Factors Associated With Identification and Management of Maternal Depression by Pediatricians
OBJECTIVE. We sought to identify characteristics of pediatricians that were associated with identification or management (referral and/or treatment) of mothers with depression.
METHODS. A cross-sectional survey was mailed to a random sample of 1600 of the 50818 US nonretired members of the American Academy of Pediatrics. Overall, 832 responded, with 745 responses from nontrainee members. The 662 fellow nontrainee members who engaged in direct patient care and completed information on identifying, referring, and treating maternal depression were included in the analyses.
RESULTS. A total of 511 of 662 respondents reported identifying maternal depression; of those who reported identifying maternal depression, 421 indicated they referred and 29 that they treated maternal depression in their practices. Pediatricians who are older, work in practices that provide child mental health services, see primarily (≥75%) white patients, use ≥1 method to address maternal depression, agree that pediatricians should be responsible for identifying maternal depression, think that maternal depression has an extreme effect on children's mental health, and are attitudinally more inclined to identify or manage maternal depression had significantly higher odds of reporting identification of maternal depression. Positive correlates of identification and management of maternal depression included practicing in the Midwest, using ≥1 method to address maternal depression, working in a practice that provides child mental health services, thinking that caregiving problems attributable to maternal health have an extreme effect on children's physical health, having attitudes that are more inclined to identify and to manage maternal depression, and usually inquiring about symptoms routinely to identify maternal depression.
CONCLUSIONS. Pediatricians' practice characteristics and attitudes are associated with their identification and management of mothers with depression.
Maternal depression, a global term encompassing a range of depressive symptoms and syndromes, may affect women immediately after childbirth or later in the child-rearing years.1,2 For women 15 to 44 years of age, depression is the leading cause of worldwide disease burden.3 Eight to 12% of women experience postpartum depression,4,5 although twice that number of women may experience elevated depressive symptoms.6,7 The risk of depression and depressive symptoms is increased in women with young children, women with >1 child, and women of low socioeconomic status.8–14
Negative consequences for women with depression include increased risk of future depression, impaired mother-child bonding, and even overt thoughts of harming their infant.15–22 In addition, extensive research has shown that maternal depression experienced during the postpartum period and beyond can have a negative impact on children's social, cognitive, and behavioral development.1,23–30
Depressed women are likely to be overlooked because of their pattern of medical care use.31–33 Although typically pediatricians do not treat the mothers of their young patients, they are the health care professionals with the most frequent contact with depressed women of childbearing age.33 The American Academy of Pediatrics (AAP) recommends a minimum of 7 well-child visits for children during the fist 1 year of life.34 Therefore, pediatricians are in an excellent position to discuss maternal depression during well-child visits. Bright Futures: Guidelines for Health Supervision encourages pediatricians to support families as part of providing primary health care for children.35 In particular, Bright Futures in Practice: Mental Health recommends that, during health supervision visits, pediatricians “ask parents about any new experiences or stresses in their own lives, and about feelings of sadness, sleep problems, loss of interest in activities they used to enjoy, and other specific symptoms of depression.”36 The AAP Task Force on the Family has advocated for “family-oriented” pediatric care, to improve family outcomes.37 The task force has stated specifically that the “health and well-being of children is inextricably linked to their parents' physical, emotional, and social health.”38 In addition, the Future of Pediatrics Education II residency education guidelines have called specifically for educating residents about family health and maternal depression.39
Despite a growing orientation toward addressing family and maternal issues in pediatric practice, pediatricians do not address these issues readily. Heneghan et al40 found that pediatricians recognized only one fourth of mothers with depressive symptoms. Chaudron et al41 showed that, even when well-structured screening programs were incorporated into pediatric primary care practice, only one half of mothers were screened for depression. In a national sample of practicing pediatricians, Olson et al42 described pediatricians' perceived roles, management practices, and barriers encountered in addressing maternal depression. Fifty-seven percent thought that it was their responsibility to recognize maternal depression, but only 7% felt responsible for providing treatment. Time constraints and incomplete training were barriers most often noted by the pediatricians surveyed. More-recent work by Horwitz et al43 demonstrated that pediatricians endorsed similar barriers to identification and management of maternal depression.
