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After giving birth, a woman experiences numerous and sometimes overwhelming changes, both physically and emotionally. The rapid drop in estrogen and progesterone that occurs can exacerbate anxiety and fatigue, leaving mothers vulnerable to postnatal depression, a distressing disorder that affects about 10 percent of women. More than the simple "baby blues," which is a common condition among mothers in the first few days following childbirth characterized by sudden mood swings, irritability and weepiness; postnatal or postpartum depression lasts longer and is more severe. As explained by the National Women's Health Information Center (NWHIC), the condition is characterized by more intense feelings of sadness, despair, anxiety and irritability. This often disrupts a woman's ability to function and care for her baby. Women who have postnatal depression once are more likely to experience it again.

It can start a few days or even months after delivery and can occur after any birth, not just the first. If left untreated, depression spirals downward, affecting the critical bonding process early in a child's life. This can have a negative effect on the child's language and behavioral development. While rare, a few new mothers will develop a more severe mental illness called postpartum psychosis which usually begins within the first two weeks after childbirth. According to the American College of Obstetricians and Gynecologists (ACOG), this happens in one to three cases for every 1,000 births and women are more at risk if they have bipolar disorder or schizophrenia.

"A mother who has postpartum depression is hindered in raising (her child)," explained John Hill, MD, general pediatrician and Le Bonheur Children's Medical Center and president of the Tennessee Chapter of the American Academy of Pediatrics (TNAAP). "Kids don't do as well developmentally."

For that reason, pediatricians at the University of Tennessee Medical Group (UTMG) have been utilizing a screening tool to test mothers for postnatal depression during well child visits at two weeks and two months. Part of a greater emphasis in total care and early detection, pediatricians are progressively taking a bigger role in being attentive to parental health along with their tiny patients.

"Pediatricians have a double whammy, we have the patient and the mother," Hill explained. "We have to deal with family units."

A simple questionnaire, called the Edinburgh Postnatal Depression Scale, was developed to assist pediatricians and primary care clinicians. Mothers take about five minutes to fill out the questionnaire, answering questions about their general emotional state over the seven days. If the score is high, indicating possible depression, pediatricians react accordingly, helping mothers find treatment resources, referring them back to their own primary care provider and if necessary, a mental health professional.

Traditionally postnatal depression was something pediatricians left to the OB/GYNs, yet OBs don't typically see mothers until six weeks after birth, which is well past that critical window for early detection.

"Talking to mothers, they may not seem depressed, but when the right questions are asked in the right way, you get surprising answers," said Hill.

In fact, Hill said the first time he screened a mother she scored highly. That isn't always the case, but it's pretty common to catch someone in the early throws of depression.

The mother screening tool, Hill explained, was included as part of a bigger mandate by TNAAP, which gave the state a grant to develop the START (Screening Tools and Referral Training) program. The START program provides pediatricians, family and nurse practitioners and other primary care providers across the state special training to evaluate children for developmental disabilities, all with the goal of improving early childhood exams. TNAAP sets up teaching programs across the state to train clinicians to conduct early childhood and parent screening during well child visits, along with information on proper coding and reimbursement.

Not all pediatricians in the state perform the screening as a standard, but Tennessee is ahead of the curve nationally, noted Hill. UTMG made the practice standard about four years ago and trains all residents to do it.

"The screening tool gives mothers a safer outlet," commented Alethea Allen, general pediatrician at UTMG. "Asking up front, you won't always get the answers. Giving the answers on the form, mothers are usually more forthcoming."

Allen said pediatricians have always looked out for postnatal depression in mothers, asking moms how they feel and interviewing them to identify red flags, but the formal screening yields a lot more information. It's more than just catching the depression, she maintained, it's about being able to help mothers get the clinical support they need, whether through mental health professionals or referring to their OBs.

"We give them as many numbers as we can," said Allen. "One mother we worked with recently said she felt really isolated, and was very appreciative we were there to (help her) find resources."

She continued, "When we have moms we're really concerned about, we'll bring them back to see for ourselves that the babies and moms are okay. It works well to establish that relationship with the moms."

Before, it was dependent on mothers to identify problems, Allen said, but now pediatricians can help them get help that they may not have realized they needed.

"It's definitely been worthwhile," added Hill. "You know you really helped this person, the mom and the baby."

Tags:

Alethea Allen, Edinburgh Postnatal Depression Scale, John Hill, postnatal depression, Screening Tools and Referral Training, University of Tennessee Medical Group

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