How to make postpartum depression screening a success in primary care

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Postpartum depression (PPD) screening is now considered a cornerstone of infant preventive care. Postpartum depression is a prevalent condition with direct impacts on the health and well-being of the infant and the family.^1-3 These include behavioral and attachment issues, early cessation of breastfeeding, and overuse of healthcare services. Given that pediatricians see mother-baby dyads an average of 8 times during the first year of life, whereas mothers typically see their own doctor only once in that time frame, assessing for PPD within the pediatric clinic makes intuitive sense and opens a window for intervention.⁴

The United States Preventive Services Task Force (USPSTF) endorsed routine PPD screening in 2016.⁵ Prior to that time, new mothers were only screened by their obstetrician at their 6-week postpartum visit, if they attended that visit. Beginning in 2018, the American Academy of Pediatrics (AAP) strengthened its recommendation in this regard. Previously, the AAP stated that pediatricians should be alert to a mother’s mood and coping. Now the AAP endorses routine screening using a validated tool such as the Edinburgh Postnatal Depression Screen (EPDS) at the 1-month, 2-month, 4-month, and 6-month well visits.⁶ Most state Medicaid plans and private payers cover this screening fee when completed during the infant well visit.^7,8

Multiple studies have found maternal depression rates as high as 15%.¹ Given the myriad of negative consequences that postpartum depression can have on infant social and mental development, it is vitally important that these mothers are identified, offered support, and referred for appropriate mental health treatment. However, incorporating this additional screening tool into 5 infant well visits can feel daunting to busy clinicians. We will outline how PPD screening can be integrated into infant well care in a busy academic pediatric practice. We will also share the key resources to consider and line up prior to instituting this screening into your practice.

Setting and evolution of the screening process

Briarwood Center for Women, Children, and Young Adults is a Pediatrics and Obstetrics/ Gynecology practice within Michigan Medicine in Ann Arbor. In 2014, our clinic launched an integrated perinatal mental health program with embedded social workers and perinatal psychiatrists to provide on-site support for pregnant women and new mothers with mental health issues including depression and anxiety.

Starting in 2016, the pediatricians began routinely screening new mothers for PPD using the EPDS. Any mother who screened positive as indicated by a score of 10 or higher or any positive response to the self-harm item was referred to our social workers. When possible, medical providers would offer a warm handoff, having the mother meet with the social worker same-day during the clinic visit. For those with current thoughts of self-harm, the same-day hand-off was a requirement. The social workers would complete additional screening and facilitate new referrals or refer back to the mother’s primary care doctor, obstetrician, or psychiatry at our clinic site or our Depression Center. Our social workers would also offer short-term counseling to serve as a bridge until patients were able to connect with mental health providers who could follow them long term.

Beginning in 2018 with the AAP endorsement of routine EPDS screening, we confirmed with our billing department that the code 96161 (standard caregiver screen) was appropriate for use to bill for the administration of this tool at the AAP-recommended intervals.⁹ We added this code to the order sets for all infant well visits in the first 6 months of life, to make it easy for clinicians to remember to bill this service. To date, we have had no private payers decline to pay for this screening. We also added tabs to enter the score in our well-visit templates, and a PPD handout to the order sets.

Initial concerns of the pediatricians included the time needed to complete another screening tool. Staff noted that the early infant visits were logistically challenging for new parents, who struggled to get the baby, stroller, diaper bag, and perhaps another sibling (or 2) from home to clinic, car to check-in, and waiting room to exam room. Our workflow including PPD screening added time at check-in to complete all screening tools. Additionally, we are a teaching clinic with medical students and pediatric residents on-site every weekday. This exacerbated the concern for timely completion of all components of the well visits, including EPDS screening, scoring, and discussion with the mother.

