Policy Statement - pdfs.semanticscholar.org · ostpartum depression (PPD) is the most common...

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What is Postpartum Depression? Perinataldepressionisdefinedasaperiodofatleast2weeksduringwhichthereisdepressedmoodorlossofinterestorpleasureinnearlyallactivities,whichoccursduringpregnancyorwithinthefirst12monthsafterbirth.Postpartumdepressionusuallybeginsfrom3to14dayspostpartum,butcandevelopanytimewithinthefirstyearafterdelivery.Symptoms of postpartum depression include:

• Socialwithdrawal

• Deepsadness,cryingspells,hopelessness

• Excessiveworryingandfears

• Irritabilityorshorttemper

• Moodswings

• Feelingoverwhelmed

• Feelingveryemotional

• Difficultymakingdecisions

• Changesofappetite

• Sleepproblems

• Mixedemotionsaboutthebaby

Majordepressiontypicallypeaksatapproximately6weekspostpartumwithanotherpeakat6months1.Theaveragedurationofanepisodeofpostpartumdepression(withouttreatment)issevenmonths. Afteroneepisodeofpostpartumdepression,theriskofrecurrenceinsubsequentpregnanciesis50-

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PolicyStatementJuly2011

Screening for Postpartum Depression at Well-Child Visits

P ostpartumdepression(PPD)isthemostcommoncomplicationofchildbirthwithanestimatedprevalenceof15-20%1.PPDhasdevastatingshort-andlong-termconsequencesforthemother,herpartner,andhernewborn.ThemostsevereadverseoutcomesofPPDincludeincreasedriskformaritaldiscordanddivorce,childabuseandneglect,and

evenmaternalsuicideorinfanticide2.Childrenofdepressedmothersareatincreasedriskforimpairedmentalandmotordevelopment,difficulttemperament,poorself-regulation,lowself-esteem,andbehaviorproblems3.Easy-to-use,reliable,self-administeredscreeningtoolsforPPDareavailable,asareeffectivetherapeuticmodalities.Nevertheless,PPDoftengoesunrecognizedandthereforeuntreated.PediatricianshaveauniqueopportunitytoscreenforPPDsincetheyseethemother/infantdyadatleast7timesduringthefirstyearoflife.ByincorporatingroutinescreeningforPPDintotheseearlywell-childvisits,pediatricianscouldhelpdepressedwomenandtheirchildrenbyidentifyingandreferringwomenforcare.

Box 1. Diagnostic Criteria for DepressionFormajordepression,atleastfiveofthefollowingsymptomsmustbepresentformostoftheday,nearlyeveryday,foratleast2weeks.Atleastoneofthefirsttwoboldedsymptomsmustbepresent.Symptoms:

◊ Depressed mood, often accompanied or overshadowed by severe anxiety

◊ Markedly diminished interest or pleasure in usual activities

◊ Sleepdisturbance–mostofteninsomniaandfragmentedsleep,evenwhenthebabysleeps

◊ Fatigueorlossofenergy

◊ Appetitedisturbance–usuallylossofappetitewithweightloss

◊ Physicalagitation(mostcommonly)orpsychomotorslowing

◊ Feelingsofworthlessnessorexcessiveorinappropriateguilt

◊ Decreasedconcentrationorabilitytomakedecisions

◊ Recurrentthoughtsofdeathorsuicide

Adiagnosisofmajordepressionalsorequiresadeclinefromthewoman’spreviousleveloffunctioning,andsubstantialimpairment.

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75%.Therefore,womenwithanypreviousepisodeofdepressionshouldbepromptlyreferredfortreatment. Anothermentaldisorderthatcanoccurintheperinatalperiodispostpartum psychosis.Unlikepostpartumdepression,postpartumpsychosisisarelativelyrareeventwithanestimatedincidenceof1.1-4.0casesper1,000deliveries4.Theonsetofpostpartumpsychosisisusuallyacute,withinthefirst2weeksofdelivery,andismorecommoninwomenwithastrongfamilyhistoryofbipolarorschizoaffectivedisorder.Itresemblesamanicpsychosiswithagitation,irritability,depressedorelatedmood,delusions,anddisorganizedbehavior,anditcarriesariskofinfanticideandsuicide,makingitapsychiatricemergency.However,withimmediatehospitalizationandtreatmentwithmoodstabilizers,womenwiththisdisordercandoverywell.Althoughitisanimportantdisorderinitsownright,itwillnotbefurtheraddressedinthisissuebrief.

