Beyond screening: a review of pediatric primary care models to address maternal depression

Abstract

Depression is one of the most debilitating chronic disorders in the United States, affecting 15 million children in homes with depressed mothers, many of whom endure household chaos, inconsistent nurturing, inadequate safety practices, and harsh discipline. Depressed mothers are under diagnosed and undertreated, yet there is broad consensus about the importance of identifying and managing maternal depression, as reflected in recommendations by pediatric and obstetric professional organizations to routinely screen for perinatal depression. Screening was shown to be acceptable to women and most pediatric providers, and adding a screening component need not impair clinic efficiency. Screening, however, is not sufficient, and there are few models in the literature to guide medical practices in implementing successful interventions to identify, treat, and prevent maternal depression, particularly in the pediatric setting. We reviewed the literature and identified six studies that evaluated models for screening and managing mothers' depression in pediatric primary care settings. Some of these interventions have promise, but no studies characterized health outcomes of the depressed mothers and children. We discuss the components of these models, their implementation, and the practice and research needed to create effective pediatrics-based systems to reduce the negative effects of maternal depression on mothers, children, and families.D epression is one of the most debilitating chronic disorders in the United States (1), a fact experienced every day by the 15 million children being raised in homes with depressed mothers (2). Children living with depressed mothers may experience household chaos, inconsistent nurturing, inadequate safety practices, harsh discipline, and child maltreatment (3,4). Compared to nonexposed peers, children of depressed mothers are two to three times more likely to develop psychiatric disorders themselves and to do poorly in school (5-9). Moreover, recent studies suggest that remission of maternal depression is associated with significant improvement in child behavioral and mental health outcomes (10). Children's home, family, and social environments appear to explain the majority of the risk for the intergenerational transmission of depression (11), with genetics contributing less than half of the risk (10,12). It is the immediate family environment, what Bronfenbrenner refers to as "proximal processes, " that powerfully shapes children's neural, cognitive, social, and behavioral development (13). Thus, it is imperative to promote the safety and wellbeing of children living in homes with depressed mothers.According to the 2009 US National Academies of Science review of maternal depression, "Few opportunities exist to identify the vulnerable population of children living in households with one or more parents experiencing depression or to offer prevention and treatment services that can improve the care of the depressed parent in a framework that also offers services for children" (2). The pedi...

Beyond Screening: A Stepped Care Pathway for Managing Postpartum Depression in Pediatric Settings

“…Recent reviews have identified several models for managing PD in pediatric settings. 18,19 Care strategies were highly similar across both pediatric and adult primary care settings. A ''screen and manage'' approach was common within pediatric models, with varying degrees of maternal depression management within the practice where screening occurred.…”

“…There is currently no well-designed clinical trial that shows a benefit of depression screening alone 17 ; positive outcomes, however, were found to be associated with screening when enhanced depression care was available for postpartum women who screen positive. [18][19][20] Existing international guidelines thus differ in their recommendations. Both the U.K. National Institute for Health and Care Excellence and the Canadian Task Force on Preventive Healthcare's guidelines recommend against formal screening for depression during the perinatal period.…”

“…The challenges of implementing protocols related to maternal mental health have been well-described. 19,30,31 Pediatric providers wrestle with issues around scope of their responsibilities, challenges with reimbursement, and care documentation for the mother. Many pediatricians report a lack of confidence and skill in effectively managing PD and do not feel that there are adequate supports in place to feel comfortable screening for maternal depression.…”

“…PD screening efforts in pediatric primary care have highlighted the importance of specific follow-up procedures with mothers who screen positive. [18][19][20] Common strategies reported in the literature for managing PD within pediatric settings include routine screening using validated tools, psychosocial risk assessments, brief counseling, motivating help-seeking, engaging social supports, and assisted referrals to mental health services. [18][19][20] In this article, we present a stepped care approach, a variant of collaborative care, 39 to address PD as part of well-child care.…”

“…First, we used elements of PD management practices found to be common across pediatric primary care. 18,19 Second, we integrated current knowledge about barriers to care for women and effective engagement strategies that have been specifically developed to facilitate help-seeking among mothers with depression. 40,41 Third, we identified brief evidence-based intervention strategies that pediatric practice staff could implement with appropriate training and support and that address common issues during the postpartum period that put women at risk for major depression.…”