1. Addressing Postpartum Depression: Opportunities in the Pediatric Setting
Lisa Honigfeld, Ph.D.
Vice President for Health Initiatives
Child Health and Development Institute
Please begin by introducing yourself and saying that you are here as part of the Educating Practices in the Community Program, which is sponsored by the Child Health and Development Institute.
“Hello, my name is ______, and I am here as part of the part of the Educating Practices in the Community Program, which is sponsored by the Child Health and Development Institute. Today I will be speaking about postpartum depression within the pediatric primary care setting.”
At this point some individuals may ask who is paying for lunch. The answer is that CHDI is funded by the Children’s Fund of Connecticut, which is made up of the funds from the old Newington Children’s Hospital. This money was put aside to fund the improvement of primary and preventive health services for children in Connecticut. The EPIC program is designed to bring information to pediatric and family medicine practices throughout the state on resources to help them deliver services to children. Say that you are leaving folders about EPIC and that CHDI would be happy to come and talk about other topics. Some practices will know about EPIC as we have been there with other presentations.

2. Goals of Presentation
To increase knowledge about postpartum depression and the possible effects of postpartum depression on infant and child development
To encourage the use of screening tools to
identify postpartum depression
Provide information about referral sources for postpartum depression
“There are three goals in our presentation today. The first goal is to increase knowledge about postpartum depression and the possible effects it can have on infant and child development. The next two goals are related to postpartum depression specifically in relation to pediatric primary care. This includes encouraging the use of screening tools, and providing information about referral sources in your community for women with postpartum depression. This presentation is designed to be useful and relevant to all individuals within this pediatric primary care setting, regardless of job description and role. As you will come to see, everyone can play a part in recognizing postpartum depression in a time-efficient way. “

3. Mood Disorders and Pregnancy
Four mood disorders associated with pregnancy:
Postpartum blues, or “baby blues”
Most common- affects 70-80% of women following childbirth
Occurs two to three days following giving birth and include feelings of sadness, depression, or anxiety.
Short-lasting
Perintal depression
Includes major or minor depressive episodes that occur during pregnancy or in the year following childbirth
Postpartum psychosis
Rare
Sudden onset within the first four weeks following giving birth
Symptoms include hallucinations, delusions, and rapid mood change
Women observed to be experiencing these symptoms must receive psychiatric care immediately
“You may know that there are actually four mood disorders associated with pregnancy: postpartum blues, or “baby blues”, perinatal depression, and postpartum psychosis. Postpartum blues are the most common of the 4, and affects between 70-80% of women. It’s short-lasting and will end without treatment. It generally occurs 2-3 days following giving birth, and the new mother may have feelings of sadness, depression, or anxiety. Slight issues with their sleeping or eating could also be observed, as well as general parenting doubts. Perinatal depression includes major or minor depressive episodes, but these may occur during pregnancy or the year following childbirth. Postpartum psychosis is the most rare of these four. It will suddenly occur, and has been sensationalized in the media as women with this disorder could be at risk of harming their infant. Symptoms include hallucinations, delusions, and quick mood changes. Women experiencing these symptoms must receive psychiatric care immediately, as they could be at risk for harming themselves or their infants. Today we will focus on postpartum depression, which is a more prolonged and severe version of the postpartum blues that also occurs following childbirth.”

4. Postpartum Depression
What is it?
Begins within 4 weeks after childbirth
Type of major depressive episode
Serious mental health problem
Extended period of emotional disturbance
Can have real consequences for the new mother and her family
“So what is postpartum depression? It is a major depressive disorder that begins within four weeks following childbirth. While not recognized as being entirely separate from major depression, it is recognized by the American Psychological Association (APA) as a serious mental health problem that can have very real and significant consequences for the new mother and her family” (American Psychological Association, 2007)

5. Prevalence of Postpartum Depression
Affects approximately 13% of women
Some prevalence rates are estimated to increase to:
41% of women with history of postpartum depression and
56% of urban and low-income women
““Unfortunately, postpartum depression is fairly common, with roughly 13% of women having the disorder. If the mothers of your patients have had postpartum depression in the past or come from urban and low-income areas, that rate of PPD significantly increases. As we see here, the rates can climb to 41 or 56% for some women. With research on how some women, such as African American women, may be more apt to deny postpartum depression symptoms, acceptance towards and education about PPD to your patients becomes even more important. Also,knowing about the background of the family can help you better determine their risk of PPD.” (American Psychiatric Association, 2010; American Psychological Association, 2007; Chaudron, et al., 2010; O Hara & Swain, 1996)