Physician and practice characteristics that are associated with increased identification of depressive symptoms have been examined in adult settings,44–51 but no study has examined the factors that influence pediatricians' identification and management of maternal depression. Because pediatricians are uniquely poised to assist mothers with depression, we sought to identify characteristics of pediatricians that are associated with identification and management, in the form of referral or treatment, of mothers with depression. In particular, we examined pediatricians' sociodemographic and practice characteristics, attitudes, and practices associated with 2 outcomes, namely, (1) pediatricians who have identified maternal depression, compared with pediatricians who have not, and (2) pediatricians who have identified and managed maternal depression, compared with pediatricians who have only identified maternal depression.
The study population for this research consisted of the 50818 US nonretired members of the AAP. The AAP has conducted a periodic survey 3 or 4 times each year since 1987, to provide information on current pediatric topics to inform policy, to develop new initiatives, or to evaluate current projects.52 Using the AAP periodic survey initiative, an AAP researcher (Ms O'Connor) selected and mailed the survey to 1600 members beginning in March 2004, with a sixth and final mailing in August 2004. The questionnaire was 8 pages in length, contained largely closed-ended questions, had been pretested, and was approved by the AAP institutional review board before the initial mailing. Overall, 832 AAP members (52%) responded. Fifty-seven percent of nontrainee members (ie, not residents or fellows) responded. Of those, 662 nontrainee members who engaged in direct patient care and completed the information on identifying, referring, and treating maternal depression were included in the analyses.
Respondents were asked a broad range of sociodemographic, practice characteristic, and patient characteristic questions that were used in previous periodic surveys. Pediatricians' impressions about the prevalence of maternal depression and caregiving problems attributable to a mother's physical or mental health issues were ascertained. The impact of maternal psychosocial problems on children's mental and physical health was rated by pediatricians as little/none, moderate, or extreme/great. Pediatricians were asked, “Do you or others working in your practice (eg, other physicians, nurse practitioner, social worker, psychologist, counselor/therapist, etc) provide medication, counseling, or psychotherapy for mental health problems for children or adolescents?” Pediatricians were asked, “During typical pediatric visits have you, yourself, ever identified depression in a mother of a patient?” Those who had identified mothers with depression were asked whether they had ever referred a mother for diagnosis or treatment or treated a mother (ie, provided in-depth counseling and/or medications). The term “manage,” as used throughout the article, was constructed to include pediatricians who have ever referred and/or treated mothers for depression. In addition, the frequency of use of specific passive and active methods to identify maternal depression was assessed as a 3-level response (usually, sometimes, or never). These methods ranged from observation to use of a screening tool. Pediatricians were asked whether they used currently, or would like to use, any of 12 different methods to address maternal depression. Examples included a team approach with gynecologists, mental health professionals, and pediatricians; partnerships with schools and early childhood providers; bulletin boards with information and resources in the waiting room or examination rooms; and use of Bright Futures in Practice: Mental Health. To assess attitudes about identifying, referring, and treating maternal depression, pediatricians were asked whether they agreed, were neutral, or disagreed that pediatricians should be responsible for each of these 3 actions. Additional assessment of pediatricians' attitudes toward maternal depression was performed by using 3 scales developed by Park et al (E.R.P., A.S.-I., K.J.K., et al, unpublished data, 2006). These scales are based on previous work by Williams et al,53 Olson et al,42,54 Park et al,55 and McLennan et al.56 They measure the following attitudinal attributes of pediatricians: acknowledgment of maternal depression (3 items), perceptions of mothers' beliefs (3 items), and treatment of maternal depression (4 items). Reliability ratings (Cronbach's α) are .59, .72, and .79, respectively. Higher scores correspond to more-favorable attitudes about managing maternal depression.
