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a Pediatrics
b Community and Family Medicine, Dartmouth Medical School, Lebanon, New Hampshire
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIX: SCREENING FORMREFERENCES |
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METHODS. Implementation of brief depression screening of mothers at well-child visits for children of all ages was studied in 3 rural pediatric practices. Two screening trials introduced screening (1 month) and then determined whether screening could be sustained (6 months). Screening used the 2-question Patient Health Questionnaire. Practices tracked the proportions of visits screened and provided data about the screening process.
RESULTS. Practices were able to screen in the majority of well-child visits (74% in trial 1 and 67% in trial 2). Of 1398 mothers screened, 17% had 1 of the depressive symptoms and 6% (n = 88) scored as being at risk for a major depressive disorder. During discussion, 5.7% of all mothers thought they might be depressed and 4.7% thought they were stressed but not depressed. Pediatric clinicians intervened with 62.4% of mothers who screened positive and 38.2% of mothers with lesser symptoms. Pediatrician actions included discussion of the impact on the child, a follow-up visit or call, and referral to an adult primary care provider, a mental health clinician, or community supports. Pediatrician time needed to discuss screening results decreased in the second trial. Prolonged discussion time was uncommon (5–10 minutes in 3% of all well-child visits and >10 minutes in 2%).
CONCLUSIONS. Routine, brief, maternal depression screening conducted during well-child visits was feasible and detected mothers who were willing to discuss depression and stress issues with their pediatrician. The discussion after screening revealed additional mothers who felt depressed among those with lesser symptoms. The additional discussion time was usually brief and resulted in specific pediatrician actions.
Key Words: depression • maternal • primary care • screening
Abbreviations: EPDS—Edinburgh Postnatal Depression Scale • USPSTF—US Preventive Services Task Force • PHQ—Patient Health Questionnaire
Depression is one of most prevalent and disabling mental illnesses in the United States and is twice as likely to affect women as men.1,2 Because rates of major depression among women peak during the childbearing years,3 their children may suffer the consequences.
Many studies from infancy through adolescence show that a mother’s depression affects her children adversely. Both clinical depressive disorders and subthreshold depressive symptoms have an impact on how effectively mothers can parent.2 Maternal depressive symptoms are associated with fewer positive parenting behaviors and more negative interactions with young children.4–6 Mothers with depressive symptoms are more likely to seek urgent care for their young child and to utilize more health services and are less likely to limit television watching, to read to their child, and to implement safety measures.4,7–10 Over time, children raised in a home with a depressed parent are more likely to develop behavioral problems and depression.11–14 Although postpartum, low-income, single, or young mothers may be at greater risk for depressive symptoms,15–18 effects of depression are seen among mothers in all sociodemographic groups.
Frequent contacts with mothers during well-child visits give pediatric clinicians the opportunity to improve child outcomes by helping mothers when they are depressed. However, current approaches used by pediatricians to detect depression may be inadequate, because they usually rely on observation of symptoms (81%); only 8% of pediatricians ask routinely about maternal depressive symptoms.19 During usual care, pediatricians have been shown to detect fewer than one half of the mothers who are depressed.20 To remedy this, more-structured screening for depression during pediatric visits has been advocated.21
An efficient depression screening option is now available. The US Preventive Services Task Force (USPSTF) recommended that all adults receive depression screening with 2 questions that assess mood and anhedonia with follow-up services provided.22 This 2-question screener has been well validated with psychiatric interviews.23–25 Incorporation of this brief screener into the well-child visit is more realistic than incorporation of earlier, longer, screening measures,17,26,27 which require more time to administer and to score. In preliminary studies, we determined that a paper-based, brief screening was well accepted by mothers and pediatricians were able to incorporate it into well-child visits.28
Currently, pediatricians report lack of time as a significant barrier to detecting and intervening for maternal depression.19 Before routine screening for maternal depression by pediatricians is proposed, a better understanding of the number of mothers who would screen positive and the time required to discuss the screening results is needed. In addition to screening, referral for follow-up care is important. Pediatricians cannot be expected to make formal diagnoses for mothers who are not their patients. However, discussing the possibility of a depressive disorder and its impact on the child and providing referrals, when indicated, would be appropriate tasks for pediatric clinicians.