Why Does Depression Matter? Withoutintervention,maternaldepressioncanhavelife-longrepercussionsforthechild,themother,andtheirrelationship.Herearewaysthatitmayhaveanegativeimpact.ForMother:

• Impairedcare-takingofselfandothers

• Alteredappetite/weight

• Sleepdisturbance

• Increasedriskofsubstanceabuse

• Increasedriskofsmoking

• Suicidalthoughtsoractions

• Long-termdepressionoranxiety

ForInfant:

• Increasedcryingandirritability

• Poorattachmenttomother

• Increasedriskofabuseorneglect

• Decreaseddurationofbreastfeeding

• Increasedriskoffailuretothrive

• Poorweightgain

• Physicaldysregulation

ForFamily:

• Maritalfrictionanddivorce

• Contributestofather’sfeelingsofhelplessnessanddepression

• Effectsonolderchildren(emotional,behavioral)

• Causesfeelingsoflossandgriefinfamily

ForChildren:• Developmentaldelays:

o Latewalkingandtalking

o Delayedreadinessforschool

o Learningdifficultiesandproblemswithschoolwork

o Attentionandfocusimpairment

• Emotionalproblems:

o Lowself-esteem

o Anxietyandfearfulness

o Increasedriskfordevelopingmajordepressionearlyinlife

• Behavioralandsleepproblems:

o Increasedaggression

o Actingoutindestructiveways

• Socialdifficulty:

o Problemswithestablishingsecurerelationships

o Difficultymakingfriendsinschool

o Socialwithdrawal

ImpactonEarlyParentingPractices5:• SafetyPractices:

o Decreaseduseofcarseatsandelectricaloutletcovers

o Decreaseduseofsmokedetector

o Lesslikelytoplacebabyonbacktosleep

o Increaseduseofcorporalpunishmentduringfirstyearoflife

o IncreasedriskforaccidentsnecessitatingEDvisits

• FeedingPractices:

o Lesslikelytobreastfeedorbreastfeedforshorterduration

o Morelikelytogivewater,juiceorcerealbeforeageof4months

• Behaviorsthatpromoteearlydevelopment:

o Lesslikelytotalkdailywhileinthehome

o Lesslikelytoplaydailywithinfant

o Lesslikelytoshowbooksdailytoinfant

o Lesslikelytobeaffectionatewithinfant

o Lesslikelytofollow2ormoreroutinesatmeals,naptimeandbedtime

o Lesslikelytomakepediatricappointmentsandfollowthroughonpediatricguidelines

o Morelikelytodisplayangeranddisengagement

Theinteractionbetweenparentandinfantiscentraltotheinfant’sphysical,cognitive,social,andemotionaldevelopment,aswellastohisself-regulationabilities6.Maternaldepressioninterfereswiththemother’scapacitytobondwithherinfantandcanseriouslyimpairthebaby’semotionalandevenphysicalwell-beingbecauseofneglectoftheinfant’sneedsandlackofreinforcementoftheinfant’sengagementcues.Maternaldepressioncanalsoresultininsecureattachmentthatincreasestheriskforsubsequentexternalizingandinternalizingbehaviorsinthedevelopingchild.Thus,itiscriticaltodetectandtreatmaternaldepressionasearlyaspossibleinthelifeoftheinfant.

Who is at risk for Postpartum Depression? Nowomanisimmunetothedevelopmentofpostpartumdepression,butsomenewmothersareatincreasedrisk8.

Medicalorpsychiatricriskfactors:• Familyorpersonalhistoryofmooddisordersorother

mentalillness,historyofdepression,ordepressionoranxietyduringpregnancy.

• Priorhistoryoftraumaorloss,especiallylossof

one’smother.

• Stressfullifeevents–separation,divorce,jobloss,move,etc.

• Unplannedand/orunwantedpregnancy.

• Difficultorhighriskpregnancy.

• Birthtraumaorcomplications.

• Multiplebirth.

• Historyofinfertility.

• Chronicmedicaldisorder.

• Substanceabuse.

• Perinatalloss:miscarriage,stillbirth,neonataldeath,infantdeath.

• BabyinNICU.

• Babywithbirthdefectordisability.

• “Fussybaby”orbabywithdifficulttemperament.

• Adoptedbaby.

Socialriskfactors:• Povertyorfinancialhardship.

• Poororinadequatesocialsupport.

• Relationshipdissatisfactionand/orstress.

• Domesticviolence.

• Highlevelsofchildcarestress.

• Teenmotherhood.

• Singlemotherhood.

• Immigrantstatus.

• Militaryservice.

