Screening for Postpartum
Depression and Anxiety:
A Perfect Pediatric Opportunity!
Project TEACH has been working with pediatric practices in New York State since 2010. The project, funded by the New York State Office of Mental Health, has supported and strengthened the critical role that New York State pediatric primary care providers (PCP’s) can play in the early identification and treatment of mild-to-moderate mental health concerns for children ranging in age from 0 to 21.
One component of the Project TEACH /NYS American Academy of Pediatrics partnership in 2019 is a series of monthly newsletters touching on topics of concern to pediatricians and to parents.
And now to our topic of this January Project TEACH Pediatric Newsletter: “Screening for Postpartum Depression and Anxiety: A Perfect Pediatric Opportunity!”
2020 is the perfect time to begin screening for postpartum depression in the pediatric primary care setting! The American Academy of Pediatrics (AAP) recently published an extensive and comprehensive policy on “Incorporating Recognition and Management of Perinatal Depression into Pediatric Practice.” According to the AAP, pediatric providers can use CPT code 96161 and bill with the infant’s visit. New York State Medicaid billing guidance can be found at health.ny.gov/health_care/medicaid/program/update/2016/aug16_mu.pdf. Pediatric providers see new mothers earlier and more frequently than other physicians, giving multiple opportunities to assess and screen parental mental health.
Perinatal Mood and Anxiety Disorders: Different Terminology
Anxiety is a common characteristic of mothers’ feelings both during and after pregnancy and is very common in postpartum depression. Additionally, depression can effect up to 20% of pregnant woman. Along with “baby blues” and postpartum depression and anxiety disorders there is also psychosis, obsessive-compulsive disorder and PTSD. Fathers may also develop postpartum depression.
Postpartum depression is common (8%-25%) and in some low income populations may include close to 50% of all new mothers! It is the most common cause of infant toxic stress in the United States. There are significant and highly detrimental effects to developing infants (Table 1). Screening helps assess the baby’s environment and to establish a positive helpful relationship with the family.
Table 1. Effects of Postpartum Depression on Infants
Failure to thrive
- Cognitive deficits
- Less language stimulation
- Less play time
- Less reading stimulation
- Less engagement with mother
Mental health concerns
- Social withdrawal
- Fussy, irritable
- Poor self control, impulsivity
- Attachment disorders
Poor safety: car seats, plug covers, sleep
Over/under use of health care and ER
Difficulty managing health conditions
What to ask at every visit?
Assessing the risk factors for postpartum depression should be part of every well visit (Table 2). Maternal history of mood disorders and/or anxiety is an important risk factor and should be carefully assessed. Discontinuation of anti-depressant medication during pregnancy is a particularly important risk factor.
Table 2. Risk Factors for Postpartum Depression
Psychosocial Risk Factors
- Maternal chronic illness
- History of depression, anxiety, mood
- isorder, substance abuse
- Adolescent pregnancy
- Social isolation
- Stressful life events, miscarriage
- Decreased activity
- Increased crying
- Poor feeding
- Failure to thrive
- Sleeping problems
- Increased accidents
Maternal behavior (observed or expressed by mother, father, grandparents)
- Depressed affect
- Sleeping more or trouble sleeping
- Lack of enjoyment of usual activities/avoidance of usual activities
- Withdrawal from family
- Neglect of newborn or other children
- Questions reflecting self-doubt/ severe anxiety
- Inaccurate expectations of behavior and/or development
- Punitive child rearing attitudes or discipline
Irritable/disruptive in office/frequent visits
Infant risk factors
- Congenital problems
- “Vulnerable child” syndrome
- Fussy temperament
When to screen and what tools are available?
Depressive symptoms peak at 6 weeks, 2-3 months and 6 months. “Baby blues” usually resolve by two weeks so that earlier screening may over identify, but post-partum depressive symptoms can be delayed or persist for up to one year or longer! Screening at one month, 2 months, 4 months and 6 months is recommended in the new AAP policy. Additional screening at 2 weeks and one year can be added. The Patient Health Questionnaire (PHQ-2, PHQ-9) or the Edinburgh Postnatal Depression Scale (EPDS) are commonly used, readily available, well researched, easy to administer, free, and have been translated into many languages (See References).
The EDPS has 10 questions and includes both anxiety and suicidal intent. The PHQ-2 is brief and contains only two questions. The PHQ-9 (which also includes suicidal intent but not anxiety) can be given alone or with the PHQ-2 to determine the extent of depression. The Survey of Well-Being of Young Children (SWYC) is a screening instrument that assesses a broad range of issues including maternal depression (PHQ-2 and EPDS), other family risk factors and child development and behavior.
Remember: Whenever inquiring about postpartum depression there must be a determination of suicide intent and safety of the mother and infant.
What are available resources?
Treatment for postpartum depression must include both treatment for the mother and the mother-infant dyad. Reassurance and parent education can be provided along with specific referrals. Medication is usually not needed but can be provided by obstetricians, internists or psychiatric providers. A pediatric office should have plans available for the rare event of emergency referral (911) or in case of safety issues.
Providers can use Project TEACH’s Maternal Mental Health Initiative (MMHI) – https://projectteachny.org/mmh/ for direct access to expert psychiatrists in maternal mental health, and for assistance with linkages to care and supports in the community. You can also access training – including two online trainings, “Diagnosis and Treatment of Depression during Pregnancy” and “Screening and Treatment of Postpartum Depression.”
Resource material, like the flyer shown here, and guidance for both providers and parents are available through the Postpartum Resource Center of NY www.postpartumny.org and Postpartum Support International www.postpartum.net. Resource material should be available for immediate referrals. Appointments should be confirmed in the pediatric office and frequent follow-up provided. Early treatment results in the best outcomes for mother and baby and should be obtained as quickly as possible (within a day or two).
Identifying and treating postpartum depression are effective ways to ensure optimal early infant brain development – which is after all, why we all do what we do!
By: Jack Levine, MD, FAAP
Dr. Levine is a pediatrician at Kew Gardens Hills Pediatrics and an Executive Committee member of the National AAP Section on Developmental Behavioral Pediatrics.
Overview of Project TEACH Services
Current initiatives in Medicaid and Commercial insurance and the NYS PCMH incentive project, all create an environment that encourages pediatric practices to work toward integrating children’s behavioral healthcare into pediatric primary care. Behavioral health integration has the potential to enhance the value proposition for most practices.
Project TEACH direct services to pediatricians include:
Accessing the educational and supportive services of Project TEACH can help your practice contract for higher payments, while also supporting you and your team in providing more comprehensive higher quality care to your patients with mild-to-moderate mental health concerns.
Funded by a grant from the New York State Office of Mental Health’s Project TEACH.
New York State American Academy of Pediatrics (NYS AAP)
A Coalition of AAP NY Chapters 1, 2, & 3
Elie Ward, MSW | Dir. of Policy, Advocacy & External Relations | email@example.com