The purpose of this study was to estimate the proportion of mothers who screen positive, how pediatricians and mothers respond to this information, and the discussion time required when community practices incorporate routine depression screening into well-child visits. These issues were explored in 2 screening trials in community practices. In the first phase, we introduced screening in a 1-month trial. In the second phase, a 6-month trial was conducted to determine whether the approach could be used routinely.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIX: SCREENING FORMREFERENCES |
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With the screening protocol, parental screening was conducted at all well-child visits, except in 1 practice that chose not to screen parents at adolescent health visits. Screening was not conducted at acute visits because providers thought time was too limited and parents were focused on their ill child. Information about the screening program was posted in the reception area. The nurses provided the paper screener to the parents as they prepared the child for the visit in the examination room. The screener required <1 minute for administration and parental completion. Clinicians were asked to discuss the screener findings during the visit. Referral for additional resources was based on parental preferences. All study data collected were anonymous. Because the screening was part of clinical practice and data had no parental identification, written consent was not obtained. Our institutional human subjects review board approved the study protocol and waived written consent requirements.
The Screening Instrument
Initially, our group developed and tested both interview and paper formats to ask parents the 2 USPSTF-endorsed, screening questions. Because the paper format cued pediatricians to address the issue and had high parental acceptance and a better yield,28 it was chosen for use in this study. Study question response choices addressed the frequency of symptoms, rather than offering yes/no responses, because recent work showed that this improved the measure’s sensitivity and specificity.25
The depression screening instrument was a single, brightly colored page with an introductory paragraph for the parent explaining why the pediatric practice was screening parents (see Appendix). It stated that parental responses would be discussed during the visit. This was followed by Patient Health Questionnaire (PHQ)-2, which asked the 2 USPTF-endorsed questions about the key Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, determinants of depression, namely, altered mood and anhedonia (the inability to experience pleasure or interest in activities usually enjoyed), occurring in the previous 2 weeks. If parents reported either symptom, then they recorded their frequency from 1 to 3 (several days = 1, more than one half of the days = 2, nearly every day = 3). Summing the PHQ-2 items yielded scores ranging from 0 to 6.
The PHQ-2 is a depression risk screener derived from a longer, 9-item, self-administered, PHQ29 depression diagnostic tool. The PHQ-2 has been validated in both primary care and obstetric populations and has been shown to perform as well as longer screening measures, in comparison with a research psychiatric interview. With a cutoff score of 
3, it has a sensitivity for major depression of 83%, a specificity of 92%, and a positive likelihood ratio of 2.9.24,25 This cutoff point was used in our study to identify screen-positive mothers who needed discussion of the findings. Pediatricians were informed that some parents who are at risk for major depressive disorders might not be detected with the cutoff point of 3. Discussion with mothers with lower symptom levels was at the discretion of individual providers and mothers.
Study Sites
The 3 participating primary care practices were in rural communities with populations of 6000 to 15000. Medicaid was the payer for 25% of the patients in these practices. The median household income for these communities ranged from $35600 to $49000. Ninety-five percent of the population in these communities is white. The practices were members of Dartmouth’s primary care practice-based research network, Clinicians Enhancing Child Health. There were 14 pediatricians (10.8 full-time equivalents) and 5 nurse practitioners (2.5 full-time equivalents). The number of pediatric providers per practice ranged from 4 to 10.
Evaluation
Practices provided weekly data on the number of well-child visits in their targeted age range, the number of screenings completed, and reasons for not screening, including parental refusal. Clinicians completed a 1-page data form about the interaction related to the screener for all encounters during the introductory, 1-month, screening trial. In the longer second trial, to reduce clinician burden and to incorporate screening into routine care realistically, clinician-reported data were collected only during well-child visits in three 1-week evaluation periods, in months 2, 4, and 6. Data collection by the pediatric providers focused on the information learned and the activities that occurred after screening. Clinicians provided data on the gender of the parent and child, the child’s age, and the length of discussion about the screening results (none, <3 minutes, 3–5 minutes, 5–10 minutes, or >10 minutes). In addition, they completed a checklist of information learned from the discussion. The response options were as follows: parent does not think these issues of concern, parent feels stressed but not depressed at present, parent agrees may be depressed but does not wish to pursue at this time, parent agrees may be depressed and is willing to take additional action, and parent has history of mood disorder but is not on treatment. Current parental mental health treatment (medication or counseling) and actions taken at the visit, as well as comments, were documented. These data checklist items were developed from the range of free-text responses in our earlier study.28 The data collection was designed not to lengthen the visit and to duplicate as closely as possible the type of information requested of, or available from, a parent during the child’s visit. Parents provided responses to the screening questions without identifiers, and we did not collect other parental demographic data, such as age or income level.
