Postpartum Depression Screening

Overview

During the first year postpartum, up to 85% of new mothers experience some kind of mood disturbance, and 10-15% will have more severe mood or anxiety symptoms. While depression is very common in the postpartum, the condition is likely to go unrecognized and untreated by a mother's own health care provider, who may see her less frequently than the pediatrician. [Silver: 2006] For this reason, the American Academy of Pediatrics (AAP) recommend that routine screening for maternal postpartum depression be integrated into the 1-, 2-, 4-, and 6-month, well-child visits. [Earls: 2019] While the pediatrician may not formally diagnose postpartum depression, it is important to be vigilant for it, screen routinely, and provide appropriate intervention and referral when encountered. [Earls: 2019]

Other Names

Caregiver depression screening
Maternal depression screening

Coding

ICD-10-CM Codes

  • Z00.1*- Well-child check/Encounter for newborn, infant and child health examinations, including routine developmental screening. Z00.1* health exam is always listed first, as the primary reason for the visit.
    • Z00.129 - well-child visits >28 days, without abnormal findings
    • Z00.121 - well-child visits >28 days, with abnormal findings
  • Z13.32 Encounter for screening for maternal depression (this can be coded in the mother’s chart but not the infant’s).

Current Procedural Terminology (CPT) Codes

The following CPT code can be used to bill to the baby's health insurance when screening the mother for maternal depression. Associate the CPT code with an appropriate ICD-10-CM code, often the Z00.12* well-child code.
  • 96161* Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient.

Practice Guidelines

Earls MF, Yogman MW, Mattson G, Rafferty J.
Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice.

Pediatrics. 2019;143(1). PubMed abstract [Earls: 2019]

Postpartum Psychiatric Illness

During an infant's early life, the mother is typically the child's primary source of emotional, cognitive, and social stimulation and interaction. Mothers with postpartum depression may show less affection to their babies, be less responsive to infant cues, and be more withdrawn, hostile, or irritable towards their infants and families. Associated childhood outcomes include postnatal changes in reflexes, motor tone, orientation, and excitability on Brazelton scales, cognitive delays including lower global IQ and language delay, behavioral problems such as eating and sleep difficulties, temper tantrums, hyperactivity and ADHD, emotional and social dysregulation, as well as increased psychiatric morbidity in adolescence. [Burt: 2009] [Quevedo: 2012] [Hay: 2001] [Field: 2010] [Sellers: 2014] In addition, children of depressed mothers are at increased risk for physical abuse. [Cadzow: 1999] Note that while most research in this area is on mothers, similar effects can be seen in any primary caregiver, regardless of gender or age.
Because evidence supports the connection of a healthy parental bond and children’s long-term mental health, the AAP) encourages pediatricians to play an active role in screening for symptoms in mothers and identifying community resources for treatment and referral. [Earls: 2019] This section briefly reviews 3 major types of postpartum psychiatric illnesses to help pediatricians recognize red flags in parents of new babies.

Postpartum Depression

Postpartum depression affects 1:8 mothers, and the incidence is greater for those with premature delivery, Cesarean sections, and other complications of birth. [Burt: 2009] Symptoms can begin during pregnancy, but generally appear over the first several months postpartum. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [American: 2013] criteria for diagnosing postpartum depression are the same as those for major depressive disorder. The Portal's Depression provides more details about diagnosis and treatment of depression.

Early Signs

Warning signs for postpartum depression may vary and include:
  • Depressed mood or irritability
  • Lack of enjoyment of usual activities
  • Changes in sleep patterns (insomnia or hypersomnia)
  • Worthlessness or guilt
  • Tearfulness
  • Self-doubt, often about her ability as a mother
  • Changes in weight or appetite
  • Avoidance of social interactions or responsibilities
  • Neglect or loss of interest in the newborn infant or other children
  • Fatigue or lack of energy
  • Changes in appetite
  • Poor concentration
  • Recurrent thoughts of suicide, death, or running away
  • Ruminations, or sometimes worries that she may harm the baby
  • Delusions or hallucinations
When postpartum depression is suspected in a caregiver, help explain that this is a common condition for which there is treatment and hope for recovery, and facilitate outreach to the parent’s primary care or obstetric provider, mental health specialist, social worker, support groups, etc. Ensure there is a safety plan for care for the infant, such as with the other parent or a relative, if the caregiver is suicidal or having thoughts of harming the baby.

