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Screening for Maternal Mental Health in the Pediatric Setting: Situational Stressors and Supports

      In clinical research, we place high expectations on health-care providers in terms of solving complex problems related to human health and the system of delivery. In the “clinical implications” section of articles, we ask them to provide more robust services and patient education and to be knowledgeable about the assets in their community that support the health and wellness of families. They are also expected, in many cases, to be “community responsive,” and potentially even lobby state and federal governments for policies that benefit their colleagues, their patients, and the community-at-large (
      • Dharamsi S.
      • Ho A.
      • Spadafora S.M.
      • Woollard R.
      The physician as health advocate: Translating the quest for social responsibility into medical education and practice.
      ). It is a tall order considering the daily patient load and the grinding pace that are characteristics of clinical work. Recent reports have placed health-care providers at a rate of burnout that is almost twice the rate of the rest of the U.S. workforce (
      • Han S.
      • Shanafelt T.D.
      • Sinsky C.A.
      • Awad K.M.
      • Dyrbye L.N.
      • Fiscus L.C.
      • Goh J.
      Estimating the attributable cost of physician burnout in the United States.
      ).
      • Olson K.
      • Marchalik D.
      • Farley H.
      • Dean S.M.
      • Lawrence E.C.
      • Hamidi M.S.
      • Stewart M.T.
      Organizational strategies to reduce physician burnout and improve professional fulfillment.
      cited several factors that can mitigate feelings of burnout, including workplace efficiency. They stated, “To promote workplace efficiency, the clinical and administrative workload should be supported by sufficient resources to maintain quality, productivity, and work-life balance” (p. 2).
      In midsize pediatric practices, providers see an average of 25 patients per day and up to 30 on the high end (
      • Farmer S.A.
      • Shalowitz J.
      • George M.
      • McStay F.
      • Patel K.
      • Perrin J.
      • McClellan M.
      Fully capitated payment breakeven rate for a mid-size pediatric practice.
      ); they also have time-consuming charting responsibilities. In 2010, a clinical report from the American Academy of Pediatrics (AAP) articulated the need to incorporate screening for postpartum depression (PPD) into pediatric primary care, given its high prevalence rate, and impact on the family unit (
      • Earls M.F.
      Committee on Psychosocial Aspects of Child and Family Health American Academy of Pediatrics
      Incorporating recognition and management of perinatal and postpartum depression into pediatric practice.
      ). Although screening rates have increased since then, considerable work remains in regard to achieving full compliance. According to the 2013 survey of AAP members, less than half of the providers who responded were conducting PPD screening (
      • Earls M.F.
      • Yogman M.W.
      • Mattson G.
      • Rafferty J.
      Committee on Psychosocial Aspects of Child and Family Health
      Incorporating recognition and management of perinatal depression into pediatric practice.
      ).
      • Long M.M.
      • Morgan F.G.
      • Wilkes C.A.
      • Fontanares A.J.
      • MacFarlane B.
      • Cramer R.J.
      Screening rates, elevated risk, and correlates of postpartum depression in an obstetric population [28O].
      stated that “screening rates are inconsistent and low” (p. 170S) despite recommendations by organizations such as the ,
      American College of Obstetricians and Gynecologists
      Number 757. Committee on Obstetric Practice.
      ,

      American Psychiatric Association. (2018). Position statement on screening and treatment of mood and anxiety disorders during pregnancy and postpartum. Retrieved from https://www.psychiatry.org/about-apa/read-apa-organization-documents-and-policies.