Characteristics from the AAP member list for responders and nonresponders for the overall sample and the nontrainee members were reported elsewhere.43 Bivariate comparisons of nontrainee responders and nonresponders surveyed showed that women, pediatricians <40 years of age, and fellows and candidate fellows were significantly more likely to respond. To avoid potential bias created by different survey nonresponse rates, poststratification sample weights were created and weighted analyses were performed. The sample weights were created with a saturated logistic regression model with age group (≥40 vs <40 years), gender, and the 2-way interaction between age and gender as predictors of response and the weights as the inverse of the probability of response. The weights were rescaled such that the mean was unity and the sum of the weights was equal to the sample size. These procedures ensured that the sample was representative of the gender and age distribution of AAP membership.
Weighted means and SDs and counts with weighted percentages were used to summarize sample characteristics for continuous and categorical data, respectively. Bivariate and regression analyses were performed for each of the 2 outcomes (has identified versus has not identified and has identified and managed versus has identified only) by using the same analytic approach. The Rao-Scott χ2 test, weighted logistic regression, and weighted linear regression were used to assess bivariate associations between each covariate and each outcome. Covariates with a statistically significant (P < .05) association with the outcome were further assessed in multivariate, weighted, logistic regression models. Main-effects models were fitted, and statistically significant predictors were retained. On the basis of the results of the main-effects models, 2-way interactions of clinical relevance were evaluated. The results are summarized with adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Analyses were performed by using procedures for survey data in SAS 9.1 (SAS Institute, Cary, NC).
Figure 1 depicts the rates of identification, referral, and treatment of maternal depression among pediatric providers. Of the 745 nontrainee respondents, 662 engaged in direct patient care and completed questions regarding identification and management of maternal depression. Of those 662 respondents, 511 (77%) reported ever identifying maternal depression; of those who reported identifying, 421 (82%) also indicated that they referred maternal depression in their practices. Of those, 363 (86%) reported the number of mothers referred for maternal depression in the past year (median: 4 mothers; range: 0–50 mothers). Only 29 pediatricians (7% of those who identify mothers with depression, or 4% of the entire sample) reported ever treating a mother for maternal depression.
Table 1 displays the weighted physician and practice characteristics for the 662 nontrainee respondents, stratified according to each outcome. Compared with pediatricians who have not identified mothers with maternal depression, on average, pediatricians who have identified mothers with depression were significantly more likely to be older, to have been in practice for a longer period of time, and to be white. Pediatricians who have practices that assign patients to a specific pediatrician and those who see primarily white patients (≥75%) were also significantly more likely to identify mothers with depression. These 2 groups did not differ significantly with respect to pediatrician's gender, location or region of practice, proportion of patients with private health insurance, or number of ambulatory visits per week.
Descriptive statistics for pediatricians who have identified and managed (referred and/or treated) maternal depression and pediatricians who have only identified maternal depression are also presented in Table 1. The results showed that the only pediatrician and practice characteristics associated significantly with the identification and management of maternal depression were the pediatrician's race and region of practice; white pediatricians and pediatricians practicing in the Midwest were more likely to have managed maternal depression.
Table 2 shows the associations between pediatricians' attitudes and practices toward mental health and their behaviors regarding mothers with depression for each outcome. Compared with pediatricians who have not identified maternal depression, those who have identified maternal depression were more likely to work in practices that provide child mental health services and to report using ≥1 method to address maternal depression. Pediatricians who perceived that adult mental health services are very or somewhat available, believed that maternal depression has an extreme or great effect on children's physical health and mental health, or believed that caregiving problems attributable to maternal health have an extreme or great effect on children's mental health were significantly more likely to identify maternal depression. Interestingly, perception of great or extreme effects of maternal caregiving problems on children's physical health was not associated significantly with identification. The perception that pediatricians should be responsible for identification of but not referrals for or treatment of maternal depression was associated significantly with identification. Pediatricians who have identified maternal depression had significantly more-favorable attitudes regarding acknowledgment of maternal depression and perception of mothers' beliefs, compared with pediatricians who have not identified maternal depression.