Why Pediatricians?AccordingtotheAmericanAcademyofPediatrics,pediatricianshaveuniqueopportunities“topreventfuturementalhealthproblemsthrough…timelyinterventionsforcommonbehavioral,emotional,andsocialproblemsencounteredinthetypicalcourseofinfancy,childhood,andadolescence.”9Thefamily-centerednessofthechild’smedicalhomeandthepediatrician’slongitudinal,trusting,andempoweringtherapeuticrelationshipwiththefamilyrepresenttheperfectframeworkforimplementingroutinescreeningformaternaldepression.Moreover,pediatricians,unlikeobstetriciansormidwives,havetheopportunitytoseethemother/infantdyadcontinuallyduringthefirstyearoflife10.Obstetriciansandmidwivestypicallyonlyhaveonepostpartumvisitwiththenewmotherandrarelyseeherbeyond6to8weeks

Box 2. Signs of Possible Problems with Emotional Well-Being in Infants of Depressed Mothers8

◊ Excessivecryingandirritability,withdifficultycalming

◊ Dysregulationinsleep

◊ Physicaldysregulation(e.g.vomitingordiarrhea)

◊ Poorweightgain

◊ Pooreyecontact

◊ Lackofbrighteningonseeingparent

◊ Notturningtosoundofparent’svoice

◊ Lackofvocalizations

◊ Extremelylowactivitylevelortone

◊ Lackofmouthingtoexploreobjects

◊ Sadorsomberfacialexpression(evidentby3monthsofage)

◊ Wariness(evidentby4monthsofage)

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postpartum,atthepointwhenmanylow-incomemotherslosetheirinsurancecoverage.Sincemostdepressedmothersdonotrecognizetheirsymptomsasdepression,theyareunlikelytobeunderpsychiatriccare.Thus,thepediatricianmaybetheonlyproviderthemotherseesonaregularbasisduringthefirstyearofachild’slife.

Screening for Postpartum Depression Studiesexploringthefeasibilityofscreeningformaternalpostpartumdepressionusingastandardizedtool11-13havefoundthattheintroductionofscreeningduringwell-childvisitsiswellreceived,withfewpatientsdeclining.Sincethestandardizedtoolsareself-administered,theycanbecompletedbythemotherwhilesheisinthewaitingroom,andthenscoredbythenurseormedicalassistant.Cliniciantimedemandsaremodest,withmostscreeningsrequiringnoadditionaldiscussion,20-30%requiringbriefdiscussions(lessthan3minutes),andonly4-5%requiringalongerdiscussion13. Thetwomostwidelyused,validatedscreeningtoolsarethePatientHealthQuestionnaire(PHQ-2orPHQ-9)andtheEdinburghPostpartumDepressionScale(EPDS-10).1Bothareavailableatnocost.14,15ThePHQ-2asksaboutthetwofundamentalsymptomsofdepression,diminishedmoodandanhedonia,andrequestssimpleyes/noresponses.MostcliniciansstartbyadministeringthePHQ-2andiftherespondentanswers“yes”toeitherorbothquestions,thePHQ-9isthenadministered.16ThePHQ-9hasbeenvalidatedformeasuringdepressionseverityandcanbeself-administered,administeredtelephonically,orreadtothepatient.Inaddition,ithasbeenvalidatedinAfricanAmerican,ChineseAmerican,Latino,andnon-HispanicwhitepatientgroupsandisavailableinEnglish,Spanish,andChinese. TheEPDS-10,a10-item,self-administeredquestionnairespecificallydevelopedfortheassessmentofpostpartumdepression,focusesonthepsychologicalratherthanthesomaticaspectsofdepression.Patientsrespondtoitemsona4-pointLikertscale.Anxiety is a more prominent feature of postpartum depression17thanofdepressionthatoccursatothertimesinlife,andforsomemotherswithPPD,anxietywillbetheonlysymptom.Therefore, if the pediatrician elects to use the PHQ-9 screening tool over the EPDS-10, we strongly recommend that the EPDS-3 (the 3-item anxiety subscale of the Edinburgh Postpartum Depression Scale18) be used concurrently (See Box 6.)

Box 4. Scoring the PHQ-9 Depression Assessment14

For initial diagnosis

1. PatientcompletesthePHQ-9QuickDepression

Assessment

2. Questions#1and#2areansweredaseither2or

3. Ifthereareatleast5✔sinthetworightcolumns

(includingQuestions#1and#2),consideramajor

depressive disorder.Addscoretodetermine

severity.

4. Functional impairmentisansweredas“somewhat

difficult”orgreater.

