Pediatric professionals are being asked to provide an increasing array of services during well-child visits, including screening for psychosocial and family issues that may directly or indirectly affect their pediatric patients. One such service is routine screening for postpartum depression at pediatric visits. Postpartum depression is an example of a parental condition that can have serious negative effects for the child. Because it is a maternal condition, it raises a host of ethical and legal questions about the boundaries of pediatric care and the pediatric provider's responsibility and liability. In this article we discuss the ethical and legal considerations of, and outline the risks of screening or not screening for, postpartum depression at pediatric visits. We make recommendations for pediatric provider education and for the roles of national professional organizations in guiding the process of defining the boundaries of pediatric care.
When a pediatrician or pediatric health care provider walks into an examination room for a well-child visit, who is the patient? It is the child, of course, but within the context of the family.1 A child who is exposed to stress, abuse, neglect, domestic violence, parental tobacco or substance use, extreme poverty, environmental toxins, or parental mental illness may be negatively affected. Pediatric providers should become aware of these conditions because they affect the child's health and because they might be amenable to prevention or treatment. Furthermore, pediatric providers may be the sole health care professional with whom the family has frequent contact. If not the pediatric provider, then who?
Herein lies an ethical and legal conundrum of well-child care within the context of family-centered care: where do we draw the boundaries of pediatric care? Should pediatric providers routinely be screening parents for mental health problems and social and environmental risk factors? If so, which problems should be systematically addressed, and what should the providers do with the information that is obtained?
Practical issues such as feasibility and reimbursement have dominated this debate. Pediatric providers are asked to provide an increasing array of services during well-child visits, and at the same time, the very core of well-child care is under intense scrutiny because of the dearth of evidence-based practices.2 As pediatrics redesigns well-child visits,3 we believe that it is critical to consider the ethical and legal dimensions of the boundaries of pediatric care.
Although a wide range of parental mental health issues—maternal depression, anxiety, substance use, personality disorders—can impact parenting practices and child health outcomes, we chose to consider one major clinical condition that has received increased attention with regard to routine screening within pediatric visits: postpartum depression. In hopes of stimulating a broader discussion of the boundaries of pediatric care, we use this specific disorder to discuss legal considerations that evolve from the US health care system and ethical considerations that are universal.
DEFINITION OF POSTPARTUM DEPRESSION
Postpartum depression is a term that is used in the literature and in clinical practice to describe a range of depressive symptoms and syndromes that women may experience after childbirth. Debate exists regarding whether postpartum depression is a distinct diagnostic disorder. To date, the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) does not recognize postpartum depression as a discrete diagnosis but applies the term “postpartum onset” as a specifier to major depression to explain the context and the time frame (ie, onset within 4 weeks of childbirth) in which the depression occurs.4 In clinical practice, and in many studies, the DSM-IV-TR definition is viewed as too narrow in both its application of “postpartum onset” to only major psychiatric disorders (major depression, bipolar disorder, brief psychotic disorder) and its time frame for the postpartum period. Many studies define “postpartum” at a minimum of 3 months to a maximum of 1 year after childbirth and include a range of depressive symptom severity. In this discussion, the term “postpartum depression” implies the broader time frame (up to 1 year) and range of symptom severity.
RATIONALE FOR POSTPARTUM DEPRESSION SCREENING IN PEDIATRICS
Pediatric providers are increasingly aware of the prevalence of postpartum depression and its potential effects on children.5–7 In the United States, with heightened awareness has come a national call to improve identification of mothers at risk and those in need of treatment.8 For example, in Illinois and New Jersey, recommendations, mandates, and even incentives (ie, reimbursement) are being given to primary care providers, including pediatric providers, to screen for maternal depression. In addition, the American Academy of Pediatrics (AAP) has described the scope of pediatricians' responsibilities to include assessment and consideration of parental and family environmental factors that may affect children's health,9 maternal depression being one of these.