Similar associations were observed for comparisons of pediatricians who have only identified maternal depression and those who have identified and managed maternal depression (Table 2). However, there were some differences. Perceived availability of adult mental health services was not associated significantly with management of maternal depression. In addition, the perception of great or extreme effects of maternal caregiving problems on children's physical health and mental health was associated significantly with management of maternal depression. Pediatricians who thought that pediatricians should be responsible for identification of maternal depression were significantly more likely to have managed maternal depression. Pediatricians who identified and managed maternal depression were more likely to agree that pediatricians should be responsible for making referrals, compared with pediatricians who only identified maternal depression; however, this did not reach statistical significance (P = .056). Of note, 77% of pediatricians who reported identifying but not managing maternal depression agreed that pediatricians should be responsible for making referrals for this condition. Finally, pediatricians' mean attitude scores for perceptions of mothers' beliefs and acknowledgment of maternal depression were significantly higher among pediatricians who identify and manage maternal depression, compared with those who only identify maternal depression. Pediatricians who identify and manage maternal depression tended to have higher attitude scores, compared with physicians who only identify maternal depression, but this difference was not statistically significant. Table 3 presents the frequency of use of methods to identify maternal depression, listed from least active (observation) to most active (screening instrument). Observation and family history were methods most often used by pediatricians. Screening instruments were rarely used; 13% of pediatricians who identify but do not manage maternal depression and 23% of pediatricians who manage maternal depression reported using a screening tool. Pediatricians who have managed maternal depression were significantly more likely to inquire about symptoms as part of routine discussion and to report that mothers inquire about depression or volunteer information about symptoms, compared with those who have only identified depressed mothers.
The results of the multivariate weighted logistic regression analyses modeling the odds of identifying a mother with maternal depression are shown in Table 4. Pediatrician and practice characteristics that were associated significantly with identification included pediatrician age and patient race. For each 5-year increase in the age of the pediatrician, the odds of identifying a mother with maternal depression increased by 27%. Pediatricians whose practice consisted of ≥75% white patients were twice as likely (OR: 2.07) to have identified a mother with maternal depression, compared with pediatricians with <75% white patients. Several mental health attitudes and practices were also associated significantly with identifying maternal depression. Pediatricians who worked in practices that provide child mental health services (OR: 1.85), used ≥1 method to address maternal depression (OR: 2.55), agreed that pediatricians should be responsible for identifying maternal depression (OR: 1.62), or thought that maternal depression has an extreme effect on children's mental health (OR: 1.78) had significantly higher odds of identifying maternal depression. Moreover, more-favorable attitudes about the perception of mothers' beliefs about pediatricians' involvement in maternal depression were associated positively with identification of maternal depression (OR: 1.27). Two-way interactions of clinical relevance (eg, patient race and responsibility for identification and effect of children's mental health) were evaluated and were not statistically significant (P > .10).
Table 5 reports the results of the multivariate, weighted, logistic regression analyses modeling the odds of identifying and managing maternal depression. Similar to the analyses of the outcome of identification, several mental health attitudes and methods were associated significantly with the outcome of management of maternal depression; pediatricians who worked in offices that provide child mental health services (OR: 2.71), pediatricians who used ≥1 method to address maternal depression (OR: 2.36), and pediatricians whose attitudes were more favorably inclined to acknowledge maternal depression (OR: 1.28) had significantly higher odds of reporting that they manage maternal depression. Moreover, pediatricians who thought that caregiving problems attributable to maternal health have an extreme effect on children's physical health were 3 times more likely to report managing maternal depression, compared with pediatricians who did not think that the effect is extreme. The results show that pediatricians who usually inquired about symptoms or contributing factors as part of routine discussion to identify maternal depression had twice the odds (OR: 2.09) of managing a mother with maternal depression. Unlike the identification outcome, the only physician or practice characteristic that was associated significantly with the management outcome was region of practice. Pediatricians practicing in the Midwest were significantly more likely to report managing maternal depression, compared with each of the other regions (compared with South: OR: 3.97; compared with West: OR: 5.16; compared with Northeast: OR: 5.06). Pediatricians' attitudes about acknowledging maternal depression were also associated significantly with management of maternal depression.