Severity Determination

TotalScore DepressionSeverity

0-4 None

5-9 Mild

10-14 Moderate

15-19 Moderatelysevere

20-27 Severe

Box 3. Screening Protocol for Postpartum Depression at Well-Child Visits

◊ Who Allmothers

◊ When Ateachwell-childvisitthefirstyear

oflife

◊ Where Waitingroom(self-administered)or

inprivateroomifpatienthaslow

healthliteracyandneedsMAto

readittoher

◊ Whoscores Nurseormedicalassistant

◊ How PHQ-2,followedbyPHQ-9if

answer“yes”toeitherquestion,

PLUSEPDS-3

◊ Why Earlydetection

Is the Patient Unsafe to Self or Others? Onceyouhavedeterminedthatthemotherisdepressed,itiscriticaltoassesssuicidaltendencies.14AskingquestionsaboutsuicidewillNOTmakeamothermoreorlesssuicidalthanshealreadyis.Infact,theopportunitytodiscusshersuicidalthoughtsisoftencathartic.Thefirstclueisifthemotheransweredyestoquestion#9onPHQ-9–“Overthepast2weeks,howoftenhaveyoubeenbotheredbythoughtsthatyouwouldbebetteroffdead,orofhurtingyourselfinsomeway?”Consideraskinganddocumentingthefollowingprogressionofquestions:

1.Doyoufeelthatlifeisworthliving?

2.Doyouwishyouweredead?

3.Haveyouthoughtaboutendingyourlife?

4.Ifyes,haveyougonesofarastothinkabouthowyouwoulddoso?

5.Doyouhaveaccesstoawaytocarryoutyourplan?

6.Whatkeepsyoufromharmingyourself?

Manypatientswillnotanswer#4directlyorwilladd,“ButI‘dneverdoit.”Givethempositivefeedback(e.g.,“I’mgladtohearthat”)butdonotdropthesubjectuntilshehastoldyouthespecificmethodsconsidered(e.g.,gun,medicationoverdose,motorvehicleaccident). Itisimportantforeachhealthcareofficeorclinic

Box 6. 3-Item Anxiety Subscale of Edinburgh Postpartum Depression Scale18

PleaseunderlinetheanswerthatcomesclosesttohowyouhavefeltINTHEPAST7DAYS,notjusthowyoufeeltoday.

1 Ihaveblamedmyselfunnecessarilywhenthingswentwrong.

Yes,mostofthetime

Yes,someofthetime

Notveryoften

No,never

2 Ihavebeenanxiousorworriedfornogoodreason.

Yes,veryoften

Yes,sometimes

Hardlyever

No,notatall

3 Ihavefeltscaredorpanickyfornoverygoodreason.

Yes,mostofthetime

Yes,sometimes

Hardlyever

No,notatall

Box 5. PHQ-9: Guide to Diagnosis and Treatment Options14

PHQ-9 Score Provisional Diagnosis Treatment Options

5-9 Minimalsymptoms Support,educatetocallifworse,returninonemonth

10-14Minordepression*Dysthymia**Majordepression,mild

Support,watchfulwaitingAntidepressantorpsychotherapyAntidepressantorpsychotherapy

15-19 Majordepression,moderatelysevere Antidepressantorpsychotherapy

>20 Majordepression,severeAntidepressantandpsychotherapy(especiallyifnotimprovedonmonotherapy)

*Ifsymptomspresent>1monthorseverefunctionalimpairment,considertherapy.**Ifsymptomspresent>2years,probablechronicdepression,warrantstherapy.

Example Suicidality Screening Flow*

Adapted from Major Depression in Adults in Primary Care 14

*Note: A clear chain of responsibility within the clinic system needs to be established and distributed to all parties who may identify a suicidal patient. Well-defined follow-up procedures for contacting the patient for further evaluation need to be established. Events need to be well documented in the patient’s medical record.

Patient answers positive on question nine of PHQ-9

Patient volunteers thoughts about suicide

LEVEL OF RISK: Current thoughts? How often? For how long? Plan? Intent? Means? Preparations? Previous attempts? Family history of suicide? Current use of alcohol or drugs? Severe stressors? Marked coping difficulties? High-risk factors (psychosis, agitation, history of aggressive or impulsive behavior, hopelessness, high anxiety, comorbid physical illness, high-risk demographics

With intent, current lethal plan

IMMINENT RISK: 1. Call 911 or 1-800-854-77712. Notify primary physician

Chronic thoughts, no intent No plan No means No previous attempts No active substance use No family history

LOWER RISK: 1. Discuss with primary physician

within 24 hours 2. Offer patient information about

contact numbers and procedures if suicidal ideation returns or worsens

3. Explain to patient that other clinical staff may be contacting them for further assessment, and confirm how they can be reached in the next 24 hours if needed

Current/acute thoughts and: Plan with no means or intent or Previous attempts or Current substance use or Family history of suicide or High-risk factors

MODERATE TO HIGH RISK: 1. Discuss with primary physician within one hour 2. Explain to patient that other clinical staff will be

contacting them for further assessment, and confirm how they can be reached within the hour if not in clinic.

