PEDIATRICS Vol. 106 No. 6 December 2000, pp. 1367-1373

Do Pediatricians Recognize Mothers With Depressive Symptoms?

Amy M. Heneghan, MD^*, Ellen Johnson Silver, PhD, Laurie J. Bauman, PhD, and Ruth E. K. Stein, MD

From the ^* Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio; and  Albert Einstein College of Medicine, Bronx, New York.

	ABSTRACT

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Objective.  To determine whether pediatric health care providers recognize maternal depressive symptoms and to explore whether maternal, provider, and visit characteristics affect pediatric providers' ability to recognize inner-city mothers with depressive symptoms.

Design.  A cross-sectional study was conducted at a hospital-based, inner-city, general pediatric clinic. Two groups of participants completed questionnaires, each unaware of the other's responses: 1) mothers who brought their children ages 6 months to 3 years for health care maintenance or a minor acute illness and 2) pediatric health care providers (attending pediatricians, pediatric trainees, and nurse practitioners). The mothers' questionnaire consisted of sociodemographic items and a self-administered assessment of depressive symptoms using the Psychiatric Symptom Index (PSI). Pediatric providers assessed child, maternal, and family functioning and documented maternal depressive symptoms. Criteria for positive identification of a mother by the pediatric health care provider were met if the provider reported one or more maternal symptoms (from a 10-item list of depressive symptoms), a rating of 4 or less on a scale of functioning, a yes response to the question of whether the mother was acting depressed, or a response that the mother was somewhat to very likely to receive a diagnosis of depression.

Results.  Of 338 mothers who completed the questionnaire, 214 (63%) were assessed by 1 of 60 pediatric providers. Seventy-seven percent of surveys were completed by the child's designated pediatric provider. The mean visit length was 23 minutes. Mothers primarily were single, were black or Hispanic, and had a mean age of 26 years (15-45 years). Almost 25% of mothers were living alone with their children. Eighty-six (40%) mothers scored 20 on the PSI, representing high symptom levels. Of these, 25 were identified by pediatric providers (sensitivity = 29%). A total of 104 of 128 mothers with a PSI score <20 were identified as such by providers (specificity = 81%). Pediatric providers were more likely to identify mothers who were <30 years old, living alone, and on public assistance. Also, mothers who were assessed by the child's own primary provider or by an attending pediatrician were more likely to be identified accurately than were mothers whose children were seen by a pediatric trainee or a nurse practitioner.

Conclusions.  Pediatric health care providers did not recognize most mothers with high levels of self-reported depressive symptoms. Pediatricians may benefit from asking directly about maternal functioning or by using a structured screening tool to identify mothers who are at risk for developing depressive symptoms. In addition, training pediatric providers to identify mothers with depressive symptoms may be beneficial.  Key words:  depressive symptoms, identification, pediatric providers.

Depression and depressive symptoms are among the most prevalent treatable mental health problems^1-3; 11.5 million Americans experience a depressive episode in a given year.⁴ Depressive symptoms are significantly more common in women than in men in both population-based¹ and clinic-based studies.² For women ages 15 to 44, depression is the leading cause of disease burden worldwide.⁵ In particular, being the mother of young children places a woman at increased risk for developing depression and depressive symptoms.^2,6-11 Studies conducted in a variety of pediatric practice settings show rates of depressive symptoms in mothers from 12% to 47%.^6,9,11-13

Unrecognized and untreated depressive symptoms may result in significant psychological, social, and occupational disability for mothers^14-16 and place their children at risk for developing serious developmental, behavioral, and emotional problems.^12,17-21 The presence of high levels of depressive symptoms that are subclinical for classification of a depressive disorder may contribute significantly to poor child outcomes from infancy to adolescence.^7,22,23 Punitive attitudes toward child rearing,²⁴ inaccurate expectations of child development,¹² and more negative, unsupportive, or intrusive parent-child interactions¹⁸ have been noted in mothers with depressive symptoms. Infants and preschool children of mothers with depressive symptoms show decreased responsiveness,²⁵ increased hostility and anxiety,²² and deviant cognitive and linguistic development²⁶ that may have long-lasting results.²⁷ Older children and adolescents of depressed mothers are more likely to experience depression, substance abuse, and conduct disorder during their adolescence than are children in comparison samples.^19-21,28-30

