Implementing Screening for Postpartum Depression in the Pediatric Primary Care Setting: A Review of the Literature

The health implications of postpartum depression not only on mothers but also on their children are far reaching. The intention of this literature review is threefoldto investigate the processes being utilized in pediatric primary care to incorporate screening for postpartum depression, to examine which screening tools are being used, and what referral or follow up processes have been implemented for positive screenings. Searches were conducted in PubMed, CINAHL, and PsychInfo databases. This yielded a total of 343 articles and six additional articles from other sources were included. After the removal of duplicates and the screening of titles and abstracts, 31 articles remained. The full text review of these articles yielded a total of eight articles that met the inclusion criteria. The findings discussed in this review have demonstrated that the implementation of postpartum depression screening into the pediatric primary care setting is feasible and successful screening programs have reflected both an intra-professional and multidisciplinary approach. Additionally, this review has highlighted an area where there is need for further clinical research and publication, particularly from pediatric primary care settings that have successfully implemented postpartum depression screening, and successfully referred women, who have screened positive for symptoms of postpartum depression. SCREENING FOR POSTPARTUM DEPRESSION 3 Implementing Screening for Postpartum Depression in the Pediatric Primary Care Setting: A Review of the Literature Introduction and Background Postpartum depression (PPD) affects approximately 10%-20% of women, and nearly half of those women go undiagnosed (Sriraman, 2012). Postpartum depression impairs a mother’s ability to engage with her family and child at an emotional and cognitive level, placing the child at greater risk for impaired development (Milapkumar et al., 2012). In fact, research has demonstrated a negative relationship between postpartum depression and language development, IQ development and physical health for children of mothers who suffered from postpartum depression (O’Hara & McCabe, 2013). While postpartum depression can have long-term consequences for both mothers and families, early diagnosis and management can reduce the negative impacts of postpartum depression. In light of this, the American Congress of Obstetricians and Gynecologists recommends that clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms. Furthermore in recognizing that screening alone is insufficient to improve outcomes, they recommend appropriate follow-up and treatment and clinicians should be prepared to initiate medical therapy and/or refer patients to appropriate resources (“Screening for Perinatal Depression. Committee Opinion No. 630,” 2015). In 2010, the American Academy of Pediatrics issued a clinical report encouraging pediatric practices to screen for postpartum depression, use community resources for treatment and referral for those women experiencing depressive symptoms, and to provide support for the mother-child relationship (Earls, 2010). However, making a recommendation is perhaps much easier than implementing a recommendation. While the majority of mothers are open to being screened for postpartum SCREENING FOR POSTPARTUM DEPRESSION 4 depression, approximately 80%, the screening rate is less than 50% (Neiman & Carter, 2010). Typically during the postpartum period women have one to two postpartum visits with their obstetricians or primary care provider, limiting the opportunity for screening to a very narrow window. A pediatric primary care provider sees a mother as frequently as six times within the first six months of her child’s life, placing pediatric providers, in a strategic position for screening for postpartum depression (Sriraman, 2012). This position, though strategic, faces several barriers. In a recent systematic review of literature, Evans et al., examined the postpartum depression screening practices of primary care providers. The authors looked specifically at research studies that involved the screening practices of pediatricians, OB/GYNs and family practitioners. They found that while most pediatricians felt a responsibility for identifying PPD, out of the three provider groups, they were the least likely to assess for postpartum depression. Pediatricians were also the least confident in their skills to recognize PPD, but the most likely to rely on their own clinical judgment rather than a screening tool to detect PPD. The review goes on to identify time constraints as the most frequently cited barrier by providers. Other perceived barriers included inadequate training, skills, or knowledge needed to screen for PPD, as well as lack of mental health services, issues of liability, lack of financial incentives, perceived ineffectual treatment and the perception that mothers did not