3. Offer patient information about contact numbers and procedures if suicidal ideation worsens

National Suicide Hotline1-800-SUICIDE or 1-800-782-24331-800-273-TALK or 1-800-273-8255L.A. County Mental Health Hotline1-800-854-7771

[divorced or separated, Caucasian or Asian race]

todevelopitsownsuicideprotocol.Theofficeshoulddevelopaclearprocessforriskassessment,includingwhentoinvolveamentalhealthspecialist,useoflocalornationalhotlines,nextsteps,etc.SeealgorithmforSuicidality Screening Flowonpage6. Amotherdeemedtobeatimminentriskforsuicideshouldnotbeleftaloneforevenashortperiodoftime(notevenwhenshegoestothebathroom);someoneshouldstaywithheruntiltheLosAngelesCountyPsychiatricMobileResponseTeam(PMRT)arrivestoevaluateher,andifnecessary,involuntarilydetainher.PMRTrespondstorequestsformobilepsychiatricserviceswithin60minutesoftheinitialcallto800-854-7771.

Educating and Engaging the Depressed Mother Successfulcareofmajordepressionasamedicalillnessrequiresactiveengagementofeachpatientandherfamily,andongoingeducation,beginningatthetimeofdiagnosis.TheNationalResearchCouncilandInstituteofMedicine’s2009report19recommendsthatafocusonpositiveparentingandchilddevelopmentbepairedwithtreatmentofparentaldepressiontopreventadverseoutcomesinthechild,enhancetheparent’sinteractionswiththechild,andhelpengagetheparentintreatment.Keymessages14include:

• You are not alone.Maternaldepressioniscommonmedicalillnessandcanaffectanywomanregardlessofage,income,culture,oreducation.

• You did nothing to cause this.Thisisnotyourfault.

• Help is available.Thesooneryougettreatment,thebetter.

• Recovery is the rule, not the exception.

• Treatment is effective for most patients.Theaimoftreatmentiscompleteremission,notjustgettingbetter,butstayingwell.

Referring the Depressed Mother for Treatment Pediatricianscanreferthedepressedmothertoherprimarycareprovider,ordirectlytoamentalhealthspecialist,forinitiationoftreatment,dependingonthemother’spreference.Ideally,thepediatricianhasasocialworkerco-locatedathisofficeorclinic.Alternatively,thepediatricianhasaworkingrelationshipwithamentalhealthprofessional(MSW,MFT,PsyD,PhD,psychiatrist)inthecommunitytowhompatientscanbeeasilyreferred.

However,ifthepediatricianneedstofindatherapistforadepressedmotherinLosAngelesCounty,hecancall2-1-1and/orPostpartumSupportInternational(PSI)at1-800-944-4PPD(www.postpartum.net). Tothegreatestextentpossible,itisimportantfortheretobea“warmhand-off”wherebytheprimarycareproviderdirectlyintroducestheclienttothementalhealthprovider.Thereasonforthisisbothtoestablishaninitialface-to-facecontactbetweentheclientandthementalhealthcounselorandtoconferonthecounselorthetrustandrapporttheclienthasdevelopedwiththeprovider.Manycliniciansreportthatthisface-to-faceintroductionhelpsensurethatthecounselingappointmentwillbekept.Nevertheless,supportandeducationintheprimarycaresetting,i.e.,thepediatrician’soffice,arecriticalandcontributetothelikelihoodofgoodfollow-throughontreatment. Theimpactofthemother’sdepressiononherolderchildrenandfamilyasawholeshouldalsobetakenintoconsiderationwhenmakingreferrals.Forexample,ifthemother’sdepressionhasbeenchronic,olderchildrenmightneedacomprehensivementalhealthevaluationand/orreferralforearlyintervention.