Postpartum Anxiety

Postpartum anxiety can occur either in conjunction with depression or on its own, and like depression, it can range from mild to severe. While there is growing evidence to support diagnosis and treatment of perinatal anxiety to avoid its impacts on the newborn and longer-term child development outcomes, there are currently no screening guidelines for pediatric providers. If a caregiver reports significant anxiety, you can help troubleshoot ideas to help, such as going for walks, mindful breathing exercises, or allowing others to feed the infant so the affected parent can get needed rest. For more severe anxiety that is impairing the caregiver’s ability to care for self or infant, offer assistance with referrals to mental health providers, the parent’s primary care provider, and/or social worker.

Postpartum Psychosis

Postpartum psychosis occurs in about 1 in 500 to 1000 births and usually begins with maternal symptoms of psychosis within the first weeks postpartum. [Osborne: 2018] Increasingly, this is thought to be related to bipolar disorder rather than major depression, and its symptoms are fairly aligned with a manic or mixed episode. The mother’s mood may rapidly change; she may appear disoriented or confused, exhibit delusions and/or hallucinations. Infanticide and suicide rates increase significantly for this population; therefore, diagnosis and rapid treatment are imperative for safety of the mother and her family. DSM-5 does not have a distinct category for this illness, rather considering such episodes as a brief psychotic disorder or major mood disorder with psychotic features. [Monzon: 2014] Help the caregiver contact social work, the parent’s primary care provider, and/or refer the parent to the emergency department for a crisis evaluation if you suspect there is new onset of psychosis, and ensure there is a safety plan in place for care of the infant (such as being cared for by the other parent or a relative). Postpartum Disorders (MGH) provides further descriptions of the degrees of postpartum depression and related disorders.

Pearls & Alerts

If you or someone you know is in crisis:
  • Dial 911 for an emergency.
  • Call the toll-free National Suicide Prevention Lifeline (Lifeline) at 1-800-273-TALK (8255), 24 hours a day, 7 days a week. The deaf and hard of hearing can contact the Lifeline via TTY at 1-800-799-4889. All calls are confidential.
  • Contact the Crisis Text Line 24 hours a day, 7 days a week, by texting HELLO to 741741 (US, Canada, UK).

Screening for Postpartum Depression

The American College of Obstetricians and Gynecologists recommends screening pregnant women for depression and anxiety at least once during the perinatal period by using a validated screening tool, and providing a full assessment for mood and emotional well-being during their comprehensive postpartum visit. However, because not all mothers have close follow-up with an obstetric provider, the pediatric clinician’s role in recognizing and referring for psychiatric disorders is crucial. As a result, the American Academy of Pediatrics advises postpartum depression surveillance and screening at the 1-, 2-, 4-, and 6-month visits.
A standardized and validated tool is recommended for screening for postpartum depression. Examples are listed below:

Response to a Positive Screen

Upon positive screen:
  • Evaluate the infant for poor feeding, growth, behavioral issues, and developmental concerns.
  • Discuss the positive screen with the mother/primary caregiver to determine the severity of depression. The PHQ-9 can help rate the severity of the depression as well if additional tools are needed.
  • Refer the parent to a mental health professional (psychiatrist, psychiatric nurse practitioner, psychologist, or social worker) for further assessment and evaluation for further behavioral health assessment and intervention.
  • With the parent’s consent, consider discussing the positive screen with the parent’s primary health provider as well. Often, the caregiver’s own family doctor, obstetrician, midwife, internist, obstetrician, internist, psychiatric nurse practitioner, or psychiatrist may work with the parent to devise a medication management plan, if necessary
  • If the parent or child’s immediate safety is at risk, refer to the nearest Emergency Room for a psychiatric evaluation. Do not leave the parent and baby alone.

Treatment of Postpartum Depression

Women who have moderate to severe postpartum depression or anxiety are often treated with selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft) or paroxetine (Paxil), which have been shown least likely to result in detectable or elevated levels of active drug in breastmilk. Although significant complications to babies who are exposed to SSRI antidepressants or TCAs (tricyclic antidepressants) through breastmilk are rare, adverse effects have been reported, especially in infants born prematurely or those with impaired metabolism. Mothers and pediatricians should be aware that worrisome behaviors, such as irritability and trouble sleeping or eating, may be side effects of medication exposure. [Weissman: 2004] [Müller: 2013]
Other modalities of treatment include increasing maternal sleep, improving maternal support, and counseling or talk therapy. Supplementing with formula may be recommended as well, should breastfeeding be a large source of stress or a cause of sleep deprivation in the new mother. See Postpartum Depression & Breastfeeding (healthychildren.org) for more information.

