Perinatal depression, defined as a major or minor depressive disorder in which an episode happens during pregnancy or within the first year of birth, is the most common complication in patients receiving obstetric care. Perinatal depression has an annual incidence of 12%, with up to 18% of women experiencing postpartum depressive symptoms. Postpartum depression has a prevalence of up to 25% in men, which can reach 50% if the mother also has postpartum depression.

Postpartum depression can affect the entire family. It has been linked to incorrect medical treatment of the infant, decreased breastfeeding duration, family dysfunction, and a greater risk of abuse or neglect, and can result in adverse effects to the brain development of infants that can determine lifetime physical and mental health. Infants who grow up with a mother experiencing significant depression are at risk of toxic stress and subsequent problems with social interaction, language, cognition, and social-emotional development. Other consequences linked to unmanaged maternal depression include not using injury prevention protocols (e.g., car safety seats, electrical outlet covers) and poor management of the child's chronic conditions (e.g., asthma). The child may even withdraw from daily activities and avoid interactions, putting him or her at risk of failure to thrive or attachment disorders.

Despite the adverse effects and outcomes associated with maternal depression, fewer than one-half of pediatricians report screening mothers for postpartum depression. Women often do not undergo further evaluation or receive treatment for perinatal depression, even when screening results indicate that depression is likely or the diagnosis is confirmed. Immediate treatment for postpartum depression is essential, because longer maternal depression will lead to prolonged developmental issues in the child, which can reduce treatment response over time. For these reasons, the American Academy of Pediatrics (AAP) has released a policy statement regarding the integration of perinatal depression recognition and management into well-child visits.

Recommendations

Because they provide frequent interaction with parents, well-child visits are existing opportunities to recognize postpartum depression. Therefore, the AAP recommends routinely screening mothers of patients for postpartum depression with a validated screening tool (i.e., Edinburgh Postpartum Depression Scale or Patient Health Questionnaire) at the one-, two-, four-, and six-month well-child visits. Repeated screening aids in overcoming initial reticence in disclosing depressive symptoms. Physicians also should consider screening the mother's partner, in person or via mail, at the six-month visit using the Edinburgh Postpartum Depression Scale. Any screening performed should be documented in the medical record, including the screening tool used, results, discussion points, and a follow-up and referral plan as needed. Immediate intervention is required when screening indicates possible suicidality; the mother has concerns about safety for her child; or the physician has suspicions about the mother being suicidal, homicidal, severely depressed, manic, or psychotic.

Positive results on screening do not confirm a diagnosis of depression, but instead indicate a risk of depression requiring clarification of the diagnosis. Although management options for patients with a positive screening result will vary based on the degree of concern, next steps often include communication and reassurance; provision of support, including identification of community and family resources; and treatment or referral as needed. To determine the effect of the depression on the infant and mother-infant dyad, the physician also should consider a social-emotional development screening, with referral of both to a mental health professional with experience in treating young children if concerns about attachment and bonding emerge.

Editor's Note: The American Academy of Pediatrics (AAP) is recommending something that is common practice for many family physicians, using the scheduled well-child visits as an opportunity to screen for postpartum depression. As this guideline points out, perinatal depression is the most common obstetric complication and can have dramatic health effects on mother and child. The U.S. Preventive Services Task Force recommends that postpartum patients at risk of perinatal depression be provided with or referred to counseling services (https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/perinatal-depression-preventive-interventions), a recommendation that is supported by the AAFP (https://www.aafp.org/patient-care/clinical-recommendations/all/perinatal-depression.html).

The new AAP guideline specifies using the well-child visits up to six months postpartum as a venue for this screening, which has not previously been recommended. For pediatricians, there are some challenges to screening and referring parents, which is standard care for family physicians. We are well suited to integrate or expand our formal screening of mothers at well-child visits.

Another novel recommendation in this guideline is adding screening for the mother's partner at six months. Studies show that the prevalence of postpartum depression in fathers can be as high as one in four, supporting the intent of the recommendation. The six-month visit was chosen for screening because paternal depression was highest at three to six months postpartum. A study in Sweden identified postpartum depression in 8% of fathers using the Edinburgh Postpartum Depression Scale, and analysis showed that screening was cost-effective even with a dedicated clinic visit for screening (J Affect Disord. 2018;241:154–163).—Michael Arnold, MD, Editorial Fellow

Guideline source: American Academy of Pediatrics

Evidence rating system used? No

Systematic literature search described? No

Guideline developed by participants without relevant financial ties to industry? Yes

Recommendations based on patient-oriented outcomes? Yes

Published source: Pediatrics. January 2019;143(1):e20183259

Available at: https://pediatrics.aappublications.org/content/143/1/e20183259.long