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Maternal Depression Screening

Background

Maternal depression affects up to 18% of mothers during the first year postpartum, yet the condition is likely to go unrecognized and untreated by a mother's own health care provider who may see her less frequently than the pediatrician. [Silver: 2006] At well-child visits, the pediatric provider has an opportunity to identify signs of maternal depression and intervene through routine screening. [Onunaku: 2005]

During an infant's early life, the mother typically is the child's primary source of emotional, cognitive, and social stimulation and interaction. Mothers with postpartum depression are at risk of showing less affection toward their babies, being less responsive to infant cues, and being more withdrawn, hostile, or irritable towards their infants. Associated childhood outcomes include postnatal changes in reflexes, motor tone, orientation, and excitability on Brazelton scales, cognitive delays including lower global IQ and language delay, behavioral problems such as eating and sleep difficulties, temper tantrums, hyperactivity and ADHD, emotional and social dysregulation, as well as increased psychiatric morbidity in adolescence. [Burt: 2009] [Lesesne: 2003] [Murray: 1997] [Quevedo: 2012] [Hay: 2001] [Field: 2010] [Sellers: 2014] In addition, there have been reports of these children being at significant increased risk for physical abuse. [Cadzow: 1999]

As more information is learned about infant mental health, more attention is being given to strengthening the bond between the mother and child and ensuring that moms, as well as their babies, get the best start in this new and important relationship. Because this early relationship is so crucial to a child, the American Academy of Pediatrics encourages pediatricians to take additional steps to support families during routine well-child visits. [American: 2014]

Defining Postpartum Psychiatric Illness

Baby blues, a term generally for mild and transient forms of maternal depression, usually with symptoms of mood lability, anxiety, tearfulness, or irritability, affecting 50-85% of moms in the first weeks after delivery, these symptoms usually peak in the first week after delivery and then slowly subside over the next week.

Postpartum depression affects 1 in 8 women and incidence increases for mothers with premature delivery, C-sections, as well as other complications. [Burt: 2009] Symptoms can begin during pregnancy, but generally appear over the first several months postpartum. Criteria for diagnosing postpartum depression in the DSMV are the same as that for Major Depressive Disorder.

Postpartum psychosis, occurring in 1-2 per 1000 births, usually begins with symptoms of psychosis within the first weeks postpartum. Increasingly, this is thought to be related to bipolar disorder rather than major depression, and its symptoms are fairly aligned with a manic or mixed episode. The mother’s mood may rapidly change, and she may appear disoriented or confused, exhibit delusions and/or hallucinations (http://womensmentalhealth.org/specialty-clinics/postpartum-psychiatric-disorders/). Infanticide and suicide rates increase significantly for this population, and therefore diagnosis and rapid treatment is imperative for safety of the mother and her family. DSM V does not have a discreet category for this illness. Instead, it usually fits into brief psychotic disorder, or to a major mood disorder with psychotic features. [Monzon: 2014]

Postpartum Disorders (MGH) provides further descriptions of the degrees of postpartum depression.

Early Signs

The American College of Obstetricians and Gynecologists recommends psychosocial screening of pregnant women at least once per trimester (or three times during pre-natal care) by using a simple two-question screen and further screening if the preliminary screen result indicates possible depression.
Warning signs for each of these above conditions may vary according to the diagnosis as well as the individual, and may include:
  • depressed mood or irritability
  • lack of enjoyment of usual activities
  • changes in sleep patterns (insomnia or hypersomnia)
  • worthlessness or guilt
  • tearfulness
  • self-doubt, often about her ability as a mother
  • changes in weight or appetite
  • avoidance of social interactions or responsibilities
  • neglect or loss of interest in the newborn infant or other children
  • fatigue or lack of energy
  • changes in appetite
  • poor concentration
  • recurrent thoughts of suicide, death, or running away
  • ruminations, or sometimes worries that she may harm the baby
  • delusions or hallucinations

Screening

A standardized and validated tool is recommended for screening of maternal depression. Examples include: Screening codes:
  • ICD-9-CM: V79.0 Screening for depression (can use thru Sept 2014)
  • ICD-10-CM: Z13.89 Encounter for screening for other disorder (use as of Oct 1, 2014) (ICD-10 Maternal Depression Screening provides further detail.)

