TECHNICAL REPORT
Incorporating Recognition Jason Rafferty, MD, MPH, EdM, FAAP,a, b,c Gerri Mattson, MD, MSPH, FAAP,d,e Marian F. Earls, MD, MTS, FAAP,f,g andMichael W. Yogman, Management MD, FAAP,h COMMITTEE ON PSYCHOSOCIAL of ASPECTSPerinatal OF CHILD AND FAMILY HEALTH Depression Into Pediatric Practice Perinatal depression is the most common obstetric complication in the abstract United States, with prevalence rates of 15% to 20% among new mothers. Untreated, it can adversly affect the well-being of children and families throught increasing the risk for costly complications during birth and lead to deterioration of core supports, including partner relationships and social networks. Perinatal depression contributes to long-lasting, and even aDepartment of Pediatrics, Thundermist Health Centers, Providence, permanent, consequences for the physical and mental health of parents and Rhode Island; bDepartment of Child Psychiatry, Emma Pendeltom children, including poor family functioning, increased risk of child abuse Bradley Hospital, East Providence, Rhode Island; cDepartment of Psychiatry and Human Behavior, Warren Alpert Medical School of and neglect, delayed infant development, perinatal obstetric complications, Brown University, Providence, Rhode Island; dWake County Health and Human Services, Raleigh, North Carolina; eDepartment of Maternal and challenges with breastfeeding, and costly increases in health care use. Child Health, Gillings School of Global Public Health, and fDepartment Perinatal depression can interfere with early parent-infant interaction and of Pediatrics, School of Medicine, University of North Carolina, Chapel Hill, North Carolina; gCommunity Care of North Carolina, Raleigh, North attachment, leading to potentially long-term disturbances in the child’s Carolina; and hDepartment of Pediatrics, Harvard Medical School, physical, emotional, cognitive, and social development. Fortunately, perinatal Boston, Massachusetts depression is identifiable and treatable. The US Preventive Services Task Drs Rafferty, Mattson, Earls, and Yogman conceptualized the statement and drafted, reviewed, and revised the initial manuscript; and all Force, Centers for Medicare and Medicaid Services, and many professional authors approved the final manuscript as submitted and agree to be organizations recommend routine universal screening for perinatal accountable for all aspects of the work. depression in women to facilitate early evidence-based treatment and This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have referrals, if necessary. Despite significant gains in screening rates from filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process 2004 to 2013, a minority of pediatricians routinely screen for postpartum approved by the Board of Directors. The American Academy of depression, and many mothers are still not identified or treated. Pediatric Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. primary care clinicians, with a core mission of promoting child and family Technical reports from the American Academy of Pediatrics benefit health, are in an ideal position to implement routine postpartum depression from expertise and resources of liaisons and internal (AAP) and screens at several well-child visits throughout infancy and to provide mental external reviewers. However, technical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the health support through referrals and/or the interdisciplinary services of a organizations or government agencies that they represent. pediatric patient-centered medical home model. The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
To cite: Rafferty J, Mattson G, Earls MF, et al. Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice. Pediatrics. 2019;143(1):e20183260
Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 1, January 2019:e20183260 FROM THE AMERICAN ACADEMY OF PEDIATRICS BACKGROUND 9 organizations, including the AAP. unique role pediatric providers Depression is experienced by Inadequate perinatal depression have in screening for mental health screening rates and limited access concerns in children and families, women most often 1during their childbearing years. Over the last to evidence-based treatment are including parental depressive attributable to the stigma associated symptoms, and working with families several decades, research has 16 with mental health, patient to improve mental health outcomes. revealed that untreated maternal apprehension about openly admitting The National Academy of Sciences depression during pregnancy or the to emotional struggles, limits in published its report on parental first year after childbirth can have provider education and skill sets, and depression in 2009, emphasizing significant adverse effects on the systemic limitations around delivery the role of the AAP Medical Home well-being of women, infants, and 7,10, 11 of and payment for screening. Initiative in reducing perinatal their families. Maternal depression 17,18 depression occurrence. It was experienced around the time of There has been increased attention followed by a clinical report from the childbirth can increase the risk for given to perinatal depression, ’ AAP that was focused on recognition costly complications during birth including the release of the US and management of perinatal and and can contribute to long-lasting Surgeon General s Report on Mental 1 ’ postpartum depression in 2010 and even permanent effects on the Health in 2000 in which postpartum 2 and the US Healthy People 2020 child s development. Only in the depression and psychosis was 12 ’ objectives to reduce the proportion last decade has universal screening mentioned, the 2000 report of the ’ of mothers experiencing perinatal for maternal depressive symptoms US Surgeon General s Conference 13 depression (maternal, infant, and during the perinatal period been on Children s Mental Health, New England Journal of Medicine child health objective 34) and to and a recent review article in the recommended by professional health 14 improve overall maternal and child . 19 care associations, including the perinatal health. It is within this American College of Obstetricians Congress designated increased 3 context that the National Institute for funding to address screening and and Gynecologists (ACOG), American Health Care Management released a treatment of perinatal depression The consequences of allowing maternal Academy4 of Family Physicians ’ report concluding: through the Health Resources and depression to go underdiagnosed and (AAFP), and American1 Academy Services Administration s Maternal untreated are detrimental to the health of of Pediatrics (AAP). However, 2 all mothers and their children. Knowing screening remains far from universal. and Child Health Bureau in 2004. a woman’s risk of developing depression In 1 study, nearly 6 out of 10 women In 2018, Congress designated $5 peaks during her childbearing years, it screening positive on the Edinburgh million for programs used to address is vital for all health care providers to maternal perinatal depression in recognize the symptoms of depression and Postnatal Depression Scale (EPDS) – the 2018 Omnibus Funding Bill understand the risk factors associated with had not spoken to a health care maternal depression to identify and treat (public law 114 255). This funding professional5 about their symptoms depression as soon as possible or concerns. It is estimated that will be used to support state grants 2 50% of women who are depressed primarily aimed at establishing, . improving, and maintaining during and after pregnancy have In 2016, the US Preventive Services programs to train professionals their depression go undiagnosed and Task Force (USPSTF) reviewed to screen and treat for maternal untreated, which makes it the most available research and asserted that ’ “ ” underdiagnosed and undertreated perinatal depression. 6 Bright Futures: Guidelines for Health direct and indirect evidence shows a obstetric complication. However, TheSupervision most recent of Infants, update Children, of the AAP and s moderate net benefit to screening most mothers (80%) report being Adolescents, Fourth Edition for perinatal depression because it comfortable with the idea7 of being contributes to a significant reduction screened for depression. Among includes in overall prevalence of depression20,21 pediatricians, 90% in 1 study a recommendation for pediatric and associated morbidities. In reported assuming responsibility for providers to screen for postpartum addition, in 2016, the Centers for identifying maternal depression, but depression at 4 well-child visits in Medicare and Medicaid Services most (71%) rarely or never assessed the first 6 months of life and refer (CMS) sent a directive to all state for it, and almost all (93%) reported to appropriate evaluation and Medicaid directors clarifying that having never or rarely provided treatment services for the mother maternal postpartum depression 8 15 “ mental health referrals. From and infant when indicated. In 2009, screening can be billed under well- “ ” 2004 to 2013, screening rates by the AAP released a policy statement, infant visits22 as a screening of the pediatricians for maternal depression The Future of Pediatrics: Mental caregiver. Both the USPSTF and ” increased from 13% to only 44% Health Competencies for Pediatric CMS encourage universal maternal in periodic surveys by a number of Primary Care, emphasizing the postpartum depression screening Downloaded from www.aappublications.org/news by guest on October 2, 2021 2 FROM THE AMERICAN ACADEMY OF PEDIATRICS by pediatric providers, with update to the 2010 clinical report1 biological factors influencing mood appropriate payment by insurers. from the AAP on this subject. may be less relevant at the later “ The USPSTF specifically states that DEFINITIONS stage, there are significant ongoing screening should be implemented psychosocial stressors that increase with adequate systems in place risk, especially with the added to ensure accurate diagnosis, responsibilities of caring for an ” Perinatal depression is characterized 3 effective treatment,21 and appropriate by an episode of major depression, infant. follow up. This requires close including 2 weeks of depressed mood Perinatal depression is 1 of a few partnerships between pediatricians, and neurovegetative symptoms recognized mood disorders that may family physicians, adult primary “ ” (alterations in sleep,Diagnostic appetite, occur around pregnancy and delivery care physicians, and obstetricians, andconcentration, Statistical Manualenergy level,of Mental etc), (Table 1). Postpartum blues is a mental health providers, and other Disorders,as described Fifth in Editionthe (DSM-5) transient state of increased emotional community agencies. reactivity occurring in approximately , ’ 50% to 80% of mothers after labor Recent research also has begun to occurring during pregnancy or after ’ and delivery. They may cry more examine the influence of a father s delivery. Although the diagnostic easily, be irritable, or demonstrate criteria for major depressive affective state on a child s early23,24 emotional lability. Peak onset is 3 development and well-being. disorder (MDD) did notDSM-5 undergo to 5 days after delivery, often when significant change between the Available evidence indicates that “ ” women begin lactating, and duration fathers independently experience fourth edition and the , the is days to weeks. Psychiatric history, higher rates of depression after the specifier with perinatal onset environmental stress, cultural birth of a child, which adversely replaced the traditional distinction context, and breastfeeding2,31 do notDSM-5 between antenatal and postpartum influences parenting25 and positive 29 seem to be related. Mothers with interactions. Paternal depression onset. The reason for this change postpartum blues do not meet may present differently with is that 50% of MDD identified criteria for a mood disorder, and substance use (alcohol and drug- during the postpartum period 30 treatment is generally supportive, related comorbidity), domestic actually begins before delivery. because symptoms generally lessen violence, and compulsive behavior, With this change, there is emphasis and“ resolve with time. ” which impairs parenting and can on the utility of early screening, 26,27 Postpartum psychosis is a rare undermine breastfeeding. There detection, and management event with an estimated incidence are virtually no empirical studies throughout pregnancy, not just of 2 in every 1000 deliveries. Often, on the rates or effects of depression after delivery. In fact, in 2015, the the onset is within the first 1 to 4 among same-sex partners or ACOG released a committee opinion weeks of delivery, with agitation, nonbiological parents. recommending mothers be screened irritability, mood lability, delusions, for depression at least3 once during the perinatal period expanding and disorganized behavior. Often, it This technical report aims the window for recommended is conceptualized as on a spectrum to review the definitions of screening into the antenatal period. with perinatal depression, but the perinatal depression, along with Despite changes in nomenclature preponderance of data suggests that its epidemiology, to discuss the and disease conceptualization, postpartumDSM-5 psychosis is an overt33 serious consequences for child much of the literature and current presentation of bipolar disorder. development and to highlight guidelines continue to reference only In the , such a patient may “ ” efforts across the country that depression after delivery using the meet criteria for major depression have demonstrated effectiveness or bipolar disorder (type I or II) term, postpartum depression. “ in increasing early screening and with psychotic features or a brief ” treatment. The technical report ThereDSM-5 is controversy around the time psychotic episode. Again, the with reviews the evidence and rationale course of perinatal depression, with peripartum onset specifier is underlying recommendations in an 28 the referencing symptom added if onset30 is within 4 weeks accompanying policy statement onset occurring any time during of delivery. Risk factors include concerning the role of the pediatric pregnancy or within 4 weeks of personal and family history of bipolar provider as a clinician and advocate delivery. However, many professional depression and schizoaffective in ensuring timely identification of organizations, including the ACOG, disorder. Hormonal shifts, sleep perinatal depression and referral to expand the criteria to include onset deprivation, environmental stress, evidence-based treatment programs. of symptoms up to 12 months after and stopping mood-stabilizing With this report, we provide an delivery. Although most of the medications are believed to be Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 1, January 2019 3 TABLE 1 Characteristics of Postpartum Blues, Perinatal Depression, and Postpartum Psychosis Type Course Prevalence Symptoms Postpartum blues Onset in first few wk after labor, 50%–80% of mothers Crying, weeping peaks at 3–5 d postpartum (with Sadness lactation), and usually resolves Irritability in <2 wk. Exaggerated sense of empathy Anxiety Mood lability (“ups and downs”) Feeling overwhelmed Insomnia Fatigue and/or exhaustion Frustration Perinatal depression 15%–20% of mothers from Persistent sadness, emptiness, hopelessness, conception to 1 y postpartum frequent crying, irritability Loss of interest in caring for self and/or child, enjoyable activities, and/or poor bonding with infant (attachment) Changes in appetite or wt Prenatal depression Onset during pregnancy, peaks in Up to 13% of mothers (incidence: Insomnia or hypersomnia first trimester, then declines. 2%–7%) Fatigue and/or exhaustion, decreased motivation Symptoms last at least 2 wk. Poor concentration or indecisiveness; difficulty remembering Postpartum depression After delivery, rates increase Up to 10% mothers (incidence: Feelings of worthlessness, guilt, inadequacy and peak at 3 mo postpartum. about 7%). Up to 4% of fathers Suicidal thoughts Symptoms present any time in (incidence 4%–25%)32 Possibly anxiety, including bizarre thoughts, the first y after delivery and last obsessions, and/or fears at least 2 wk. Postpartum psychosis Onset 1–4 wk postpartum. 1–2 cases in every 1000 new Auditory hallucinations and delusions (including mothers commands and/or beliefs that need to harm the infant) Visual hallucinations Agitation, irritability, anger Insomnia Mood lability or highly elevated mood Disorganized thoughts and behaviors High levels of anxiety Paranoia; distrusting of others Confusion Thoughts of harming or killing self, others, or the infant Adapted from Santoro K, Peabody H. Identifying and Treating Maternal Depression: Strategies and Considerations for Health Plans. NIHCM Foundation Issue Brief. Washington DC: National Institutes of Health Care Management; 2010:3.
contributing factors. Postpartum Monitoring System (PRAMS) (most postpartum. The rate of newly psychosis is an emergency, because recent published data) and found diagnosed cases or incidence of MDD there is risk of infanticide and a prevalence of self-reported during pregnancy was 7.5% during up to a 70-fold33 increased risk of depressive symptoms ranging pregnancy and 6.5%35 in the first 3 suicide. from 7.7% in37 Illinois to 19.9% months postpartum. Authors of a EPIDEMIOLOGY in Arkansas. The Agency for more recent large epidemiological Healthcare Research and Quality study found comparable results, conducted a systematic review as with period prevalence rates of Various sources estimate up to part of its Evidence-Based Practice 12.4% during pregnancy and 15% to 20% of women experience Program in 2015, reviewing 30 9.6% in the postpartum period; perinatal depression in the United epidemiological studies of perinatal incidence rates were38 2.2% and States, with worldwide– prevalence depression (as confirmed by clinical 6.8%, respectively. Studies have almost double3,9, 34 in36 low-income assessment or structured interview). suggested that even higher rates of countries. The Centers for They estimated that at any given postpartum depression may be seen Disease Control and Prevention time, 12.7% of women meet criteria in low-income or ethnically diverse surveyed 29 reporting areas for an episode of MDD during populations, teenagers, individuals across the United States in the pregnancy, with an additional 7.1% with a previous history of perinatal 2009 Pregnancy Risk Assessment meeting criteria in the first 3 months depression, and those with a personal Downloaded from www.aappublications.org/news by guest on October 2, 2021 4 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 2 Risk Factors for Perinatal Depression Risk Factors Additional Risk Factors Specific for Depression After Delivery History of depression Depression before or during pregnancy History of anxiety Anxiety before or during pregnancy Preexisting stressor or relationship issues Experiencing stressful life events during pregnancy or the early postpartum period Lack of social support Traumatic birth experience Unintended, unwanted pregnancy Preterm birth and/or infant admission to neonatal intensive care Medicaid insurance or uninsured Breastfeeding problems Domestic and/or family violence Lower income or socioeconomic status Lower education Smoking and substance use Single status Young parents (<30 y of age) Having previous children As reviewed in Lancaster et al,49 Robertson et al,50 and Underwood et al.42
or family history of postpartum 7,36, 39 New fathers are 1.38 times more 5 possible co-occurring issues or depression or major depression. likely to be depressed43 than age- comorbidities: use of tobacco during matched males. In at least 2 the last 3 months of pregnancy, The prevalence of depression during prevalence studies, 4% of fathers physical abuse before or during ’ pregnancy is highest40 during the experienced clinical depression44, in45 pregnancy, partner-related stress, second 2 trimesters. Controlling the first year of the child s life. traumatic stress, and48 financial stress for antenatal medical complications In an 18-city study, 18% of fathers during pregnancy. In 14 states, and past maternal psychiatric of children enrolled in Early Head maternal depressive symptoms were history, including depression, in Start had symptoms of depression, significantly correlated with delivery late pregnancy has been shown to and fathers with depression had23 of an infant with low birth weight and be associated with obstetric and higher rates of substance use. experiencing emotional stress during pediatric complications, including In general, men are more likely to pregnancy. NICU admission was increased need for epidural avoid emotional expression, deny associated with maternal48 depressive analgesia, operative deliveries, vulnerability, and not seek help, symptoms in 9 states. preterm birth, and41 neonatal intensive which may help explain46,47 discrepancies care admissions. In the postpartum in prevalence rates. It is documented that maternal period, peak prevalence is at 3 RISK FACTORS AND COMORBIDITIES stress, whether attributable to months after delivery (12.9%) and ’ complications of the pregnancy or then remains steady through 7 35 the mother s psychosocial situation, months at 9.9% to 10.6%. A recent may contribute to and result from study in New Zealand revealed Multiple conditions are believed perinatal depression. Perinatal that even at 9 months postpartum, to increase the risk for perinatal depression is strongly associated more than 5% of women endorsed depression (Table 2), although 42 with previous miscarriage, past significant depressive symptoms. it is often difficult to clearly pregnancy complications, chronic These figures provide further distinguish confounding factors medical disease, and shorter empirical support for the expanded and comorbidities. It was identified 51 gestation and labor. Psychosocial definition of perinatal depression in PRAMS data from 2004 to 2005 risk factors for perinatal depression with a time course of up to 1 year that younger, non-Hispanic African include low socioeconomic status, postpartum and the expanded time American mothers were most likely being a single mother, being a frame of monitoring for symptoms. to report postpartum48 depression symptoms. The PRAMS data also teenager, having low self-esteem, The incidence of paternal postpartum revealed that women who had lower prenatal anxiety, substance use, depression ranges from 4% to32 educational attainment and who poverty, history of mood disorder, 25% in community samples, and received Medicaid benefits for their family history or past medical history maternal postpartum depression was deliveries were more likely to report of depression, having poor social identified as the strongest predictor, depressive symptoms. In all or nearly support, and49,50, experiencing52, 53 general with 24% to 50% incidence in all of the 17 states participating life stress. Having an infant families in which there was also 23 in PRAMS, depressive symptoms with a difficult temperament is also a maternal postpartum depression. were significantly associated with risk factor for perinatal depression, Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 1, January 2019 5 ’ but a mother s perception of her complications, which compound changes in the infants, such as inability to soothe her infant has a the risk for perinatal depression. increase in69 heart rate and decreased Anxiety symptoms in pregnancy are vagal tone. When the mother stronger association with postpartum ’ depression than the actual54 duration associated with preterm62 birth, low reentered and again responded of infant crying or fussing. birth weight infants, increased reciprocally, the infant s behavior rate of cesarean delivery, reduced and physiologic changes recover. Unwanted and unplanned duration of breastfeeding, and This paradigm has been repeated pregnancies and relationship increased maternal health care63 with fathers and their infants 70 stress, including domestic violence use within 2 weeks of delivery. demonstrating identical results, and lack of social support, also Maternal anxiety has also been and limited additional research have strong associations with 49,55 connected to altered infant64 further support the important71,72 role of perinatal depression. Perinatal immune system function, altered paternal attachment. This study depression may be comorbid with patterns of infant gastrointestinal65 ultimately reveals that the emotional marital discord, divorce, family microorganism growth, and life of an infant is heavily influenced violence (verbal and/or physical),56 some limited research suggests by social interactions, particularly and substance use and abuse. The that neural structures are modified with parents, and the loss of parental directionality of effect and potential that may predispose66 the child for engagement and reciprocity can reinforcement between these issues anxiety disorders. In terms of be emotionally, behaviorally, and and perinatal depression is complex fathers, a correlation has also been physiologically distressing, even if and warrants more study. documented between fathers who just temporarily. “ ” The etiology of perinatal depression have preterm infants and higher levels of self-reported depression and is likely multifactorial, but there is 67 Attachment describes the evidence for a significant genetic anxiety symptoms. emotional connection between a basis. Familial trends in MDD are well EFFECTS AND CONSEQUENCES child and parent that is characterized established: first-degree relatives of by a desire for closeness to maintain– Effect on the Parent-Child Dyadic someone with MDD have nearly 3 a sense of security, especially during73 75 Relationship times of stress and separation. times the risk of developing it than 57 those without such a family history. From a psychoanalytic perspective, Among women with a family history the primary dyadic relationship of postpartum depression, 42% In a classic experiment from the serves as a prototype74 for all future experienced depression after their 1970s, researchers manipulated social interactions. Furthermore, first delivery compared with only interactions between mothers and the model is transactional, so infants, illustrating that infants rejection from a parent may cause 15% of 58women with no such family history. not only attempt to spontaneously the child to interpret the parent initiate social exchanges but also as rejecting76 as well as the self as Depression and anxiety are common modulate affect and attention unlovable. From an organizational comorbidities in the general around the presence and absence perspective, children progress population, with almost 60% of of reciprocal response. In the through a hierarchy of relevant individuals with a diagnosis of experiment, mothers first engaged developmental tasks, each building MDD meeting criteria for an anxiety in face-to-face reciprocal interactions on each other. Early effects of being