Screening tools for postpartum depression and recommendations for responding to a positive screen

During the first year postpartum, up to 85% of new mothers experience some mood disturbance, and 10-15% will have more severe mood or anxiety symptoms. These symptoms can affect the infant and other children in the home in addition to the parent. While depression is very common in the postpartum period, the condition may go unrecognized and untreated by the mother’s health care provider who often sees her less frequently than the pediatrician. [Silver: 2006] Because pediatricians are in a unique position to identify maternal postpartum mental health disorders, the American Academy of Pediatrics (AAP) recommends 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

• Provide crisis information:
  • Dial 988 to reach the 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) to call or chat with a crisis counselor. 24/7. The deaf and hard of hearing can contact the Lifeline via TTY using their preferred relay service or dialing 711, then 988. All calls are confidential.
• The pediatric clinician’s role in recognizing and referring caregivers for psychiatric disorders is crucial. The American Academy of Pediatrics advises postpartum depression surveillance and screening at the 1-, 2-, 4-, and 6-month visits.
• When there are concerns, facilitate outreach to the parent’s primary care or obstetric provider, mental health specialist, social worker, or support groups. 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 has thoughts of harming the baby.

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]

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depression may provide their babies with less affection, be less responsive to their infant’s cues, and be more withdrawn, hostile, or irritable towards their infants and families. Associated childhood outcomes to babies whose mother’s experienced untreated or poorly treated depression 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 may be seen due to any primary caregiver, regardless of gender or age.

Because evidence supports the connection between 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 Anxiety

Postpartum Psychosis

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-ups 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.

Edinburgh Postnatal Depression Scale - EPDS (English & Spanish)

Patient Health Questionnaire Screeners (PHQ-9 & PHQ-2)

The Survey of Well-Being of Young Children (SWYC)

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 psychiatrist or experienced mental health provider for further assessment and evaluation.
• With the parent’s consent, consider discussing the positive screen with the parent’s primary health provider. Often, the caregiver’s family doctor, obstetrician, midwife, internist, obstetrician, 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.

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 exposed to SSRI antidepressants or TCAs (tricyclic antidepressants) through breastmilk are very rare, adverse effects have been reported. They are more likely to occur 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 or withdrawal (in the early postnatal period). [Weissman: 2004] [Müller: 2013]

Other treatment modalities include increasing maternal sleep, improving maternal support, and talk therapy. Supplementing with formula may be recommended if breastfeeding becomes a large source of stress or cause of sleep deprivation for the new mother. See Postpartum Depression & Breastfeeding (healthychildren.org) for more information.

Refer caregivers with suspected postpartum depression or anxiety to their primary care clinician, obstetrician, or midwife, or encourage them to follow up with existing mental health support systems they have in place:

• General Counseling Services (see RI providers [30])
• Tele-Mental Health (see RI providers [14])
• Mental Health Evaluation/Testing/Screening > … (see RI providers [48])
• Mental Health Evaluation/Assessment (see RI providers [24])

For assistance with complicated diagnoses or medication management, refer to:

• Psychiatry/Medication Management (see RI providers [80])

ICD-10-CM

• 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)