6. Symptoms of Postpartum Depression*
Difficulty with daily living tasks
Increased risk for anxiety, guilt, fear, crying
Difficulty providing care for the infant
Isolation from family and friends
Thoughts of hurting oneself or the infant
Loss of pleasure in previously enjoyed activities
Infants may be: gazing less at mothers and others, making less noise, displaying limited or a lack of positive facial expressions, have very irritable or fussy behaviors, a lack of interest in objects, and obvious attempts at disengaging (such as arching their backs)
* Cultural/ethnic differences are possible
““There are several symptoms of postpartum depression. Notice that some of this may represent the normal adjustment symptoms following this huge life change that giving birth entails. However, keep in mind that these symptoms, when at a severe enough level, and when experienced in combination, can be debilitating for both mother and baby: A reduction in the ability to function in daily life, which can look like difficulties getting out of bed, managing the household, food-shopping, etc. Next, increased risk for feelings of anxiety, guilt, and fear of hurting the baby that appear to be unreasonable or illogical fears. Difficulty providing care for the infant is another clue. For example, is the infant’s diaper soiled, or their clothes dirty? Additionally, crying, a lack of interest in being with others (especially if they had enjoyed social interactions previously), thoughts of hurting oneself and others would certainly indicate need for assistance, as well as loss of pleasure in previously enjoyed activities. Also, infants may be one of the most useful sources of information when evaluating whether the most has postpartum depression. Look for infants who are: gazing less at mothers and others, making less noise, displaying limited or a lack of positive facial expressions, have very irritable or fussy behaviors, a lack of interest in objects, and obvious attempts at disengaging (such as arching their backs).” (American Psychological Association, 2007, Jellinek, et al., 2002). However, it’s important to know that women of different ethnic backgrounds or cultures (for example, African American women) may experience symptoms somewhat differently or attempt to hide or minimize their symptoms because of a lack of trust of the healthcare system.”
American Psychological Association, 2007, Jellinek, et al., 2002

7. Effects on Child
Postpartum depression has the potential to affect MANY individuals beyond the mother (spouse, friends, children)
The infant who is your patient is at risk of experiencing a range of consequences in the areas of:
Developmental, physical, cognitive, and behavioral
Mother’s parenting behaviors
““You still may be wondering how postpartum depression affects your primary care practices. Postpartum depression has the potential to affect MANY individuals beyond the mother, including their children, spouse, and friends. The infant, who is your patient, could be at risk for experiencing consequences in developmental, physical, behavioral, and cognitive areas as well as the parenting behaviors of the mother. We’ll start with how it can affect their development. “

8. Developmental Effects on Child
Infant’s quality of attachment is incredibly important
If the mother is physically or emotionally unavailable, (such as when depressed) emotional dysregulation can occur
From this, the infant experiences changes that can affect his or her affect, motor, physiological, and biochemical levels
Maternal depression is associated with infants developing insecure attachment styles
“When considering the development of the infant into a healthy child and healthy adult, their quality of attachment is incredibly important. The mother, who is likely to be the main caregiver, provides the infant with physical and emotional support. If the mother is physically or emotionally absent (such as when depresssed), dysregulation can occur that could affect their entire existence: their mood, motor, physiological, and biochemical levels. Maternal depression is also associated with infants developing insecure attachment styles, which usually persist through adulthood and are extremely difficult to change even with therapeutic intervention.”

9. Physical Effects on Child
Infants of depressed mothers have been documented as:
Demonstrating less interaction, smiling, vocalizing,
Poorer muscle control
Gaze aversion
More lethargy
“As discussed in a previous slide, infants of depressed mothers can show behaviors that are different from infants of non-depressed mothers. This could look like being less interactive with their mothers or the staff in your office, less smiling, less noise-making, difficulties having age-appropriate muscle control, not looking at their mother or you, and being overly tired. Unfortunately these physical differences could have big consequences for their later development.”