disorder at some59,60 point during (eg, when the child smiled, raised by a parent who is emotionally their lifetime. Depression and the mother smiled back, etc) in absent and depressed, if sustained, anxiety are also comorbidities a laboratory with their can carry forward and adversely77 in the perinatal period; in 1 2- to 6-month-old infants. Mothers influence future adaptation. review, anxiety had the strongest were then instructed to leave the Research suggests that parent- “ ” ’ correlation with antepartum room and reenter sitting opposite child relationships or attachment 49 “ ” depression. Biologically, studies the infant with a still face (ie, likely influences a child s ability to have revealed that women with an unresponsive poker face ). In integrate positive representations78 of perinatal depression have abnormal response, the infants reacted with parents and of the self. Therefore, stress hormone levels, particularly fussiness, averting their gazes, high-quality parent-child dyadic increased cortisol secretion, which slumping in their infant seats, and interaction facilitates a secure is believed to be an underlying61 then reattempting to elicit interaction attachment, which is 1 important factor in anxiety symptoms. with68 a smile before finally giving factor in promoting early life Maternal anxiety is independently up. In later replications, exposure resiliency, emotional regulation,79 and related to obstetric and pediatric to the still face produced physiologic cognitive development. Adaptations Downloaded from www.aappublications.org/news by guest on October 2, 2021 6 FROM THE AMERICAN ACADEMY OF PEDIATRICS to the still-face experiment described by others. They may be apathetic, to have social and emotional provide some support for this claim, avoidant, clingy, or indifferent, awareness of others in their “ because infants at 6 months of age and they tend not to exhibit any environment, and to adjust affect ” who were assessed as securely maternal preference or anxiety and attention in response to their “ attached with their parents around strangers. Long-term impact parent. It also revealed that the ” recovered faster with more positive of insecure attachment extends to absence of reciprocal interactions expression immediately80 after the preschool and older children with can have emotional consequences, still-face exposure. anxiety, behavior problems, poor including distress and withdrawal. peer relationships, school problems, This basic understanding of early Supportive behaviors by mothers 88 ’ and depression. Such behaviors emotional states combined with that have been identified as may even serve to worsen a parent s attachment research has given especially important for cognitive ’ sense of worthlessness, rejection, and rise to transactional or social and socioemotional development 89 ’ depression. relational models of development. include following the child s Effect on the Child These models suggest that a child s interests and attention, responding ’ ’ emotional regulation, as well contingently, and stimulating the as possibly the child s physical, child s engagement with his or her In the prenatal period, maternal cognitive, and social well-being, environment through verbal and stress and depression negatively depends heavily on close, intimate practical encouragement. Parents affect fetal growth and 90 parent-infant relationships that who are depressed speak less, are development. Stress hormones, begin early in life. Through mutually less responsive (eg, smiling), present such as cortisol, are chronically – reinforcing and reciprocal interaction with flat affect, and express more elevated in states of generalized 81 83 patterns, infants develop building negative emotions. Mothers anxiety and depression, and they blocks for social exchanges and and fathers who are depressed are readily pass through the placenta. future relationships, including the less likely to engage in enrichment Animal and human studies reveal that skill of turn taking, which is the activities with their child, including increased maternal cortisol levels 25 basis for the pragmatics of language reading, singing, and storytelling. have been associated with decreased development. The theory suggests Mothers with perinatal depression placental size, increased rates of fetal – that as the child grows, his or her also demonstrate less reciprocal growth restriction, and premature ’ 91 93 network of relationships becomes interaction; distorted perceptions delivery. Norepinephrine, complex, which may promote more of the infant s behavior, particularly another stress hormone, does advanced levels of interactions, rejection; less positive attribution, not cross the placenta, but it may – such as language and coordinated leading the child to irritability; less influence the placental environment 96 98 behaviors. It would follow sensitivity and attunement; apathy; through peripheral effects, including 84,85 that physical, social, and cognitive and lower rates of breastfeeding. increasing uterine arterial resistance development are likely inextricably and decreasing blood flow and Ultimately, insecure mother-child linked, and disruption of early oxygenation, resulting in fetal growth attachment is associated with social reciprocal relationships may have deprivation. Norepinephrine has also withdrawal from daily activities and long-term adverse effects on overall been associated with increased risk less interaction. As early as 2 months 94 development and health. of preeclampsia. Consequently, of age, infants look at mothers who in 1 study, it was found that are depressed less, and infants of This reasoning has been supported antenatal maternal depression led mothers with a history of poorly or by the body of research investigating to a 34% increase in the odds of untreated perinatal depression tend adverse childhood experiences a developmental delay using the to demonstrate poor behavioral (ACEs), such as abuse, neglect, and Denver II Developmental Screen in regulation, less explorative play, and family dysfunction. In a retrospective children at 18 months of age. This lower activity levels. The infants 1998 study of a large adult effect was statistically significant have poor orientation skills and population, it was found that ACEs and independent of any postnatal tracking, lower activity level, and 95 were common, which may point depression. irritable temperament. There is an to high levels99 of resiliency present increased risk of feeding and sleeping In the postpartum period, the still- in childhood. Those with high problems81,86, as87 well as failure to face experiment revealed that social levels of risk behaviors and disease thrive. Infants of mothers with development starts early. In the as adults (eg, obesity, smoking, untreated perinatal depression cry experiment, infants demonstrated depression, suicidality) reported a lot because of difficulty with both basic abilities to connect facial being exposed to multiple ACEs as self-comforting and being soothed expression to emotional states, children. Childhood exposure to Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 1, January 2019 7 household mental illness, such as depression is also strongly tied hormone levels in infants, suggesting perinatal depression, was 1 of the with other unfavorable states and that it is likely a contributing factor ’ more common ACEs reported, and events that may add to the adverse to toxic stress states. In 1 study, it was often associated with other effect on a child s overall health and children exposed to mothers with ACEs, such as exposure to parental •development,• including the following: postpartum depression had elevated substance use or domestic violence. •• child abuse and neglect; levels of salivary125 cortisol levels The conclusion has been that during infancy and at 3 years of failure to implement the injury- accumulation of ACEs throughout age compared 126with children in a childhood as well as their presence prevention components from control group. This effect was also during particularly sensitive periods, anticipatory guidance (eg, car revealed with adolescents at 13 years such as early childhood, may have safety seat114,115 and electrical plug of age after controlling for current •• long-lasting effects on development covers) ; maternal or adolescent depression, and overall health into adulthood failure to implement– preventive experience of undesirable life events and may even contribute to an health practices114, for116 the119 child (eg, by the adolescent, maternal partner intergenerational99,100 cycle of recurring •• Back to Sleep) ; and conflict, and127 duration of maternal ACEs. depression. Therefore, not only is difficulty managing chronic health the parent with depression impaired Since the original ACEs study conditions such as asthma or 117,120 in his or her ability to function as a was conducted in 1998, there disabilities in the young child. supportive buffer of adversity, but has been growing evidence, ’ Families with a parent with also, there may be a direct long- including prospective studies, depression have been reported term activation of the child s stress directly associating perinatal to overuse health care and responses. Persistent elevation of depression with increased risk ’ emergency facilities120 because of cortisol can disrupt the developing for problematic psychological– and somatic complaints and often brain s architecture in the areas of socioemotional development in 101 105 fall behind on well-child visits the amygdala, hippocampus, and children over time. The longer 121 ’ and immunizations. Perinatal prefrontal cortex, affecting learning, a mother continues to experience – ’ depression also reduces a mother s memory, and behavioral and depression, the more likely the 122 124 chances of continued breastfeeding emotional adaptation. child s developmental issues are – because of decreased satisfaction, to persist with less response to 106 108 more reported complications, and Animal studies with rats reveal intervention. In 1 study of 84 lower self-efficacy. compelling evidence for a causal children with internalizing symptoms relationship between maternal (anxiety, depression), a history The adverse effect of accumulating ’ behaviors and stress reactivity of maternal depression during ACEs on child development may be in offspring through individual the child s first 2 years of life was mediated through the development differences in neuronal gene the best predictor of elevation in of toxic stress, or the state of expression transmitted from mother baseline109 cortisol levels at 7 years of excessive, persistent, repetitive, to pup through parenting behaviors age. Prolonged cortisol elevation and/or uncontrollable adversity in the first week of life. There is in preschool children– predisposes without the buffering of a safe, stable, natural variation in maternal rat them to anxiety disorders110 112 and nurturing, and responsive parent licking and/or grooming and nursing social withdrawal. Children of to promote adaptive coping. Over behaviors, so litters were split mothers with perinatal depression time, toxic stress has consequences between mothers varying in levels have been documented to have on brain architecture and disrupts of such behaviors. Pups exposed to lower standardized scores of mental multiple organ systems through less maternal care not only went and motor development, poorer chronic activation of stress hormone on to provide less care to their own self-control, and social adjustment responses, cytokines, and immune future young but also demonstrated difficulties up to 5 years of age. modulators. The association between increased gene expression in brain Children of mothers with depression toxic stress states in early childhood regions regulating behavioral and128 also had lower IQ with more and impaired language, cognitive endocrine responses to stress. attentional problems and difficulty and socioemotional development,– The influence of paternal depression with mathematical88,112, reasoning113 up to and even lifelong disease122 has124 been 11 years of age. independently validated. on children and families27, has72 only recently been explored. In addition to primary associations There is growing evidence that A large study from the United with poor long-term outcomes perinatal depression in parents Kingdom revealed that paternal for the child, untreated perinatal contributes to elevated stress postpartum depression, when Downloaded from www.aappublications.org/news by guest on October 2, 2021 8 FROM THE AMERICAN ACADEMY OF PEDIATRICS Postpartum Depression maternal postpartum depression was Early identification and management controlled for, was associated with of depressive symptoms antenatally A variety of interventions have adverse emotional and behavioral are needed to optimize the revealed some success in preventing outcomes in children at 3 to 5 years postpartum environment and postpartum depression. Delivery of age, particularly conduct disorder prevent such symptoms from 44 50,131, 133 room companions who provide in sons. Fathers with depression persisting. Recommendations early support with child-mother negatively interact not only with by several professional organizations, interaction combined with home their partners but also with their such as the Centers for Disease 48 visitation programs with nursing child, including being less likely Control and Prevention, the National 25 134 interventions, including cognitive to play with the child outside. Center for Children in