Although screening for postpartum depression may seem a simple task that pediatric providers could undertake easily, arguments for and against depression screening should be considered carefully.10,11 In its report on screening for depression in adults, the US Preventive Services Task Forces (USPSTF) found sufficient evidence that screening for depression can improve clinical outcomes12 and that the benefits of depression screening in primary care outweigh the risks. The USPSTF “recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.”13
Whether this recommendation could, or should, be applied to postpartum depression and pediatric providers remains undecided. When weighing the risks and benefits of screening specifically for postpartum depression in pediatrics, it is important to determine if postpartum depression meets the criteria for a disease that should be periodically screened for at a preventive health visit. Key questions to consider are:
Is the burden of suffering from postpartum depression sufficient to warrant a screening test?
Do screening tests exist that are safe, inexpensive, feasible, simple, and have sufficient sensitivity and specificity?
Do effective interventions exist if the screening test does detect postpartum depression?
The Burden of Postpartum Depression Is Well Established
Postpartum depression affects ∼14% of new mothers14 and can have lasting effects on women, children, and families.15–17 Among young and socioeconomically disadvantaged mothers the prevalence rates are even greater: 1 in 4 women.18 Studies have also found that if maternal mental health is impaired, children may be adversely affected. Children can suffer from the direct effects of depression such as impaired attachment19 or abuse or neglect.20–22 They may also suffer from the indirect effects such as lack of attendance at well-child visits, parental inattention to preventive actions such as immunizations or use of car seats,23–26 and maternal reluctance to engage in and continue breastfeeding.27
Safe, Inexpensive, Simple, Valid Screening Tools Exist
They have been used successfully in multiple settings, including pediatric settings, to screen mothers.18,28–30 Screening tools such as the Edinburgh Postnatal Depression Scale31 and the Postpartum Depression Screening Scale32,33 were designed specifically to screen for depression in the postpartum period. These tools have been validated and tested in multiple community and ethnically diverse populations34–41 and have been shown to increase identification of postpartum depression in both obstetrical and pediatric settings. However, as with any screening tool, they should not be administered in a vacuum, and although feasible, implementation can be difficult in some systems.42 Health care providers should be educated on the appropriate use of the screening tool, including its interpretation and limitations, and should have a set of guidelines for action based on the outcome of the screening test.
Effective Treatment for Postpartum Depression Exists
Both psychotherapy43,44 and antidepressants44,45 are effective and generally acceptable and accessible treatments for postpartum depression. However, few studies have evaluated the direct connection between screening and increased identification and treatment outcomes.14 In 1 study, universal postpartum depression screening did increase referrals to social work,18 and in a more recent study, treatment of maternal mental health improved both maternal and child mental health outcomes.46
Because pediatric providers are not often the primary care providers for the mothers (unless the mother is an adolescent patient of the provider), a critical issue, as identified by the USPSTF, is ensuring adequate follow-up and treatment. Family practitioners, internists, and obstetricians/gynecologists may directly prescribe medication and/or refer mothers to mental health providers, but even so, these primary care providers often receive little or no training on specific screening for or treatment of postpartum depression. Although family practitioners are in the unique position of being the medical provider for both the mother and child, pediatricians, pediatric nurse practitioners, and pediatric physician assistants are left in a “gray zone.” Most do not provide direct maternal care; however, they can refer women back to their primary care providers, offer information about local and national mental health resources, disseminate educational materials about postpartum depression, provide educational counseling on the effects of depression on children and families, and help track how mothers and children are doing. Although not a classic intervention, there is potential value in education of front-line providers and enhanced awareness of and access to other providers and community-based sources for care and support.
An often-voiced concern is that in many communities, mental health resources are limited or mothers may not have adequate health insurance coverage to access needed mental health services. This is a challenge for all health care providers and is not limited to women with postpartum depression; in fact, pediatric providers often encounter similar dilemmas with their own patients. Hence, although accessibility to maternal mental health care is a challenge, it is not an absolute limitation.
Beyond the above-mentioned challenges, it is important to consider the ethical and legal considerations of screening for postpartum depression.