Because depression and depressive symptoms in mothers who have young children are prevalent and associated with adverse outcomes in their children, pediatricians and other pediatric health care providers have been urged to screen for maternal mental health problems and family stresses.^9,11 Pediatric health care providers develop an ongoing relationship with mothers and often discuss various stresses experienced in parenting children. As such, they are poised to address family problems in the context of health supervision, as recommended by Green.³¹ Some investigators advocate that this is a promising avenue by which pediatric primary care providers can increase their effectiveness in dealing with and preventing childhood problems.^9,32-35

Previous studies, however, suggest that pediatricians are not accurate in identifying mothers with depressive symptoms without the assistance of a screening tool.³⁶ Similar findings have been observed among family practitioners and primary care providers of adults, who underrecognize depressive symptoms in their own patients.^37-41 Physician factors that are associated with increased identification of depressive symptoms such as sex,⁴² differences in knowledge or training,^43,44 communication styles,⁴⁵ and attitudes about psychosocial issues in practice have been examined in adult primary care,^44-48 but no study has examined the factors that influence pediatricians' ability to recognize depressive symptoms in mothers of their patients. Therefore, this study was designed 1) to determine whether pediatricians and other pediatric health care providers could recognize maternal depressive symptoms in the context of primary care for children, using only clinical indicators without the assistance of a screening tool, and 2) to explore whether maternal characteristics, provider characteristics, and visit factors affected pediatric health care providers' ability to recognize mothers with depressive symptoms.

	METHODS

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Study Design

This cross-sectional study was conducted during the months of June through August in 1995, 1996, and 1997 at a hospital-based, inner-city, general pediatric clinic that has approximately 30 000 primary care visits per year. The study population was composed of 2 groups of participants. The first group was English-speaking, mothers who brought their biologic children ages 6 months to 3 years for a health care maintenance visit or for a minor acute illness. Mothers of children of this age group were selected because they come frequently for preventive health care for their children and have been studied by other investigators.^6-10 The second group was pediatric health care providers who were attending pediatricians, pediatric trainees, and nurse practitioners. Two separate questionnaires were completed, one by the mother, the other by her child's pediatric health care provider, each unaware of the other's responses. Mothers were approached by trained interviewers while waiting to see the child's pediatric health care provider and asked to participate in the study, which was approved by the Institutional Review Board. Informed consent was obtained following the guidelines of our institution. At the same primary care visit, pediatric health care providers were asked by the interviewer to complete a short questionnaire on maternal and family functioning that was attached to the child's medical chart. These assessments were most often completed by the child's provider immediately after the visit and returned directly to the research assistant who was waiting close by. On rare occasions when the provider had other clinical demands, the research assistant left a self-addressed envelope with the provider to ensure that the assessment form was completed and returned that same day. Providers were told that the survey was designed to evaluate specific child health issues and contained several questions about the child's health status. The specific purpose of the study (ie, to assess providers' ability to identify depressive symptoms in mothers) was not revealed to the pediatric health care providers to reduce response bias.

Mothers' Questionnaire

The mothers' questionnaire consisted of sociodemographic items and a self-reported assessment of depressive symptoms. Sociodemographic items included age, marital status, ethnic background, languages spoken, birthplace, educational level, employment and income status, and household composition. To determine health status, mothers were asked several questions adapted from the 1994 National Health Interview Survey⁴⁹ about whether they had any ongoing health conditions or limitations in activity as a result of their health. In addition, they were asked to compare their health with that of other people their age on a 5-point scale (excellent to poor).