Poverty, the ’ 123 behavioral therapy (CBT), have been Furthermore, it is well documented Center on the Developing Child, the 4 3 shown to be successful, particularly that a father s affective state mirrors AAFP, and the ACOG have included for women at risk for depression, that of the mother, so there may screening women for depression – ’ minorities, and underserved be a compounded adverse effect routinely by antenatal providers, such 136 138 populations. In another study, on the child s social and emotional as obstetricians, family physicians, 23,71 midwives were trained to provide development. nurse midwives, behavioral health individualized emotional support to providers, and other primary care Fortunately, perinatal depression mothers throughout their pregnancy, clinicians. is identifiable and treatable. which led to improved continuity Early identification via screening Ideally, pediatric providers can of care between antenatal and increases access to timely care collaborate with obstetric antenatal postpartum providers and reductions and significantly reduces the care providers so that maternal risk in symptoms of postpartum139 potential negative consequences factors for perinatal depression are maternal depression. In addition, for the child and family. Even brief accurately communicated through prenatal childbirth classes or psychosocial interventions within 133 all transitions of care. weekly parenting classes offered primary care settings have shown 129 Establishing this line of postpartum are potentially effective to be efficacious. Recent studies communication can be facilitated educational environments in which have revealed that supports to through a prenatal visit with the mothers and fathers can be engaged increase maternal engagement 135 pediatric provider. A prenatal with messages around postpartum and responsiveness can reverse visit with the pediatric provider parental depression139 recognition and gene expression patterns related Bright Futures: Guidelines for Health is the first visit recommended in prevention. to stress via epigenetic pathways Supervision of Infants, Children, Finally, Practical Resources for and, thereby, buffer initial adverse and Adolescents, Fourth Edition Effective Postpartum Parenting effects of perinatal depression (DNA 15 140 . (PREPP) is 1 promising brief methylation and neuroendocrine 130 An AAP clinical report defines the mother-infant dyadic intervention. functioning). ’ PREVENTION prenatal visit as important in building PREPP is aimed at promoting the a relationship with the mother and infant s sleep while reducing fussing Antenatal Depression father, coordinating services, and and/or crying. This is achieved providing key anticipatory guidance through integrating evidence-based
and prevention education in the135 caregiving techniques, traditional Prevention of perinatal depression context of the upcoming birth. psychotherapy approaches, is challenging, given the complex If there are identified risk factors psychoeducation, and mindfulness biopsychosocial factors that for perinatal depression, this visit meditation through a training influence the entire perinatal allows the pediatric patient-centered program for at-risk women. As a period. Historically, much of the medical home (PPCMH) to coordinate result, mothers reported an increased focus has been exclusively on resources for the anticipated primary sense of accomplishment, rest, and reducing risk factors, comorbidities, care and mental health needs of effectiveness while the incidence and and adverse outcomes related the mother and the mother-child severity of postpartum depression to depression in the postpartum dyad. More research is needed to symptoms declined. PREPP revealed period, particularly on childhood understand and promote dyadic strong effects on reducing depression development. There is growing mother-child and parent-child mental symptoms at 6 weeks, but the effect evidence that untreated antenatal health across131 the entire perinatal was not140 sustained beyond that depression is 1 of the highest risk continuum. Advocacy is needed to period. This suggests a role for factors for meeting criteria51,94, for131, 132 ensure payment to pediatric providers135 pediatric providers in providing postpartum depression. for prenatal visits and services. ongoing parenting education along Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 1, January 2019 9 with evidence-based strategies for state Medicaid agencies may allow treatment. In 2010, Massachusetts coping with stress. such screening to be claimed as policymakers led the way by SCREENING a service for the child as part of creating a statewide Postpartum ” the Early and Periodic Screening, Depression Commission to advocate National and State Integrated Diagnostic, and Treatment benefit. for screening and treatment and to Screening Systems State programs can train providers monitor implementation. Several to screen and refer mothers with other states have since made efforts positive screens if necessary, and to provide training and support even Despite the growing empirical states are eligible for Medicaid without a formal legislative mandate. evidence and support for screening administrative matching funds to In addition, a growing number of for perinatal depression that leads to help with the cost of training. state Medicaid programs are now paying for perinatal depression early identification and referrals for The Well-Women Task Force is a screening. For more information effective treatment, implementation collaborative initiative hosted by on related state laws and policies, of screening by pediatricians has the ACOG. Existing guidelines were contact AAP State Advocacy at been slowly increasing from 13% reviewed to develop consensus stgov@aap.org. Many states have in 2001 to9,21 47% in 2013 in periodic recommendations on the care of developed quality improvement surveys. In January 2016, the adolescent and adult women. This programs, community support USPSTF completed its most recent task force asserted that, in addition to review of the evidence for perinatal groups, media campaigns, and “ ” providers offering annual screening other resources to improve both depression screening, providing for depression in adolescent and provider and public awareness of a grade B recommendation for adult women using a validated tool, the need for early identification and implementation. The task force found additional screening for depression 145 treatment of perinatal depression. that there is a moderate net benefit is specifically recommended in the Bright Futures: Guidelines144 for Health Ultimately, such state-level efforts to screening for perinatal depression, postpartum period. The 2017 particularly when treatment such as Supervision of Infants, Children, have fostered early identification and Adolescents, Fourth Edition and treatment of affected parents psychotherapy or counseling20,141, 142 can be and have increased public made readily available. awareness of screening protocols Moderate net benefit refers to a recommendations from the AAP also and procedures and appropriate situation in which the evidence now include screening for maternal referrals for additional family supporting a prevention practice depression by the 1-, 2-, 4-, and 15 assessment, support, and treatment. indicates a determined effect on 6-month well-child visits. health outcomes, but assessing the The recent AAP recommendations magnitude of effect may be limited by On the state level, health care are for universal screening 146of infant issues with the number, size, quality, providers, academic centers, behavior and development and consistency, and generalizability Medicaid programs, legislatures, and partnering with mental health “… of available studies. The report local professional bodies, including care providers to implement specifically stated that there is AAP chapters, have been working evidence-based treatments147 convincing evidence that screening of for decades to incorporate maternal during early childhood. These pregnant and postpartum women in perinatal depression screening with recommendations are increasingly ” “… primary care improves the accurate standardized tools into prenatal, being adopted15 by pediatric providers identification of depression and postpartum, and periodic well-child in all states. An important aspect adequate evidence that programs visits. Ideally, screening would of screening is to also assess for combining depression screening be conducted within a system of common perinatal depression with adequate support systems in care that also provides access to comorbidities that adversely affect place improve clinical outcomes additional mental health evaluation child development, behavior, and ” and treatment when concerns the family environment, including for pregnant143 and postpartum women. are identified. Although such substance use, domestic violence, interdisciplinary integration is not and food insecurity. Standardized In May 2016, CMS sent an always available or feasible, progress screening tools are now, more than informational bulletin (https:// has been made. New Jersey and ever, being used148 to assess for such www.medicaid .gov/ federal-policy- Illinois (2008) were the first to pass comorbidities. guidance/downloads/cib051116.pdf) legislative requirements for perinatal “ to all state Medicaid directors stating, depression screening, which resulted State perinatal depression screening since maternal depression screening in increased awareness, conducted efforts were also aided when the is for the direct benefit of the child, assessments, and referrals for National Quality Forum developed Downloaded from www.aappublications.org/news by guest on October 2, 2021 10 FROM THE AMERICAN ACADEMY OF PEDIATRICS a quality measure (National Quality handoffs that include important with pediatric providers to prevent, Forum Measure 1401) that assesses information on antenatal screening, buffer, and ameliorate– the adverse whether a maternal perinatal risk factors, and comorbidities of effects of postpartum depression on ’ 81 83,142 depression screen was administered perinatal depression, particularly the family. to a patient s mother at 1 face-to-face the existence of any intimate ’ visit with her provider during the149 partner violence, substance use, The PPCMH setting provides an first 6 months of the child s life. or obstetricBright complications Futures: Guidelines. The interdisciplinary infrastructure This measure was endorsed by the forprenatal Health visit, Supervision recommended of Infants, by to both implement postpartum CMS for the Electronic Health Record150 Children,the 2017 and Adolescents, Fourth depression screening and respond Incentive Program in March 2013. Edition to specific concerns. PPCMHs The quality measure was anticipated may have embedded services or to help with the adoption of perinatal recommendations from the expertise from multiple disciplines, depression screening by providers AAP, is an opportunity for obtaining including care managers, lactation participating in Meaningful Use such information, assessing existing consultants, social workers, and Incentive programs, although these supports, and providing direct pediatric mental health providers. programs have since been modified. education to potential parents about Role of the Primary Pediatric ’ Collocating or integrating mental Clinician and the PPCMH expectations during the first few days health and pediatric primary care of a child s life and the15, symptoms135, 151 of services has been shown to help with perinatal depression. access to and compliance with mental Perinatal depression is a pertinent health services for infants, children, In the postpartum period, the issue for the primary care clinician and their parents. Having these USPSTF and CMS recommend because of the significant risks to the services collocated or integrated also screening of parents by pediatric health and well-being of the infant facilitates communication across 2 providers caring for infants with and the family. Pediatric primary services, particularly using a shared a validated tool at the 1-, 2-, 4-, 152,153 care practices, particularly those medical record. and 6-month well-child visits. This identifying as PPCMHs, can build a recommendation is supported by system to implement postpartum Over the well-child visit schedule, the current understanding of when depression screening, to connect the pediatric provider, ideally postpartum depression peaks in affected families to supportive as a part of a PPCMH, develops a prevalence. Repeated screenings are community resources, and to refer longitudinal relationship with the important, because mothers who parents for additional treatment 1 may not be comfortable disclosing infant and his or her parents starting when indicated. initially may do so at later visits as at an early age. As trust is built in Early identification and appropriate trust and familiarity builds with the provider-patient relationship, it treatment of perinatal depression can the pediatric provider. Perinatal provides opportunities to emphasize result in more favorable outcomes depression is also associated with the importance of both 16infant and parental mental health. Well- for the expectant143 and postpartum missed appointments, so having child visits have an important role mother,1 her infant, and the entire multiple screening times also family. As mentioned, prevention increases the probability that such in assessing social determinants and screening for risk factors and families are screened and maximizes of health and promoting healthy comorbidities of perinatal depression opportunities for identification of social-emotional15, development16, 154 in start well before birth in the concerns and engagement in ongoing young children. In addition, preconception and antenatal periods supports and pediatric health well visits offer opportunities for where obstetric providers, midwives, surveillance. Pediatric providers can screening for psychosocial stressors and family and adult primary also screen for and promote healthy and concerns, including parental care practitioners are optimally social-emotional development in the depression, as mentioned previously, positioned. The ACOG has specific infant using general developmental as well as intimate partner violence, recommendations for antenatal and specific social-emotional substance use, poverty, food 154 screening as well as collaboration screening tools when risks factors for insecurity, and homelessness. between obstetric providers or maternal symptoms of postpartum These psychosocial issues can have ’ and their pediatric colleagues to depression are present. In the a compounding effect with perinatal facilitate ongoing assessment, postpartum period, the parents depression and can promote155 an treatment, and support for women primary care and mental health environment of toxic stress. “ with perinatal3 depression and their providers are important partners Recognized in the AAP policy families. Ideally, this occurs through that can communicate with and work statement, The Future of Pediatrics: Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 1, January 2019 11 ” Mental Health Competencies16 for reimbursement to screen and discuss anticipatory guidance, and the 6plan Pediatric Primary Care, is the results, and fears associated with7,10 for follow-up and/or referrals. unique advantage of the primary care legal implications of screening. 