Patient Self-Management Alldepressedwomenneedpsychosocialsupportandshouldbeencouragedtoidentifyfamilymembersandfriendswithwhomtheycantalk.Ifnonecanbeidentified,itisimportanttoreferthemtoapostpartumsupportgroup.20Activityschedulingisastraightforwardbehavioralinterventioninwhichpatientsaretaughttoincreasetheirdailyinvolvementinpleasantactivitiesandtoincreasetheirpositiveinteractionswiththeirenvironment 21.Physicalactivity,atadoseconsistentwithpublichealthrecommendations(i.e.,30minutesofmoderate-intensityaerobicexercise,3to5daysaweek,forotherwisehealthyadults),canalsobehelpfulineasingthesymptomsofmajordepression.

Treatment Options Pharmacologicand/orpsychotherapyinterventionsarealsoeffectiveintreatingdepression.Factorstoconsiderinmakingtreatmentrecommendationsaresymptomseverity,presenceofpsychosocialstressors,presenceofco-morbidconditions,chronicityofsymptoms,andpatientpreferences.If the mother has mild to moderate depression, either an antidepressant or psychotherapy is indicated, or possibly both.Ontheother

hand,ifthepresentingsymptomsofdepressionaresevereorchronic,acombinationofanantidepressantandpsychotherapyisoftennecessary. Itisimportanttoalsotakeintoaccountculturalbeliefsandtheavailabilityofresourcessuchastransportation,finances/insurance,andchildcarewhenmakingthedecisiontotreatwithmedicationand/orpsychotherapy.Resultsfromasystematicreview22showedclinicalbenefitswhenracialandethnicminoritywomenwereallowedtochoosetheirtreatmentandprovidedwithsupportandoutreachservices. Psychotherapyfordepressionincludesindividual,family,dyadic(motherandinfant),andgrouptherapy.Cognitive-behavioraltherapy,interpersonaltherapy,short-termpsychodynamicpsychotherapy,andproblem-solvingtreatmentallhavedocumentedefficacy.However,justbecauseamotherreceivestreatmentforherPPDdoesnotmeanherinfantwillexperienceimprovedoutcomes. Unhealthydyadicrelationshippatterns,establishedduringtheearlierstagesofthepostpartumdepression,maycontinue.23Thesearepatternsthattheinfantparticipatedinasawayofcopingwithor“normalizing”interactionwithadepressedcaretaker.Thus,manyexpertsrecommendinfant-motherpsychotherapy.24 Effectivenessofantidepressant medicationsisgenerallycomparablebetween,andwithin,classesofmedications.However,therearedistinctdifferencesinside-effectscausedbytheclassesofmedicationsandindividualagents.14,24,26Moreover,whentreatingpostpartumwomen,itisimportanttoconsiderwhetherthemedicationissafeforbreast-feedingorpregnantwomen.27Nortriptyline,paroxetine,andsertralinearethepreferredchoicesinbreastfeedingwomen14.Foracompletelistofmedications,pleaseseewww.otispregnancy.org. Whenantidepressanttherapyislikelytobeprescribed,thefollowingkeyeducationalmessagesshouldbehighlighted:

• Sideeffectsfrommedicationoftenprecedetherapeuticbenefitandtypicallyrecedeovertime.

• Successfultreatmentofteninvolvesdosageadjustmentsand/ortrialofadifferentmedicationatsomepoint,tomaximizeresponseandminimizesideeffects.

• Mostpeopleneedtobeonmedicationatleast6-12monthsafteradequatealleviationofsymptoms.

• Patientsmayshowimprovementwithin2weeksbut

needalongerperiodoftimetoreallyseeresponseandremission.

• Continuetotakethemedicationasprescribedevenafteryoufeelbetter.Prematurediscontinuationofantidepressanttreatmenthasbeenassociatedwitha77%increaseintheriskofrelapse/recurrenceofsymptoms.

• Donotstoptakingthemedicationwithoutfirstcallingyourprovider.Sideeffectscanoftenbemanagedbychangesinthedosageordosageschedule.

• Mostimportantly,instructthemotherandheradultfamilymemberstobealertfortheemergenceofagitation,irritability,andothersymptoms.Theemergenceofsuicidalityandworseningdepressionshouldbecloselymonitoredandreportedimmediatelytoherhealthcareprovideror9-1-1.

Establish Follow-Up Plan Proactivefollow-upcontacts(inperson,bytelephone)significantlylowerdepressionseverity28.Theadditionofacaremanagercanhelpthebusypediatricianmakesurethemotherhasfollowedthroughonhisreferrals.