Response to a Positive Screen

Upon positive screen:
  • Evaluate the infant using a social-emotional screening tool.
  • Evaluate the infant for poor feeding.
  • Evaluate the mother to determine the severity of the maternal depression.
  • Refer the mother to a mental health professional for further assessment and evaluation.

Initial consultation, assessment, and evaluation by a mental health professional may be made by a social worker, psychiatric-mental health nurse practitioner, psychologist, or psychiatrist. A psychiatric-mental health nurse practitioner or psychiatrist may work with the mother to devise a medication management plan, if necessary. If the mother or child’s immediate safety is at risk, refer to the nearest Emergency Room for a psychiatric evaluation.

See Services, below, for a list of providers.

Resources

Information & Support

For Professionals

Clinical Report—Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice (AAP)
Guidance for primary care providers on recognition and management of maternal depression; American Academy of Pediatrics.

Parental Depression Screening for Pediatric Clinicians: An Implementation Manual
Describes the role of the pediatric provider in the screening process; implementation of screening at the practice level and how organizations can assist; by A. Olson and C. Gaffney, The Commonwealth Fund, April 2007.

Maternal Depression Poster(PDF Document 90 KB)
Includes two screening questions and description of postpartum depression.

Postpartum Depression and the Family Poster(PDF Document 65 KB)
Describes postpartum depression and how it affects the family.

For Parents and Patients

Support

Postpartum Support International
Support for women and their partners who are dealing with post-partum depression. Includes professional assessment tools and access to a volunteer network of local service providers and resources.

General

Postpartum Depression (Utah Department of Health)
Facts for families about postpartum mental health.

Postpartum Disorders (MGH)
General information about the various forms of postpartum depression; Massachusetts General Hospital.

Medicaid Information Bulletin, 2013(PDF Document 165 KB)
Informs states about resources available to help them meet the needs of children specifically with respect to mental health and substance use disorder services.

Patient Education

Depression During & After Pregnancy: A Resource for Women, their Family, & Friends (HRSA)
Information for the woman and/or her family about the definition and symptoms of postpartum depression and when to seek treatment. Includes a perinatal depression booklet in English and Spanish; Department of Health & Human Services.

Tools

Care Pathways Algorithm
For medical professionals evaluating postpartum women for depression. The outcome will indicate if the patient should be referred for additional mental health services or put on an antidepressant regimen and monitored.

Depression Tool Kit (MacArthur Foundation Initiative on Depression and Primary Care)
Designed for primary care practices to help in the diagnosis and management of maternal depression; contains screening tools, patient handouts, medication information, resources, and references and includes the 9-question Public Health Questionnaire (PHQ-9). Available for download upon agreement to terms.

Edinburgh Postnatal Depression Scale (English)(PDF Document 120 KB)
A validated, quick, 10-question screening tool for maternal depression to be used by primary care providers; includes scoring instructions. Sensitivity 65-100%; specificity 49-100%. Free, may be printed without permission.

Edinburgh Postnatal Depression Scale (Spanish)(PDF Document 54 KB)
A validated, quick, 10-question screening tool for maternal depression to be used by primary care providers and includes scoring instructions. Sensitivity 65-100%; specificity 49-100%. Free, may be printed without permission.

Maternal Depression Screening - PHQ-2 and PHQ-9(PDF Document 205 KB)
Two-question (PHQ-2) or nine-question (PHQ-9) screening and assessment tool for maternal depression by Bright Futures (AAP). Scroll toward bottom of page for pdf of questionnaire and instructions with interpretation of scores information.

Services

Crisis Intervention, Mental Health

See all Crisis Intervention, Mental Health services providers (105) in our database.

Family Support, Mental Health

See all Family Support, Mental Health services providers (43) in our database.

Family Therapy

See all Family Therapy services providers (165) in our database.

Mental Health Clinics, Public

See all Mental Health Clinics, Public services providers (40) in our database.

Social Work

See all Social Work services providers (23) in our database.

For other services related to this condition, browse our Services categories or search our database.

Studies

Maternal Depression (clinicaltrials.gov)
Listing of open trials related to maternal depression.

Authors

Author: Jessica Lu, M.D., M.P.H - 4/2014
Contributing Author: Kathleen Smart, LCSW - 9/2006
Content Last Updated: 4/2014

Page Bibliography

American Acadamy of Pediatrics, Bright Futures.
2014 recommendations for pediatric preventive health care.
Pediatrics. 2014;133(3):568-70. PubMed abstract / Full Text
Chart of guidelines for preventive care of normally developing children; represents an AAP and Bright Futures consensus.

