Pregnancy-related depression screening and services in pediatric primary care
By Jennifer L. Lovell, PhD, Ryan Roemer, MA, and Ayelet Talmi, PhD
Although pregnancy-related depression (PRD) is one of the most common postpartum conditions, fewer than half of all cases are diagnosed (Gaynes et al., 2005). PRD can adversely affect the mother-child relationship and increase risk for child mental health problems (NIMH, 2010). Well-child visits offer frequent and ongoing contact with the infant, mother, father and siblings. Pediatric clinicians are uniquely positioned to identify and coordinate clinical care of PRD (Feinberg et al., 2006). Gjerdingen and Yawn (2007) argued that, “for screening to positively impact clinical outcomes, it needs to be combined with systems-based enhanced depression care that provides accurate diagnoses, strong collaborative relationships between primary care and mental health providers” (pg. 280). This is of greatest importance with ethnic minorities and families of low socioeconomic status (SES), who face double stigma, higher rates of PRD and more barriers accessing mental health services (Corrigan, 2004).
Model Program for PRD Screening in Primary Care: Project CLIMB
Project Consultation Liaison in Mental Health and Behavior (CLIMB) is an integrated mental health program within a pediatric primary-care clinic in Colorado. The clinic is a residency-training site in a large teaching hospital. The population served is predominantly low SES and ethnic minority families. Members of the CLIMB team include licensed psychologists, psychiatrists, fellows and interns. Integration of behavioral health services allows for children to receive intervention prior to the emergence of more severe disturbances later in development (Talmi, Stafford, & Buchholz, 2009). Project CLIMB was founded in 2005 and the PRD initiative began in 2008. There are three main components of the PRD program: screening, prevention/intervention and training.
The Edinburg Postnatal Depression Scale (EPDS) is a well-validated 10-item screening tool (Cox, Holden, & Sagovsky, 1987) given to all mothers attending their child’s primary-care visits from birth through four months of age. Although not routinely administered to fathers, the EPDS also has reasonable sensitivity and specificity in evaluating paternal PRD (Edmondson et al., 2010). This brief questionnaire takes approximately five minutes to complete, is easily scored and available in English and Spanish. Providers are trained to informally screen fathers and make referrals.
Prevention and Intervention for PRD and Infant Mental Health
Pediatric clinicians involve CLIMB when a mother scores 10 or above on the EPDS or there are concerns about un-endorsed symptoms. A CLIMB team member meets with the family to discuss current symptoms, social support and parental coping. Risk for harm is also assessed. Referrals for mental health services are made when appropriate.
The pediatric provider collaborates with the CLIMB clinician to schedule the child’s next appointment. Multi-stressed families may not be able to follow through with referrals, thus increasing the importance of contact with pediatric primary care to monitor child and family well-being. CLIMB follows the family at the next visit to provide support, explore solutions and help link them with services.
Training Transdisciplinary Pediatric Professionals
The CLIMB team takes an active approach to training residents and other pediatric providers about the importance of screening and intervention for PRD. CLIMB team members present didactics and conduct individual training for residents. We facilitate discussion about using clinical judgment, considering sociocultural factors and making referrals. Training presentations include scripted examples for introducing the EPDS and starting a conversation about how parents are doing.
Policy and Health Reform
Lack of reimbursement for administering behavioral health screening and providing prevention is a barrier to creating sustainable behavioral health programs (Talmi & Fazio, 2012). Healthcare reform offers the opportunity for advocacy around the inclusion of integrated behavioral health and PRD screening in the primary-care setting where the child is the patient (NIMH, 2010). HealthTeamWorks, an organization dedicated to quality improvement in healthcare delivery, published the “Pregnancy-Related Depressive Symptoms Guideline;” these guidelines provide information, talking points and considerations for screening, assessment, diagnosis and treatment. This is a useful tool for the dissemination of research-based information for medical providers.
This model of integrated pediatric primary care encourages strong collaborative relationships between families, primary care providers and mental health providers. An important goal of this initiative is to increase pediatric providers’ competence and comfort in recognizing and managing PRD. This approach is especially important for socioeconomically disadvantaged and ethnic minority populations who are at greater risk for PRD and most profoundly impacted by it (Turney, 2011). This family-based approach also takes advantage of preventive care interventions and continuity to assure appropriate treatment and follow-up.
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Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786.
Edmondson, O.J., Psychogiou, L., Vlachos, H., Netsi, E., & Ramchandani, P.G. (2010). Depression in fathers in the postnatal period: Assessment of the Edinburgh Postnatal Depression Scale as a screening measure. Journal of Affective Disorders, 125, 365–368.
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Turney, K. (2011). Maternal depression and child health inequalities. Journal of Health and Social Behavior, 52, 314-332.