163 The EPDS is a free, widely-used Studies reveal that providers who clinician, particularly in a PPCMH 10-question instrument that is used rely solely on observational cues and context, for surveillance, screening, specifically to screen for perinatal do not use validated tools to screen and addressing child and parental depression. The EPDS was originally •• tend to underdiagnose parental mental health outcomes through: 157,158 developed for screening postpartum depression. As a result, many longitudinal, trusting relationship women in outpatient, home-visiting women may erroneously attribute with the family, including the settings or at the 6- to 8-week their changes in mood, fatigue, creation of a safe space for postpartum examination. The tool sleep, eating, body weight, and other •• discussion of psychosocial issues; has been validated with numerous– symptoms of postpartum depression ’ populations and is available in family centeredness, including to their pregnancy and do not seek 164 165 167 3 Spanish and for fathers. attention to the parents emotional necessary support. Of note, it includes reverse-scored •• needs; There is some evidence that items that can be used to assess unique opportunities for screening for perinatal depression reliability of responses. The most prevention and anticipatory can also be conducted effectively in recent 2016 recommendations of the guidance, including communication emergency department and pediatric USPSTF clearly conclude that there and discussion with families in a inpatient settings for the mother of is sufficient evidence to support way that fosters early detection 159,160 the use of the EPDS as an effective Perinatalan infant inDepression the first year of life. and intervention of emerging screening tool for depression in Screening Tools 20 social-emotional and mental health pregnant and postpartum women. •• concerns and problems; The Survey of Well-being of Young understanding of common social- Children (SWYC) (www.theSWYC . Multiple screening tools exist that org) is a validated developmental and emotional and learning issues in can efficiently identify patients at risk •• the context of development; psychosocial screening tool that now for perinatal depression, and most includes the EPDS in the 2-, 4-, and experience in coordinating are available free online (Table 3). 6-month questionnaires (available with and referring to a broad If there is an interest in reproducing in English, Spanish,168 Burmese, Nepali, range of relevant specialists any of these tools, it is important and Portuguese). The EPDS has and community-based agencies, to check with the authors and/or some benefit in identifying anxiety particularly those that are focused developers of the tools to honor any disorders as well but is not focused on the care of children with of the copyright requirements and/ on somatic symptoms or parent- special health care needs and their or requests for permission for use. infant relationships. •• families; and Before using any screening tool, it is also important to have detailed A total score of 10 or more on the familiarity with chronic policies and protocols about how EPDS is a positive screen indicating care principles156 and practice to address identified depressive a concern for depression, which improvement. symptoms, including follow-up or necessitates further discussion Several validated and effective referral to a licensed mental health in which providers can clarify screening instruments for perinatal provider, if necessary. Knowledge of the findings, determine acuity of depression have been developed appropriate emergency mental health concerns, and, if necessary, make and are readily available1,3 (reviewed resources is important. Immediate appropriate referrals for further in detail below). However, despite action is required at any time during assessment and treatment of129, the163 the administration of a screening tool parent (as described below). It having access to these screening ’ tools, many physicians do not 8,21 if a parent expresses any concern is important to note that similar to screen for perinatal depression. about the infant s safety or if the all screening tools, the EPDS is not a Many barriers to screening for parent reports being (or pediatric diagnostic instrument. In situations perinatal depression are reported provider suspects the parent in which there is any indication by providers, including the lack is) suicidal, homicidal, severely 161 of suicidal ideation (on the EPDS depressed, manic, or psychotic. question 10 or in discussion), if the of time to screen and competing ’ demands, inadequate knowledge Appropriate documentation of parent expresses concern about his about the validated tools available perinatal depression screenings or her ability to maintain the infant s and how to appropriately document includes the screen used, results, safety, or if the pediatric provider findings, lack of or insufficient discussion with the parent including suspects that the parent is suicidal or Downloaded from www.aappublications.org/news by guest on October 2, 2021 12 FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 3 Valid Screening Tools for Perinatal Depression Screening Tool No. Items Sensitivity and Specificitya,b Available for Free EPDS 10 Mothers (score >9–12) Yesc Sensitivity 80%–90% Specificity 80%–90% Fathers (score >10) Sensitivity 90% Specificity 78% PDSS 35 Sensitivity 80%–90% No Specificity 80%–90% http://www.wpspublish.com/store/p/2902/postpartum- depression-screening- scale-pdss PHQ-2 2 Sensitivity 100% Yesc Specificity 44.3%–65.7% PHQ-9 9 Sensitivity 75%–89% Yesc Specificity 83%–91% Beck Depression Inventory–II 21 Sensitivity 75%–90% No Specificity 80%–90% http://www.pearsonclinical.com/psychology/products/ 100000159/beck-depression-inventoryii-bdi-ii.html All of the above screening tools take <10 min to complete, on average, and are available in Spanish. a Validity specifically for postpartum depression as reviewed in Myers et al.162 b For EDPS only; as reviewed in Siu et al.21 c Indicated free screening tools are available on the AAP Web site: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/Screening-Tools.aspx; https:// brightfutures.aap.org/materials-and-tools/tool-and-resource-kit/Pages/Developmental-Behavioral-Psychosocial-Screening-and-Assessment-Forms.aspx.
homicidal, it is considered a positive Agency for Healthcare Research the longer 9-question Patient Health screen that warrants an immediate and Quality also reviewed validity Questionnaire-9 (PHQ-9) (discussed evaluation for safety of the parent statistics for various screening in the following paragraph). The and/or infant, often in an emergency tools among postpartum women PHQ-2 does not include a question psychiatric setting. Immediate action specifically and found that the EPDS about suicidality. The PHQ-2 has with a referral to an emergency had a sensitivity of 80% to 90%162 been studied in both primary176 care psychiatric setting has also been and specificity of 80% to 90%. and obstetric populations. The 2 recommended with scores greater Higher cutoff scores for EPDS have questions in the PHQ-2 are: than 20 or if there is clinical concern been proposed (up to a threshold of 171 1. Over the past 2 weeks, have you that the parent may be severely 13) to limit false-positive results. 163 ever felt down, depressed, or depressed, manic, or psychotic. Recently, shorter versions of the hopeless? EPDS have been validated, including
The accuracy of the EPDS as a a 2-question172 screen for adolescent 2. Over the past 2 weeks, have you screening tool in pregnant and mothers. felt little interest or pleasure in postpartum women has been doing things? n The EPDS has demonstrated cross- established by a recent USPSTF 163 cultural sensitivity, including A person is asked to choose 1 of 4 review of 23 studies ( = 5298) the Spanish version, which possible choices for each question comparing the accuracy of the showed acceptable performance that comes closest to how he or she EPDS with a diagnostic interview. 143 characteristics. The EPDS is also has been feeling: not at all (0), several Sensitivity of the EPDS using a – available in French, Dutch, Swedish, days (1), more than half the days (2), cutoff of 13 ranged from 0.67 (95% – Spanish, Chinese, Thai, Turkish, and or nearly every day (3). A score of 3 confidence interval [CI], 0.18 0.96) Arabic. Cutoff scores may vary in out of a maximum of 6 is the accepted to 0.8 (95% CI, 0.81 1.00) for the 173 different populations. cutoff for a positive screen, with a detection of MDD. Specificity for sensitivity of 83% and a specificity detecting MDD was consistently 0.87 One screen that has been used over 176 20,141, 143 of 92% for MDD. Studies in or higher. Two studies in this the last decade in some primary postpartum populations, specifically, review were conducted in the United care settings is the Patient Health 174,175 reveal that the sensitivity of the States (1 specifically among African Questionnaire-2 (PHQ-2). PHQ-2 is 100% and the specificity is American women) demonstrating an The PHQ-2 is a simple, free general 162 44.3% to 65.7%. average sensitivity of approximately depression screening tool (ie, not 143 0.80. The positive predictive value limited to use in the postpartum The most recent USPSTF review for detecting MDD would be 47% period or with women) with 2 concluded that no studies of to 64% in a population143,169, with170 a 10% questions about depressed mood screening in pregnant or postpartum prevalence of MDD. The and anhedonia that are derived from women conducted with the PHQ-2 Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 1, January 2019 13 met methodologic inclusion criteria. of 88%180 and specificity of 88% for in appetite, low energy, etc, which As a result, the USPSTF currently MDD and among postpartum may be normative in pregnancy, so has determined that there is not women had a specificity of 75% their specificity3 is lower for perinatal sufficient evidence to support the to 89%162 and specificity of 83% to depression. use of the PHQ-2 at this time as a 91%. However,143 the most recent A drawback to these currently less primary screening tool in20 pregnant USPSTF review concluded commonly used questionnaires and postpartum women. Yet that no studies of screening in is that they tend to yield higher many practices continue to use pregnant or postpartum women estimates than clinician-administered it as an initial screen. If a parent conducted using the PHQ-9 met interviews, so clinical assessment screens positive with the PHQ-2, methodologic inclusion criteria. is recommended but often not then the recommendation is that Although the USPSTF currently conducted. Also, studies differ in it be followed up with a more has determined that there is not their methods in terms of cutoff comprehensive screening tool (eg, sufficient evidence to support the use scores, reporting of cutoff scores, PHQ-9, discussed in the following174,175 of the PHQ-9 specifically in pregnant 20 and use of scores as continuous61 paragraph, or the EPDS). and postpartum women, it still measures in analysis. Just as with continues to be used widely. the EPDS, these other questionnaires The longer 9-question PHQ-9 has are only screening tools, and they been used as a primary screening Other screens are available with a do not diagnose MDD or perinatal instrument for perinatal depression cost and may be used by adult and depression. Diagnosis requires a and to monitor for worsening or mental health providers during the face-to-face clinical assessment and, improvement of perinatal177 depression pregnancy or postpartum period and in some circumstances, referral symptoms over time. The PHQ-9 much less often by pediatric primary for clinical correlation by an has also been widely used to178 care clinicians. However, some appropriately129 licensed health care screen nonpregnant adults 179 and adult and pediatric providers may professional. adolescents for depression. The choose to use these in partnership Infant Assessment diagnostic validity of the PHQ-9 has with mental health providers who been established in both primary179,180 are collocated, integrated, or linked care and obstetrical clinics, with an obstetric, family medicine, Routine well-child visits allow although the USPSTF concluded that or pediatric practice. The Beck181 for pediatric providers to assess the data were insufficient for specific Depression Inventory (BDI-II) is a and promote healthy early child use in postpartum depression 21-question scale that is a self-report development, including assessing ’ screening. In addition to the tool used to provide more feedback overall family strengths and supports questions from the PHQ-2, the PHQ-9 on severity of depressive symptoms. and the child15,s142, social-emotional146 also asks how often over the past 2 This tool141 is currently endorsed by the adjustment. Identified weeks the person has been bothered USPSTF as an effective screening developmental concerns and by different problems related to tool for postpartum depression delays in an infant may be the only sleep, lack of energy, feeling bad or and also continues to be endorsed indication of perinatal depression, letting someone down (feeling like by the USPSTF for use in screening difficulty with early adjustment as a failure), appetite, concentration, all adolescents between 12 182and 18 a new family, as well as many other speaking slowly, or being restless. years of age for depression. Two factors. When developmental delays
