1. AAP Perspective on Post Partum Depression Screening
Thank you to Tufts and RI SIM
Elizabeth B. Lange, MD, FAAP
Co-Director, PCMH-Kids
Pediatrician, Waterman Pediatrics/Coastal Medical, Inc.
April 26, 2017

2. Post Partum Depression leads to –
AAP Clinical Report – Pediatrics Vol 126, Number 5, November 2010, pp Incorporating Recognition and Management of Perinatal and Postpartum Depression in Pediatric Practice
Perinatal depression is the most underdiagnosed obstetrical complication in America
Post Partum Depression leads to –
Increased costs of medical care
Inappropriate medical care
Child abuse and neglect
Discontinuation of breastfeeding
Family dysfunction
And adversely affects early brain development

3. Breastfeeding The depressed mother is – less likely to breastfeed
more likely to nurse for shorter durations
have more negative emotions and experiences towards breastfeeding
New mothers experiencing breastfeeding difficulties may be more likely to be suffering from postpartum depression.

4. Post Partum Depression affects Infant Brain Development
Threatens the mother-child relationship of attachment and bonding
An infant living in an emotionally neglectful environment can have adverse changes visible on brain MRI
Impaired social interaction
Delays in physical development and language acquisition
Without early intervention these delays become less responsive to intervention over time.
As early as 2 months the infant looks at the depressed mother less often, shows less interest in objects, exhibits lower activity level and has poor state regulation.

5. Paternal Post Partum Depression
Estimated at 6% of all fathers
In one study of children in Early Head Start, 18% of fathers had symptoms
Depressed fathers have higher substance abuse rates
Rate of paternal depression is higher when the mother has postpartum depression, which compounds the effect on children
Conversely, a non-depressed father has a protective effect on children, acting as a factor in resilience.

6. The pediatric medical home is uniquely positioned -
To establish a system of post partum depression screening
To identify and use community resources for treatment
To refer the depressed mother (or father) to these resources
To increase local awareness of the need for screening in obstetrical and pediatric care schedules
To ensure payment for post partum depression screening

7. Why Pediatricians?
New Moms often only have 1-2 postpartum visits with their OB and post partum depression symptoms may not be present at those times
New babies often have up to 6 visits in the first six months, so pediatricians see the infant-mother dyad much more often
Also, the nature and longevity of the pediatrician-patient (mother) relationship, and the frequency of visits allows mothers to develop a certain level of trust, thus more likely to speak about issues affecting the child’s health, environment and well being
Studies have shown that up to 80% of mothers are comfortable with the idea of being screened for depression

8. Primary Care Pediatrician
We are often the first clinicians to see the infant-mother dyad after birth
We have a continuity with the infant and family
BUT – the infant is our patient
Therefore, it is our role to provide guidance, support, referrals and follow up for the infant and the dyad relationship to optimize the child’s healthy development and the healthy functioning of the family

9. Perceived Barriers to Implementation
Lack of time
Incomplete training to diagnose and counsel
Lack of adequate mental health referral sources
Fear that screening means ownership of the problem
Lack of payment
Fear of liability

10. Pediatrician studies
The majority of pediatricians agree that screening for perinatal depression is in the scope of pediatric practice Pediatrics, 2002:110(6):
Few pediatricians felt responsible for the diagnosis and management of post partum depression but the majority reported they had provided brief intervention Pediatrics, 2006;118(1):
Chaudron et al - “We believe that from the perspective of feasibility and now from the legal and ethical standpoints, the benefits of screening outweighs the risks.” Pediatrics, 2007;119(1):

11. Endorsements
US Preventative Services Task Force endorses the Edinburgh Postnatal Depression Scale as well as the general 2-question screen for depression
US Surgeon General’s office recognizes and calls for early identification and treatment
May 11, 2016 – CMS released an informational bulletin
Maternal Depression Screening and Treatment – A Critical Role for Medicaid in the Care of Mothers and Children
Asks states’ Medicaid to support screening and treatment in EPSDT benefit
“Maternal depression screening during the well-child visit is considered pediatric best practice.”
(Early and Periodic Screening, Diagnostic and Treatment)

12. Bright Futures The Pediatricians’ standard for well child care
Guidelines include surveillance regarding parental social-emotional well being
Bright Futures 4 (2017)
recommends post partum depression screening at well child visits – age 1 month, 2 month, 4 month, 6 month

13. Coding aappublications.org/new/2016/11/04/coding110416
deleted for 2017
96161 – administration of caregiver-focused health risk assessment instrument for the benefit of the patient, with scoring and documentation, per standardized instrument (i.e. Edinburgh postnatal depression scale billed under baby)
Aka – use of a standardized instrument to screen for health risks on the caregiver for the benefit of the patient. It is intended that the code will be reported to the patient’s health plan as it is a service for the benefit of the patient.
RVU 0.13 x 2017 Medicare Conversion Factor $35.89 = $4.67

14. RIAAP Pediatric Council
2008 – post partum depression screening on first agenda
Payment was variable but increasingly consistent
Depending on patient’s plan, the screening may drop to the family’s deductible
2017 – and the discussion continues
The new CPT code has presented coverage and payment glitches
One insurer bulletin notes that post partum depression screening is a covered service but not separately paid

15. Waterman Pediatrics’ Work flow
Many years of experience screening for post partum depression with the Edinburgh 2-question screener
Clipboard, pen, screening questionnaire, Bright Futures page and VIS handed to parents in the exam room at the visit start
Pediatrician reviews the screen with the mother at the visit, the data is entered into structured EHR fields and the paper is scanned into the chart
We choose to administer screen at each baby visit up to 6 months
To create awareness of the topic with parents
To capture any family member involved in this baby’s life
Dad is often only at the first visit or two, and Grandma may attend other visits
To show support of the mother right from the start