population
19.4% of the US population speaks a
language other than English at home
12.4% of the US population is foreign-born
Governing bodies of medical schools and
residency programs require that cultural
competence be included in medical school
and residency curricula
It is good medicine
Source: US Census, 2000. http://www.census.gov/main/www/cen2000.html.
A Culturally Effective Office: the
Environment
Establish appropriate physical environment
• Language- and topic-appropriate
magazines for adults
• Books and toys appropriate to children
• Staff to match patient population served
• Bilingual/ language-appropriate wall
posters and signs
Provide interpretation services
• The US Office of Civil Rights requires the
healthcare provider’s office to provide a
trained medical interpreter
Train staff appropriately
• Overcome cultural assumptions/ bias
Recognizing Culturally-Relevant Signals
Case Study: Gloria
Presentation:
22 year-old Latino woman brings baby for well
child-visit
She is accompanied by her husband
When healthcare provider inquires about child:
• Gloria’s husband answers cheerfully and
enthusiastically, assuring the provider that
all is well with mother and child
• Gloria sits quietly in background
How should the care provider proceed?
Considerations for Latin-American
Patients
Recognize the central role of male family members
(especially among individuals who have recently come to
the US)
• Men may make health care decisions
• Father may be the family interpreter (making it
difficult/impossible for mother to discuss issues of
depression or domestic violence)
• Women may depend upon their husbands to drive
them to clinic
Understand cultural views of illness
• May be seen as imbalance between external and
internal sources (e.g., hot and cold, body and soul)
• Some diseases are folk-defined [e.g., empacho
(stomach ailment)]; others are defined by Western
medical criteria (e.g., measles, asthma)
Recognize role of spiritual belief in treatment
• Patients may believe that God determines outcome
• Provider must help patient take an active role in
recovery
Source: University of Washington Medical Center. “Communicating with Your Latino Patient.” Culture Clues.
http://depts.washington.edu/pfes/pdf/LatinoCultureClue4_05.pdf.
Considerations for Latin-American
Patients
Refer to the mother as Señora rather than Señorita, even if she is
a young and possibly unmarried mom
• Señora implies the dignity of a mature woman
To ensure understanding, ask open-ended questions and
encourage the patient to ask questions
• Nodding of head may signify that patient is listening but not that
patient is understanding
Recognize the central role of the family (la familia) as a source of
emotional support during treatment and recovery processes
• When possible, engage family in discussions that involve decisions
about care
Understand cultural views of depression
• May not be seen as an illness
• May be viewed as a weakness and/or an embarrassment to family
• Provider should consider involving/offering services of a clergy
member
Source: University of Washington Medical Center. “Communicating with Your Latino Patient.” Culture Clues.
http://depts.washington.edu/pfes/pdf/LatinoCultureClue4_05.pdf.
Latin-American Patients: Finding the
Words…
Examples of Culturally-Sensitive Questions for LatinAmerican Women with Maternal Depression
Do you have a name to describe the way you feel?
What do you think has caused you to feel this way?
What are the chief problems caused by the way you
feel?
What do you fear most about feeling this way?
What kind of treatment would you like to have?
What are the most important results that you hope to
receive from this treatment?
Why do you think that your feelings began when they
did?
Do you feel safe at home? (to assess for domestic
violence)
Source: University of Washington Medical Center. “Communicating with Your Latino Patient.” Culture Clues.
http://depts.washington.edu/pfes/pdf/LatinoCultureClue4_05.pdf; Juckett GJ. Am Fam Physician 2005;72:2267-2274.
Recognizing Culturally-Relevant Signals
Case Study: Gloria
Follow-up
Action Taken:
Screen Gloria for depression using EPDS (if “screen and refer”) or
PHQ-9 (if “screen and treat”)
Her PHQ-9 score is 17, suggesting depression
Assess for depression; if confirmed, explain and offer a
combination of medication and counseling
Key Messages of this Case:
Routine depression screening is important for all mothers
Attitudes toward mental illness are influenced by cultural beliefs
and norms (patients may not be forthcoming about their concerns
or may deny existence of mental illness)
A culturally diverse practice must recognize roles of other family
members.
Considerations for African-American
Patients
Build trust with patient through communication
and careful listening
Respect the patient’s understanding of his/her
illness
Use open-ended questions to ensure that you and
patient have common meaning (e.g., anemia and
“low blood”)
Avoid “labeling” (e.g., maternal depression,
developmentally-slow child)
• Concerns over loss of public financial support
or communal stigmatization
Recognize medical beliefs of patients/parents,
e.g. folk remedies, home remedies, herbal
remedies
• Seek ways to combine folk remedies with
Western medicine
• Incorporate beneficial or neutral remedies into
plan of care
Source: University of Washington Medical Center. “Communicating with Your African-American Patient.” Culture Clues.
http://depts.washington.edu/pfes/pdf/AfricanAmericanCultureClue4_05.pdf.
Considerations for African-American
Patients
Recognize role of religious beliefs in patient’s
understanding of illness and treatment
• Overcome barriers of “God will heal me” by using an
appropriate explanation, e.g., “God would want you
to feel good so you can care for your baby.”
• Recommend support groups or services at patient’s
church
Understand importance of communal and kinship ties
• Ask about key individuals in community who may
assist in supporting key medical recommendations
Be aware of denial of “illness,” especially mental health
conditions
• Consider incorporating a family member in the
treatment
• Do not use term “maternal depression”
• Gradually introduce diagnosis; talk to patient about
symptoms and their treatment
Source: University of Washington Medical Center. “Communicating with Your African-American Patient.” Culture Clues.
http://depts.washington.edu/pfes/pdf/AfricanAmericanCultureClue4_05.pdf.
