Addressing Postpartum Depression: Opportunities in the Pediatric Setting

Lisa Honigfeld, Ph.D.Vice President for Health Initiatives

Child Health and Development Institute

Goals of Presentation

• To increase knowledge about postpartum depression and the possible effects of postpartum depression on infant and child development

• To encourage the use of screening tools toidentify postpartum depression

• Provide information about referral sources for postpartum depression

Mood Disorders and Pregnancy

• Four mood disorders associated with pregnancy: • Postpartum blues, or “baby blues”

– Most common- affects 70-80% of women following childbirth – Occurs two to three days following giving birth and include feelings of sadness,

depression, or anxiety. – Short-lasting

• Perintal depression – Includes major or minor depressive episodes that occur during pregnancy or in

the year following childbirth• Postpartum psychosis

– Rare– Sudden onset within the first four weeks following giving birth – Symptoms include hallucinations, delusions, and rapid mood change – Women observed to be experiencing these symptoms must receive

psychiatric care immediately

Postpartum Depression

What is it?• Begins within 4 weeks after childbirth• Type of major depressive episode• Serious mental health problem• Extended period of emotional

disturbance• Can have real consequences for the new

mother and her family

Prevalence of Postpartum Depression

• Affects approximately 13% of women• Some prevalence rates are estimated to

increase to: – 41% of women with history of postpartum

depression and– 56% of urban and low-income women

Symptoms of Postpartum Depression*

• Difficulty with daily living tasks • Increased risk for anxiety, guilt, fear, crying• Difficulty providing care for the infant• Isolation from family and friends• Thoughts of hurting oneself or the infant• Loss of pleasure in previously enjoyed activities• Infants may be: gazing less at mothers and others, making less

noise, displaying limited or a lack of positive facial expressions, have very irritable or fussy behaviors, a lack of interest in objects, and obvious attempts at disengaging (such as arching their backs) * Cultural/ethnic differences are possible

Effects on Child

• Postpartum depression has the potential to affect MANY individuals beyond the mother (spouse, friends, children)

• The infant who is your patient is at risk of experiencing a range of consequences in the areas of:– Developmental, physical, cognitive, and behavioral– Mother’s parenting behaviors

Developmental Effectson Child

• Infant’s quality of attachment is incredibly important• If the mother is physically or emotionally unavailable,

(such as when depressed) emotional dysregulation can occur

• From this, the infant experiences changes that can affect his or her affect, motor, physiological, and biochemical levels

• Maternal depression is associated with infants developing insecure attachment styles

Physical Effectson Child

• Infants of depressed mothers have been documented as:– Demonstrating less interaction, smiling, vocalizing, – Poorer muscle control– Gaze aversion– More lethargy

Behavioral Effectson Child

• Slower to orient• Less time spent exploring new objects • More crying during periods of stress• More conduct issues at school• More physical play behaviors at school

Cognitive Effectson Child

• Cognitive Development– Lower scores (by as much as 10 points) on Bayley

Scales of Infant Development, Mental, and Motor Scales

– When tested at age 11, they had lower IQ scores, made more errors on an attention task, and also showed more conduct issues at school

• Brain Development– Infants show EEG activity that suggests vulnerability

for depression

Parenting Effectson Child

• Poorer care-giving skills including being less likely to:– Breastfeed, play with infants, talk to infants – Follow routines– Read to child – Seek preventive services such as Well-Child visits

and vaccinations

Twice as frustrated with child’s behaviors

Interventions that Can Help

• There are options for reducing PPD and it’s effects, including:– Psychological Therapy– Psychopharmacological treatment – Home support– Support groups

• However, – Crucial for early intervention• More chronic, severe, and recent the depression, the

more negative effects on children

Primary Care and Postpartum Depression

–Why is pediatric primary care (the Medical Home) a good venue for addressing postpartum depression?• First contact• Universal• Longitudinal • Has a range of services• Linked to larger systems

Primary Care andPostpartum Depression

2003 report of the Task Force on the Family by the American Academy of Pediatrics:

• Family pediatrics requires partnernship between family and pediatrician

• Responsibility of pediatrician: screening, assessment, and referral of parents with physical, emotional, or social problems that may affect functioning of the child– However, the Task Force also understands that some pediatricians

may be:• Limited in training• Limited in experience• Unaware of referral sources• Concerned about reimbursement• Concerned about time constraints

Primary Care and Postpartum Depression

• It is not required to screen for postpartum depression, but screening does improve detection– For example: Pediatricians detect only 29% of mothers with high depressive

symptoms through clinical indicators alone

• 3 postpartum depression screening that have been used in pediatric primary care settings: – The Edinburgh Postnatal Depression scale (EPDS) – Center for Epidemiologic Studies Depression Scale, or

the CES-D – The Patient Health Questionnaire 2 (PHQ-2)

Screening for Postpartum Depression

• The Edinburgh Postnatal Depression scale (EPDS)• Available online for free • 10 item self-administered scale• <5 minutes to complete

• Center for Epidemiologic Studies Depression Scale (CES-D)

• Available online for free• 20 item self-administered scale • 5-10 minutes to complete

• Patient Health Questionnaire 2 (PHQ-2)• Available online for free• 2 item screener• 1-2 minutes to complete

Referral Options forPostpartum Depression

• Referral sources in your community–United Way’s 211 (1-800-505-7000)• Perinatal Depression Provider

Consultation Line (1-800-505-7000)

–CT Behavioral Health Partnership (877-552-8247)

Tips forPostpartum Depression Screening

• Incorporate into routine• Designate office “point person”• Monitor screening, update materials, be available for

referral assistance

• Decide when to screen• Well-Child visits (all, certain ages, etc.)

• Cue and Administer• Place forms in Well-Child packets• Have secretaries or nurses hand out• Medical charts cueing screen

Tips forPostpartum Depression Screening

• Most screening results do not require additional discussion by pediatrician– If PPD is identified, discussions are usually brief

• Provide materials in waiting room• Facts about PPD• Notice about screening program

Summary• Postpartum depression:

– Prevalence of 13% of women (higher rates if previous history, urban, or low income)

– Begins within first 4 weeks following childbirth– Symptoms include crying, guilt, fear, anxiety, isolating, difficulty caring

for self and infant

• Effects on child: developmental, physical, cognitive, and behavioral

• Early intervention is crucial

Summary

• Clinical observation alone only detects 29% of symptoms

• Screening tools improve detection– Edinburgh Postnatal Depression Scale, Center for

Epidemiologic Studies Depression Scale, Patient Health Questionnaire

– All are free, quick, and available online

• Referral options exist in your community• United Way’s 211 (1-800-505-7000)

– Perinatal Depression Provider Consultation Line

(1-800-505-7000)• CT Behavioral Health Partnership (877-552-8247)

Additional Resources• Connecticut Dept. of Public Health

http://www.dph.state.ct.us/BCH/Family%20Health/Perinatal_depression.html

• Postpartum Support International – Conn. Chapterhttp://www.postpartum.net

• National Women’s Health Information Centerhttp://www.4woman.gov

• Maternal and Child Health Library - Knowledge Path: Postpartum Depressionhttp://www.mchlibrary.info/KnowledgePaths/kp_postpartum.html

• American Pregnancy Associationhttp://www.americanpregnancy.org

• National Institute of Mental Healthhttp://www.4woman.gov/faq/postpartum.htm

• PPD Moms Projecthttp://www.1800PPDMOMS.org

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