Postpartum depression (PPD) is an under-recognized disorder that has long-term implications for both parents and children. PPD symptoms are very similar to major depression with the additional thought of harm to the child.1 PPD occurs within the first four months after delivery and can last up to a year.1
In the U.S., fifty to eighty percent of mothers experience temporary changes in mood, loss of sleep and disinterest in activities after childbirth, in what is commonly known as the “baby blues.”2 However, the duration and severity of symptoms differentiate the “baby blues” from PPD.1,2 Ten to twenty percent of mothers experience PPD but PPD is highest among adolescent mothers, those from low-income households, as well as women who lack support structures at home or previously suffered interpersonal violence, anxiety and substance abuse.1,2
Recent Updates for Postpartum Depression Screening
PPD is screened through one of two preferred methods; the Edinburgh Postpartum Depression Scale (EPDS) and the Patient Health Questionnaire (PHQ). When mothers are screened for PPD, a score is calculated based on the answers to the screening questions to determine if further evaluation or treatment is needed. Guidelines have recently changed to encourage more frequent screening before and after delivery.1,2
- The American College of Obstetrics and Gynecology (ACOG) and the United States Preventive Task Force (USPTF) recommends PPD screenings at least once before and after birth.
- The American Academy of Pediatrics (AAP) recommends more frequent screening at the one-, two-, four- and six-month wellness visits.
Why Postpartum Depression Screening Matters
PPD has long-term implications on the child, including failure to thrive, developmental delay, altered mother-child bonding, decreased breastfeeding, and non-accidental trauma.1,2 Children of PPD mothers are also at an increased risk of developing mood and behavioral disorders as adolescents and adults. Therefore, more frequent PPD screenings by pediatricians is important.
Pediatricians are in a unique position to observe the parent-child dynamic during their care and offer screening for PPD. Mothers may feel strongly that they do not need help but it is important to emphasize PPD’s effect on the child’s health if PPD is left untreated. At the very least, it is important to start this discussion early and offer resources.
Some mothers may feel that their mental health is no longer a concern once their child is born. In reality, this is one of the most vulnerable times for the parents as they
worry about the intricacies of childcare. Pediatricians must facilitate a conversation with the new parents about mental and emotional health, using the patient-provider trust developed in caring for their children. It is important to emphasize that the health of the mother is crucial to safely care for her child.
New California Postpartum Depression Screening Legislation Under Review
Assembly Bill (AB) 2193 was introduced in February by Assemblymember Maienschein to provide a structured framework for PPD screening and treatment in California. As of April 2018, some of the recommendations from AB 2193 include3:
- Physicians treating a mother or child must screen for PPD at least once before and once after birth and report the finding to the mother’s primary care physician. Failure to comply would be grounds for discipline.
- Health care entities and insurers must develop a case management system that assists in coordinating care with a therapist trained in maternal mental health.
- A quality management program must be established to analyze program effectiveness and patient satisfaction.
While promising and important to bringing awareness and treatment for postpartum depression and mental health, physicians have been concerned over the proposed provisions in this bill. For example, some pediatricians have reservations about PPD screenings due to their lack of training in maternal mental health, inadequate time to screen, and the legal implications of caring for the mother.1,4 Others worry that there is no way to assure that those who screen positive will seek care.
While these reservations are valid, I am hopeful that the proposed case management provisions in AB 2193 will assist physicians with triage and coordinate the treatment of new mothers with positive screening results. It is also important to continue to educate new medical trainees and raise public awareness for postpartum depression and maternal health to preserve the health of mothers and children in the long term.
Saisho Mangla, DO is a board certified pediatrician who completed his training at Lehigh Valley Children’s Hospital in Allentown, Pennsylvania. He will be pursuing further training in preventive medicine and public health at Loma Linda University.
- Sriraman, N.K., Pham, D.Q., and Kumar, R. Postpartum Depression: What Do Pediatricians Need to Know? Pediatrics in Review. December 2017. 38(12): 541-551.