Legal and Ethical Considerations OnebarriertoscreeningforPPDhasbeenpediatricians’legalandethicalconcernsoverscreeningparentsduringapediatricvisit,foraconditionthatcanhaveseriousnegativeeffectsontheinfant.29Liabilityoftendependsonthe“standardofcare”inthecommunity.NowthatAAP’sTaskForceonMentalHealth(TFOMH)hasproposedthatpediatricians,aspartoftheirSurveillanceofEnvironmentforRiskFactors,“screenformaternaldepressioninthefirstyearoflifeofthechildandwhenpsychosocialhistoryindicates”30,thestandardofcareislikelytoshift.Withrespecttoethicalconsiderations,ifcliniciansknowthatatreatabledisorderisprevalentintheirpopulationandmayaffectthehealthoftheirpatient,i.e.,thechild,theyareindeedethicallyboundtoscreenandrefermothersforhelp.Whenscreening,pediatriciansshouldclarifythatscreensforPPDareperformedforthepurposeofenhancingthechild’swell-being.Moreover,pediatricprovidersshouldbecautiousaboutoversteppingtheboundsoftheirrole,andleaveongoingcareandtherapyoftheadulttoqualifiedprofessionals.31

Coding TheAAPhasdevelopedacomprehensivetoolkittohelpprimarycarecliniciansmoreeffectivelyidentifyandmanageavarietyofmentalhealthissues,includingmaternalPPD.Thetoolkit,“AddressingMentalHealthConcernsinPrimaryCare,”releasedinJune2010,includesscreeningtools,step-by-stepcareplans,parenthandouts,andotherresources. Ofnote,itincludesaguidetohelpcodeforthespecificstepsinthementalhealthalgorithmsintroducedbytheAAPTFOMH.32,33ScreeningformaternalPPDfallsunderAlgorithmA.TheTFOMHprovidesavarietyofoptionsforcodingprimarycarevisits,somemightreflectthepossibilityofanextendedvisit(i.e.,multiplestepsinthealgorithmduringoneencounter),whileothersreflectacontactfocusedonaspecificstep.Theguidealsotakesintoconsiderationifthepediatricianhasaco-locatedlicensedmentalhealthprofessionalintheofficetoperformorassistwithsomesteps. TheAAPandtheAmericanAcademyofChildandAdolescentPsychiatryreleasedawhitepaperaddressingtheadministrativeandfinancialbarrierstoaccessingmentalhealthservicesaswellascollaborationbetweenpediatricprimarycareprovidersandtheirmentalhealthcolleagues.34Thepediatricianplaysacriticalroleinongoingcommunicationandco-managementtomonitorthechild’sprogress,supportthechildandfamily,andensurecarecoordination.Inthecontextofmaternaldepression,carecoordinationbecomesevenmorecomplex–oftenbringinginthemother’sprimarycareprovider,therapist,and/orpsychiatrist,aswellasthetherapistprovidingdyadiccare. ThePatientProtectionandAffordableCareActrequiresinsurerstocoverpreventivecareandscreeningswithoutanycostsharing,includingscreeningforpostpartumdepression.In2010theNationalInstituteforHealthCareManagementreleasedanimportantissuebrief 35highlightingwhathealthplanscandotoensureearlyidentificationofmaternaldepressionandcarecoordination.SomehealthplanssuchasWellPoint,Inc.andKaiserPermanentearealreadyaddressingthisissue,byencouragingobstetricians,pediatricians,andprimarycareproviderstoscreenformaternaldepression,byraisingawarenessofmaternaldepressionthroughpatienteducationinmaternityprograms,andbyprovidingfreeaccesstophysicianeducation.

Home Visiting Pediatriciansconcernedaboutthewell-beingofaninfantofaseverelydepressedmothershouldalsoconsiderreferringthefamilytoanevidence-basedhomevisitingprograminthecommunity,suchasEarlyHeadStart,HealthyFamiliesAmerica,Nurse-FamilyPartnership,HomeInstructionforParentsofPreschoolYoungsters,orParentsasTeachers.Thesehomevisitingprogramscanimproveoutcomesformothersandyoungchildreninavarietyofareas,includingpreventionofchildabuseandneglect,childhealth,maternalhealth,childdevelopmentandschoolreadiness,familyeconomicself-sufficiency,andpositiveparentingpractices.Unlikeaphysician,thehomevisitorhastheopportunitytoseethemotherinherreal-lifecontextandthetimetositandlistentoher.

