1. Texas Pediatric Society Electronic Poster Contest
Implementation of a Postpartum Depression Screening Tool in a Pediatric Primary Care Resident Clinic
Karen Wittenburg, MD; Kim Tran, MD, MPH; Laura Wise, MD; Caroline Camosy, MD; Katie Sanford, MD; Michelle Gallas, DO; Tara Greendyk, MD
The University of Texas at Austin, Dell Medical School Pediatrics Residency Program
Introduction
Results
Postpartum depression (PPD) affects up to 15% of mothers and is associated with childhood attachment difficulties, developmental delay, behavior and mood disorders, and abuse or neglect.1-4 Among medical providers, pediatricians have the most frequent interactions with mothers in the postpartum period, but pediatricians are less likely to ask about maternal psychiatric symptoms, use a screening tool, have confidence in their ability to recognize PPD, and refer for intervention.5,6 Resident and attending physicians in our clinic inconsistently screened for PPD during the month prior to the implementation of routine screening. Low comfort levels in counseling and referring mothers with positive screens, as well as lack of knowledge of resources were major barriers identified.
Chart review indicated PPD screening increased from 21% to 80% during targeted WCC visits after implementation of routine screening.
Percent of providers who reported always screening for PPD in the 0-28 days and 2-9 month age groups increased 17% to 29% and 0% to 42%, respectively.
Percent of providers somewhat confident to diagnose PPD increased from 60% to 77%. Very confident responses increased from 9% to 16%.
The percentage of providers who identified lack of knowledge of resources as a barrier to PPD screening had decreased by 20%. However, percent of providers who identified lack of time as a major barrier increased by 17% after implementation.
Figure 1. Root cause analysis diagram used to help define our project aim.
Purpose
Figure 4. Provider reported screening before and after educational intervention .
Our primary goal centered on increasing screening mothers for PPD in a pediatric resident clinic. Our approach was two-fold.
Educational interventions aimed to impact provider attitudes and practices regarding screening.
Implementation of routine screening using a validated screening tool, the Edinburgh Postnatal Depression Scale (EPDS), at all 2,4,6, and 9 month well child checks (WCCs).
Methods
Educational interventions consisted of presentations designed to increase provider awareness of PPD, familiarize with interpretation of the EPDS tool, and educate about available community resources. Pre-intervention and 3-month post-intervention surveys were obtained to evaluate change in provider attitudes and practices.
Implementation of routine screening consisted of identifying English and Spanish community resources, modifying clinical workflow, making informative handouts readily available, and establishing a documentation system. In doing this, we strengthened an existing relationship with our clinic’s behavioral health counseling team to provide services and crisis intervention, and formed a partnership with a local organization, Pregnancy and Postpartum Health Alliance of Texas, who provided additional resources and recommendations.
Figure 5. Provider reported confidence before and after educational intervention
Figure 6. Perceived barriers before and after education intervention.
Conclusions
Providing educational interventions prior to implementation of PPD screening in a pediatric resident continuity clinic may assist in supporting the desired change in provider behavior and decrease perceived barriers. Post intervention and implementation of routine screening providers reported increased rates of screening for PPD in all targeted WCCs. The interesting finding of reported increased screening in the 0-28 day age group, visits during which the EPDS tool was not utilized, points to heightened provider awareness of PPD overall. Though lack of screening tools and lack of training as perceived barriers decreased after intervention, lack of time and resources continued to be identified as major constraints to screening. Ongoing efforts will be aimed at better utilizing our established behavior health team, identifying other community resources, and making all resources more easily accessible to providers and patients. We will also examine cultural factors that may contribute to variable perceptions of postpartum depression.
Figure 2. Algorithm displayed in clinic outlining when to screen and how to score the EPDS.
Results
References
1. Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum Depression. Am J Obstet Gynecol April; 200(4):
2.Earls, MF. Clinical Report—Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice. Pediatircs November; 126(5):
3. Shonkoff JP, Garner AS. The Lifelong Affects of Early Childhood Adversity and Toxic Stress. Pediatrics January; 129(1): e
4 Olson AL, Kemper KJ, Kelleher KJ, Hammond CS, Zuckerman BS, Dietrich AJ. Primary Care Pediatricians’ Roles and Perceived Responsibilities in the Identification and Management of Maternal Depression. Pediatrics December; 110(6):
5. Evans MG, Phillippi S, Gee RE.  Examining the Screening Practices of Physicians for Postpartum Depression: Implications for Improving Health Outcomes.  Women’s Health Issues September;
6. Olson AL, Dietrich AJ, Prazar G, Hurley J. Brief Maternal Depression Screening at Well Child Visits. Pediatrics July; 118(1):
Figure 3. Electronic chart review of 2, 4, 6, and 9 month WCCs 4 weeks prior to and 4 weeks after implementation of routine screening.
Texas Pediatric Society Electronic Poster Contest