Similar to the PHQ-2, the respondent additional tools are the Hamilton 183 are present in the child, they often is asked to choose 1 of 4 responses Depression Rating Scale (HAM-D) increase the stress and decrease the for symptoms corresponding to how and the Postpartum Depression perceived efficacy185 experienced by often they are experienced, ranging Screening Scale (PDSS). The Hamilton the mother. Therefore, several ’ from not at all to nearly every day. Depression Rating Scale uses an screening tools (some are free online) The PHQ-9 specifically asks about interview format and is mostly used can be used to assess the child s suicidal thoughts and how any of in research settings. The PDSS is a social-emotional development, ’ the identified symptoms affect the 35-question screen that identifies family supports, and early family respondent s ability to function patients at high risk for depression184 adjustments. These tools can be used at work, at home, or in interacting but is less commonly used. Among whenever there are developmental with other people. Scores of 5, 10, postpartum women, the PDSS has a concerns or delays, particularly
15, and 20 on the PHQ-9 represent sensitivity162 and specificity of 80% to if the mother presents with other mild, moderate, moderately severe, risk factors identified or has been ≥ 90%. It should be noted that these and severe depression, respectively. screening tools include constitutional previously diagnosed with perinatal PHQ-9 scores 10 had a sensitivity symptoms such as insomnia, changes depression. These tools include the Downloaded from www.aappublications.org/news by guest on October 2, 2021 14 FROM THE AMERICAN ACADEMY OF PEDIATRICS Ages and Stages186 Questionnaire Social are available to support families provider can implement1 that will Emotional-2, the Early187 Childhood as well. Information about local be discussed below. In discussion Screening148,168 Assessment, the organizations available to support with the parent and family, it may be SWYC, and the Baby Pediatric victims of intimate partner violence determined that referrals to mental
Symptom Checklist,188,189 which is included can be accessed through the health and specialty providers are in the SWYC, among others. National Domestic Violence Hotline necessary for diagnostic evaluation, Guidance on these and other similar at http://www.thehotline .org or psychotherapy, or even consideration screening tools is available in a 1-800-799-SAFE. of psychiatric142 medication policy statement and technical report management.“ ” A positive screen leads to a about early childhood emotional and 147 discussion with the parent about the In high-risk situations in which behavioral problems. specific mental health concerns and there are concerns for suicidal DIAGNOSIS AND TREATMENT symptoms identified in the screening ideation, risk of harm to the infant, or severe mental illness, there may be tool and/or142 during a patient encounter. There is literature urgent or emergent need for referral As discussed, screening tools alone showing that, in addition to pediatric to an emergency psychiatric setting ’ are inadequate for diagnosing providers, such a discussion can be for evaluation and treatment. perinatal depression, but when they ’ conducted by the parent s primary Regardless of the level of risk or indicate concerns, the pediatric care provider, obstetric provider, or a modality of treatment, it is important provider s role is to discuss results licensed mental health129 provider with to explain to parents the assessed and facilitate referral for appropriate perinatal expertise. There may be need for follow-up or referral, supports and treatment. Some times when the screening is positive, specifically if further evaluation ’ PPCMHs may have mental health, without suicidal ideation or risk of and treatment is necessary by a social work, lactation support, harm to the infant, and the mother parent s primary care provider or a and other such services collocated is not interested in a referral for mental health specialist. If perinatal or even integrated directly into a further evaluation and diagnosis. It is depression is ultimately diagnosed, visit, which decreases153,190 stigma and important for the pediatric provider then reassurance can be offered that improves access. In the context and/or other members of the PPCMH pediatric providers can work with of discussing screening results, ’ to inquire about existing supports such adult providers and community an opportunity exists to validate and clarify the psychosocial concerns organizations to support the parent parents experiences and inquire and comorbidities, such as domestic and his or her ability to best care ’ about existing supports available violence and substance use, that may for the child. Consideration of risk to them and their family in times affect the welfare of the infant and to factors, parent s previous psychiatric of transient acute stress. These follow-up to monitor the abatement history, and former treatments, if supports may include extended of risk. known by the pediatric provider at family, friends, and even therapists “ ” When a screen is positive in the time of referral, is important to or counselors who are providing low-risk situations, without communicate through the transition mental health treatment. It is also suicidal ideation or risk of harm in care 3,to191 develop an accurate risk a time when careful attention can to the infant, a pediatric provider Accessprofile. to Treatment be given to assessing for any risk of may consider recommending suicide or harm to the infant as well the mother to follow-up with her as the presence of other psychosocial obstetric or primary care provider Although progress is being made stressors or comorbidities in addition for additional discussion and also in identifying and effectively to depression. closely monitoring the infant and treating perinatal depression, the As was previously discussed, rates mother with a visit or telephone call cumulative shortfalls in mothers of intimate partner violence and before the next scheduled well-child receiving effective treatment are substance use are elevated in families visit. The pediatric provider may still large. In a recent study, only in which a parent has perinatal also recommend adjustments in 49% of women with antenatal depression symptoms. If there schedule to provide adequate sleep, depression and 30.8% of women is specific concern for domestic additional supports from community with postpartum depression were ’ or intimate partner violence or agencies such as quality child care, screened and identified in practice. substance use, especially in the home visiting, mother s morning In addition, 13.6% of women with perinatal period, then state agencies out programs, or other programs. antenatal depression and 15.8% of may require notification. Many There are additional office-based women with postpartum depression national and community agencies interventions that a pediatric received any treatment, and only Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 1, January 2019 15 8.6% of women with antenatal through to ensure patients are the mother requires immediate depression and 6.3% of women with able to access necessary specialty16,196 evaluation, it is important that postpartum depression received providers in a timely manner. someone is available to specifically adequate treatment. Ultimately, 4.8% An integrated frontline mental maintain care for the infant. An ideal of women with antenatal depression health provider, such as a licensed process is that the mother is not left and 3.2% of women with postpartum192 clinical social worker or counselor, alone at any time, and if sent to an depression achieved remission. can provide immediate triage for a emergency psychiatric setting, the Despite the consequences of positive screen, conduct additional mother is accompanied by a trusted ’ untreated perinatal depression and assessments, offer support, and adult or staff member. coordinate follow-up and referrals the presence of a range of options for If the provider s level of concern for the infant, mother, and family. effective, evidence-based treatment, is elevated but an emergency Regardless of whether a clinic has most mothers with perinatal intervention is deemed not a care coordinator or integrated depression do not seek therapy and necessary, precautions are taken mental health provider, many treatment11,193 for themselves and their to promote safety, including having sources emphasize the importance infants. Mothers may not seek the mother leave with a support of close working relationships therapy because of concern about person (not alone), ensuring and communication between perceptions of others (ie, stigma), adequate supervision of the mother pediatric providers and mental cost and a lack of insurance coverage, and infant at home, composing a health providers, adult primary need for child care during the mental specific safety plan (including phone care providers, and other agencies health visit, lack of access to a trained numbers and steps for accessing in the community with expertise in provider and lack of knowledge about help urgently), and scheduling close the evaluation, treatment, and/or perinatal depression, unrealistic follow-up. Pediatric providers can support of the mother with perinatal beliefs about coping with being a be prepared by having a current depression1,3 and the mother-infant mother, feelings of failure, and fears11 list of contacts for pediatric and dyad. about using mental health services. Emergency and/or Urgent Situations adult emergency mental health These challenges are compounded providers on hand. Fortunately, by the symptoms of depression, ’ most positive perinatal depression especially low energy and motivation, screens do not necessitate urgent or Many screening tools have critical which adversely affect a mother s emergency action by the pediatric thresholds above which they 197 ability to access help. provider. Intervention for the recommend that the pediatric mother ranges from support, to Fortunately, data suggest that provider take immediate action, therapy, to therapy plus medication, when providers speak to patients which usually means referring the to emergency mental health services about their depression, they are parent to an emergency psychiatric 198,199 and hospitalization. more likely to become engaged and setting to ensure safety with timely Infant and/or Dyadic Interventions seek treatment. Use of provider evaluation and treatment. If question notification systems and motivational 10 inquiring about161, suicidality163 on the interviewing techniques can EPDS is positive, if question In promoting evidence-based assist providers in engaging their 9 inquiring about suicidality on mental health treatments for infants patients in discussions194 about their the PHQ-9 is positive, if the parent and their mothers with perinatal ’ depression. A study from the expresses concern about maintaining depression, most approaches University of Michigan found that the infant s safety during any caution against implying any blame a single motivational interviewing screening, or if the pediatric provider or carrying an exclusive focus on session can increase rates of is concerned at any time with challenges faced by the mother. treatment adherence, particularly screening that the parent is suicidal, Strengths-based approaches that through the process of identifying homicidal, severely depressed, manic, are focused on the infant-mother and challenging practical and 195 or psychotic, immediate evaluation dyad are promoted on the basis psychological barriers to care. is warranted in an emergency of some evidence of efficacy in In many pediatric clinics and psychiatric setting (ie, calling 911) generally addressing attachment