Conversely, the pediatricians and staff agreed that pediatric primary care is an ideal setting to identify risk factors in mothers who were known to the practice and who would be following up there for years. We screen for adverse childhood experiences (ACEs) and are aware of the life circumstances of our patients and families, and are thus able to keep mothers with multiple risk factors for PPD on our radar. Overall, the benefits were felt to outweigh the potential downsides and it was not difficult to get staff and faculty on board to commence this screening.

Clinic data

We reviewed our initial 16 months of screening (September 2016 to December 2017). Overall, we screened 1119 mother-baby dyads, including some mothers screened twice.^10,11 Our overall prevalence rate of mothers screening positive for PPD, cumulative over this period, was 8.2%. Our weekly volume of referrals to social work was not overwhelming and did not detract from the various other referral, psychosocial, and tangible needs services provided by social work.

During this time, 22 mothers screened positive for self-harm (question 10 on the EPDS screener); of those, 18 indicated “hardly ever” and only 4 indicated “sometimes” or “very often” regarding thoughts of self-harm. Within this group of higher-risk mothers, 15 received immediate referral to social work to assess safety; 2 on further discussion needed no intervention; 2 were connected to our state maternal infant health program for home visits; 2 could not be definitively tracked on subsequent chart review; and 1 was suffering a psychiatric emergency and was sent to Psychiatric Emergency via ambulance. We recognize that these rare instances where there is concern for self-harm are more time consuming and anxiety provoking for the pediatricians and staff. However, these are the most important mothers to identify by screening to ensure they receive timely and appropriate interventions.

Chart review revealed an overall screening rate of 75% at well visits in babies’ first 6 months. Those not screened (either patient declined or the provider opted out) fall into 3 distinct groups. First, mothers who are known to be in therapy already are not rescreened at all subsequent well visits. Second, multiparous mothers who at the 2-month and later visits endorse no signs or symptoms of PPD can decline to complete screenings. Third, we recognize the important group of mothers whose first language is not English. We currently have the EPDS in English or Spanish and rely on interpreters by phone or in person to help with translation during clinical encounters.

By phone, it is challenging to complete the EPDS and other tools such as developmental screening. We will, in those cases, endeavor to ask some but not all of the screening questions. These visits tend to take longer at baseline and we recognize this additional barrier to effective and routine screening of all mothers in our practice for whom English is not their first language. When noted ahead of time, we book additional check-in and provider time for these babies’ well exams. We are also considering how best to implement EPDS in other languages.¹²

Translating our experience into other pediatric settings

Our pediatric clinic enrolls approximately 400 newborns annually. We worked with our staff to create a standard workflow to incorporate EPDS screening at infant well visits in the first 6 months of life (Figures 1 and 2). At check-in, the parent is given a tablet to complete social determinants, developmental screening, and update clinical information. The EPDS is given in paper-pencil format with an attached cover page offering information about PPD and resources that we encourage the mother to take home and read carefully after the visit. It takes mothers less than 2 minutes to complete the EPDS while the medical assistant is entering baby’s vitals into the electronic health record (EHR).

In other settings, EPDS may be available online through CHADIS¹³ (Child Health and Development Interactive System) and/or could be programmed into your EHR for completion. The physician can quickly score and review the EPDS during the visit, discuss mood swings and PPD, and let mothers know our clinic has many resources to help if the mother is struggling in any way. This takes the pediatrician fewer than 5 minutes. We aim for universal screening, to decrease the odds of missing subtle cases of mood disturbance and to destigmatize the postpartum mood swings that many mothers experience. We highlight the common challenges new parents face and offer tools and resources to manage the feeding, sleep, and other issues this new family member brings to the home.

If we tally a positive screen-including any score greater than 10 or any positive response on the item about self-harm-we then access additional resources. Our clinic social worker or on-call hospital social worker is available during office hours even on Saturdays. If your clinic does not have this most helpful resource, then it is essential to research local and online partners for care prior to initiating this screening.