10. Behavioral Effects on Child
Slower to orient
Less time spent exploring new objects
More crying during periods of stress
More conduct issues at school
More physical play behaviors at school
“Studies document the range of differences in behaviors that infants and children of depressed mothers may show. For example, in one study they infants were slower to orient to faces, which could show attention issues. They also were less likely to explore, and had difficulties calming themselves during times of stress. Long-term studies document kids who have more behavioral difficulties and physical play behaviors at school, showing us that early intervention to reduce the impact of postpartum depression is crucial.”

11. Cognitive Effects on Child
Cognitive Development
Lower scores (by as much as 10 points) on Bayley Scales of Infant Development, Mental, and Motor Scales
When tested at age 11, they had lower IQ scores, made more errors on an attention task, and also showed more conduct issues at school
Brain Development
Infants show EEG activity that suggests vulnerability for depression
“Cognitive effects are possible, with infants having lower scores by as much as ten points on the Bayley scales. Long-term studies tested infants of mothers with postpartum depression 11 years later found lower IQ scores (most particularly if they were boys), more errors on an attention tasks, and more conduct issues at school.”
In the area of brain development, EEG studies found that infants of depressed mothers display a vulnerability for depression.”

12. Parenting Effects on Child
Poorer care-giving skills including being
less likely to:
Breastfeed, play with infants, talk to infants
Follow routines
Read to child
Seek preventive services such as Well-Child visits and vaccinations
Twice as frustrated with child’s behaviors
“Postpartum depression can also change the way the mother parents (and keep in mind that these are also good clues that the mother may be experiencing depressive symptoms). The mother with postpartum depression may breastfeed less, play with their infants less, talk to their infants less, or be less able to follow routines. They also may be less likely to attend Well-Child appointments. While this absence from services may make detection more difficult, reviewing the chart and noticing missed or lack of appointments and vaccinations could be another clue that the mother is experiencing PPD symptoms. And, overall, mothers can be twice as frustrated with their child’s behaviors if they are experience.”

13. Interventions that Can Help
There are options for reducing PPD and it’s effects, including:
Psychological Therapy
Psychopharmacological treatment
Home support
Support groups
However,
Crucial for early intervention
More chronic, severe, and recent the depression, the more negative effects on children
““So now that we have reviewed symptoms of postpartum depression and it’s possible effects on your patient the infant and child, it’s important to stress that interventions for postpartum depression can work and continue to be developed and evaluated. There are many options that have been studied and reduce postpartum depressive symptoms, including: psychological therapy, psychopharmacological treatment, home nursing assistance and general support groups. However, the more chronic, severe, and recent the maternal depressive symptoms are, the worse the impact is on the child. So early intervention is crucial!.”

14. Primary Care and Postpartum Depression
Why is pediatric primary care (the Medical Home) a good venue for addressing postpartum depression?
First contact
Universal
Longitudinal
Has a range of services
Linked to larger systems
“So why is pediatric primary care, or ‘the Medical Home’, a good venue for addressing postpartum depression? For many reasons. First, it is the ‘first contact’”, which means it exists for prevention, monitoring, and acute problems. Next, it is ‘universal’, as it is required for entry into many systems. It is also ‘longitudinal’, as it operates on a relationship based, birth to 21 format. The ‘range of services’ means you offer prevention, diagnosis, and treatment. Finally, the medical home allows you to be ‘linked to larger systems’ meaning you can access referral sources, labs, and hospitals in ways that your patients or even other systems cannot.
Before we continue on the opinions of some other pediatric primary care providers, at this point, I’m wondering what your thoughts are on addressing postpartum depression in primary care settings. ” Pause for brief commentary and discussion.

15. Primary Care and Postpartum Depression
2003 report of the Task Force on the Family by the American Academy of Pediatrics:
Family pediatrics requires partnernship between family and pediatrician
Responsibility of pediatrician: screening, assessment, and referral of parents with physical, emotional, or social problems that may affect functioning of the child
However, the Task Force also understands that some pediatricians may be:
Limited in training
Limited in experience
Unaware of referral sources
Concerned about reimbursement
Concerned about time constraints
“The American Academy of Pediatrics stresses the importance of the functioning of the family when treating your child patient. In the 2003 report of the Task Force on the Family, parents are recognized as a crucial aspect of the pediatric primary care approach. Family pediatrics requires an active partnernship between pediatrician and family. This partnernship extends the responsibility of the pediatrician to include the screening, assessment, and referral of parents with physical, emotional, or social problems that may affect the functioning of the child. However, the Task Force understands that some pediatricians may be either unprepared or unwilling to provide this family-centered care. This could be a result of limits of their training, experience, referral sources, reimbursement issues, and available time. Our EPIC program is prepared to help you address these perceived barriers.”