Burt VK, Quezada V.
Mood disorders in women: focus on reproductive psychiatry in the 21st century--Motherisk update 2008.
Can J Clin Pharmacol. 2009;16(1):e6-e14. / Full Text
Review of the significant negative impact of maternal depression on maternal and child health and psychological well-being and other possible consequences of chronic depression.

Cadzow SP, Armstrong KL, Fraser JA.
Stressed parents with infants: reassessing physical abuse risk factors.
Child Abuse Negl. 1999;23(9):845-53. PubMed abstract / Full Text
Examines the relationship among potentially adverse psychosocial and demographic characteristics identified in the immediate postpartum period and child physical abuse potential at 7 months.

Field T, Diego M, Hernandez-Reif M.
Prenatal depression effects and interventions: a review.
Infant Behav Dev. 2010;33(4):409-18. PubMed abstract / Full Text
Research on the negative effects of prenatal depression and cortisol on fetal growth, prematurity, and low birth weight.

Hay DF, Pawlby S, Sharp D, Asten P, Mills A, Kumar R.
Intellectual problems shown by 11-year-old children whose mothers had postnatal depression.
J Child Psychol Psychiatry. 2001;42(7):871-89. PubMed abstract
Examines long-term sequelae in the children of mothers who were depressed at 3 months postpartum.

Lesesne CA, Visser SN, White CP.
Attention-deficit/hyperactivity disorder in school-aged children: association with maternal mental health and use of health care resources.
Pediatrics. 2003;111(5 Pt 2):1232-7. PubMed abstract / Full Text
Investigates the association between the mental health status of mothers and attention-deficit/hyperactivity disorder (ADHD) in their school-aged children and characterizes the health care access and utilization of families affected by ADHD.

Monzon, C. M.D., Lanza di Scales, T. MD, Pearlstein, T. MD.
Postpartum psychosis: updates and clinical issues.
Psychiatric Times; (2014) http://www.psychiatrictimes.com/special-reports/postpartum-psychosis-u.... Accessed on 3/26/2014.
In preparation for DSM-5, evidence of the onset of symptoms in postpartum disorders was examined. Study findings suggest that 50% of major depressive episodes that present postpartum actually began during pregnancy.

Murray L, Cooper P.
Effects of postnatal depression on infant development.
Arch Dis Child. 1997;77(2):99-101. PubMed abstract / Full Text
Discusses early maternal depression and adverse cognitive and emotional infant development.

Onunaku, Ngozi.
Improving maternal and infant mental health: Focus on maternal depression.
National Center for Infant and Early Childhood Health Policy at UCLA. July. / http://main.zerotothree.org/site/DocServer/maternaldep.pdf
Discusses the impact of maternal depression on the social and emotional health of young children. Recommends specific steps that early childhood program and public health administrators can take to address the unmet mental health needs of mothers ultimately promoting the social and emotional health, school readiness, and future functioning of very young children.

Quevedo LA, Silva RA, Godoy R, Jansen K, Matos MB, Tavares Pinheiro KA, Pinheiro RT.
The impact of maternal post-partum depression on the language development of children at 12 months.
Child Care Health Dev. 2012;38(3):420-4. PubMed abstract / Full Text
Analyses the effect of the duration of the mother's depression on the language development of children at 12 months old.

Sellers R, Harold GT, Elam K, Rhoades KA, Potter R, Mars B, Craddock N, Thapar A, Collishaw S.
Maternal depression and co-occurring antisocial behaviour: testing maternal hostility and warmth as mediators of risk for offspring psychopathology.
J Child Psychol Psychiatry. 2014;55(2):112-20. PubMed abstract / Full Text
Using a longitudinal study of offspring of mothers with recurrent depression, the study tests whether maternal warmth/hostility mediated links between maternal depression severity and child outcomes, and how far direct and indirect pathways were robust to controls for co-occurring maternal antisocial behaviour.

Silver EJ, Heneghan AM, Bauman LJ, Stein RE.
The relationship of depressive symptoms to parenting competence and social support in inner-city mothers of young children.
Matern Child Health J. 2006;10(1):105-12. PubMed abstract
Discusses how negative ratings of parenting competence, low perceived social support, and presence of health-related activity restrictions can be useful markers of likely depression among inner-city mothers of young children.