What Are the Risks of screening?
Many clinicians' primary concerns involve a combination of ethical and legal considerations. Pediatric providers may be concerned that mothers will find these questions intrusive or stigmatizing; in response, mothers may not seek care for their children. In this way, as a pediatric provider whose primary obligation is to the child, they run the risk of “harming” children by implementing screening. The acceptability of screening for maternal mental health issues at pediatric visits is mixed and requires further exploration.28,47 Alternately, to the extent that the mother's health affects the child, simply doing nothing might be a “harm” in and of itself. Furthermore, if providers do identify women who are at risk but whom they do not treat and, with due diligence, educate and refer women for care, what is the pediatric provider's responsibility for follow-up with the mother? If the mother chooses not to seek care or injures the child in the context of an identified mental illness, does the pediatric provider face any liability? Clarifying the “best interests of the patient” (child) is critical for this debate. These issues are not insurmountable but certainly highlight the need for an incremental and empirical approach to adoption of screening.
What Are the Risks of Not Screening?
If clinicians know that a treatable disorder is prevalent in their population and may affect the health of the child, are they not ethically bound to ask and to help mothers receive help if possible? That is, at what point does having the knowledge, means, and ability to detect postpartum depression cross a line to reach a “standard of care” that we should expect primary care providers to meet? And then, is the standard to simply screen or do more? Furthermore, if clinicians do not proactively attempt to identify a disorder about which they have knowledge and expertise to inform the mother and refer her for help, are primary care providers exposing themselves to potential liability?
With these questions in mind, it is important to address the “practical” and legal issues that would likely arise in an effort to craft national guidelines and build an evidence base that might shift the “standard of care” to routine screening for postpartum depression. Among these issues are confidentiality, medical charts/documentation, liability, and scope of practice.
Confidentiality, Medical Charts, and Documentation
The Health Insurance Portability and Accountability Act of 1996 (HIPAA)48 impacts the ability of multiple providers to share information and the ability to share information within families. In this instance, it is important to remember that the child is the pediatric provider's patient, which limits the health care pediatric provider's ability to obtain information about the mother. Family practitioners who treat both the mother and the infant would not have the same limitations. HIPAA is not a bar to sharing, but it requires consent of the mother before proceeding. Health care providers should work across disciplines and, with the full involvement of the mother/family, create data-sharing agreements for certain information that impacts the health of the child and mother. Because of heightened confidentiality related to mental health records, extra attention should be paid to the extent of documentation of maternal mental health issues in the pediatric record. It is important to record a note in the child's chart that a screening for postpartum depression took place and, if necessary, that a referral was made. However, what takes place when the mother seeks care after such referral is part of the mother's record, not the child's record.
Liability is a complicated issue that often depends on “standard of care.” At this time, because of the lack of evidence behind a single screening tool and lack of adoption in practice of sufficient scope, a standard of care does not yet exist that would obligate a pediatric provider to conduct a screening. However, as data accumulate and guidelines are put into practice, the standard of care will likely shift. Even if screening is considered standard of care in certain areas or practices and if providers are currently screening, liability issues to consider also include the quality and context of the screening assessment, the nature of the referral, and follow-up after identification and referral.
Scope of Practice
Finally there exist concerns over the scope of practice of pediatric providers, including fears that already time-limited sessions will now have mental health interventions for mothers added on and that pediatric providers will not be reimbursed for the time spent addressing maternal mental health issues. Some of these issues are echoed in the concerns of the American Academy of Family Physicians, which are stated in their position paper on general mental health issues in family practice.49 Pediatric providers should clarify that screens are performed with the purpose—in their role as the child's health care provider—of enhancing that child's well-being. Pediatric providers should be cautious in overstepping the bounds of their role and leave ongoing adult care and therapy to qualified professionals. Mothers should recognize that the pediatric provider's primary obligation is not to them but to their children and should be approached with screens as tools to enhance their ability to care for their children in a way that is supportive and not punitive.