Data Analysis
Only maternal data were analyzed in this report. Frequencies and sample characteristics were calculated overall and for each screening trial. When no significant differences existed between the 2 trials for an item, data from the 2 trials were combined and analyzed together. Analyses were conducted with the 
2 test and Fisher’s exact test for categorical variables and the t test and Pearson’s correlation for continuous variables. Variation at the practice level was examined in bivariate analyses for depression screening responses, discussion time, and maternal responses. For the outcome of referral for additional assistance, a binary logistic regression model was developed to determine which information obtained predicted maternal referral. Encounters with missing data were excluded from this analysis. To adjust for clustering according to practice influencing provider referral predictors, practice site was included in the model. Child’s age was the most commonly missing variable in the model (n = 100) and did not change the outcomes if omitted. Analyses were conducted with SPSS version 11 software (SPSS, Chicago, IL)
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIX: SCREENING FORMREFERENCES |
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12 months of age, 29.2% for children 1 to 5 years of age, 27.8% for children 6 to 12 years of age, and 11.7% for children 13 years of age.
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3), resulting in a positive depression screen. The responses in Table 1 did not vary significantly between the 2 screening trials or according to practice site or child’s age. Mothers of younger children (<6 months, <1 year, or <5 years of age) were no more likely than mothers of older children to screen positive or to have any depressive symptoms. Among all mothers, 7.3% had symptom scores of 1, 3.6% had scores of 2, 2.1% had scores of 3, 1.9% had scores of 4, 0.6% had scores of 5, and 1.4% had scores of 6. The average depressive symptom score also did not vary significantly according to practice site.
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3. The screening process resulted in discussion between pediatric providers and mothers who had lower symptom levels, as well as mothers who screened positive (discussion time of >5 minutes for 17.1% [36 of 152 mothers] with scores of 1 or 2, compared with 36.5% [31 of 85 mothers] with scores of 3 to 6).
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3. This discussion of low-level symptoms resulted in nearly twice as many mothers who acknowledged that they might be depressed than if we had provided pediatricians with information only on the screen-positive mothers. Mothers also shared information about their history of mood disorders and current treatment. We do not have data on their length of treatment. Among mothers currently under treatment by their primary care provider or a mental health clinician, 30.9% (30 of 97 mothers) had positive depression screening scores of 3.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIX: SCREENING FORMREFERENCES |
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Clinicians were able to screen in 
70% of well-child visits in the 2 trials. Higher screening rates were obtained when clinicians and nurses integrated the screening forms into their daily routines completely. Screen-positive rates were similar in the 2 screening periods. Providers seemed to become more efficient in the second trial, taking less time while continuing to assist the same proportion of mothers.
One strength of this study is that it evaluated the implementation of routine screening in community private practices and not academic teaching practices involving less-experienced trainees. It also examined the clinician and mother responses to screening and not just screening results. To our knowledge, this study is the first to explore the time required and visit interactions as a result of routine maternal depression screening.
There are certain limitations of this study. This study was conducted in 1 region, in a small number of practices located in small towns. How would these results generalize to other settings? A study by Grupp-Phelan et al30 that screened for maternal depression in both inner-city primary care and emergency department settings used the 9-question version of the PHQ. We can compare our results with the results of that study because, as a screener, the PHQ-9 performs similarly to the PHQ-2 used in this study. In that urban setting, 9% to 10% of mothers screened positive as being at risk for a major depressive disorder, compared with our private practice settings, where 6% of mothers screened positive as being at risk for major depression.30 Kemper and Babonis,31 using the short version of the Rand screener, also had 50% more mothers screen positive for maternal depression in an urban teaching clinic than in private practice settings. Therefore, in an urban, low-income, clinical setting, a 50% increase in clinician screening discussion time might be expected. For screening to be effective in clinical settings serving predominantly low-income families, with fewer household resources and supports, additional on-site social service supports and referral resources may be required.
