Postpartum depression (PPD) screening is now considered a cornerstone of infant preventive care. Postpartum depression is a prevalent condition with direct impacts on the health and well-being of the infant and the family.1-3 These include behavioral and attachment issues, early cessation of breastfeeding, and overuse of healthcare services. Given that pediatricians see mother-baby dyads an average of 8 times during the first year of life, whereas mothers typically see their own doctor only once in that time frame, assessing for PPD within the pediatric clinic makes intuitive sense and opens a window for intervention.4
The United States Preventive Services Task Force (USPSTF) endorsed routine PPD screening in 2016.5 Prior to that time, new mothers were only screened by their obstetrician at their 6-week postpartum visit, if they attended that visit. Beginning in 2018, the American Academy of Pediatrics (AAP) strengthened its recommendation in this regard. Previously, the AAP stated that pediatricians should be alert to a mother’s mood and coping. Now the AAP endorses routine screening using a validated tool such as the Edinburgh Postnatal Depression Screen (EPDS) at the 1-month, 2-month, 4-month, and 6-month well visits.6 Most state Medicaid plans and private payers cover this screening fee when completed during the infant well visit.7,8
Multiple studies have found maternal depression rates as high as 15%.1 Given the myriad of negative consequences that postpartum depression can have on infant social and mental development, it is vitally important that these mothers are identified, offered support, and referred for appropriate mental health treatment. However, incorporating this additional screening tool into 5 infant well visits can feel daunting to busy clinicians. We will outline how PPD screening can be integrated into infant well care in a busy academic pediatric practice. We will also share the key resources to consider and line up prior to instituting this screening into your practice.
Setting and evolution of the screening process
Briarwood Center for Women, Children, and Young Adults is a Pediatrics and Obstetrics/ Gynecology practice within Michigan Medicine in Ann Arbor. In 2014, our clinic launched an integrated perinatal mental health program with embedded social workers and perinatal psychiatrists to provide on-site support for pregnant women and new mothers with mental health issues including depression and anxiety.
Starting in 2016, the pediatricians began routinely screening new mothers for PPD using the EPDS. Any mother who screened positive as indicated by a score of 10 or higher or any positive response to the self-harm item was referred to our social workers. When possible, medical providers would offer a warm handoff, having the mother meet with the social worker same-day during the clinic visit. For those with current thoughts of self-harm, the same-day hand-off was a requirement. The social workers would complete additional screening and facilitate new referrals or refer back to the mother’s primary care doctor, obstetrician, or psychiatry at our clinic site or our Depression Center. Our social workers would also offer short-term counseling to serve as a bridge until patients were able to connect with mental health providers who could follow them long term.
Beginning in 2018 with the AAP endorsement of routine EPDS screening, we confirmed with our billing department that the code 96161 (standard caregiver screen) was appropriate for use to bill for the administration of this tool at the AAP-recommended intervals.9 We added this code to the order sets for all infant well visits in the first 6 months of life, to make it easy for clinicians to remember to bill this service. To date, we have had no private payers decline to pay for this screening. We also added tabs to enter the score in our well-visit templates, and a PPD handout to the order sets.
1. Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum depression. Am J Obstet Gynecol. 2009;200(4):357-364.
2. Logsdon MC, Wisner KL, Pinto-Foltz MD. The impact of postpartum depression on mothering. J Obstet Gynecol Neonatal Nurs. 2006;35(5):652-658.
3. Muzik M, Borovska S. Perinatal depression: implications for child mental health. Ment Health Fam Med. 2010;7(4):239-247.
4. Shah PE, Muzik M, Rosenblum KL. Optimizing the early parent-child relationship: windows of opportunity for parents and pediatricians. Curr Probl Pediatr Adolesc Health Care. 2011;41(7):183-187.
5. US Preventive Services Task Force. Evidence summary (pregnant and postpartum women). Other supporting document for depression in adults: screening. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/evidence-summary-primary-care-screening-for-and-treatment-of/depression-in-adults-screening1. Published May 2019. Accessed September 9, 2019.
6. Rafferty J, Mattson G, Earls MF, Yogman MW; Committee on Psychosocial Aspects of Child and Family Health. Incorporating recognition and management of perinatal depression into pediatric practice. Pediatrics. 2019;143(1):e20183260..
7. American Academy of Pediatrics. Maternal depression screening: Medicaid and EPSDT coverage. Available at: https://www.aap.org/en-us/advocacy-and-policy/state-advocacy/Documents/MaternalDepressionScreeningGuidance.pdf. Accessed September 9, 2019.
8. Cox JL, Holden JM, Sagovsky R. Edinburgh Postnatal Depression Scale (EPDS). Br J Psychiatry. 1987;150:782-786. Available at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/practicing-safety/Documents/Postnatal Depression Scale.pdf. Accessed September 9, 2019.
9. American Academy of Pediatrics (AAP) Division of Health Care Finance. CPT code changes for health risk assessments take effect Jan. 1. AAP News. Available at: https://www.aappublications.org/news/2016/11/04/Coding110416. Published November 4, 2016. Accessed September 9, 2019.
10. Lemke S, Orringer M, Orringer K, Muzik M, Kileny S. Challenges and opportunities of postpartum depression screening in a pediatric primary care clinic. Poster presented at: Pediatric Academic Society (PAS) Regional Meeting; Troy, MI; 2019.
11. Orringer K, Kileny S. Unpublished clinic chart review data; 2018.
12. Department of Health, Government of Western Australia. Edinburgh Postnatal Depression Scale (EPDS): translated versions—validated. Perth, Western Australia: State Perinatal Mental Health Reference Group. Available at: https://www.dchealthcheck.net/documents/10-2015-EPDS-Translations.pdf. Published 2006. Accessed September 9, 2019.
13. Total Child Health Inc. CHADIS (Clinical Process Quality Improvement System). Available at: https://www.site.chadis.com/. Accessed September 9, 2019