1. Behavioral Health Screening Postpartum Depression

2. I have no relevant financial relationships with the manufacturers of any commercial products and/or providers of commercial services discussed in this CME activity.I do not intend to discuss an unapproved or investigational use of a commercial product/device in my presentation.

3. Summary – 1)Early childhood screening is indicated for adverse childhood events which are highly correlated to long term problems 2)Toxic stress without buffering interventions leads to changes in brain structure (hippocampus,amygdala,prefrontal cortex),function,epigenetics,childhood and adult physical and behavioral morbidity 3)Postpartum depression is one example of toxic stress– a hidden time bomb: under identified and under treated with long term morbidity 4)Screening and referral for postpartum depression by pediatricians is valid, effective and feasible at well visits during the first year of life. The standard of quality pediatric care (Bright Futures) incorporates this as part of our broader assessment of the ecology of children and their families

12. Perinatal/Postpartum Depression(Pregnancy to 1 year after birth) Despite the frequency of depression among new mothers and fathers,large numbers of affected individuals may not be identified as having a treatable condition,and only 15% obtain professional care.This has long term adverse effects on both parents and children,i.e. a hidden time bomb.

13. Spectrum Mothers: 1)postpartum blues (50-80%,first weeks):crying sadness,mood swings,needs reassurance,support 2)Major depression(13- 20%),400,000/year in US,1/11 infants,DSM4 diagnosis 3)Postpartum psychosis(1-3/1000,first month),paranoia,hallucinations, delusions,suicidality,homicidal Fathers: limited data,6-10%, different manifestations,i.e.substance abuse

14. Co-morbidity/Risk Factors –Poverty (increased prevalence ¼ infants) Substance Abuse Domestic Violence Family history depression Personal history depression Infant temperament (colic) Isolation

16. Consequences: Parents,Parent child interaction(hostile,intrusive or disengaged,withdrawn),Child and ?Adult Children who experience maternal depression early in life may suffer lasting effects on their brain architecture and persistent disruptions of their stress response systems

18. Consequences –1)ER visits, health costs 2)Delays in cognition,socio-emotional and language development 3)At risk for later mental health problems,aggression,school problems 4)Abuse and Neglect 5)Failure of Breast Feeding 6)Brain structure and stress response:increased cortisol levels in preschoolers associated with anxiety and depression

19. Parent Infant Interaction at 3months

21. Screening instruments Edinburgh Postnatal Depression Scale Patient Health Questionnaire 9 Patient Health Questionnaire 2

23. PHQ PHQ 2: 2 items,takes 1 minute,self administered high sens,low spec in which a pos PHQ2 is followed up with a higher specificity PHQ9 PHQ 9: 9 items,self administered,sens75% spec 90%,free in public domain,10 min,staff scored,cutoff typically 10

27. Pediatric Screening Feasible to screen, to support parents and facilitate access to resources to optimize child development (most pediatricians not comfortable diagnosing and treating maternal depression) Barriers: time, training, reimbursement,adequacy of referral services,legal and ethical barriers-shred form or give to parent BENEFITS OUTWEIGH RISKS Billing codes:96110, 99420 Illinois, HCPCS S3005

28. Treatment Reducing mother’s depressive symptoms alone does not necessarily lead to improvements in parenting and child development Evidence suggests that intensive interventions that focus specifically on parent-child interactions have shown promising results in recent studies;focussing on both parents and young children together can improve child outcomes

30. Treatment Parent Support groups Referral to parents OB, PCP, mental health resource, ER Early intervention DPH resource list Online CBT Models from Illinois, Virginia Bright Futures, Pediatric implementation manual www.cmwf.org,federal, Resource for parents www.mchb.hrsa.gov/pregnancyandbeyond/depr ession www.cmwf.org,federal

31. Standard of Care Guidelines 1999 Surgeon General’s Report on Mental Health AAP-Bright Futures Guidelines (ACCA) USPSTF has endorsed both the Edinburgh and the PHQ 2 28 states and AAP chapters,especially Illinois, Commonwealth Fund and Natl Assn of State Health Plans have web sites below with listings ; www.abcdresources.org,www.nashp.org

33. Conclusion Postpartum depression is underidentified and undertreated with short and long term morbidity for parents and children Pediatric postpartum depression screening at well child visits during the first year of life is valid,effective and feasible and along with/or part of other behavioral screens that Dr. Perrin will now discuss should be part of the standard of quality pediatric care.