16. Primary Care and Postpartum Depression
It is not required to screen for postpartum depression, but screening does improve detection
For example: Pediatricians detect only 29% of mothers with high depressive symptoms through clinical indicators alone
3 postpartum depression screening that have been used in pediatric primary care settings:
The Edinburgh Postnatal Depression scale (EPDS)
Center for Epidemiologic Studies Depression Scale, or the CES-D
The Patient Health Questionnaire 2 (PHQ-2)
“While the American Academy of Pediatrics notes that it is not necessarily required practice to screen for postpartum depression, studies have found that screening does indeed improve detection. For example, when a screening tool is not used providers miss an estimated 29% of women with high levels of depressive symptoms. Several postpartum depression screening tools have been developed and used, and three that have been used in pediatric primary care settings include: The Edinburgh Postnatal Depression Scale (EPDS), the Center for Epidemiologic Studies Depression Scale (the CES-D) and the Patient Health Questionnaire (PHQ-2).”

17. Screening for Postpartum Depression
The Edinburgh Postnatal Depression scale (EPDS)
Available online for free
10 item self-administered scale
<5 minutes to complete
Center for Epidemiologic Studies Depression Scale (CES-D)
20 item self-administered scale
5-10 minutes to complete
Patient Health Questionnaire 2 (PHQ-2)
2 item screener
1-2 minutes to complete
““These three scales are also included in your packet for reference and copying. It may help to refer to the copies as I describe them. All of these scales are available online for free. The EPDS was developed specifically to assess postpartum depression. It focuses on questions about mood, and it is scored by adding together the responses to the 10 items. It takes less than five minutes to complete.
CES-D: This is a 20 item self-administered scale that takes 5-10 minutes to complete and also assesses the mother’s life for the past 7 days. It is also available online for free. The items come previous depression scales and it includes a range of depression symptoms. Scoring requires about 12 minutes.
The PHQ-2 is a two item screener and focuses on the past two weeks. You may be familiar with it as it is one of the screening tools evaluated by the U.S. Preventive Services Task Force and found to be as effective as some longer tools. It takes about one to two minutes to administer and is also available online. The purpose of the screener is not to finalize a diagnosis or monitor the severity of the depression but instead is useful to determine if additional screening is necessary. With only two questions, the authors propose that routinely investigating the presence of depressive symptoms will be encouraged and more likely to be incorporated into an office routine.
Please consult the direction sheet for each tool for more information about administration.”

18. Referral Options for Postpartum Depression
Referral sources in your community
United Way’s 211 ( )
Perinatal Depression Provider Consultation Line
( )
CT Behavioral Health Partnership
( )
“We want to help you become comfortable with screening options. As you know, ethically it is very important to identify referral options prior to beginning any screening practices. At least two great options exist for providers in this state. First is United Way’s 211 Child Development Infoline. You may be familiar with this free service that provides referral options for children across the state and may not be aware that it can also assist with finding services for adults. It operates 24 hours a day and is multilingual. While the operators can direct you to options, you could also call the Perinatal Depression Provider Consultation Line or call the Child Development Infoline directly. At these numbers only healthcare providers can speak with a consultant about consultation, information and resources regarding symptoms of perinatal depression, treatment possibilities, and available community resources. They can also mail you a perinatal depression toolkit for providers.
The CT Behavioral Health Partnership is another great option for children insured by HUSKY, Nurturing Families, and Healthy Start, and they can be reached at the number listed. “