To assess depressive symptoms, mothers self-administered the Psychiatric Symptom Index (PSI),⁵⁰ a 29-item scale that was developed on a community sample of 2299 men and women. The PSI provides a total symptom score as well as subscale scores on 4 dimensions (depression, anxiety, anger, and cognitive disturbance). Internal consistency, reliability, and concurrent validity have been well-established.⁵⁰ The item content of the PSI has been compared with 2 narrow-band instruments for depression and anxiety, the CES-D⁵¹ and the State-Trait Anxiety Inventory,⁵² and was found to have comparable content validity to these instruments in meeting a majority of the DSM-IV criteria for major depressive disorder and generalized anxiety disorder.⁵³ The PSI has been found to be valid and reliable in a multiethnic, disadvantaged, urban population.⁵⁴ Cross-cultural reliability of the PSI has been tested on the subscales separately and on the total score in Puerto Rican and African American mothers of an inner-city population.⁵⁵ Other studies also have used the PSI successfully with urban, minority populations, including mothers of ill children.⁵⁶

The PSI contains items that measure the frequency of symptoms experienced during the past 2 weeks from never to very often. Examples include how often you have had trouble concentrating, or noticed your hands trembling, or felt fearful or afraid, or felt downhearted or blue. PSI items are scored using a 4-point scale (0-3); the total score and subscales are calculated as a percentage of the total possible score. A total score of 20 represents a high level of symptoms.⁵⁰ Scores of 30 strongly suggest major depression; Bauman⁵⁷ found a sensitivity of 90% and specificity of 58% against the section on Major Depression within the Diagnostic Interview Schedule⁵⁸ using this cutoff. A total PSI score of 20 is used as a cutoff in presenting data from this study, because we are interested in mothers who have high levels of depressive symptoms and wanted to assess whether pediatric providers were able to identify such mothers. For comparison, we also present data using a total PSI cutoff of 30 to assess whether pediatric providers are better able to identify mothers who not only would have high levels of depressive symptoms but also likely would receive a diagnosis of depression.

Pediatric Health Care Providers' Questionnaire

The pediatric health care providers' questionnaire collected data on provider sex, race, type of training (medicine or nursing), and level of training (attending, resident, or nurse practitioner). Information was also obtained about the type of visit (well-child care, acute care, follow-up visit), whether the provider was the child's primary provider, and how well the clinician believed that he or she knew both the child and the mother (on a 5-point scale from not very well to very well). The provider assessed child, maternal, and family functioning using a 10-category checklist of medical, psychosocial, and mental health problems based on items adapted from Horwitz et al.⁵⁹ For each problem noted, providers were asked to indicate whether the problem occurred and, if so, its duration and severity. Types of treatment, if any, were noted as well (eg, evaluated, treated, counseled, or referred to a specialist).

To assess maternal depressive symptoms, providers were asked 1) "Is this mother acting depressed?" (yes or no) and 2) "How likely is this mother to receive a clinical diagnosis of depression?" (1-5 scale from not likely to very likely). Next, providers were asked how well they thought each particular mother was functioning 1) as a parent and 2) in social interactions using a 0 to 10 rating scale for each evaluation. Finally, providers were asked to check off any applicable symptoms from a list that included the following 10 items: sadness, low self-esteem, no energy, somatic complaints, wide mood swings, depression, anxiety or nervousness, excessive anger or irritability, thought problems or delusions, or other mental health concerns. This symptom list was derived from a similar list of maternal depressive symptoms and represents those symptoms most commonly seen and described by clinicians in practice.

Data Analysis

Criteria for positive identification of a mother by the pediatric health care provider were met if at least 1 of the following provider responses was made: 1 or more symptoms from the 10-item list of depressive symptoms, a rating of 4 or less on either scale of functioning, a yes response to the question of whether the mother was acting depressed, or a response that the mother was somewhat to very likely to receive a diagnosis of depression. Because these criteria are not strenuous, providers were given the best opportunity to identify a mother with symptoms. We evaluated the sensitivity, specificity, positive predictive value, and negative predictive value of provider identification of mothers with depressive symptoms against a total score of 20 or higher on the PSI. The relationships of maternal, provider, and visit characteristics to accurate identification of mothers who had high PSI scores by the providers were examined using cross tabulation and ² analyses. In addition, we used stepwise logistic regression to determine which variables were related independently to provider identification with all other variables controlled.

