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Screening at
well-child visits uncovers
maternal depression
(November
2006 Issue)
By Nan Shnitzler
Depression is one of the most prevalent mental illnesses in the
U.S., twice as likely to affect women, with a tendency to peak during
childbearing years, according to a study in July's Pediatrics. The
study found that two simple questions inserted into well-child visits
was feasible to administer, detected mothers willing to discuss
their issues, led to clinician action, and that the whole process
usually took fewer than five minutes.
Asking parents whether during the last two weeks they have felt
down, depressed or hopeless and whether they had any interest or
pleasure in doing things opened the door to a dialogue with pediatricians
that could motivate parents to get help, says Ardis L. Olson, M.D.,
study leader and associate professor of pediatrics and family medicine
at Dartmouth Medical School.
Of 1,398 mothers questioned, about five percent screened positive
and six percent scored at risk for major depression. Of the study
population, about ten percent were fathers. While the paternal data
is still being analyzed, Olson says preliminary results are similar,
about five percent.
Olson says this was the second study conducted among a practice-based
research network of pediatricians in Vermont and New Hampshire who
were determined to come up with a way to talk to parents about depression.
The 2005 study found that mothers screened in writing were more
than twice as likely to reveal depression than those who were interviewed
face-to-face, and that mothers in 8.8 percent of routine visits
could have mental health issues. The results led to funding for
the 2006 study from the Commonwealth Fund of New York and the Health
Resources and Services Administration.
The 2006 study reports that parental depression could fall through
the cracks between pediatricians and mental health providers. Pediatricians
tend not to take notice of parents, who technically are not their
patients. Only eight percent of pediatricians routinely ask mothers
about depressive symptoms. Also, pediatricians are not necessarily
linked to adult-oriented mental health providers. Perhaps more important,
mental health providers tend not to talk to their adult patients
about their roles as parents, according to the study.
UMass Medical School psychiatry professor Joanne Nicholson, Ph.D.,
who established the National Advisory Group on Parents with Psychiatric
Disorders, says, "Our research shows that adult mental health providers
are not necessarily tuned into issues of their patients as parents."
The public policy, service integration and training implications
are vast. But before parents even see a provider, they have to realize
they have a problem.
Often, parents don't realize they are depressed, Nicholson says.
Or they don't want to deal with it because of the stigma of mental
illness, lack of awareness of treatment options or fear their children
could be taken away. What's worse, they don't make the connection
that their depression could compromise their parenting ability.
"It's ironic that treatment and rehabilitation have never been better,
yet parents are reluctant to seek it," Nicholson says.
That's why Olson's research is so important, Nicholson says. When
children interact with any medical or behavioral professionals like
pediatricians or day care providers, it's a great opportunity to
ask parents how they are doing. "What I appreciate about Olson's
work is she created a simple way for pediatric providers to address
and raise this issue with parents," Nicholson says.
Nicholson has no patience with physicians who resist sourcing mental
health information. It's not "rocket science" to provide educational
materials about mental illness, offer advice about self-help approaches
such as social support and exercise, and to compile a list of area
professionals, she says. "It's incumbent on all physicians to understand
what resources are available in the community," Nicholson says.
Ed Tronick, Ph.D., associate professor of pediatrics and psychiatry
at Harvard Medical School, has studied how caregiver mood affects
the social and emotional development of infants. He agrees that
the key to depression screening is having referral backup for complete
patient assessment.
That's why he favors the nine-question Patient Health Questionnaire,
of which the study's two-question screener is a subset. He would
rather err on the side of over- rather than under-identifying depression.
However, two questions are better than none, he says.
And two questions are better than pediatricians making mental health
judgments solely based on observation, the typical approach, according
to the study.
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