Even though postpartum depression affects 10% to 20% of women, less than 50% of women are screened. A new study published in the Journal of Pediatric Care in early 2018 looked at evidence for implementing postpartum depression screening in pediatric primary care and found that it is not only “feasible” but can also be “adapted to the local setting.”
Here is an interview with study author, Julee Waldrop, Professor, School of Nursing at the University of North Carolina at Chapel Hill and Associate Editor of The Journal for Nurse Practitioners.
Patricia: What is the right name to call this study? Is it a study or a review?
Julee: This is a great question. It is not a research study. It is a description of the evidence based process (which does include a review of the evidence) that our team used to develop a systematic process for implementing postpartum depression screening and referral that can be used in pediatric primary care, in particular primary care practices that are not a part of a larger system where mental health services are more integrated.
Patricia: Why did you want to look at developing postpartum depression screening in pediatric primary care?
Julee: We have known that maternal depression impacts child development for many years and now our professional organizations recommend that women be screened for depression in the first year after birth. The problem is that many women only visit their obstetrician once or twice in the first two months after delivery providing a very limited opportunity for screening. Contrast that with the number of times a mom will see a pediatric provider just for her child’s wellness visits (often eight times during the first six months of a child’s life) and you can see the where the opportunity lies.
Patricia: You and the authors mention in the study, "making a recommendation is much easier than implementing a recommendation". Why is it difficult for pediatricians to implement postpartum depression screening?
Julee: Pediatric focused practitioners, for example pediatricians and pediatric nurse practitioners, receive their education, training and certification in caring for children not adults. As stated in the article, there are some common barriers to getting pediatric practices on board with this process. The number one barrier in instituting or “adding” any new process to already busy practices always starts with the worry of “how can we find the time?” In addition, concerns about lack of training and knowledge needed (again, remember these are folks who spent years learning to care for children) along with the worry that there will not be any resources available for these mothers are others cited.
Patricia: Would the only way for recommendations or guidelines to be mandatory is if they are legislated?
Julee: Most clinical practice recommendations and guidelines are just that, guidelines and not mandatory. Legislating postpartum depression screening in pediatric primary care practices will not totally solve the problem. Because of the lack of mental health services available in many areas and to many people some might argue the ethics of identifying someone who could use help but to whom you know there is none available. This is why the process we developed and recommend in the article really looked at developing a thorough resource/referral list before screening starts so that the providers will know to who and where they can send these mothers for assistance.
Patricia: What does "clinical decision support algorithm" mean in layman's terms?
Julee: It is really a decision tree. If this happens, you do one thing. If something else happens you do another.
Patricia: What kind of local resources and referrals available at the point of care should there be as mentioned in your abstract results?
Julee: Each practice should have a list of contact information for any practitioner or organization that provides mental health services in the area, including emergency services. Additional information about costs, or insurances taken or sliding scale fees is also helpful as well as the ability to provide services in a language other than English. Psychoeducational information is also important at point of care and helps to normalize the problem. Our research group has also developed a toolkit with these types of resources for non-health professionals working in early intervention to use. Free resources are available from many reputable sources and can be distributed. From the National Institutes of Mental Health (example on depression http://www.nimh.nih.gov/health/publications/depression-listing.shtml) or Substance Abuse and Mental Health Services Administration (SAMHSA) Depression in Mothers: More Than the Blues http://store.samhsa.gov/shin/content/SMA14-48478/SMA14-4878.pdf and many are available in Spanish and sometimes other languages.
Patricia: What happens after a study such as yours is published? How are study results become implemented into practice?
Julee: We hope that the specificity of the information described in the article will lower the barriers to implementation and that practices will give it a try. In fact, we are just finishing data collection on implementation of postpartum screening and referrals based on this process right now in a small rural pediatric primary care clinic and look forward to disseminating the results later this year. I think that pediatric provider screening is going to be the key. Women just do not see (nor in the U.S. can many afford to see - different from Canada) their own primary care provider.
Waldrop J, Ledford A, Perry LC, Beeber LS., US National Library of Medicine National Institutes of Health, (January 2018), Developing a Postpartum Depression Screening and Referral Procedure in Pediatric Primary Care, https://www.ncbi.nlm.nih.gov/pubmed/29305113