	RESULTS

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Of the 372 eligible mothers who were asked to participate in the study, 338 (91%) completed questionnaires and 34 (9%) refused to participate. Of the 338 mothers who participated, 214 (63%) were also assessed by their child's pediatric provider and compose the study cohort for this report. Mothers whose child's provider completed an assessment did not differ from mothers whose child's provider did not in terms of race, birthplace, family type, marital status, employment status, public assistance, health conditions, and mean PSI total score. However, mothers whose children's providers completed assessments tended to be younger (25.5 vs 27.8 years; P < .05), completed fewer grades in school (12 vs 13; P < .05), and knew the provider for less time (0.9 vs 1.4 years; P < .05) than did mothers who were not assessed by their child's provider. Sixty of the 90 pediatric health care providers (67%) who were working at the clinic completed 1 or more assessments. The 30 nonparticipating providers did not have patients whose mothers participated in the study and were primarily residents²⁴ who spent only 1 half-day per week in the clinical setting where the study took place and pediatric nurse practitioners⁴ who worked part time in pediatric primary care.

Pediatric providers completed a mean of 4 assessments (range, 1-12). One third of the 60 providers rated only 1 mother, whereas more than half of the participating providers rated 2 or more. Of the successfully completed maternal and provider pairs, 156 (73%) provider surveys were completed by the child's usual primary care provider, 50 (23%) visits were with a provider other than the child's primary provider, and 8 (4%) visits had no information regarding the provider's relationship with the mother. Nine percent of the 156 visits to the child's usual primary care provider were first visits, whereas most of the visits to a provider other than the primary care provider were first visits (86%). Ninety percent of visits were for well-child care or follow-up; the remainder of the visits were for mild acute illnesses such as upper respiratory infections. The mean visit length was 23 minutes. Pediatric providers knew the mother for approximately 17 months (range: 0-180 months); 60% of the providers reported that they knew the mothers they assessed well (3 on a 5-point scale).

Characteristics of Pediatric Providers and Mothers

Of the 60 providers represented in the study, 43 (72%) were female and almost 75% were white. Forty percent of the providers were attending pediatricians, 43% were pediatric trainees, and 17% were nurse practitioners.

Characteristics of the 214 mothers rated by the child's pediatrician are shown in Table 1. Mothers' mean age was 26 years (range: 15-45 years). Mean level of education was 12 years (range: 6-17 years). Mothers primarily were black and Hispanic, and slightly more than half were single. Almost 25% of the mothers were living alone with their children. Fifty-five percent of the mothers received public assistance, and 79% of the mothers were unemployed.

When asked about their physical well-being, 24% of the mothers reported having a medical condition. Overall, very few mothers reported that their health status was poor or fair. In terms of their psychological well-being, mothers' mean PSI total score was 21. Forty percent of mothers scored at or above 20; 21% scored at or above 30.

Providers' Identification of Mothers With Depressive Symptoms

Table 2 shows the agreement between the pediatric health care provider's identification and the mother's having a total PSI score of 20, which represents a high level of symptoms. Twenty-five of 86 mothers who had a PSI score at or above 20 were identified by providers for a sensitivity of 29%, whereas 104 of the 128 mothers who had PSI scores <20 were identified by providers for a specificity of 81%. The positive predictive value of providers' identification was 51%; the negative predictive value was 63%. Increasing the cutoff on the PSI to 30, reflecting mothers who would be likely to receive a diagnosis of a major depressive disorder, did not improve accuracy. Of the 44 mothers who scored at or above 30, only 15 were identified by providers (sensitivity = 34%). A total of 136 of 170 mothers who had a PSI score of less than 30 were identified (specificity = 80%). The positive predictive value of providers' identification was 31%; the negative predictive value was 82% (Table 3).

When we restricted the analyses to the 153 mothers who had an established relationship with their child's primary provider (ie, not the first visit to that provider), we found that the sensitivity improved from 29% to 37.5% whereas the specificity essentially remained unchanged (81% vs 82%).

