I just came back from a research conference put on by the Marce society on the topic of perinatal mood disorders. It was great—the science is growing rapidly, and there are lots of clinical programs that are trying to promote recognition and treatment for women across the social spectrum, here and around the world. The human genome project is really bearing fruit.
Even as I got fired up (again) on this subject, I felt my usual sorrow and frustration that most pediatricians and obstetricians don’t screen for these disorders, even though they see the women (and their fetuses and then children) at risk, repeatedly. Today, many more obstetricians and pediatricians are now mothers themselves. Yet the demographic change in those professions doesn’t seem to compensate for the dis-incentives, blindspots, and confusion that discourage psychosocial pregnancy care.
I hope I am wrong, and that this area has just become so routine that my younger colleagues address it well and take it for granted. Is it?
PS: PLEASE VOTE ON NOV 2
i agree. it's supposed to be "Standard of Care" at the 6 week postpartum visit. I think it's silly to go from baby and then not be seen formally by your OB for 6 weeks. I was a (TRAIN WRECK!) for a long time....the problem comes in that the pediatricians aren't really seeing mom as their patient. I was on the verge of tears and did cry some at each of my child's well check ups. Never did I get asked about it. To make it worse, I never was screened at my postpartum visit. I don't know if it was because I'd just graduated med school or what...but I was an anxious mess. I'm currently in FM residency and I love that I have the dual role of OB and pediatrician...so although I may be seeing baby for a 2 wk wcc...I can have the freedom to "see" mom as a patient to at the same time. Anyhow, point being...6 wks pp is late and pediatricians may not feel comfortable with their role as likely first-line defense in post-partum disorders.
ReplyDeleteI think that many MDs may see PPD as another item on our ever-growing-list of "things to screen for that I don't know what to do with." Just my 2 cents; and I do recognize that, as an emergency physician, I probably have a different perspective from many of you. That said, god knows I try to screen for depression, anxiety, IPV, alcohol abuse, etc., as much as humanly possible. But with 10 minutes [if I'm lucky] per patient, I sometimes feel huge negative disincentives to ask those questions.
ReplyDeleteIndeed, I remember reading some study that showed that if the average PCP screened for everything that s/he was supposed to, it would take 4 hrs per patient... Not to mention the utter lack of resources to which patients can be referred for the problems we've discovered on universal screening... Plus there's the added challenge of providing effective referrals if the person you're screening isn't actually your patient...
Not to be negative. I think it's a STELLAR idea. (And I agree with Ashley, above, that the 6-wk visit is much too late. I suffered miserably from PPD, and it wasn't picked up til I was back at work!) But I am (clearly) skeptical about how it would work in reality.
I am only a med student, so what do I know, but I did just have my first baby nine months ago. I understand that it's difficult to properly screen. I think that in my case, while I didn't have ppd, I was still an anxious mess, I wished I had two things: more information on how so much of what I was feeling was temporary and normal, and a way to connect with other moms- local groups, etc. I think those things would have kept me calmer and helped a lot. I agree w op though that the issue seems to be completely ignored. My ob is young, too, having her own children. But it was never even addressed.
ReplyDeleteAs a pediatrician with a h/o borderline PPD with my first child, I strive to screen moms for PPD with each newborn visits. Then in that same 15-min visit, I try to cram in counseling on back-to-sleep, tummy time, breastfeeding, vitamin D, what to do in case of a fever. It's exhausting. Unless I open a boutique practice, which is not a practical option for my family, I do not have the freedom to stretch my well-childs to longer than 20 minutes. Of course, my newborn/well-child visits run overtime, then I get patient complaints that I value my time more than the patient's time. This is going on a tangent, but what the hell does this even mean? Do patients actually think I just sit in the lounge sipping my latte while reading People magazine and letting my waiting room fill up? OK, vent is over.
