Postpartum depression is experienced by 10-15% of women and carries risks to both mother and baby. Untreated maternal depression is associated with negative outcomes for children including behavioral problems, cognitive or developmental delays and impaired attachment. Treatment of a mother’s depression can improve not only her own functioning and quality of life, but can improve her children’s symptoms as well (Pilowsky 2008). Given the importance of a mother’s mental health on her baby’s well-being, the American Academy of Pediatrics (AAP) released a recent report which recommends that pediatricians screen mothers for postpartum depression at baby’s one-, two-, and four-month visits (Earls 2010).
To screen for depression, the AAP recommends using either the Edinburgh Postnatal Depression Scale (EPDS) or a two-question screen.
The EPDS is a 10-question screen, completed by the mother, which has been extensively validated. The AAP recommends using a cutoff score >10 to indicate a positive screen. In primary care settings this is often the threshold used to indicate a risk that depression is present and a woman should receive further evaluation (Cox 1987).
In place of the EPDS, the AAP states that a two-question screen may also be used. This screen is considered positive if a woman answers yes to either of the two following questions:
1. Over the past two weeks have you ever felt down, depressed or hopeless?
2. Over the past two weeks have you felt little interest or pleasure in doing things?
It is important to note that a positive screen on either the two-question screen or the EPDS indicates risk for depression and further evaluation is required before a diagnosis of depression can be made.
When a woman scores greater than 20 on the EPDS or when suicidality or psychosis is a concern, the AAP recommendations are clear: the pediatrician should access crisis intervention services. Recommendations for women with mild to moderate symptoms, however, are less specific. Depending on an individual pediatrician’s level of concern, he or she may offer reassurance and support to a woman with mild symptoms, or, may refer a woman back to her obstetrician or internist for more extensive evaluation. Alternatively, if a pediatrician’s concern were higher, referral for evaluation by a mental health clinician for treatment with therapy or medication may occur. While a pediatrician may have more contact with a mother than her own physician in the early postpartum, the pediatrician is not the mother’s doctor and must help to facilitate further treatment through communication with the mother’s primary care provider or obstetrician or by referring her to community resources.
Routine screening of mothers for postpartum depression by pediatricians will certainly identify women at risk for postpartum depression. The challenge we face is to determine how to best approach women with positive screens. Few studies have investigated what types of treatments are effective for women identified by routine screening and therefore it is unclear what interventions, if any, would be best for these women. It will be important for mental health clinicians and pediatricians to work together to help determine what is the best care for the women we identify in new screening efforts.
Julia Wood, MD
Cox JL, Holden JM and Sagovsky R. Edinburgh Postnatal Depression Scale Detection of postnatal depression. Development of the 10-item.The British Journal of Psychiatry 1987 150: 782-786
Earls MF, Committee on Psychosocial Aspects of Child and Family Health American Academy of Pediatrics. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics. 2010 Nov;126(5):1032-9.
Pilowsky DJ, Wickramaratne P, Talati A, Tang M, Hughes CW, Garber J, Malloy E, King C, Cerda G, Sood AB, Alpert JE, Trivedi MH, Fava M, Rush AJ, Wisniewski S, Weissman MM. Children of depressed mothers 1 year after the initiation of maternal treatment: findings from the STAR*D-Child Study. Am J Psychiatry. 2008 Sep;165(9):1136-47.