want to discuss PPD (Goldin Evans, Phillippi, & Gee, 2015). SCREENING FOR POSTPARTUM DEPRESSION 5 Purpose Given the American Academy of Pediatrics’ recommendation to screen for postpartum depression and their conclusion that doing so is best practice, much of the present literature reflects support for this recommendation and encourages pediatric primary care providers to implement screening (Byatt, Biebel, Friedman, Debordes-Jackson, & Ziedonis, 2013; Earls, 2010; Garg, Toy, Tripodis, Cook, & Cordella, 2016; Olin et al., 2015). However, there is a gap in the literature with regard to how pediatricians are meeting this recommendation in light of the barriers described previously. Therefore, the purpose of this literature review is to examine the literature that presently reflects the processes being utilized in pediatric primary care to incorporate screening for postpartum depression, to examine which screening tools are being used and what referral or follow up processes have been implemented for positive screenings. Methods This literature review was conducted using PubMed, CINAHL, and PsychInfo searches for articles published after 2010. This date was selected because the AAP published their recommendation for PPD screening in 2010. Ultimately, however, three articles with publication dates prior to 2010 were included because they met all other criteria. The search included the following key words: maternal depression, post-partum depression, postpartum depression, postnatal depression, postnatal depression, screen*, test*, tool*, scale*, instrument*, determin*, assess* idnetif*, recogn*, primary care, pediatric*, nurse practitioner, nurse practitioners. SCREENING FOR POSTPARTUM DEPRESSION 6 Articles were included if they described the implementation of postpartum depression screening in a pediatric primary care setting and the results thereof. Articles were excluded if the research was conducted outside of the United States and if the article was written in a language other than English. The PubMed search yielded 143 articles. After screening of titles and abstracts this was narrowed to 17 articles. The CINAHL search yielded 71 articles. After the removal of duplicates and screening of titles and abstracts, 7 relevant articles remained. The PsychInfo search yielded 129 articles. Of these, only one relevant article was found after the removal of duplicates and screening the titles and abstracts. A total of 6 additional articles were found from other sources. This yielded a total of 31 articles for full text review. Two articles were excluded because the pediatric primary care settings were outside of the United States. Of the remaining articles only eight articles met the inclusion criteria, describing the implementation and outcomes of PPD screening in the pediatric primary care setting. Results Research Design Two studies featured experimental designs; two were quasi-experimental in design; two featured quality improvement projects following the Plan-Do-Study-Act (PDSA) model, and the remaining two were case studies. Fernandez y Garcia, et al. (2014) and Carrol et al. (2013) conducted randomized control trials. The nature of the studies conducted by Chaudron et al. (2004) and Freeman et al. (2005) was categorized as quasi-experimental. Mgonja and Schoening (2016) as well as Fernandez y Garcia, et al. (2011) carried out quality improvement projects utilizing the PDSA model. The studies by Whichman et al. (2010) and Feingberg et al. (2006) were considered case studies. SCREENING FOR POSTPARTUM DEPRESSION 7 Purpose/Aims of Studies While the purpose and aims of each study were slightly nuanced, overarching each was a desire to implement and evaluate the effectiveness of post partum depression screening in a pediatric primary care setting. The specific purpose/aims of each study are summarized in Table 1 (see Appendix A). Setting and Sample All of the studies included in this review were conducted in the United States. Five out of the eight were associated with academic universities(Carroll, Biondich, Anand, Dugan, & Downs, 2013; Chaudron, Szilagyi, Kitzman, Wadkins, & Conwell, 2004; Fernandez y Garcia et al., 2015; Fernandez y Garcia, Lacaze, & Ratanasen, 2011; Freeman et al., 2005). Six of the eight studies were conducted in urban settings(Carroll et al., 2013; Chaudron et al., 2004; Feinberg et al., 2006; Freeman et al., 2005; Whichman, Angstman, Lynch, Whalen, & Jacobson, 2010); one was conducted in a metropolitan area that saw patients from both urban and rural populations (Fernandez y Garcia et al., 2011), and one was conducted in a faith-based clinic in the Midwest (Mgonja & Schoening, 2016). The majority of the studies reflected some degree of ethnic diversity, however, the Fernandez y Garcia, et al. (2011) quality improvement study did limit their project to English speaking mothers. Findings from Studies Each approached the implementation of screening slightly differently. Some practices using electronic medical records (EMR) created