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ReplyDeleteSomething we pediatricians work to identify and begin to address. Your post is quite timely, with the new clinical report in Pediatrics (Nov 2010) about "Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice" to further highlight the issue.
ReplyDeletehttp://pediatrics.aappublications.org/cgi/content/full/126/5/1032
Thanks for blogging and worrying about it.
VOTE indeed.
I *do* screen for post partum depression, and have always done so. It is part of my well child check at newborn and 1 month. I typically don't do a 2 week WCC - insurance typically doesn't cover it. And yes, it is terribly burdensome to do all the screenings we're supposed to do. I also have the latest guidelines from the American Academy of Pediatrics recommending using a standardized questionnaire to screen for post partum depression at all the well child checks from newborn to 6 months, and have copies of them in my office to use. And yes, this will be yet another form to fill out, and and another screening to accomplish, among others. But it hasn't fallen through the cracks!!
ReplyDeleteI am glad to know people are thinking about this. Just fyi, a lot of recommended screening can be done by waiting room self report (the EPDS), and a lot of the support and counseling can be done by trained nurses or health visitors, or by referring mothers to postpartum support international (www.postpartum.org). The volunteer/survivors are good at getting the complete story and responding appropriately. Maybe not in the ER, but for everyone else, identifying and treating perinatal mood problems tends to save time and money in the long run--fewer visits for vague physical distress or excessive anxiety about the child. And the consequences of untreated,unrecognized illness really do affect the child's health and development. There may be too many things to screen for overall, but for this particular time in a woman and a child's life, this issue is worth the effort.
ReplyDeleteI make it a point to screen at every post-partum check (even just asking "How are you adjusting emotionally?", including wound checks and BP checks, but you are right in stating that at 6 weeks it may be too late. Raising awareness for mothers to recognize the symptoms is key, as well, and could be addressed at one of the myriad antepartum appointments in the office.
ReplyDeleteHave to say that the military system is quite good at screening this - before and after the baby comes. I've delivered x 2 at a military hospital and got screened at almost every visit. Of course, military families are under high levels of stress and peripartum mood disorders are more prevalent - but glad to know they are on top of screening new moms.
ReplyDeleteThis site is great. I think that in my case, while I didn't have ppd, I was still an anxious mess, I wished I had two things: more information on how so much of what I was feeling was temporary and normal, and a way to connect with other moms- local groups, etc.
ReplyDeleteHi there - glad to find this blog (linked from the NYT I think) of people who are likely to have lives sort of similar to mine!
ReplyDeleteI'm a family physician - and a mother, and had a very hard time adjusting after my first (daughter, now 7) was born. I screen everyone for those first few months; but just by asking a few "how are you doing/how is your mood" questions.
Anyone know if there is a "best" way to screen for PPD? Would it be "better" to use the PHQ-9 or something instead of just inquiring and being attentive?
to kgood above-- if you're a subscriber to the AFP journal, there's a good article in there recently (oct 15th issue) about ppd-- edinburgh depression scale is the one recommended by most.
ReplyDeleteGood post. I had severe PPD after my last daughter - over 9 years ago, that had me crashing pretty soon after delivery and peaked at 3 weeks pp which had me feeling suicidal... which necessitated... a trip back to the hospital and a stay in the psych ward. This of course was all in the wake of the Andrea Yates postpartum psychosis deal. It was embarassing to break down in front of my Dr. because mood changes/disorders STILL to this day have such a bad stigma. You never know how people are going to react. But I am glad I did and glad that I had the support system I had. I was so afraid to tell people what I was feeling and thought, because I thought for sure they would take my child away from me.
ReplyDeleteI was grateful for the OB that was there for me, and even though he didn't have all the answers, put me in touch with the psychologists/psychiatrists that COULD help me. He called periodically to check on me. It was a Hellish year and following that, when my daughter was 3 years old, I knew I could not go through that again, so my spouse and I made the decision that we were done having kids.
Kudos to those of you that are Doctors and are screening for these perinatal mood disorders.