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 et al., 2011
). 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 et al., 2019
). Olson et al., 2019
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 et al., 2016
); 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, 2010
). 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 et al., 2019
). Long et al., 2018
stated that “screening rates are inconsistent and low” (p. 170S) despite recommendations by organizations such as the American Academy of Pediatrics,
, 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.
ACOG, 2018
, APA,
, American Psychological Association, and the 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.
United States Preventive Services Task Force, 2016
—all of which support screening for perinatal depression (Barkin et al., 2020
). Current AAP guidelines recommend screening within the well-child visit framework at 1, 2, 4, and 6 months (of infant age; American Academy of Pediatrics,
).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.
Pediatric providers have cited valid challenges to screening implementation that largely relate to insufficient resources (
Olson et al., 2003
). 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 et al., 2004
). 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 et al., 2003
; Wiley et al., 2004
).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 et al., 2010
). 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 et al., 2020
). 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 and Wisner, 2014
). Postpartum support international,
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/
Postpartum support international,
). 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.Postpartum support international (PSI). n.d. Retrieved from https://www.postpartum.net/
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 et al., 2009
) and may convey advantages to the provider related to patient satisfaction.References
- Number 757. Committee on Obstetric Practice.2018, October 24 (Retrieved from)
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.
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.
- Training frontline providers in the detection and management of perinatal mood and anxiety disorders.Journal of Women's Health. 2020; 29: 889-890
- Development of the Barkin index of maternal functioning.Journal of Women's Health. 2010; 19: 2239-2246
- Perinatal depression screening: Let's not throw the baby out with the bath water!.Journal of Psychosomatic Research. 2014; 76: 489-491
- The physician as health advocate: Translating the quest for social responsibility into medical education and practice.Academic Medicine. 2011; 86: 1108-1113
- Incorporating recognition and management of perinatal and postpartum depression into pediatric practice.Pediatrics. 2010; 126: 1032-1039
- Incorporating recognition and management of perinatal depression into pediatric practice.Pediatrics. 2019; 143e20183259
- Fully capitated payment breakeven rate for a mid-size pediatric practice.Pediatrics. 2016; 138e20154367
- Postpartum depression screening at well-child visits: Validity of a 2-question screen and the PHQ-9.Annals of Family Medicine. 2009; 7: 63-70
- Estimating the attributable cost of physician burnout in the United States.Annals of Internal Medicine. 2019; 170: 784-790
- Screening rates, elevated risk, and correlates of postpartum depression in an obstetric population [28O].Obstetrics and Gynecology. 2018; 131: 170S
- Primary care pediatricians’ roles and perceived responsibilities in the identification and management of maternal depression.Obstet Gynecol Surv. 2003; 58: 304-305
- Organizational strategies to reduce physician burnout and improve professional fulfillment.Curr Prob Pediatr Ad. 2019; 49100664
Postpartum support international (PSI). n.d. Retrieved from https://www.postpartum.net/
- Final recommendation statement.Depression in adults: Screening, 2016, January 26 (Retrieved from)
- Pediatricians views of postpartum depression: A self-administered survey.Archives of Women's Mental Health. 2004; 7: 231-236
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.
Article info
Publication history
Published online: May 12, 2020
Footnotes
Conflicts of interest: None to report.
Identification
Copyright
Copyright © 2020 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.