We also examined the frequency of each maternal symptom identified according to the providers' reports. Providers were most likely to note 1 or more symptoms from the 10-item checklist, with sadness being the individual symptom most often indicated (11 mothers). Anxiety (9) depression (9), and low self-esteem (7) also were frequently noted. Of the 25 mothers who had a PSI total score of 20 and who were identified accurately by providers, 15 (60%) were identified when providers noted symptoms on the checklist of symptoms, either alone or in combination with other criteria, and 18 (72%) were identified when providers noted that the mother likely would receive a clinical diagnosis of depression alone or in combination with other criteria. Three mothers who were identified accurately by providers met all 4 criteria (ie, 1 or more symptoms, poor functioning, acting depressed, and likely to receive a diagnosis of depression).

Table 4 shows the relationships of selected maternal, provider, and visit characteristics to the accuracy of the provider's identification for the 86 mothers who had PSI scores of 20. Providers were more likely to identify mothers who were <30 years old, mother who were living alone, and mothers who received public assistance. Other maternal sociodemographic characteristics, such as level of education, race, and employment status, were not significantly related to accurate identification. When we examined visit characteristics, we found that length of visit did not affect accuracy of identification. Mothers who had high PSI scores and who were assessed by the child's usual primary care provider or were known to the provider (ie, not a first visit) were identified accurately more often. Mothers whose provider reported that he or she knew the mother well were significantly more likely to be identified as having high levels of depressive symptoms. Mothers who were assessed by an attending pediatrician were more likely to be identified than were mothers whose children were seen by a pediatric nurse practitioner or a pediatric trainee (37% vs 21% vs 11%). Although the differences among these 3 groups do not reach statistical significance, attending pediatricians have better identification rates than either nurse practitioners or trainees. When compared with trainees alone, attending pediatricians have significantly better identification rates (P < .05).

Stepwise logistic regression showed 3 relationships between providers' accurate identification of mothers who had PSI scores of 20 and provider, mother, or visit characteristics that held when other variables were controlled for. Mothers who were <30 years old and mothers who were living alone were more likely to be identified accurately by providers (odds ratio = 9.6 and 4.4, respectively). Mothers whose provider reported that he or she knew the mother well (3 on a 5-point scale) were also more likely to be identified as having high symptom levels (odds ratio = 6.7).

	DISCUSSION

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Pediatric health care providers did not recognize most mothers who had high levels of self-reported depressive symptoms. Recognition was not better when severity of maternal symptoms was high. However, several maternal, provider, and visit characteristics did seem to be related to improved recognition of mothers with depressive symptoms. Mothers who had high symptom scores on the PSI (20) and who were young, living alone, or receiving public assistance were more likely to be identified accurately by pediatric health care providers. Also, there was better agreement when the mother had an established relationship with the child's provider or was assessed by an attending pediatrician. These findings suggest that both continuity of care and level of experience are important elements in recognizing mothers with depressive symptoms.

In this study, pediatric providers who were not seeing mothers for the first time but rather had an established relationship with a mother had better accuracy in recognizing mothers with depressive symptoms. Among providers who had met mothers before, however, recognition was still low (sensitivity = 37%). An initial visit between mother and pediatric provider is a time of getting to know each other, with the primary focus on the child. In a primary care setting, continuity of care between children and pediatric providers is important not only to follow the child's ongoing medical and psychosocial issues but also to become more attuned to family issues that may affect the pediatric patient, such as maternal depressive symptoms. Providers who reported that they knew the mother well did indeed have better recognition of mothers with depressive symptoms.

Provider recognition of maternal depressive symptoms was better among attending pediatricians than among pediatric nurse practitioners or pediatric trainees. During pediatric residency training, trainees are accumulating and integrating vast amounts of factual medical information. Residency is also a time when trainees begin to acquire the skills needed to communicate effectively with patients. Therefore, residency training is the ideal time to consider pediatric patients in the context of their family environments and is recommended in the expanded health supervision guidelines in Bright Futures.³¹ Furthermore, this study suggests that pediatric providers need to be given the knowledge and skills to better identify mothers with depressive symptoms.

Because they did not seem to recognize most mothers with depressive symptoms, pediatric health care providers can assist by asking directly about maternal functioning or by using a structured tool to identify mothers with depressive symptoms . Screening for maternal depressive symptoms in a pediatric primary care setting is feasible.^8,11,13 In addition, because depressive symptoms may indicate the presence of a treatable disease, namely depression, screening for maternal depressive symptoms is warranted on the basis of criteria developed by other investigators.^60-62 They postulated that for screening to be beneficial, there must be a high prevalence of undetected cases or a high incidence of frequently occurring cases, the disease must be associated with adverse consequences, a good screening test must be available, and effective treatments that reduce or eliminate morbidity from the disease must exist.

