Now 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.

Why screen?

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

• Decreased breastfeeding
• Failure to thrive
• Developmental delay
  • Cognitive deficits
  • Less language stimulation
  • Less play time
  • Less reading stimulation
  • Less engagement with mother
• School problems
• Sleep problems
• Mental health concerns
  • Social withdrawal
  • Fussy, irritable
  • Poor self control, impulsivity
  • Anxiety/depression
  • Attachment disorders
  • Aggression
• 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

• Poverty
• Maternal chronic illness
• History of depression, anxiety, mood
• isorder, substance abuse
• Adolescent pregnancy
• Social isolation
• Stressful life events, miscarriage

Infant behavior

• 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

• Prematurity
• 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.