Local adult primary care physicians and obstetricians often manage mothers with PPD, especially those who require medication. Licensed clinical social workers and psychologists are essential therapeutic partners as well. Identify your resources during the planning phase and assess how to most effectively partner with, refer, and co-manage mothers needing care. This will ensure that the pediatric office has the appropriate referral resources.

We recommend having a list of local therapists who are skilled at working with this patient population. Additionally, there are now excellent telehealth resources in several states (Table 1), especially for those in a rural or low-resourced setting. Online tools (Tables 2 and 3) offer more excellent resources and therapy options for caregivers in your practice.

Conclusions

Identifying and caring for mother-baby dyads is one of the joys of pediatric primary care. Postpartum depression is one of the most common clinical scenarios faced by new mothers. It can have significant impact on attachment and infant development, so it is critical that it is addressed in a routine way to optimize infant mental and physical health.

Pediatricians are ideally situated to help identify, refer, and support mothers who are affected by PPD because we see babies so often during their first year of life and establish close bonds with the families in our practices. Implementing a standard PPD screening using EPDS is very feasible in a busy pediatric primary care practice if local and online resources are identified and a clinic workflow is established ahead of implementation. This practice can destigmatize PPD and set mothers and babies on a trajectory to strong attachment and good health.

References:

1. Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum depression. Am J Obstet Gynecol. 2009;200(4):357-364.

2. Logsdon MC, Wisner KL, Pinto-Foltz MD. The impact of postpartum depression on mothering. J Obstet Gynecol Neonatal Nurs. 2006;35(5):652-658.

3. Muzik M, Borovska S. Perinatal depression: implications for child mental health. Ment Health Fam Med. 2010;7(4):239-247.

4. Shah PE, Muzik M, Rosenblum KL. Optimizing the early parent-child relationship: windows of opportunity for parents and pediatricians. Curr Probl Pediatr Adolesc Health Care. 2011;41(7):183-187.

5. US Preventive Services Task Force. Evidence summary (pregnant and postpartum women). Other supporting document for depression in adults: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/evidence-summary-primary-care-screening-for-and-treatment-of/depression-in-adults-screening1. Published May 2019. Accessed September 9, 2019.

6. Rafferty J, Mattson G, Earls MF, Yogman MW; Committee on Psychosocial Aspects of Child and Family Health. Incorporating recognition and management of perinatal depression into pediatric practice. Pediatrics. 2019;143(1):e20183260..

7. American Academy of Pediatrics. Maternal depression screening: Medicaid and EPSDT coverage. Available at: https://www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/MaternalDepressionScreeningGuidance.pdf. Accessed September 9, 2019.

8. Cox JL, Holden JM, Sagovsky R. Edinburgh Postnatal Depression Scale (EPDS). Br J Psychiatry. 1987;150:782-786. Available at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/practicing-safety/Documents/Postnatal Depression Scale.pdf. Accessed September 9, 2019.

9. American Academy of Pediatrics (AAP) Division of Health Care Finance. CPT code changes for health risk assessments take effect Jan. 1. AAP News. Available at: https://www.aappublications.org/news/2016/11/04/Coding110416. Published November 4, 2016. Accessed September 9, 2019.

10. Lemke S, Orringer M, Orringer K, Muzik M, Kileny S. Challenges and opportunities of postpartum depression screening in a pediatric primary care clinic. Poster presented at: Pediatric Academic Society (PAS) Regional Meeting; Troy, MI; 2019.

11. Orringer K, Kileny S. Unpublished clinic chart review data; 2018.

12. Department of Health, Government of Western Australia. Edinburgh Postnatal Depression Scale (EPDS): translated versions-validated. Perth, Western Australia: State Perinatal Mental Health Reference Group. Available at: https://www.dchealthcheck.net/documents/10-2015-EPDS-Translations.pdf. Published 2006. Accessed September 9, 2019.

13. Total Child Health Inc. CHADIS (Clinical Process Quality Improvement System). Available at: https://www.site.chadis.com/. Accessed September 9, 2019