Screen New Moms for Depression at Well-Child Visits, AAP Says

Norra MacReady

December 17, 2018

The American Academy of Pediatrics (AAP) released an updated policy statement in which they recommend pediatricians routinely screen mothers for postpartum depression during well-child visits at 1, 2, 4, and 6 months.

Perinatal depression affects 15% to 20% of new mothers in the United States, making it the most common obstetric complication, but few mothers are screened for it or referred for evidence-based treatment, the authors warn.

The consequences of untreated perinatal depression on parents and child may be severe and long-lasting, they add.

Marian F. Earls, MD, MTS, FAAP, from Community Care of North Carolina, Raleigh, and the School of Medicine, University of North Carolina, Chapel Hill, North Carolina, and colleagues published the policy statement online December 17 in Pediatrics on behalf of the AAP's Committee on Psychosocial Aspects of Child and Family Health.

The recommendations are an update of a statement initially published in 2010, Earls told Medscape Medical News. Since then, "there's been a lot of attention paid to early brain development and the effects of toxic stress on young infants and the effects of social determinants on families. So this is very much a part of a two-generational approach: understanding the impact, not just on the mother, but on the mother-infant relationship and even on family relationships and family health."

In other words, "this is very much in keeping with all of the interest in addressing all kinds of stressors on families and their effects on the health of the child," said Earls, who is chair of the AAP's Mental Health Leadership Work Group

Mothers with perinatal or peripartum depression may be less sensitive or less attuned to their child's needs, the authors explain. They may have a distorted perception of their child's behavior and pay less attention to elements essential to the child's safety, such as the use of car seats or participating in the Safe to Sleep campaign.

What is more, children raised in an environment of significant maternal depression are "at risk for toxic stress and its consequences," which the authors define as "an unhealthy prolonged activation of the stress response unbuffered by a caregiver."

Consequences may include "impaired social interaction and delays in language, cognitive, and social-emotional development." Indeed, postpartum depression has been identified as "1 of the most common adverse childhood experiences that are associated with the costliest adverse adult health outcomes."

The Importance of Screening

Universal screening of new mothers for depression has been recommended by several professional organizations for the past decade, yet an estimated 50% of women who may be depressed during or after their pregnancies "go undiagnosed and untreated, which makes it the most underdiagnosed and undertreated obstetric complication," the authors write in the technical report.

This may have to do with the stigma surrounding mental illness and the fear among many clinicians that asking questions about mental health could make the mother uncomfortable, Earls said. But "if we routinely ask about it, it might make the moms feel more comfortable in bringing it up. Often mothers who are experiencing these symptoms have a tremendous amount of guilt and self-blame, so I think just making it a standard question that we ask everyone, and explaining that this is a common thing that happens — that in itself is very important."

Recommendations

Pediatric primary care clinicians (PCCs) have "a unique opportunity to identify [postpartum depression] and help prevent untoward developmental and mental health outcomes for the infant and family," the authors write.

Patient education can begin as early as the prenatal pediatric visit, during which the clinician can discuss some of the stressors new parents should expect during pregnancy, including the possibility of depression. Pediatricians can even coordinate care with the woman's obstetrician if it is warranted.

After delivery, the authors recommend routine screening of the mother with a validated screening tool at the 1-, 2-, 4-, and 6-month well-infant visits. Clinicians should discuss the results of these tests with her, even if the result is negative. Screening of the partner is also encouraged at the 6-month visit.

The screening tests are not diagnostic, the authors warn. "A positive screen indicates a risk that depression is present, and the purpose of referral is to clarify the diagnosis and offer the indicated treatment." Practices should have resources available to refer the mother for further testing or treatment if necessary, and if the child or family needs supportive therapy, they write.

Pediatric PCCs can help reduce the guilt or shame a mother with a positive screen might feel by emphasizing that these feelings are common and normal. Follow-up also is essential to ensure that she and the family are receiving appropriate care, and that the care is effective.

Mothers often express gratitude when clinicians conduct these screening tests, Earls said. "Some of my colleagues have told me that, even when the screen is negative, the moms have expressed how much it meant to them that the practice cared enough to ask about it. I think that's very important, because often we don't realize the level of support we impart just by asking the question."

Fathers Also at Risk

Perinatal depression may affect new fathers as well as mothers, Jason Rafferty, MD, MPH, EdM, FAAP, from Thundermist Health Center, Providence; Emma Pendleton Bradley Hospital, East Providence; and the Warren Alpert Medical School of Brown University, Providence, all in Rhode Island; and colleagues on the AAP's Committee on Psychosocial Aspects of Child and Family Health, write in an accompanying technical report.

"Available evidence indicates that fathers independently experience higher rates of depression after the birth of a child, which adversely influences parenting and positive interactions." Signs of paternal depression include domestic violence, substance abuse, and compulsive behaviors, all of which may impair parenting and can even interfere with breastfeeding.

Types of Perinatal Mood Disorders

Mood disorders associated with pregnancy appear on a continuum starting with postpartum blues, a relatively minor condition experienced by 50% to 80% of new mothers, with symptoms including sadness, anxiety, insomnia, and feeling exhausted or overwhelmed. This condition usually resolves within 2 weeks or less, the technical report authors explain.

Perinatal depression may occur prenatally or postpartum, they continue. Prenatal depression, which occurs in up to 13% of mothers, usually peaks during the first trimester and then declines. Symptoms include fatigue, exhaustion, decreased motivation, and problems with memory or concentration.

As the name implies, postpartum depression occurs after delivery. The rates peak within 3 months after birth, but symptoms may occur up to 1 year postpartum and include feelings of guilt, worthlessness, and inadequacy, suicidal ideation, and sometimes anxiety or even bizarre thoughts or obsessions.

Postpartum psychosis occurs within 1 to 4 weeks postpartum and affects only two in 1000 births but is considered an emergency because patients may have auditory hallucinations or delusions compelling them to harm themselves or their child. Other symptoms include visual hallucinations, agitation or irritability, anxiety, and disorganized thoughts and behaviors.

The exact causes of perinatal depression are unknown, but several risk factors have been identified, Earls said. "Families who already have other stressors in place, young mothers, poverty, a child with health challenges in infancy — we know that with those factors, the risk is higher." Other risk factors include a personal or family history of depression, marital discord, multiple or preterm births, or stressful transitions, such as returning to work.

The authors have disclosed no relevant financial relationships.

Pediatrics. Published online December 17, 2018. Full text, Report

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