Because the study aim was to determine whether depression screening could be incorporated into routine well-child care, the clinician data collected were limited to readily available information and did not involve obtaining consent for follow-up monitoring. Although clinicians included comments about other psychosocial information learned (eg, marital issues, alcoholism, domestic violence, or death in the family), these psychosocial data were not collected systematically. With this study design, we could not determine mothers’ views of the screening process or actions on the referrals. Previous research showed that mothers are receptive to their pediatricians discussing the mothers’ mental health,32 particularly in the context of an ongoing relationship.33 Clinicians in this study gave us feedback, in this study and earlier studies, that parents in their practice viewed this screening approach positively. The clinicians received comments that the parents were glad someone cared and the clinicians’ help had made a difference in the parents’ lives. It will be important in future research to learn more about the brief clinician interactions (eg, the best approach to discussing different symptom levels) and what aspects of the encounter determine whether the mother is willing to consider depression and to seek help. Ultimately, it will be important to study whether better maternal and child outcomes occur as a result of primary care screening.
The approach to screening used in this study may offer clinicians a more-effective way to detect mothers at risk for depression (see Appendix for our recommended screening form). Pediatric clinicians have faced challenges when using other approaches to detect depression in the family. The most commonly used approaches of observation or selective inquiry about symptoms have been shown to have a low yield when used by pediatricians.20 Use of a longer depressive symptom screener is difficult because the additional time needed to complete and to score the screener may be too long for busy clinicians. Even a 10-item measure such as the Edinburgh Postnatal Depression Scale (EPDS) can be challenging to complete. Chaudron et al34 reported that screening occurred in 46% of visits and 31% of screening forms (28 of 90 forms) either were not scored by providers or were scored inaccurately when the 10-item EPDS was implemented at infant well visits.
Screening for depression raises some issues for clinicians. First, clinicians have voiced the concern that the resulting discussions would lead routinely to lengthy well-child visits. This study showed that screening did not require discussion at most visits and usually did not result in prolonged visits. Our clinicians commented that the information learned in the discussion about the family, psychosocial stressors, and mother’s status was important to them in providing appropriate care to the child and was worth the time invested. Incorporation of screening into other longer visits would be appropriate.
Second, limited formal mental health resources may present a challenge. However, there are many precipitants for these mothers, and not all mothers need or chose to use mental health services. A variety of resources and options, rather than only traditional mental health services, should be used to meet mothers’ needs. Our practices reported that many mothers used adult primary care and obstetric providers, social services and other community programs, pastoral counseling, and friend and spouse support.
Third, many depressed mothers already feel isolated, guilty, and less competent as a parent. It is important that depression screening and discussion be a supportive and not judgmental process. Pediatricians who are supportive and empathetic and provide practical assistance with child behavioral and developmental issues can help reduce and not increase mothers’ self-blame.
National recommendations have emphasized the role of pediatricians in detecting postpartum depression, with less emphasis on depression among other mothers.35 Recently, comprehensive analyses of studies with diagnostic interviews showed that the prevalence of major depression is the same for postpartum women as for other women with children. The analyses showed that the point prevalence for major depression at different times during the first postpartum year ranged from 1% to 5.9%.36 The point prevalence of major and minor depression combined varied between 6.5% and 12.9% in the first year.36 Although our data were limited in the number of young infants <3 months of age, we also found no differences in positive screening results or depressive symptoms according to the age of the child.
This study produced lower screen-positive rates than did other screeners used in pediatric primary care. There are several possible reasons, beyond sociodemographic variation. The EPDS rates might be higher because the EPDS detects both anxiety and depressive symptoms. Factor analysis showed that, in the postpartum period, 38% of the total score was accounted for by 3 anxiety questions.37 Differing EPDS cutoff points (scores of 10–13) are used, and higher screen-positive rates for the EPDS (20%) are noted in pediatric primary care when a lower threshold (scores of 10) for positive screening results is used.34 The 3-item Rand screener has higher screen-positive rates but assesses a longer time period of 1 to 2 years, rather than focusing only on current symptoms like the PHQ-2.31 The PHQ-2 is being used widely in adult clinical care settings, and additional investigations comparing the PHQ-2 with the EPDS in the prenatal and early postpartum periods are needed.