From this risk/benefit assessment, we believe that from both ethical and legal perspectives, the benefits of screening for postpartum depression outweigh the risks. Yet, this does not discount the limited data available to guide pediatric practitioners and the need to proceed with caution to create policies, practices, and guidelines that are supported by evidence from studies. To adequately address these issues, studies must be conducted among diverse populations (ie, diverse cultures, ethnic groups, and socioeconomic groups) as well as among diverse pediatric settings (ie, urban versus rural, community health centers versus private practitioner offices, etc).
NEXT STEPS FOR PEDIATRIC HEALTH CARE PROVIDERS
To limit pediatric providers' liability and enhance their impact on maternal mental health, a multifaceted approach should be taken. First, pediatric providers should receive training in the symptoms and effects of postpartum depression as well as the use of postpartum depression screening tools. Training might be obtained through a variety of venues. For example, (1) postpartum depression educational Web sites may provide training, including continuing medical education, to pediatric providers, (2) pediatric departments should work closely with psychiatry departments to develop workshops or grand rounds designed specifically for pediatric practitioners, and (3) pediatric residency programs should include a curriculum on maternal mental health issues, including postpartum depression. Second, providers should develop a systematic approach to screening, including choice of a screening tool; determining the minimal number of times to screen and at which pediatric visit(s) and standardizing documentation to record outcomes of the screening process, education or counseling of the mother, safety issues assessed and addressed, referrals, refusals, and any follow-up attempted. Finally, pediatric providers should gather information about local and national mental health resources so that they can provide this information directly to the mothers and potentially collaborate directly with their mental health providers.
NEXT STEPS FOR POLICY MAKERS
More research must be conducted and evidence must be gathered to support development of evidence-based screening tools that are culturally sensitive and that are easy to implement in pediatric settings. Professional organizations such as the AAP, the American Academy of Family Physicians, and the National Association of Pediatric Nurse Associates and Practitioners should consider the boundaries of pediatric care and develop guidelines for practitioners that address the roles, responsibilities, and limits of the pediatric provider's role with regard to the mother's mental health needs. For example, the AAP's Mental Health Task Force is currently developing a statement that will include recommendations for screening for postpartum depression. The task force will need to consider the boundary issues described herein to help define the scope of practice and the needs of pediatric practitioners to effectively help mothers.
In addition, pediatric professional organizations should work collaboratively with mental health professional organizations such as the American Psychiatric Association and the American Psychological Association to develop appropriate tools to educate pediatric providers and to develop guidelines for screening for postpartum depression. Regulatory agencies, insurers, and other payers also will need to address how to break down barriers to support pediatric providers in this “new role” and to facilitate effective collaboration between primary care providers and maternal mental health providers, systems that traditionally have very little, if any, interaction.
With apologies to Benjamin Franklin, we believe that we should acknowledge that an ounce of secondary prevention is worth a pound of tertiary cure and develop the systems required to support pediatric providers in screening mothers for postpartum depression. We believe that from the perspective of feasibility, and now from the legal and ethical standpoints, the benefits of screening outweigh the risks. Implementation, however, must be seen as an iterative process, one that relies on additional studies to improve the feasibility of the screening process and the ability of pediatric providers to help mothers with postpartum depression. Although it challenges the pediatric profession to consider the boundaries of pediatric care, implementing screening for postpartum depression in a systematic, comprehensive approach is critical to the ultimate well-being of children and families.
- Accepted September 25, 2006.
- Address correspondence to Linda H. Chaudron, MD, MS, Department of Psychiatry, University of Rochester School of Medicine, 300 Crittenden Blvd, Rochester, NY 14642. E-mail:
Financial Disclosure: Dr Chaudron is on the speakers bureau of Wyeth Pharmaceuticals and has received grant support from Forest Laboratories. Drs Szilagyi, Mounts, and McInerny and Ms Campbell have indicated they have no financial relationships relevant to this article to disclose.
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- Copyright © 2007 by the American Academy of Pediatrics