African-American Patients: Finding the
Words…
Examples of Culturally-Sensitive Questions for AfricanAmerican Women with Maternal Depression
Do you have a name to describe the way you feel?
What do you think has caused you to feel this way?
What are the chief problems caused by the way you
feel?
What do you fear most about feeling this way?
What kind of treatment would you like to have?
What are the most important results that you hope to
receive from this treatment?
Why do you think that your feelings began when they
did?
Do you feel safe at home? (to assess for domestic
violence)
Sources: University of Washington Medical Center. “Communicating with Your African-American Patient.” Culture Clues.
http://depts.washington.edu/pfes/pdf/AfricanAmericanCultureClue4_05.pdf; Juckett GJ. Am Fam Physician 2005;72:22672274.
Summary and Conclusions
Postpartum depression is a clinically
significant illness that may have long-lasting
effects on the well-being of the mother and
her family
Postpartum depression differs from “baby
blues,” a normative condition that resolves
within 2 weeks following birth
Postpartum depression is treatable and can
be easily screened during well-child visits
and routine checkups
Establishing a culturally-effective office will
help the provider to screen and assist
women whose cultural milieu may
discourage the admission of mental illness
References
1. Cox JL, Holden, JM, Sagovsky R. Edinburgh Postnatal Depression
2.
3.
4.
5.
6.
7.
Scale (EPDS). British Journal of Psychiatry. (1987). 150:782-786.
Epperson CN. Postpartum major depression: detection &
treatment. American Family Physician. (April 15, 1999). 59:8:22472254.
Mandl KD, Tronick EZ, Brennan TA, Alpert HR, Homer J. Infant
health care use and maternal depression. Archives of Pediatric
Adolescent Medicine. (1999). 153:(8):808-813.
Stowe ZN, Nemeroff CB. Women at risk for postpartum-onset major
depression. American Journal of Obstetrics & Gynecology. (August
1995). 173:2:639-645.
Whiffen VE, Gotlib IH. Infants of postpartum depressed mothers:
temperament and cognitive status. Journal of Abnormal
Psychology. (1989). 98:3:274-279.
Miller, L, Postpartum Depression. JAMA. 2002;287:762-765
Driscoll, JW. (2006). Postpartum depression: the state of the
science. Journal of Perinatal and Neonatal Nursing, 20, 40–42.
References (cont.)
1. McCoy SJ, et.al. Risk Factors for Postpartum Depression: A
2.
3.
4.
5.
6.
Retrospective Investigation at 4-Weeks Postnatal and a Review of the
Literature, J Am Osteopath Assoc 2006;106:193-198.
Bonari L, et.al. Use of antidepressants by pregnant women: evaluation
of perception of risk, efficacy of evidence based counseling and
determinants of decision making. Can J Psychiatry 2004;49:726-735.
Paulson JF, et.al. Individual and combined effects of postpartum
depression in mothers and fathers on parenting behavior. Pediatrics
2006;118:659-668.
Minkovitz CS, et.al. The Timing of Maternal Depressive Symptoms and
Mothers' Parenting Practices With Young Children: Implications for
Pediatric Practice; Pediatrics 2005;115:306-314.
Burke L. The impact of maternal depression on familial relationships
Int Rev Psychiatry 2003;15:243-255.
Olson AL, et.al. Primary Care Pediatricians’ Roles and Perceived
Responsibilities in the Identification and Management of Maternal
Depression, Pediatrics 2002;110:1169-1176
References
1.
2.
3.
4.
5.
Kroenke K, et.al, The PHQ-9: A New Depression Diagnostic and
Severity Measure, J Gen Intern Med 2001;16:606–13.
Mian AI. Depression in pregnancy and the postpartum period:
balancing adverse effects of untreated illness with treatment risks. J
Psychiatr Pract. 2004;11:389-396.
Wisner KL, Piontek CM. Postpartum Depression. N Engl J Med.
2002;347:194-199..
University of Washington Medical Center. Culture Clues.
“Communicating with Your African-American or Latino Patient.”
http://depts.washington.edu/pfes/pdf/AfricanAmericanCultureClue4_
05.pdf.
Cohen LS, Harlow BL, Nonacs R, et al. Relapse of major depression
during pregnancy in women who maintain or discontinue
antidepressant treatment. JAMA. 2006;295:499-507.
References
1. Sheeder J, Screening for Postpartum Depression at Well-Child Visits:
Is Once Enough During the First 6 Months of Life? Pediatrics Vol. 123
No. 6 June 1, 2009. pp. e982 -e988
2. Earls, M et al, Incorporating Recognition and Management of Perinatal
and Postpartum Depression Into Pediatric Practice, Pediatrics Vol. 126
No. 5 November 1, 2010 pp. 1032 -1039
3. US Preventive Services Task Force. Screening for depression:
recommendations and rationale. Ann Intern Med. 2002;136(10):760–
764
4. Siegel BS, Foy JM; American Academy of Pediatrics, Committee on
the Psychosocial Aspects of Child and Family Health, Task Force on
Mental Health. The future of pediatrics: mental health competencies
for pediatric primary care. Pediatrics. 2009;124(1):410–421