They come to your home where you are comfortable. Because I’ll tell you right now, they don’t come out in suits. They come out dressed like whoever. They don’t make you feel uncomfortable… It’s not going into somebody’s office. It’s almost like sitting down talking to a friend.36

Therearealsosomehomevisitingprogramsspecificallydesignedtomeettheneedsofparentsofinfantsandtoddlersstrugglingwithmentalhealthproblems,suchasLosAngelesChildGuidanceClinic’sFirst Steps Program.Thisprogrampromotesastrongparent-childattachmentusingastructuredhome-basedinterventionmodel.Thismodelfacilitatesunderstandingandsupportforparentsinwaysthatleadtoabetterunderstandingofhowtheycanimproveoutcomesfortheirchildren,e.g.throughtalking,singingandreadingtoinfantsandtoddlers,playinginteractivegames,andinterpretinginfantandtoddleremotionalcues.Thisapproachtotreatmentincreasesparents’awarenessabouttheirchildren’sneeds,improveschildren’sdevelopmentalcourse,andexpandssafetyandstimulationinthehomeenvironment.

ResourcesAAPMentalHealthToolkitPediatrics2010;Volume125Supplement#3EnhancingPediatricMentalHealthCare

Freeonlinetraining:www.step-ppd.com/step-ppd/home.aspx

Medications:www.otispregnancy.org

LACountyPerinatalMentalHealthTaskForce’sPerinatalDepressionToolkit:www.lacountyperinatalmentalhealth.org

PostpartumSupportInternational1-800-944-4773http://www.postpartum.net/

SuicideHotlines:National1-800-SUICIDEor1-800-784-2433LACounty1-800-854-7771

References1. GaynesBN,GavinN,Meltzer-BrodySetal.Perinatal

Depression:Prevalence,Screening,Accuracy,andScreeningOutcomes.AgencyforHealthcareResearchandQuality.EvidenceReport/TechnologyAssessment,Number119,2005.

2. McCoySJ.PostpartumDepression:AnEssentialOverviewforthePractitioner.SouthMedJ2011;104:128-132.

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5. McLeanKT,MinkovitzCS,StrobinoDMetal.MaternalDepressiveSymptomsat2to4MonthsPostpartumandEarlyParentingPractices.ArchPediatrAdolescMed2006;160:279-284.

6. EarlsMF&TheCommitteeonPsychosocialAspectsofChildandFamilyHealth.ClinicalReport-IncorporatingRecognitionandManagementofPerinatalandPostpartumDepressionintoPediatricPractice.Pediatrics2010;126:1032-39.

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Adolescents:PromotingMentalHealth,ThirdEdition,ElkGrove,IL:AmericanAcademyofPediatrics,2008.

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10. ZuckermanBS,BeardsleeWR.MaternalDepression:AConcernforPediatricians.Pediatrics1987;79:110-117.

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Sample Screening Form16

Depressionisacommonbuttreatableillnessthatoccursmoreoftenamongparents.Manypeoplewhosufferdon’trealizetheyhaveamedicalillnessandcouldbenefitfromtreatment.TheU.S.PreventiveServicesTaskForcerecommendsthatalladultsbecheckedfordepressionwhentheyseeadoctor.Parentsofchildrenwhoarecaredforinthispracticemayseeusmoreoftenthananyotherhealthcareprovider.TheTaskForceisconsideredtheauthorityonpreventivehealthcareandwebelieveitiswisetofollowtheiradvice.Itisourjobbecause,ifaparentisdepressed,theirchildisaffected.Thechilddoesbetteriftheparentgetshelp.

Forthisreason,pleasetakeaminutetorespondtothefollowingquestions.Wewillthentakealookatyourresponsestogetherduringthisvisit.

1. Overthepast2weeks,youhavefeltdown,depressed,orhopeless?(True or false)Iftrue,haveyoufeltthiswayfor:severaldays,morethanhalfthedays,ornearlyeveryday?

2. Overthepast2weeks,youhavefeltlittleinterestorpleasureindoingthings?(True or false) Iftrue,haveyoufeltthiswayfor:severaldays,morethanhalfthedays,ornearlyeveryday?

PleaseunderlinetheanswerthatcomesclosesttohowyouhavefeltINTHEPAST7DAYS,notjusthowyoufeeltoday.

1. Ihaveblamedmyselfunnecessarilywhenthingswentwrong.Yes,mostofthetimeYes,someofthetimeNotveryoftenNo,never

2. Ihavebeenanxiousorworriedfornogoodreason.Yes,veryoftenYes,sometimesHardlyeverNo,notatall

3. Ihavefeltscaredorpanickyfornoverygoodreason.Yes,mostofthetimeYes,sometimesHardlyeverNo,notatall

Policy Statement - pdfs.semanticscholar.org · ostpartum depression (PPD) is the most common...

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