In this representative sample of practicing pediatricians, more than three fourths reported identifying maternal depression, and 82% of those who do identify also manage mothers with depression (refer or treat). The overwhelming number of pediatricians who manage mothers with depression do so by referring them for additional assessment and treatment; very few (4%) reported that they provide treatment themselves. Pediatricians' age and the racial distribution of their patients were associated with identification but not management of maternal depression. Practice characteristics (provision of mental health services and use of screening methods) were associated with identification and management of maternal depression. Pediatricians' attitudes toward maternal depression, as measured by perceptions of mothers' beliefs and acknowledgment of maternal depression, and their perceptions about the effect that maternal mental health has on children also affected pediatricians' behaviors.
There was also some effect of experience. Older pediatricians and those who had been in practice longer were more likely to report identifying and managing mothers with depression. These covariates were highly correlated, and both might have been related to exposure to mothers with depression. Interestingly, neither was associated with management of mothers in logistic models controlling for other factors. The fact that age and years of experience in practice were not significant correlates of identification or management of maternal depression suggests that experience may increase a pediatrician's facility with initiating discussion about maternal depression but the “next steps” of referral or treatment do not occur more often. It is important, therefore, to develop strategies that not only increase recognition of mothers with depression but also enable pediatricians to refer mothers at risk.
Pediatricians' attitudes drive behavior for both identification and management of maternal depression. If pediatricians think that a problem is important for children's well-being and they feel that they are responsible for it, then they act to identify and to manage it, as in the case of maternal depression. Previous research suggested that perceived barriers to mental health care, such as lack of time, lack of availability of mental health resources for referrals, and inadequate training to identify and to manage maternal depression may affect best practices for identification and management of maternal depression.43,53 Additional study is needed to disaggregate the interactions that influence pediatricians to identify and to manage mothers with depression.
It is not surprising to find that, compared with pediatricians who did not identify mothers with depression, respondents who thought that pediatricians should be responsible for identification were more likely to identify mothers with maternal depression. What is surprising is that the proportions of physicians who agreed that pediatricians should be responsible for making referrals for or treating maternal depression were similar regardless of whether they do not identify, only identify, or identify and manage maternal depression in practice. In fact, the majority of respondents thought that pediatricians should be responsible for referring mothers with depression. These findings are consistent with those of Olson et al,42 who reported that ∼58% of pediatricians agreed that it is the responsibility of pediatricians to identify maternal depression, 83% of pediatricians agreed that it is the responsibility of pediatricians to refer patients for maternal depression, and only 5% of pediatricians thought that it is the responsibility of pediatricians to treat maternal depression. Therefore, it is important to ascertain the reason for lack of action on the part of pediatricians who think that it is their responsibility to identify and to treat maternal depression. This finding warrants careful investigation because, without identification, no appropriate referrals and treatment are possible.
In our sample, pediatricians in the Midwest were more likely to identify and to manage mothers with depression than were respondents from other geographic areas. Several highly populated Midwestern states (eg, Wisconsin, Michigan, and Illinois) have implemented large public-awareness campaigns about maternal depression.57–59 These statewide programs include not only information but also enhanced treatment options in the mental health community for maternal (postpartum) depression. As a result, pediatricians may have increased knowledge regarding postpartum depression and may have enhanced networks for referral of mothers. Additional research is needed to explain this interesting finding.