19. Tips for Postpartum Depression Screening
Incorporate into routine
Designate office “point person”
Monitor screening, update materials, be available for referral assistance
Decide when to screen
Well-Child visits (all, certain ages, etc.)
Cue and Administer
Place forms in Well-Child packets
Have secretaries or nurses hand out
Medical charts cueing screen
“Here we have some general tips from other screening practices that have worked in offices like yours. Most importantly, we know that rates of screening increase when screening is incorporated into daily routines. So, it can be helpful to designating a “point person”, or person who oversees the screening process (making sure materials are well-stocked, screening is occurring, and being available to assist for referral options).
Next, decide when you will be screening. Because sick visits can be more urgent and time-pressured as well as bias the mood of the mother, screening at Well-Child visits only has found to be feasible. It is important to decide if you will screen at all or only some Well-Child visits and which one those would be.
Whatever way your practice finds is most practical, it is important to remain routine in the administration process. Some have found either placing the forms in the Well-Child packets, having secretaries provide the screener to parents as they check in, as nurses prepare the child for the visit or, if electronic medical charts are used, cueing providers to screen during the Well-Child visits to be helpful reminders to keep up screening rates.”

20. Tips for Postpartum Depression Screening
Most screening results do not require additional discussion by pediatrician
If PPD is identified, discussions are usually brief
Provide materials in waiting room
Facts about PPD
Notice about screening program
“Following the administration, at some point you will need to review the results with the mother. We can reassure you that most depression screenings did not require additional discussion, 20-30% required a less than three minute discussion, and only 4-5% required a longer discussion. Depending on results, many actions by the pediatrician are possible, including: discussing the impact of the depressive symptoms on the infant, scheduling a follow-up visit or call, providing PPD materials, and referral to an adult primary care provider, mental health clinician, or community health support. This is where those referral options through the United Way’s 211 line or the CT Behavioral Health Partnernship are so helpful.
And finally, one site found it useful to have available literature in the waiting room about depression, as well as information about the screening program. Please see the postpartum depression factsheet included in your folder for an option of material for your waiting room.”

21. Summary Postpartum depression:
Prevalence of 13% of women (higher rates if previous history, urban, or low income)
Begins within first 4 weeks following childbirth
Symptoms include crying, guilt, fear, anxiety, isolating, difficulty caring for self and infant
Effects on child: developmental, physical, cognitive, and behavioral
Early intervention is crucial
“This brings us to the end of the presentation. In summary, PPD is a mood disorder that begins within the first 4 weeks following childbirth. Symptoms include difficulties carrying for themselves or their infant, crying, high levels of anxiety, fear, and guilt, and thoughts of harming themselves or their child. PPD can affect the infant in many ways, including developmentally, physical, cognitively, and behaviorally. Early intervention is key, as we know that the more chronic and severe the depressive symptoms, the worse the potential impact on the child.”

22. Summary Clinical observation alone only detects 29% of symptoms
Screening tools improve detection
Edinburgh Postnatal Depression Scale, Center for Epidemiologic Studies Depression Scale, Patient Health Questionnaire
All are free, quick, and available online
Referral options exist in your community
United Way’s 211 ( )
Perinatal Depression Provider Consultation Line
( )
CT Behavioral Health Partnership ( )
“Pediatricians detect less than 30% of depressive symptoms with clinical observation alone, and the American Academy of Pediatricians supports screening. The Edinburgh Postnatal Depression scale, the Center for Epidemiologic Studies Depression Scale, and the Patient Health Questionnaire are screening tools that are available online for free, can be hand-scored, and take less than 10 minutes to complete. And, most importantly, referral options exist and are readily available through both United Way’s 211 service and the CT Behavioral Health Partnership.”

23. Additional Resources
Connecticut Dept. of Public Health
Postpartum Support International – Conn. Chapter
National Women’s Health Information Center
Maternal and Child Health Library - Knowledge Path: Postpartum Depression
American Pregnancy Association
National Institute of Mental Health
PPD Moms Project
“These are additional resources both for pediatric primary care providers as well as for mothers, families, and friends. Thank you for the opportunity to visit your practice today, and please contact EPIC at CHDI if we can be of any further assistance.“

24. “
“There is no doubt that you come into contact with pregnant women in this setting. Popular culture can suggest that pregnancy is a happy, blissful time in the life of a woman. While this may be true, there is growing research on the potential physical and emotional issues that pregnant and postpartum woman my experience that can then impact the life of your patients, the infant and child.”
Please read quote
“As we will see, pregnancy and postchildbirth can include a range of physical and emotional issues.”