PPCMHs, care coordinators have a or by a crisis team that can respond issues and developmental147,200, 201 concerns significant role in developing and directly to the provider161 (if available in other settings. Most maintaining a referral network in the community). Although of these dyadic interventions of community resources and the ultimate goal is to support the are focused on infant-mother specialty providers for perinatal mother so she can best care for attachment, but limited evidence is depression. They can often follow her child, in a situation in which now suggesting the importance of Downloaded from www.aappublications.org/news by guest on October 2, 2021 16 FROM THE AMERICAN ACADEMY OF PEDIATRICS Supervision of Infants, Children, and Adolescents, Fourth Edition supporting attachment with202 fathers interventions. Components of most and nontraditional families. For •office-based• interventions include: provides example, there are specific evidence- explanation and open dialogue health promotion themes, including based dyadic interventions that have with the mother and family to family support, child development, been used with high-risk families, help reduce stigma, normalize and mental health. Specifically, it often in the setting of interpersonal the stress faced by new families, includes surveillance for parental violence or abuse, such as Child203 and ultimately, foster early socioemotional well-being and15 for Parent Dyadic Psychotherapy identification of those who social determinants of health. “ ” and Attachment204 and Biobehavioral205 may need additional resources The common factors theory asserts Catch-up. Circle of Security •• ( demystification ); that therapies can be designed for has been specifically validated for broad classes of people rather than “ ” use specifically with mothers with communication about the potential specific individuals who are deemed perinatal depression and their impact on the infant and need for at-risk or fit a specific diagnostic 147,201 •• 206 infants. Videotaped interactions infant screenings and surveillance; category. The common factors of mothers and their infants with initial and ongoing support, which theory emphasizes that providers ’ feedback94 and coaching has shown includes providing validation can influence behavioral change efficacy. and empathy for the mother s in patients and families through Dyadic psychotherapy is an evolving experiences and identifying specific evidence-based interaction field. These interventions may not community resources to promote approaches, such as motivational be readily available in all areas and •• family wellness; and interviewing, integrated into routine visits. A mnemonic for a group require mental health providers to reinforcement, when necessary, of common factors that can be obtain specialized training. Pediatric through referrals to evidence- routinely assessed and monitored providers can play an important based treatment programs. “ ” throughout the scheduled well- role in advocating for increased Referrals may take the form of child visits is HELLPPP, which availability of such services, a mental health provider for the stands for hope, empathy, language, specialized training, and availability parent or lactation support for the loyalty, permission, partnership, of a specialized workforce with mother, as will be discussed later. 206 experience working with young and plan. In the absence of an children, parents, and families. Demystification is directed at urgent psychiatric crisis, pediatric Office-Based Supportive — providers can build alliance and Management by Pediatric Providers removing the mystery about maternal and paternal depression common understanding over time that postpartum depression can that will foster greater disclosure and ’ affect any parent, that it is not the recognition of mental health needs Pediatric providers can have an “ ” parents fault, and that it does not and social-emotional concerns. For important role in partnering with example, pediatric providers may parents, families, and various other imply bad parenting. Depression is treatable, and the support recognize the need for anticipatory involved providers to manage and guidance and education on parenting support parents with perinatal facilitated by the pediatric provider for appropriate intervention is an and lifestyle issues (eg, sleep, depression. However, considering 1 exercise, diet, rest) that ultimately the demands placed on pediatric essential ingredient. Having an infant and expanding the family is a could mitigate the risk of depression providers in most settings, it and promote the mental health of is essential to evaluate what is transition that can be difficult when there are other stressors involved. parents and children. More details feasible and effective for any given are available on the AAP Mental practice and in the context of each However, many parents also experience resiliency factors, such as Health Initiatives site, with a individual family. It is important resource in the AAP Mental Health that the pediatric provider consider stable housing, adequate family ’ and/or friend supports, and access to Toolkit at https://www.aap .org/ en- collaborating closely with the us/advocacy-and-policy/aap-health- mother s adult providers, mental care, which may help attenuate the risk of perinatal depression. initiatives/Mental-Health/Pages/ health care providers, and various Primary-Care- Tools .aspx . local agencies to provide optimal The AAP Task Force on Mental Health support for the mother-child dyad promoted the use of a common Following is an example of how a within the entire family structure. factors approach to206 routine mental brief intervention can be designed by When time and resources allow, Brighthealth Futures:assessmen Guidelinest to engage for Health16 using the common factors approach pediatric providers can offer parents families and build an alliance. within the context of a PPCMH to in low-risk situations office-based provide support to a parent when Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 1, January 2019 17 there are concerns for perinatal community as available206 and because of limitations in state- •depression:• ’ described below. specific eligibility requirements (emphasizing cognitive, motor, Hope: increase the parent s Other brief interventions that could and language delays but not social- hopefulness by describing realistic take place when there are concerns emotional delays) and insufficient expectations and reinforcing for postpartum depression could funding. Inadequate funding may the value and strengths of the •include:• also limit the ability of such services mother-infant relationship and ’ ’ encourage understanding and to provide adequate and uniform understanding and responding to response to the infant s cues; interventions addressing social- •• the infant s cues; emphasize the importance of emotional developmental delays for •• observing nonverbal behavior; Empathy: communicate empathy infants and the207 mother-infant dyad •• by listening attentively; ’ encourage routines for across sites. These challenges •• to accessing early intervention are Language: use the parent s predictability and security; concerning given the inextricable language to reflect your encourage focus on wellness connection of social-emotional understanding of the concerns for •• (sleep, diet, exercise, stress relief); development to physical health, •• perinatal depression; •• acknowledge personal experiences; language acquisition, and cognitive Loyalty: communicate loyalty to promote realistic expectations and development. the parent by expressing your •• prioritizing important things; and •• support and commitment to help; Early Head Start, Head Start, encourage social involvement home-visiting programs, and Permission: ask for permission to and bolster social networks and postpartum support groups are •• share information; Partneringsupports .With Community additional examples of community Partnership: partner to work Agencies resources that are available in many together to address common areas. There are opportunities in •• concerns; and various regions for public health Mental health providers are an nurses, lactation specialists, parent ⚬Plan:⚬ important resource, but many educators, and facilitators of encourage infant and parent community agencies can also family support groups (see http:// routines for predictability and provide essential support, such www.motherwoman .org or www. ⚬⚬security; as home-based services or partial postpartum.net) to form partnerships hospitalization programs that encourage focus on wellness: with pediatric providers aimed at specialize in addressing stressors ⚬⚬sleep, diet, exercise, stress relief; reducing perinatal depression. of the postpartum period. Part C of Ask about concerns regarding the Individuals with Disabilities in In Massachusetts, the legislature breastfeeding, and support and/ Education Act (IDEA) governs how has funded an adjunct to the or encourage if the mother is states and community organizations Massachusetts Child Psychiatry able to breastfeed. It is important and programs provide services Access Project (MCPAP) called to address specific worries to infants and children from birth MCPAP for Moms. This statewide and try to reassure the mother to 3 years of age with disabilities project improves access through when she is doing well with the or developmental delays, with or providing immediate consultation breastfeeding and her infant is without an established condition. and referral services to pediatric ⚬⚬adequately gaining weight; This legislation supports early providers and other providers when encourage social connections intervention programs that provide a positive perinatal depression ⚬⚬and supports; family-centered services to help screen is identified in the community. children from birth to age 3 develop Furthermore, MCPAP for Moms depending on the degree of skills necessary to promote health has created a toolkit for pediatric concern from the perinatal and positive development in early providers that is available free of depression screening, refer life. Early intervention programs can charge (www.mcpapformoms .org) . the parent and infant dyad to provide education and assessment The Substance Abuse and Mental mental health providers who use targeting the infant-parent Health Services Administration also evidence-based treatments, and dyad, often by modeling positive has a similar toolkit that describes ⚬⚬ 1,207 follow-up closely; and interactions and play. However, how community service agencies make referrals to a variety of in many areas, early intervention can approach perinatal depression, agencies and efforts in your local referrals can be difficult to facilitate specifically through forming Downloaded from www.aappublications.org/news by guest on October 2, 2021 18 FROM THE AMERICAN ACADEMY OF PEDIATRICS 210 effective partnerships208 with pediatric strategies,211,212 Internet-based primary care, psychiatric, or other Psychotherapyproviders. and Psychological CBT,213 and home-based qualified mental health professionals. Interventions CBT. A recent Cochrane review However, pediatric providers evaluated computer or Internet- can still play a role in dispelling based interventions to address myths, providing education, and Several validated individual perinatal depressive symptoms and responding to specific concerns psychological treatments are offered suggested promising trends, but about medications that a parent by mental health professionals such interventions212 are largely still may have, particularly as they in development. Small studies relate to the health and welfare of to help mothers199 with perinatal depression. Psychotherapy is often of additional alternative treatment the infant. A detailed discussion preferred by women over medication options, including yoga, massage, comparing psychotherapy and during the perinatal period because light therapy, acupuncture, and psychopharmacology is outside of perceived adverse effects of omega-3 fatty acids in fish oil, show the scope of this article, but a some limited efficacy, but more Cochrane review of a few studies medication on209 pregnancy and with 4,214 breastfeeding. Many women research is needed. There are no consisting of mothers with identified with mild to moderate formal recommendations for these postpartum depression showed * postpartum depression are optimally Psychotropictreatments at thisMedications time. that there is no difference between the effectiveness of antidepressants treated with psychotherapy198 and do not require medication. and psychological215 or psychosocial 143 Pharmacologic treatment of treatments. The USPSTF evaluated the depression is often indicated efficacy of psychological treatment during pregnancy and/or lactation. Despite the availability of effective with trials in postpartum women, Review and discussion of the risk of medications, many mothers prefer revealing a 28% to 59% reduction in untreated versus treated depression not to use psychotropic medications symptoms of depression at follow-up ’ is advised. Consideration of each in the perinatal period because of the compared with usual care. All 10 216 patient s previous disease and fear of adverse effects. Discussions trials of a CBT intervention showed treatment history, along with the risk