How Feasible is it to Screen for Parental Depression in Urban Pediatric Practices?
In the spring of 2015, the American College of Obstetricians and Gynecologists (ACOG) released a recommendation on screening women for perinatal depression with the aims of spreading awareness of depression and decreasing the effects that it has on pregnant and postpartum mothers and their families. Postpartum depression is a serious, incapacitating illness that affects anywhere from 10 to 20 percent of new mothers at a time when their infant requires considerable attention. Recognizing the gravity of this illness, ACOG urged practitioners to prescribe treatment when appropriate, either directly or through referrals to behavioral health resources.
To test the feasibility of this new recommendation, PolicyLab researchers Dr. James Guevara, Dr. Marsha Gerdes and Dr. Rhonda Boyd developed a study to understand how urban primary care practices are screening for parental depression. This mixed methods study involved implementing a screening tool to screen for depressive symptoms of parents at one- to three-year-old well visits, as well as conducting semi-structured interviews with fifteen clinicians from five practices associated with Children’s Hospital of Philadelphia and two community health clinics affiliated with the City of Philadelphia’s Department of Public Health.
With this data, they were able to identify barriers and facilitators for screening parents for depression in the pediatric setting.
The three stages of the screening phase included first using paper and pencil screens, then implementing electronic reminders for physicians within electronic health records (EHRS) and, finally, turning off the electronic reminders to see if there was a lasting impact. Of the more than 8,500 eligible parents included in the study, the overall screening rate was 21.1 percent, which is consistent with previously-published research. However, the electronic reminders to clinicians to screen parents improved screening rates by more than 200 percent (45 parents screened per month compared to 173.0).
In the interview phase, clinicians revealed a number of barriers to screening. They focused on issues such as the length of time it takes and other aspects of the child’s visit taking priority.
…When you’re behind and you’re going into a room and you have ten minutes, and you’re running an hour behind, it’s sort of like, oh, I don’t even want to open up that can of worms.
When you only have X number of minutes, it may not come across as the most important thing to ask.
Some of the clinicians also expressed a lack of confidence in referrals for treatment of adults.
You shouldn’t screen unless you can do something about it… The doing something about it is hard, and that’s probably where people push back.
These concerns are likely shared by other clinicians in the field of pediatric care, and may have contributed to the low overall screening rates in this study. That said, the clinicians PolicyLab interviewed also indicated that they wanted to do the screening and that it was feasible. They believe that depression screening can develop stronger ties with parents, improve their own clinical skills and facilitate referrals to mental health resources for parents.
Since clinicians view the practice of screening favorably and ACOG is urging practitioners to regularly screen parents for depression, pediatric practices and policymakers should consider the challenges described by clinicians when moving forward on policy changes.
Current Federal and State Policies
While there are currently no federal policies mandating screening of new mothers for postpartum depression in the U.S., 12 states have already adopted state legislation, developed awareness campaigns or put together task forces about perinatal depression. To spur federal action, Representatives Katherine Clark (D-MA) and Ryan Costello (R-PA) introduced a bill in the U.S. House of Representatives in July 2015 titled “Bringing Postpartum Depression Out of the Shadows Act of 2015,” which would give grants to states for screening and treatment for maternal depression. Congress passed this legislation as part of the 21st Century Cures Act, which President Obama signed into law in December 2016.
In Pennsylvania, Sens. Judy Schwank (D-Berks) and Camera Bartolotta (R-Washington) introduced legislation in May 2016 that would add postpartum depression to the list of conditions that qualify families for the state’s Early Intervention system for infants and toddlers. This legislation did not make it through the last General Assembly, and could be reintroduced in the new General Assembly that also convened on January 3.
Recommendations for Pediatric Practices
To address some of the clinician-identified concerns from the PolicyLab study, pediatric practices could work on establishing (or continuing) electronic alerts and utilizing screening tools such as the Edinburgh Postnatal Depression Scale or, even simpler, the Patient Health Questionnaire-2 (PHQ-2) to address the time screening takes. Also, we would encourage additional education and training for providers regarding the impact of postpartum depression on children.
Policy changes could have a significant, positive impact on improving parental depression screening rates in our country. By using studies like these – concentrated on the heart of barriers and facilitators to screening for physicians and parents – these policies can be well-informed, evidence-based and most effective.