Resources

Information & Support

For Professionals

MCPAP for Moms Toolkit for Pediatric Provider
A perinatal psychiatrist provides real-time consultation via the telephone to clinicians. The consultation may involve diagnostic support, guidance in regards to medication treatment (when indicated), psychotherapy and community support needs, treatment planning, and medication concerns regarding preconception, pregnancy, and lactation. A resource team works with providers in arranging outpatient mental health and/or substance use support for patients; Massachusetts Child Psychiatry Access Program.

Postpartum Support International’s Perinatal Psychiatric Consultation Line for Clinicians
A service provided at no cost to assist clinicians with questions related to diagnosis and treatment for patients by calling 1-800-944-4773, ext 4.

Maternal Depression Poster (PDF Document 90 KB)
Encourages new mothers to speak with their doctor if they answered "yes" to either of the 2 questions on this poster.

American College of Obstetricians and Gynecologists
Clinical information about postpartum depression and other issues.

For Parents and Patients

Support

Postpartum Support International
Support for women and their partners who are dealing with post-partum depression. Includes professional assessment tools and access to a volunteer network of local service providers and resources.

General

Postpartum Disorders (MGH)
General information about the various forms of postpartum depression; Massachusetts General Hospital.

Depression During & After Pregnancy: A Resource for Women, their Family, & Friends (HRSA) (PDF Document 20 KB)
Information for the woman and/or her family about the definition and symptoms of postpartum depression and when to seek treatment. Includes a perinatal depression booklet in English and Spanish; Department of Health & Human Services.

Postpartum Depression & Breastfeeding (healthychildren.org)
Discusses how postpartum depression affects the baby, when to seek help, how to preserve breastfeeding goals, and the effects of antidepressant medications and breastfeeding; from the American Academy of Pediatrics.

Tools

Edinburgh Postnatal Depression Scale (English) (PDF Document 120 KB)
A self-administered, 10-question, 5-minute screen for maternal depression with scoring instructions. Free, may be printed without permission.

Edinburgh Postnatal Depression Scale (Spanish) (PDF Document 54 KB)
A Spanish, self-administered, 10-question, 5-minute screen for maternal depression with scoring instructions. Free, may be printed without permission.

Screening Time (AAP)
An extensive list of screening tools organized by title, topics covered, number of items on the screen, parent completion time, cost, and validation information. Topics can be filtered for specific results; American Academy of Pediatrics.

Services for Patients & Families in Rhode Island (RI)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Studies

Maternal Depression (clinicaltrials.gov)
Listing of open trials related to maternal depression.

Helpful Articles

PubMed search for articles about postpartum depression within the last 5 years

O'Connor E, Rossom RC, Henninger M, Groom HC, Burda BU.
Primary Care Screening for and Treatment of Depression in Pregnant and Postpartum Women: Evidence Report and Systematic Review for the US Preventive Services Task Force.
JAMA. 2016;315(4):388-406. PubMed abstract

Murray L, Cooper P.
Effects of postnatal depression on infant development.
Arch Dis Child. 1997;77(2):99-101. PubMed abstract / Full Text
Discusses early maternal depression and adverse cognitive and emotional infant development.

Lesesne CA, Visser SN, White CP.
Attention-deficit/hyperactivity disorder in school-aged children: association with maternal mental health and use of health care resources.
Pediatrics. 2003;111(5 Pt 2):1232-7. PubMed abstract / Full Text
Investigates the association between the mental health status of mothers and attention-deficit/hyperactivity disorder (ADHD) in their school-aged children and characterizes the health care access and utilization of families affected by ADHD.

Onunaku, Ngozi.
Improving maternal and infant mental health: focus on maternal depression.
National Center for Infant and Early Childhood Health Policy at UCLA. July 2005. / https://www.hrsa.gov/archive/mchb/dataspeak/pastevent/june2005/files/i...
Discusses the impact of maternal depression on the social and emotional health of young children. Recommends specific steps that early childhood program and public health administrators can take to address the unmet mental health needs of mothers ultimately promoting the social and emotional health, school readiness, and future functioning of very young children.