It is important to remember that the screening process in this study informed providers about mothers at higher risk for a clinical depressive disorder but did not provide a definitive diagnosis. In primary care and obstetrics/gynecology settings, 75% of patients who screened positive had a depressive disorder and 38% had major depression.25 It is important for pediatricians to be aware of both groups when caring for the children, because depressive symptoms as well as major depression may affect parenting practices negatively, may result in behavioral problems, and may increase utilization of health care.38,39 Individuals with subthreshold depression have poorer functioning in daily life, feel they have difficulty caring for their child, and are at higher risk of developing a major depressive disorder in the next year.30,40,41 If it was desired by mothers, pediatricians discussed depression issues with any symptoms. The tested screening process seems to have triggered discussions with pediatric clinicians that led to actions for mothers who self-identified that they might be depressed even without positive screening results. Therefore, the screener supported an appropriate pediatric role of engaging mothers in a discussion of whether they might be depressed, discussing the impact on the child, and encouraging mothers to receive follow-up services.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIX: SCREENING FORMREFERENCES |
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APPENDIX: SCREENING FORM |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIX: SCREENING FORMREFERENCES |
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The US Preventive Services Task Force recommended that all adults be checked for depression when they see a doctor. Parents of children who are cared for in this practice may see us more often than any other health care provider. The Task Force is considered the authority on preventive health care and we believe it is wise to follow their advice. It’s our job because, if a parent is depressed, their child is affected. The child does better if the parent gets help.
For this reason, please take a minute to respond to the 2 statements below. We’ll then take a look at your responses together during this visit.
Over the past 2 weeks, you have felt down, depressed, or hopeless (true or false).
If true, have you felt this way for (several days, more than half the days, or nearly every day)?
Over the past 2 weeks, you have felt little interest or pleasure in doing things (true or false).
If true, have you felt this way for (several days, more than half the days, or nearly every day)?
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ACKNOWLEDGMENTS |
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We thank all of the clinicians and staff members from our participating Clinicians Enhancing Child Health practices (Exeter Pediatric Associates, Exeter, NH; Monadnock Pediatrics, Peterborough, NH; Plymouth Pediatrics, Plymouth, NH) for their participation. We appreciate the input of Viking Hedberg into design and implementation and the dedicated efforts of Stephanie Singer, our project coordinator.
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FOOTNOTES |
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Address correspondence to Ardis Olson, MD, Department of Pediatrics, Dartmouth Hitchcock Medical Center, HB 7450, 1 Medical Center Dr, Lebanon, NH 03756-0011. E-mail: ardis.olson{at}dartmouth.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSAPPENDIX: SCREENING FORMREFERENCES |
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This article has been cited by other articles:
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  K. Kabir, J. Sheeder, and L. S. Kelly Identifying Postpartum Depression: Are 3 Questions as Good as 10? Pediatrics, September 1, 2008; 122(3): e696 - e702. [Abstract] [Full Text] [PDF]
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G. Caspary, D. M. Krol, S. Boulter, M. A. Keels, and G. Romano-Clarke Perceptions of Oral Health Training and Attitudes Toward Performing Oral Health Screenings Among Graduating Pediatric Residents Pediatrics, August 1, 2008; 122(2): e465 - e471. [Abstract] [Full Text] [PDF]
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 I. M. Bennett, A. Coco, J. C. Coyne, A. J. Mitchell, J. Nicholson, E. Johnson, M. Horst, and S. Ratcliffe Efficiency of a Two-Item Pre-Screen to Reduce the Burden of Depression Screening in Pregnancy and Postpartum: An IMPLICIT Network Study J Am Board Fam Med, July 1, 2008; 21(4): 317 - 325. [Abstract] [Full Text] [PDF]
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A. Garg, A. M. Butz, P. H. Dworkin, R. A. Lewis, R. E. Thompson, and J. R. Serwint Improving the Management of Family Psychosocial Problems at Low-Income Children's Well-Child Care Visits: The WE CARE Project Pediatrics, September 1, 2007; 120(3): 547 - 558. [Abstract] [Full Text] [PDF]
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K. J. Kemper, K. Kelleher, and A. L. Olson Implementing Maternal Depression Screening Pediatrics, August 1, 2007; 120(2): 448 - 449. [Full Text] [PDF]
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M. R. Sills, S. Shetterly, S. Xu, D. Magid, and A. Kempe Association Between Parental Depression and Children's Health Care Use Pediatrics, April 1, 2007; 119(4): e829 - e836. [Abstract] [Full Text] [PDF]
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L. H. Chaudron, P. G. Szilagyi, A. T. Campbell, K. O. Mounts, and T. K. McInerny Legal and Ethical Considerations: Risks and Benefits of Postpartum Depression Screening at Well-Child Visits Pediatrics, January 1, 2007; 119(1): 123 - 128. [Abstract] [Full Text] [PDF]
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