Integrating Postpartum Depression Screening in Your Practice in 4 Steps

How to Integrate Postpartum Depression Screening in Your Practice

1. Identification
Postpartum depression falls on a spectrum.
Postpartum blues: An estimated 50% - 80% of birthing parents experience “baby blues.”‍ These symptoms begin a few days after childbirth and last up to two weeks, but they do not impair function.‍ Symptoms include crying, depressed mood, irritability, anxiety and confusion.
Postpartum depression: PPD lasts longer than the “baby blues” and interferes with the ability to perform daily activities. The person feels intense symptoms of sadness, anxiety and hopelessness that last up to one year.
Postpartum psychosis: PPP is relatively rare, experienced by 1-2 people in 1,000.‍ Occurring in the first four weeks after childbirth, impairment is serious and may include paranoia, mood shifts, hallucinations and/or delusions, and suicidal and/or homicidal thoughts.‍ If a parent mentions thoughts of suicide on a screening form or in conversation, they should receive immediate, emergency mental health services.
2. Screening
Pediatricians’ time is limited; nobody has enough of it. But by spending time now, you can make a lifelong difference for a child.
AAP recommends that birth parent should be screened for depression at the 1-, 2-, 4- and 6-month well-infant visits, using a validated screening tool. A prenatal visit to the pediatrician is also a good opportunity for screening, as depression during pregnancy is the most common predictor of postpartum depression.
Many pediatricians use the validated Edinburgh Postpartum Depression Scale (EPDS), a form the visiting parent fills out during their child’s regular wellness check. Here it is in Spanish.
Others use the two-question Patient Health Questionnaire (PHQ-2) or the nine question Patient Health Questionnaire (PHQ-9). Both can be found at this link.
The AAP Screening Technical Assistance and Resource (STAR) Center has these and other screening tools, which can be found at this link.
It’s hard for some parents to talk about depression because of fear or stigma. Cultural or community values sometimes pressure parents to just “tough it out” or to sacrifice themselves for their children and family.
Others mistrust psychotherapy and the safety of medications or fear being labeled “crazy” and losing their children. This discourages treatment or recognition that there’s a problem. Many people with postpartum depression do not need medication.
It may take more than one visit for a new parent to open up about mental health struggles — keep checking in.
The AAP recently asked four pediatricians about the conversation starters they find most effective when screening for PPD. You can read that article here.
3. Referring Treatment
Pediatricians can help reduce the shame or guilt by assuring the parent how common depressive feelings are and by assuring them that they are not at fault or a bad parent.
Parents who screen positive for depression should be referred promptly to community resources for treatment. And it’s important to follow up to ensure that the parent is getting appropriate care and that the depressive symptoms subside.
If your practice has a counselor or social worker on site, that team member can provide immediate support.
If your practice is small and you do not have experts on site, you can turn to Early Head Start, Healthy Start, home visiting programs, or other community resources like public health nurses, lactation specialists, parent educators, parent support groups, parent-child groups, and postpartum support groups.
Many states also have perinatal access programs, which connect pediatricians with perinatal psychiatrists.
North Carolina pediatrician Marian Earls, MD, FAAP, recommends Postpartum Support International (800-944-4773), which has state and regional offices, or your state’s Association for Infant Mental Health. Here’s a link to Illinois’ chapter for an example.
“Both of these groups want to help,” Dr. Earls said, “and will be delighted that you’ve contacted them.”
Dr. Diasio recommends that pediatricians get to know their community’s obstetricians and team up with them, since they’ve already established a relationship with the parent during pregnancy. Diasio is on a first-name basis with the OB/GYNs in his small, semi-rural county. And, with the parent's permission, he will pick up the phone to call them about a parent who is struggling postpartum.
He also has made it a point to get to know representatives from the mental health resources in his community.
“Call them up, get coffee, and get to know them so you have somewhere to turn if a new parent screens positive for depression,” Dr. Diasio says.
After referring a parent for treatment, pediatric practices should follow up at the next visit to see if they followed up on the referral. You also can check on the status of the parent-infant dyad with screening tools like the Baby Pediatric Symptom Checklist or the The Ages & Stages Questionnaires: Social-Emotional, Second Edition.
ASHEW, the Academy’s project on Addressing Social Health and Early Childhood Wellness, offers a detailed roadmap for pediatric practices to implement depression screening practice-wide. It covers step-by-step actions to create and sustain best practices.
It is important to identify resources and a process for assessment and referral in your community, ideally before you start screening.
4. Payment
Since parental depression presents a risk to the infant, billing for the time spent screening for parental depression is appropriate. Current Procedural Terminology code 96161 allows for reporting of the administration of a health risk assessment for the benefit of the patient.‍
State Medicaid programs may pay for PPD screening using a validated screening instrument, such as the EPDS, Patient Health Questionnaire or the SWYC.
However, because billing codes vary by payer and by state, pediatric practices are advised to consult AAP state chapter pediatric councils and payers for updated coding guidance. When a screen result is positive, the practice should be familiar with coding on the basis of counseling time and complexity.