Our practice explored community resources for maternal depression when we decided to implement screening, and I was able to link Nicole with a local postpartum support group we had identified through Postpartum Support International. We agreed on a follow-up visit to check on her baby ‘s social-emotional development and how she and her baby were bonding. At that follow-up, Nicole expressed gratitude and said she had chosen the right practice for her baby and family.
Perinatal depression, of which postpartum depression is a subset, is the most common obstetric complication in the United States. It affects as many as 12 percent of all women who are pregnant or new mothers, while an estimated 11-18 percent of women report postpartum depressive symptoms.
Effects of the condition can be far-reaching, adversely affect a child’s critical early period of brain development. Left untreated, perinatal depression can interfere with healthy parent-child attachment and lead to inappropriate medical treatment, family dysfunction, and impaired attention to and judgment concerning safety. An estimated 50 percent of women who are depressed during and after pregnancy are undiagnosed and untreated.
It’s important to respond to postpartum depression as early as possible, since potential developmental issues may be less responsive to interventions over time. Maternal depression in infancy are predictive of increased cortisol levels in preschoolers, and this, in turn, is linked with anxiety, social wariness, and withdrawal. As they get older, children of mothers with untreated postpartum depression often have poor self-control, poor peer relationships, school problems, and aggression.
"Pediatricians have long recognized the two-generational nature of providing care for children. Addressing perinatal depression is an example of this—one that has a long term impact on the health of the child, the mother-infant relationship, and the whole family.”
Pediatric primary care clinicians have the opportunity to identify depression and give support to the mother-infant dyad, as the American Academy of Pediatrics (AAP) emphasizes in the policy statement, “Incorporating Recognition and Management of Perinatal and Postpartum Depression into Pediatric Practice.” The statement, and its accompanying technical report, updates the AAP’s 2010 clinical report on the topic.
Incorporating perinatal depression screening into pediatric practice aligns with our recognition of toxic stress, adverse childhood experiences, resilience, and the need for trauma-informed care. Screening is also recommended by the U.S. Preventive Services Task Force and Centers for Medicare and Medicaid Services.
Based on when postpartum depression is most likely to occur, AAP recommends that screening be done at the 1, 2, 4, and 6 month infant visits. The AAP recommends coordinating care with prenatal providers for women diagnosed with depression during pregnancy, as does the American College of Obstetrics and Gynecology.
When screening shows
depression concerns, pediatricians can help prevent it from leaving a lasting
- Provide primary care intervention. Begin by acknowledging that postpartum depression happens to many new parents, that the mother is not at fault or a “bad” mother, and that it is treatable. A brief intervention at the visit also would involve:
- Promoting the strength of the mother-infant relationship, such as reading and/or singing to the infant.
- Encouraging the mother to breastfeed and recommending lactation support if needed. Evidence suggests breastfeeding may protect against postpartum depression or help women recover from its symptoms more quickly.
- Encouraging the mother to make time to meet other new parents and increase social connections
- Facilitating connections with community resources, support and/or mental health services for the mom.
- Providing a referral for evidence-based treatment such as Child-Parent Psychotherapy.
- Referring to Early Intervention programs for targeted support of social-emotional development.
Beyond the clinic, there are
many opportunities for advocacy. Pediatricians, working with their
AAP Chapters can:
- increase awareness of
the need for screening (both in pediatric and obstetric care);
- advocate with payers to
ensure payment for screening and services;
- advocate for creation of
postpartum support resources in local communities; and
- promote workforce
development of mental health providers who care for very young children
and the parent-infant dyad.
Pediatricians have long
recognized the two-generational nature of providing care for children.
Addressing perinatal depression is an example of this—one that has a long term
impact on the health of the child, the mother-infant relationship, and the
* The views expressed in this article are those of the author, and not necessarily those of the American Academy of Pediatrics.
Marian Earls, MD, MTS, FAAP, is lead author on the AAP policy statement, “Incorporating Recognition and Management of Perinatal and Postpartum Depression into Pediatric Practice,” published in the January 2019 Pediatrics. She chairs AAP’s Mental Health Leadership Work Group and its Screening Learning Collaborative Project Advisory. Among other AAP leadership roles, she has also served on its Committee on Psychosocial Aspects of Child and Family Health and Council on Early Childhood. Board-certified in both General Pediatrics and Developmental and Behavioral Pediatrics, Dr. Earls is Director of Pediatric Programs and Deputy Chief Medical Officer for Community Care of North Carolina and a Clinical Professor of Pediatrics for the University of North Carolina Medical School. Since 2000, she has been the director of the North Carolina ABCD (Assuring Better Child Health and Development) Program.