about the risks and benefits of using an increased likelihood of remission – profile for individual pharmacologic or withholding medications are from depressive symptoms with agents, is important when selecting important for parents to have with short-term treatment (7 8 months). pharmacologic therapy with the their own adult health care providers At the 1-year follow-up, there was greatest likelihood of treatment so they can make informed decisions a 35% increase in remission rates success. Psychotropic medications, regarding the role of antidepressant with CBT compared with usual care – particularly antidepressants such medications used antenatally or in (pooled relative risk, 1.34; 95% CI, 20 as selective serotonin reuptake the postpartum period, especially 1.19 1.50). There is little risk of inhibitors (SSRIs), may have a role while breastfeeding. Studies about adverse effects from psychotherapy. in the management of postpartum the long-term effects on the infant of In women with antenatal depression, depression depending on the maternal antidepressant medication CBT-based interventions have presenting symptoms and needs use, such as SSRIs, during pregnancy also been shown to be effective in of individual parents. Most often, are mixed, because it is difficult to preventing depression recurrence 136 psychotropic medications are control for many other cooccurring during the perinatal period. The managed through referrals to adult factors that may influence birth USPSTF has recommended that outcomes, including maternal illness clinicians consider CBT or other * This section on pharmacological management 216 or problematic health behaviors. evidence-based counseling, such as of perinatal depression is being included to In 1 study, mothers made a list interpersonal psychotherapy, when provide context to the pediatric provider; it is not to imply that pediatric providers would or should of potential risks and benefits of managing depression in pregnant or 141,199 be instituting psychiatric care for adult parents. treatment with medication in the breastfeeding women. It is acknowledged that even when referred to context of their therapeutic goals for appropriate mental health specialists, parents Different methods of delivering will often still return to pediatric providers caring a healthy pregnancy and postpartum interpersonal psychotherapy and CBT for their children with questions or concerns. period. An exercise like this should are being developed and preliminarily This section is not meant to be an exhaustive be conducted in partnership with ’ show reduction in depression resource, but rather it is used to provide a appropriate providers, including prevalence. These methods include basic overview of core understandings around the parent s prescriber, who can perinatal psychopharmacology that may be 4,198 postpartum telephone-based and relevant. provide accurate information. telecare sessions using CBT, relaxation The pediatric provider can also play techniques, and problem-solving an important role in reinforcing and Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 1, January 2019 19 sharing accurate information about have previous positive response to and may be preferred for some various treatment options. medications. women with high risk of relapse and co-occurring conditions, such Untreated and severe perinatal Detailed guidance in regard to 199 as anxiety disorders. More depression poses significant risk specific medications is outside the studies are needed to evaluate for morbidity and occasionally scope of this article, but SSRIs have the relative efficacy of different mortality for the mother and become the mainstay of treatment of psychotherapeutic approaches as fetus during pregnancy. Studies moderate to severe major perinatal well as other psychological and have demonstrated that the depression because of their favorable psychosocial treatments, with and risks associated with untreated profiles of adverse reactions. 199 without medication. depression are far more detrimental Parents often express concerns to (including suicide) than the unclearly and have questions for pediatric CODING AND BILLING associated risks of growth effects, providers regarding the use of neurobehavioral outcomes, preterm antidepressant medication while birth, low birth weight, structural breastfeeding. There is increasing Given the 2016 recommendations malformations, and respiratory – evidence to support the safe by the USPSTF and CMS, providers distress, which vary among 198,217 219 use of these medications during are encouraged to bill for perinatal studies. Yet, many lactation. The ABM has developed depression screening at 1-, 2-, mothers choose to stop taking a clinical protocol on the use of “ 4- and 6-month well-child visits. psychotropic medications during antidepressants in breastfeeding However, coding may vary by pregnancy, although they report mothers but stipulates, [There is] state or payer. The AAP Web site, significant symptoms of depression, no widely accepted algorithm for ” state AAP chapters, and specific placing them at high risk for the Current Procedural 209 antidepressant medication treatment191 payers can be consulted with any sequela of perinatal depression. Terminology of depression in lactating women. questions. A new In mothers who are suicidal, In the context of breastfeeding, it has code, 96161, for the homicidal, manic, or psychotic, again been asserted that the benefit administration of a mother-focused there is often an urgent need for of effectively treating perinatal health risk assessment for the benefit medication in the context of an depression far outweighs the risks220,221 to of the patient was approved by the emergency or inpatient psychiatric 198 the infant through breastfeeding. American Medical Association in setting. Clinical studies in breastfeeding 2016. Providers can consider the 4 3 patients who are using sertraline, The AAFP, ACOG, Academy of 191 opportunity to bill for time-based Breastfeeding Medicine (ABM), fluvoxamine, and paroxetine suggest counseling and coordination of that the transfer of these medications and American198 Psychiatric care with a separate evaluation and Association endorse the into human milk is low and that management code with a 25 modifier appropriate use of antidepressant there is even lower uptake by the when there are significant concerns medications during the perinatal infant. No or minimal adverse for maternal depression. ’ period. The ABM recommends effects on infants have been CONCLUSIONS consideration of each patient s reported after the use of these 3 medications in lactating mothers previous disease and treatment 216,220, 221 history, along with the risk profiles themselves. Sertraline for individual treatments when was preferred over the other 2 There is strong evidence that choosing the treatment with the drugs, because many studies have parental, particularly maternal, greatest likelihood of treatment shown that human milk and infant depression during pregnancy and the 191“ plasma have low to undetectable effect. The ABM states that 216 first year after childbirth (perinatal in the setting of moderate to concentrations of this drug. depression) has profound negative severe depression, the benefits Many parents may experience consequences on the well-being of of [psychotropic medication] combined or sequential treatment women and infants, including family treatment likely outweigh the risks with psychotherapy, such as CBT, dysfunction, disruption of critical ” of the medication191 to the mother or and antidepressant medication infant brain development, cessation infant. Therefore, antidepressant management. This may implicate of breastfeeding, and increased medications can be an important multiple providers, which health care use, and may place the option to consider for parents with emphasizes the importance of child at increased risk for future perinatal depression symptoms, collateral communication. Evidence anxiety and depression. A growing particularly if their symptoms are suggests that combined treatment198 body of research shows that fathers not responsive to therapy or they may lead to even further benefit are also at increased risk of perinatal Downloaded from www.aappublications.org/news by guest on October 2, 2021 20 FROM THE AMERICAN ACADEMY OF PEDIATRICS ’ depression, which can magnify the and have recommended screening and evidence-based treatments for ’ Bright Futures: Guidelines adverse effects on an infant23,45, 167 s social- forconsistent Health Supervisionwith those assertedof Infants, by parents and the parent-infant dyad emotional development. Children,the AAP sand Adolescents, Fourth need to be identified, advocated for, Perinatal depression is the most Edition and brought to scale to allow access prevalent ACE and can lead to toxic to care to promote the best outcomes stress and present challenges to . These recommendations LEADfor women AUTHORS and their infants. essential early attachments between have encouraged, even mandated, 100 Jason Rafferty, MD, MPH, EdM, FAAP children and their parents. many commercial insurers to pay Gerri Mattson, MD, MPH, FAAP for screening. Medicaid programs With a core responsibility to promote Marian Earls, MD, FAAP are now encouraged to cover and Michael W. Yogman, MD, FAAP the well-being of children and the pay for screening for perinatal benefit of longitudinal relationships depression. The recommendation COMMITTEE ON PSYCHOSOCIAL ASPECTS with families, pediatric providers OF CHILD AND FAMILY HEALTH, 2016 2017 for maternal depression screening – have a critical role in screening ’ is once during pregnancy and then Michael W. Yogman, MD, FAAP, Chairperson and supporting parents and their during the infant s well visits at 1, 2, Thresia B. Gambon, MD, FAAP infants with concerns for perinatal 15,20 Arthur Lavin, MD, FAAP 4, and 6 months of age. However, depression. This responsibility Gerri Mattson, MD, FAAP despite the efforts of many state and includes supporting parents at risk Jason Richard Rafferty, MD, MPH, EdM local AAP and AAFP chapters and Lawrence Sagin Wissow, MD, MPH, FAAP for or with a diagnosis of perinatal other advocacy groups, perinatal depression and communicating and depression screening remains far LIAISONS working with adult obstetric, primary from universal in clinical practice Sharon Berry, PhD, LP – Society of Pediatric care, and/or mental health providers. 140 or payment. As more providers Psychology If indicated, referrals to community Terry Carmichael, MSW National Association of are screening and identifying – agencies or specialty providers may Social Workers psychosocial risk factors in diverse be necessary for support, diagnostic Edward R. Christophersen, PhD, FAAP – Society of clinical settings, more emphasis Pediatric Psychology evaluation, or treatment. needs to be put on improving Norah L. Johnson, PhD, RN, CPNP-BC – National Over the past decade, multiple collaboration and transitions of care Association of Pediatric Nurse Practitioners Leonard Read Sulik, MD, FAAP – American professional health care throughout the perinatal period. Academy of Child and Adolescent Psychiatry and regulatory bodies have Finally, there are many models recommended routine perinatal around the country of creative and STAFF depression screening. Most effective interventions to promote Stephanie Domain, MS recently, both the USPSTF and early identification and treatment of CMS have reviewed the evidence perinatal depression. Best practices
ABBREVIATIONS Diagnostic and Statistical Manual of Mental Disorders, DSM-5: Fifth Edition PPCMH: pediatric patient-centered AAFP: American Academy of medical home Family Physicians PRAMS: Pregnancy Risk AAP: American Academy of EPDS: Edinburgh Postnatal Assessment Monitoring Pediatrics Depression Scale System ABM: Academy of Breastfeeding MCPAP: Massachusetts Child PREPP: Practical Resources for Medicine Psychiatry Access Effective Postpartum ACE: adverse childhood experience Project Parenting ACOG: American College of MDD: major depressive disorder SSRI: selective serotonin reuptake Obstetricians and PDSS: Postpartum Depression inhibitor Gynecologists Screening Scale SWYC: Survey of Well-being of CBT: cognitive behavioral therapy PHQ-2: Patient Health Young Children CI: confidence interval Questionnaire-2 USPSTF: US Preventive Services CMS: Centers for Medicare and PHQ-9: Patient Health Task Force Medicaid Services Questionnaire-9
Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 1, January 2019 21 All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
DOI: https://doi.org/10.1542/peds.2018-3260
Address correspondence to Jason Rafferty, MD, MPH, EdM, FAAP. Email: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2019 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 143, number 1, January 2019 29 Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice Jason Rafferty, Gerri Mattson, Marian F. Earls, Michael W. Yogman and COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH Pediatrics 2019;143; DOI: 10.1542/peds.2018-3260 originally published online December 17, 2018;
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Downloaded from www.aappublications.org/news by guest on October 2, 2021 Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice Jason Rafferty, Gerri Mattson, Marian F. Earls, Michael W. Yogman and COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH Pediatrics 2019;143; DOI: 10.1542/peds.2018-3260 originally published online December 17, 2018;
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