Depressive symptoms in mothers are common^6,8-11 and can have serious negative consequences for their children,^12,17-21 yet mothers with depressive symptoms may not be recognized and treated by their own primary care providers.^17-41 Pediatric primary care settings may be the only health system in which mothers are consistently involved.⁶³ Pediatric primary care visits can provide an opportunity to identify mothers with depressive symptoms for several reasons. First, most mothers do interact with pediatricians on a regular basis when they bring their young children for pediatric health care. Second, pediatricians should be motivated to identify mothers with depressive symptoms to mitigate the potential negative effects that they may have on the child's health and well-being. Finally, women who do not have primary care providers of their own or who do not feel comfortable discussing their concerns with their own providers may be more inclined to discuss with pediatricians problems, such as depressive symptoms, that affect their children. Pediatricians routinely address family issues and are therefore in a position to assist mothers if given the opportunity and the training to discuss maternal mental health issues comfortably in the context of pediatric primary care. Other investigators also found that mothers consider it appropriate to discuss family stresses and problems during well-child visits,⁶⁴ and, in fact, both the National Depressive and Manic Depressive Association Consensus Statement on the Undertreatment of Depression⁶⁵ and Healthy Children 2000 recommend increases in the number of "primary care providers who include in their clinical practices assessment of cognitive, emotional, and parent-child functioning, with appropriate counseling, referral, and follow-up."⁶⁶

There are several limitations to this study. First, it did not attempt to confirm symptoms or make a diagnosis of major depression in mothers. Although this would have been ideal, our aim was simply to compare pediatric providers' assessment of mothers with a self-assessment tool that mothers can complete in a busy clinical setting. Additional study would be needed to determine the rates of clinical depression among mothers who had PSI scores of 20 and which of those mothers were recognized by pediatric providers. It must be acknowledged that providers may not have had sufficient discussion with a mother to identify depressive symptoms. In addition, although there are no standardized measures for providers to use to report on their observations of mothers, the questions that we used have inherent face validity. Pediatric providers care for children in the context of their family environment; therefore, we believe that it is important for pediatric providers to identify women who have high levels of symptoms regardless of whether they qualify for a diagnostic label. Brown et al⁶⁷ showed that both chronic and severe life stress with subclinical symptoms may be important contributors to the development of depressive disorders, and Horwitz et al.⁵⁹ showed that recognition of children's psychosocial problems proved therapeutic. However, additional study is needed to determine whether acknowledging mothers' symptoms in the context of pediatric primary care is beneficial.

Pediatricians are poised to discuss parenting stress or mild depressive symptoms with mothers and to refer those who are more symptomatic to adult health care providers for treatments that are known to be effective.^68,69 Because pediatric health providers did not recognize most mothers who had high levels of self-reported depressive symptoms, they may benefit from asking directly about maternal functioning or by using a structured screening tool to identify mothers who are at risk for depressive symptoms. In addition, training pediatric providers to identify mothers with depressive symptoms may be beneficial.

	ACKNOWLEDGMENTS

We thank the New York City Health and Hospitals Corporation and the Jacobi Medical Center for their cooperation. In addition, we thank the students from the Albert Einstein College of Medicine and the Health Research Training Program of the New York City Department of Health for their assistance in data collection.

	FOOTNOTES

Received for publication Mar 6, 2000; accepted Mar 6, 2000.

This work was presented in part at the 37th Annual Meeting of the Ambulatory Pediatric Association, Washington, DC, May 3, 1997.

Reprint requests to (A.M.H.) Case Western Reserve University, Department of Pediatrics, Rainbow Babies and Children's Hospital, 11000 Euclid Ave, Cleveland, OH 44106. E-mail: a.heneghan{at}worldnet.att.net

	ABBREVIATIONS

PSI, Psychiatric Symptom Index.

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