One of the interesting findings of this study is that pediatricians who use ≥1 method to address maternal depression were 2.36 times more likely to report having managed (referred or treated) an at-risk mother. Many pediatricians use family history as a means to identify women at risk, because family and personal histories of depression and postpartum depression are known risk factors and may be very helpful in identifying women at risk. The primary method reported for identifying maternal depression, that is, observation, has been shown repeatedly to be inadequate.40,41,60 Furthermore, more than one half of respondents do not inquire about symptoms, and more than three fourths do not use a screening tool. Both methods, when structured with specific depression questions, are more effective than observation or clinical assessment.61 In fact, many validated and easy-to-use screening tools exist62–64 and would be helpful in identifying mothers with depression. Olson et al61 found that, although paper-based screening for maternal depression yielded 4 times the number of positive screens, compared with interviewer-based questioning, both increased discussion of maternal depression and subsequent referral of mothers for additional care. There are many methods available to pediatricians to identify maternal depression, but using ≥1 is the first step in assisting mothers at risk.
Patient race was associated significantly with identification of maternal depression. This might have important implications. Smedley et al65 suggested that bias or stereotyping might contribute to different patient care and health outcomes. Patient attitudes also affect physician practices. Although some research has shown that black patients show more-favorable attitudes toward mental health treatment than do white patients,66 they are less likely to receive appropriate care, because of lack of insurance or distrust of health care providers.67 Other research has suggested that racial and cultural differences exist regarding the acceptability of antidepressant use or counseling for depression, with black subjects being less likely than white subjects to find antidepressant use acceptable and with Hispanic subjects being more inclined than white respondents to find counseling acceptable.68 The findings in our study suggest that the underlying racial and cultural differences among both patients and health care professionals in identifying and managing maternal depression warrant additional study.
The findings from this study must be evaluated in light of their limitations. First, this survey, like others of physicians, had a suboptimal (although solid) response rate.69,70 Although a detailed analysis of response rates in AAP surveys showed little nonresponse bias,71 the analyses were weighted for nonresponse; it is possible that this did not correct fully for nonresponse bias. Furthermore, pediatricians who are most interested in this topic are most likely to respond, and the results must be viewed with this fact in mind. Second, this was a cross-sectional, self-reported survey, rather than direct observation of pediatricians' practices. Given the possibility of response biases for socially desirable behaviors, it may be that respondents overestimated some of the behaviors or actions listed on the survey. Additional study is warranted to test the associations found in this nationally representative sample of pediatricians, preferably with directly observed care72 or other prospective methods.
Pediatricians' practice characteristics and attitudes are associated with their identification and management of mothers with depression. A significant shift in pediatricians' attitudes toward mental health issues is necessary to improve recognition and care of depressed mothers. Training and education are essential, especially to encourage systematic screening for maternal depression, a condition that is amenable to treatment, which can reduce the duration of the depressive episode and the likelihood of adverse outcomes for both the child and the family. In fact, pediatricians are in an ideal position to screen for and to intervene in a myriad of conditions that affect mothers and their children, including children's mental health problems, parental substance abuse, and domestic violence. Addressing such issues in the context of pediatric primary care may be uncomfortable for many pediatricians, but early systematic education, enhanced methods of identification that use technologic advancements, and improved systems of care that ensure appropriate treatment for mothers and their children must be the goal for pediatricians in the 21st century.
This study was supported by the AAP. This research was funded by the Annie E. Casey Foundation.
- Accepted October 20, 2006.
- Address correspondence to Amy M. Heneghan, MD, Department of Pediatrics, Rainbow Babies and Children's Hospital/Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106. E-mail:
Financial Disclosure: Dr Chaudron discloses grant funding from Forest Laboratories and the Wyeth Pharmaceuticals speaker's bureau.
The findings and conclusions presented in this articles are those of the authors alone and do not necessarily reflect the opinions of the Annie E. Casey Foundation.
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