Authors & Reviewers

Initial publication: March 2014; last update/revision: May 2020
Current Authors and Reviewers:
Author: Jessica Lu, M.D., M.P.H
Authoring history
2018: update: Jessica Lu, M.D., M.P.HA
2015: update: Jessica Lu, M.D., M.P.HA
2014: first version: Jessica Lu, M.D., M.P.HA
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders, DSM-5.
Fifth ed. Arlington, VA: American Psychiatric Association; 2013. 978-0-89042-554-1

Burt VK, Quezada V.
Mood disorders in women: focus on reproductive psychiatry in the 21st century--Motherisk update 2008.
Can J Clin Pharmacol. 2009;16(1):e6-e14. / Full Text
Review of the significant negative impact of maternal depression on maternal and child health and psychological well-being and other possible consequences of chronic depression.

Cadzow SP, Armstrong KL, Fraser JA.
Stressed parents with infants: reassessing physical abuse risk factors.
Child Abuse Negl. 1999;23(9):845-53. PubMed abstract / Full Text
Examines the relationship among potentially adverse psychosocial and demographic characteristics identified in the immediate postpartum period and child physical abuse potential at 7 months.

Earls MF, Yogman MW, Mattson G, Rafferty J.
Incorporating recognition and management of perinatal and postpartum depression into pediatric practice.
Pediatrics. 2019. PubMed abstract / Full Text

Field T, Diego M, Hernandez-Reif M.
Prenatal depression effects and interventions: a review.
Infant Behav Dev. 2010;33(4):409-18. PubMed abstract / Full Text
Research on the negative effects of prenatal depression and cortisol on fetal growth, prematurity, and low birth weight.

Hay DF, Pawlby S, Sharp D, Asten P, Mills A, Kumar R.
Intellectual problems shown by 11-year-old children whose mothers had postnatal depression.
J Child Psychol Psychiatry. 2001;42(7):871-89. PubMed abstract
Examines long-term sequelae in the children of mothers who were depressed at 3 months postpartum.

Monzon, C. M.D., Lanza di Scales, T. MD, Pearlstein, T. MD.
Postpartum psychosis: updates and clinical issues.
Psychiatric Times; (2014) http://www.psychiatrictimes.com/special-reports/postpartum-psychosis-u.... Accessed on 4/28/2020.
In preparation for DSM-5, evidence of the onset of symptoms in postpartum disorders was examined. Study findings suggest that 50% of major depressive episodes that present postpartum actually began during pregnancy.

Müller MJ, Preuß C, Paul T, Streit F, Brandhorst G, Seeliger S.
Serotonergic overstimulation in a preterm infant after sertraline intake via breastmilk.
Breastfeed Med. 2013;8(3):327-9. PubMed abstract / Full Text
Case study of a preterm infant who was exposed to sertraline and its main metabolite desmethylsertraline in utero and via breastmilk.

Osborne LM.
Recognizing and Managing Postpartum Psychosis: A Clinical Guide for Obstetric Providers.
Obstet Gynecol Clin North Am. 2018;45(3):455-468. PubMed abstract / Full Text

Quevedo LA, Silva RA, Godoy R, Jansen K, Matos MB, Tavares Pinheiro KA, Pinheiro RT.
The impact of maternal post-partum depression on the language development of children at 12 months.
Child Care Health Dev. 2012;38(3):420-4. PubMed abstract / Full Text
Analyses the effect of the duration of the mother's depression on the language development of children at 12 months old.

Sellers R, Harold GT, Elam K, Rhoades KA, Potter R, Mars B, Craddock N, Thapar A, Collishaw S.
Maternal depression and co-occurring antisocial behaviour: testing maternal hostility and warmth as mediators of risk for offspring psychopathology.
J Child Psychol Psychiatry. 2014;55(2):112-20. PubMed abstract / Full Text
Using a longitudinal study of offspring of mothers with recurrent depression, the study tests whether maternal warmth/hostility mediated links between maternal depression severity and child outcomes, and how far direct and indirect pathways were robust to controls for co-occurring maternal antisocial behaviour.

Silver EJ, Heneghan AM, Bauman LJ, Stein RE.
The relationship of depressive symptoms to parenting competence and social support in inner-city mothers of young children.
Matern Child Health J. 2006;10(1):105-12. PubMed abstract
Discusses how negative ratings of parenting competence, low perceived social support, and presence of health-related activity restrictions can be useful markers of likely depression among inner-city mothers of young children.

Weissman AM, Levy BT, Hartz AJ, Bentler S, Donohue M, Ellingrod VL, Wisner KL.
Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants.
Am J Psychiatry. 2004;161(6):1066-78. PubMed abstract
Analysis of available data on antidepressant levels in nursing infants to calculate average infant drug levels and determine what factors influence plasma drug levels in breast-feeding infants of mothers treated with antidepressants.