Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice

We read with interest Rafferty et al’s technical report1 regarding perinatal depression (PD) and pediatric practice. We agree that well-child care (WCC) visits offer a unique opportunity to diagnose PD and that repeated screenings may provide more occasions to diagnose depression. We present our experience of extended PD screening in our private practice pediatric clinic in Connecticut staffed by 3 pediatricians and 2 nurse practitioners.
At baseline, routine practice screening for PD was done at 1-month WCC visits. As a Maintenance of Certification quality improvement project, we planned an intervention to extend screening to 1-month, 2-month and 6-month WCC visits starting in June 2017. We used the 10 question Edinburgh Postpartum Depression Scale (EPDS) for screening with a cut-off of 10 for a positive screen. Our workflow directed the office staff to offer the questionnaire to mothers in the waiting room which was then reviewed by the provider during the visit. Prior to starting intervention, we met with community mental health providers, specializing in PD, to discuss a direct referral process for mothers with positive screens. For this analysis we compared prevalence of PD 1 year pre-intervention (June 2016-May 2017) to 1 year post intervention (June 2017-May 2018). Data was compared using Chi square tests for categorical variables.
Pre-intervention, the prevalence of PD was 3.3% in 182 mothers at the 1-month visit. Post intervention, 187 mothers were longitudinally followed. The prevalence of PD was 2.1% at the 1-month visit. With extended screening, we identified PD in an additional two mothers out of 133 at 2 months (1.5%) and six mothers of 178 at 6 months (3.4%). Our overall prevalence of PD rose from 3.3% to 6.4% (p=0.13, Chi-square test) following the intervention. Following discussion of results, 25% of mothers with positive screens were referred directly to a community mental health provider. To determine feasibility of this intervention, we also measured our screening rates. Pre-intervention, our 1-month screening rate for PD was 95% and increased to 98% post intervention. Our 2-month and 6-month screening rates were 93% and 90% respectively. Refusal to complete the screen was minimal with only 4 mothers out of 392 refusing the screen throughout the entire study. Other reasons for not achieving 100% screening rates include mother not being present at the visit (N=9) and office staff error (N=24).
Our experience demonstrates the importance of extended screening in increasing the detection and treatment of perinatal depression as reported by Rafferty and colleagues. Despite the lack of statistical significance, we believe that our results are of clinical significance in improving care for both the mother and child. Many studies of PD screening are reported from large academic centers2,3. We report feasibility and increased yield of extended PD screening in a small private pediatric clinic.

References
1. Rafferty J, Mattson G, Earls MF, et al. Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice. Pediatrics. 2019;143(1):e20183260
2. Chaudron LH, Szilagyi PG, Kitzman HJ, et al. Detection of postpartum depressive symptoms by screening at well-child visits. Pediatrics 2004;113:551-8.
3. Freeman MP, Wright R, Watchman M et al. Postpartum Depression Assessments at Well-Baby Visits: Screening Feasibility, Prevalence, and Risk Factors. J Women’s Health 2005; 14: 929-35.