Maternal Depression Screening

Background

Maternal depression affects up to 18% of mothers during the first year postpartum, yet 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] At well-child visits, the pediatric provider has an opportunity to identify signs of maternal depression and intervene through routine screening. [Onunaku: 2005]

During an infant's early life, the mother typically is the child's primary source of emotional, cognitive, and social stimulation and interaction. Mothers with postpartum depression may show less affection toward their babies, be less responsive to infant cues, and be more withdrawn, hostile, or irritable towards their infants. 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]

Evolving evidence related to infant mental health affirms the importance of strengthening the bond between the mother and child and ensuring that moms, as well as their babies, get the best start in this new and important relationship. The American Academy of Pediatrics encourages pediatricians to identify and use community resources for the treatment and referral of the depressed mother and support for the mother-child relationship. [American: 2014]

Defining Postpartum Psychiatric Illness

Baby blues, which affect 50-85% of moms in the first weeks after delivery, is a general term for mild and transient forms of maternal depression. The symptoms, usually mood lability, anxiety, tearfulness, or irritability, tend to peak in the first week after delivery and then slowly subside over the next week.

Postpartum depression affects 1 in 8 mothers and the incidence is greater for those with premature delivery, C-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 details.

Postpartum psychosis occurs in about 1 in 500 to 1000 births and usually begins with symptoms of psychosis within the first weeks postpartum. 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 is 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]

Postpartum Disorders (MGH) provides further descriptions of the degrees of postpartum depression.

Early Signs

The American College of Obstetricians and Gynecologists recommends psychosocial screening of pregnant women at least once per trimester (or 3 times during pre-natal care) by using a simple 2-question screen and further screening if the preliminary screen result indicates possible depression.
Warning signs for each of these above conditions may vary according to the diagnosis as well as the individual, and may 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

Screening

A standardized and validated tool is recommended for screening for maternal depression. An example is: A list of postpartum depression screening tools can be found at Screening Time (AAP) by filtering for maternal depression (on left of page).
The following billing codes can be used:
  • ICD-10: Z13.32, Encounter for screening for maternal depression
  • CPT Code: 96161, Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument

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 to determine the severity of the depression.
  • Refer the mother to a mental health professional (social worker, psychiatric nurse practitioner, psychologist, or psychiatrist) for further assessment and evaluation.
  • A family doctor, obstetrician, internist, psychiatric nurse practitioner, or psychiatrist may work with the mother to devise a medication management plan, if necessary.
  • If the mother or child’s immediate safety is at risk, refer to the nearest Emergency Room for a psychiatric evaluation. See the list of Services, below.

Treatment of Postpartum Depression

Women who have postpartum depression or anxiety are often treated with 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 there are no known long-term risks to babies who are exposed to antidepressants through breastmilk, 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]
In addition to treatment with medication, recommendations include increasing maternal sleep, improving maternal support, and mental health therapy. Should breastfeeding be a large source of stress and cause of sleep deprivation in a new mother, supplementation with formula might be recommended.

Resources

Information & Support

For Professionals

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.

Postpartum Depression and the Family Poster (PDF Document 65 KB)
Describes postpartum depression and how it affects the family.

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 Depression (UDOH)
Facts for families about postpartum mental health; Utah Department of Health.

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)
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.

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

Crisis Intervention Mental Health

See all Crisis Intervention Mental Health services providers (76) in our database.

Family Counseling

See all Family Counseling services providers (47) in our database.

Family Support Centers/Outreach

See all Family Support Centers/Outreach services providers (13) in our database.

Mental Health Counselor (LPC, LCPC, CMHC)

See all Mental Health Counselor (LPC, LCPC, CMHC) services providers (283) in our database.

Outpatient Community Mental Health Agencies

See all Outpatient Community Mental Health Agencies services providers (5) in our database.

Social Workers

See all Social Workers services providers (1) in our database.

For other services related to this condition, browse our Services categories or search our database.

Studies

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

Helpful Articles

PubMed search for postpartum depression.

Earls MF.
Incorporating recognition and management of perinatal and postpartum depression into pediatric practice.
Pediatrics. 2010;126(5):1032-9. PubMed abstract

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.

Authors & Reviewers

Initial Publication: October 2018; Last Update: November 2018
Current Authors and Reviewers (click on name for bio):
Authors: Jessica Lu, M.D., M.P.H

Page Bibliography

American Academy of Pediatrics, Bright Futures.
2014 recommendations for pediatric preventive health care.
Pediatrics. 2014;133(3):568-70. PubMed abstract / Full Text
Chart of guidelines for preventive care of normally developing children; represents an AAP and Bright Futures consensus.

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.

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 3/26/2014.
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.

Onunaku, Ngozi.
Improving maternal and infant mental health: Focus on maternal depression.
National Center for Infant and Early Childhood Health Policy at UCLA. July. / 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.

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.