      , American Psychological Association, and the
      United States Preventive Services Task Force
      Final recommendation statement.
      —all of which support screening for perinatal depression (
      • Barkin J.L.
      • Osborne L.M.
      • Buoli M.
      • Bridges C.C.
      • Callands T.A.
      • Ezeamama A.E.
      Training frontline providers in the detection and management of perinatal mood and anxiety disorders.
      ). Current AAP guidelines recommend screening within the well-child visit framework at 1, 2, 4, and 6 months (of infant age; ).
      Pediatric providers have cited valid challenges to screening implementation that largely relate to insufficient resources (
      • Olson A.L.
      • Kemper K.J.
      • Kelleher K.J.
      • Hammond C.S.
      • Zuckerman B.S.
      • Dietrich A.J.
      Primary care pediatricians’ roles and perceived responsibilities in the identification and management of maternal depression.
      ). As stated earlier, placing additional demands on an overburdened system contributes to feelings of provider burnout, and one can understand the hesitancy in assuming care for the mother in addition to the child. Providers have described a lack of time and perinatal mental health–related training, administrative burden on both the clinic staff and the patient, a fear of alienating the patient's family owing to the stigma associated with mental illness, and uncertainty with how to handle women that screen positive for depression—especially in communities where mental health infrastructure is weak or nonexistent (
      • Wiley C.C.
      • Burke G.S.
      • Gill P.A.
      • Law N.E.
      Pediatricians views of postpartum depression: A self-administered survey.
      ). The sentiment that maternal mental health screening is out of the scope of pediatric practice is also a factor in provider attitudes toward the process (
      • Olson A.L.
      • Kemper K.J.
      • Kelleher K.J.
      • Hammond C.S.
      • Zuckerman B.S.
      • Dietrich A.J.
      Primary care pediatricians’ roles and perceived responsibilities in the identification and management of maternal depression.
      ;
      • Wiley C.C.
      • Burke G.S.
      • Gill P.A.
      • Law N.E.
      Pediatricians views of postpartum depression: A self-administered survey.
      ).
      Despite the detractors, there are also many benefits to screening within the pediatric setting, chief among them being the health of the mother-infant dyad. The development of the infant is particularly sensitive to the quality of the interaction with the mother in the first postpartum year and bonding is negatively affected when the mother is depressed (
      • Barkin J.L.
      • Wisner K.L.
      • Bromberger J.T.
      • Beach S.R.
      • Terry M.A.
      • Wisniewski S.R.
      Development of the Barkin index of maternal functioning.
      ). Pediatric providers have a distinct logistical advantage in assessing maternal mental health over obstetricians and gynecologists owing to their frequency of interaction with new mothers across the first postpartum year (
      • Barkin J.L.
      • Osborne L.M.
      • Buoli M.
      • Bridges C.C.
      • Callands T.A.
      • Ezeamama A.E.
      Training frontline providers in the detection and management of perinatal mood and anxiety disorders.
      ). The advantages are not solely on the patient side—in our research team's recent conversations with pediatric providers who were screening for PPD, they described a sense of satisfaction in providing more robust care; they also remarked on an improved relationship with the family as a whole.
      In the case of women who screen positive for PPD, there are options, even when there is a dearth of psychiatric care in the corresponding geographic location. The woman's OB/GYN or other primary care provider should be notified of the result, as they have the benefit of ready access to the woman's medical records. This might appear to be a partial and imperfect solution, but it is superior to inaction and conveys a critical message to the mother—that her needs are important too (
      • Chaudron L.H.
      • Wisner K.L.
      Perinatal depression screening: Let's not throw the baby out with the bath water!.
      ).

      Postpartum support international (PSI). n.d. Retrieved from https://www.postpartum.net/

      is also a valuable resource that is available to anyone with a mobile phone or computer. They offer a warmline that is accessible 24 hours a day, several online support groups, and opportunities to talk directly with a mental health-care provider at no cost (

      Postpartum support international (PSI). n.d. Retrieved from https://www.postpartum.net/

      ). PSI represents a lifeline for struggling parents because they also have built-in supports for struggling fathers—this is especially true in locations where mental health care is lacking. In addition to notifying the primary care provider, pediatric providers can recommend that mothers in need tap into PSI as a resource for mental wellness and social support.
      In summary, the recommendation to include maternal mental health screening into pediatric primary care is both evidence-based and challenging in several respects. It also promotes maternal child health, is feasible (
      • Gjerdingen D.
      • Crow S.
      • McGovern P.
      • Miner M.
      • Center B.
      Postpartum depression screening at well-child visits: Validity of a 2-question screen and the PHQ-9.
      ) and may convey advantages to the provider related to patient satisfaction.

      References

        • American College of Obstetricians and Gynecologists
        Number 757. Committee on Obstetric Practice.
        2018, October 24 (Retrieved from)
      1. American Academy of Pediatrics. Screening Technical Assistance & Resource Center. Retrieved fromhttps://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/Screening-Recommendations.aspx.

      2. American Psychiatric Association. (2018). Position statement on screening and treatment of mood and anxiety disorders during pregnancy and postpartum. Retrieved from https://www.psychiatry.org/about-apa/read-apa-organization-documents-and-policies.

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      Biography

      Jennifer L. Barkin, Associate Professor, Department of Community Medicine, Mercer University School of Medicine, Macon, GA.

      Biography

      Susan Van Cleve, Clinical Professor and Primary Care Pediatric Nurse Practitioner Program Director, College of Nursing, University of Iowa, Iowa City, IA.