Postpartum depression (PPD) affects over 400,000 new mothers each year and has a reported incidence of 10–15%.1 PPD has profound effects not only on the mother but also on her infant, and untreated PPD can significantly impair mother–infant bonding, leading to insecure attachment of the infant.1,2,3 These impairments can result in breast-feeding difficulties, early discontinuation of breast-feeding, and maternal inattention to the health and safety of her infant.4,5 Furthermore, untreated PPD can lead to long-term neurobiological, psychological, and medical consequences including: greater medical morbidity, stunted growth, poor behavioral and cognitive outcomes, language delays, increased anxiety and depression, and lower academic achievement.1,6,7,8
During pregnancy, the mother and the infant are treated together as a dyad, where the health of the mother is expected to determine the health of the fetus. However, once the infant is born, we instantaneously separate mother’s health from that of her infant: the obstetrician cares for the mother while the pediatrician cares for the infant and they have two separate medical records. Given the extensive evidence that a mother’s health during the first year of the infant’s life has significant effects on the long-term health of her infant, this separated view of mother and infant may need to be adjusted such that the mother’s health is taken as seriously as the health of her infant, emphasizing the importance of identifying and treating PPD.
There is effective treatment for PPD, so systematic screening is essential. The United States Preventative Services Task Force has made an evidence-based recommendation in favor of universal PPD screening.9 The American College of Obstetricians and Gynecologists (ACOG) recommends that all pregnant and postpartum women be screened at least once during the perinatal (pregnant and 12-month postpartum) period for depression and anxiety.10 This recommendation falls short of what is actually needed to improve the lives of many mothers as well as their infants and children.
In this issue of Pediatric Research, Ahlqvist-Bjorkroth et al.11 report that screening for PPD in the Neonatal Intensive Care Unit (NICU), coupled with a family-centered intervention (Close Collaboration with Parents) decreased depression symptoms among mothers of very preterm infants. Mothers of preterm infants are at substantially higher risk for PPD, so implementing these practices in NICU’s is particularly important. Many, perhaps most, NICU’s do not have a well-developed approach to PPD screening and appropriate referral of mothers. Implementing such a screening program in NICU’s has great potential to improve the outcomes of the premature infants under their care. In addition, Ahlqvist-Bjorkroth found that their intervention had effects that lasted up to 6 months postpartum, when the mothers were screened again. This emphasizes the need to screen mothers not only early in the postpartum period, but throughout the infant’s first year of life.
Beyond the unique environment of the NICU, pediatricians have an opportunity to significantly improve the lives of infants and mothers through screening mothers for PPD. Because of the frequency of child visits in infancy, systematic maternal PPD screening can occur at multiple intervals over the first 12 months. A number of validated PPD screening tools are available (e.g., the Edinburg Postpartum Depression Scale), and maternal PPD screening can be billed for by the pediatrician.12
The American Academy of Pediatrics strongly recommends that pediatricians conduct PPD screening, and the proportion of pediatricians screening for PPD has improved over time.12 Nevertheless, the majority of pediatricians have yet to implement PPD screening. Despite the potential to improve both maternal and child health, there remain barriers to PPD screening: some of these barriers include lack of awareness and sufficient training, lack of appropriate referral resources, and a paucity of mental health providers.
While these barriers are significant, the evidence for the benefits of screening and treatment for mothers and children is so overwhelming that policy changes must be made to accommodate the need. Improving training and providing continuing medical education for pediatricians on the effects of PPD and ways to quickly screen a mother for PPD is an important first step. State governments should be encouraged to establish and maintain programs for screening, assessment, and treatment for PPD. Commercial insurance companies and Medicaid must provide adequate reimbursement to pediatricians for screening mothers for depression, and screening should be incorporated into quality metrics used for payment. These issues are real but fully addressable.
Screening must naturally be followed by recommendations for treatment and this too can be a barrier. The good news is that PPD is treatable with medications and with therapy, but finding a psychiatrist or therapist with expertise in PPD is not always easy.13 While many larger cities and medical communities may have several therapists and psychiatrists who are willing and able to treat this population, there are many communities that lack this resource. In addition to organizations like Postpartum Support International (PSI), individual states’ Departments of Mental Health can be more helpful in maintaining a list of local resources for PPD treatment. Providers should be encouraged to pursue additional education: Maternal Mental Health Certificate Training for Mental Health and Clinical Professionals has been developed by PSI and 2020 Mom.14 A collaborative health care model can be a useful guide in providing both mental health and medical care in a primary care population.15 In some cases, this may occur through the promising novel approach of telepsychiatry to provide adequate support and treatment. The pediatric community should strongly advocate for improved access to mental health care providers, and for a sustained effort to increase the mental health care provider workforce.
Pediatricians are fully committed to the children under their care and take their obligations seriously. There is great opportunity to improve the lives of children by implementing systematic PPD screening programs in NICU’s and pediatricians’ offices, and by vigorous policy advocacy to overcome the barriers necessary to achieve universal PPD screening and treatment.
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Chambers, J.E., Denne, S.C. & On behalf of the Pediatric Policy Council. Screening for postpartum depression: obligation and opportunity for pediatricians to improve the lives of children. Pediatr Res 85, 923–924 (2019). https://doi.org/10.1038/s41390-019-0373-0
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DOI: https://doi.org/10.1038/s41390-019-0373-0
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