AAP Perspective on Post Partum Depression Screening

1. AAP Perspective on Post Partum Depression Screening Elizabeth B. Lange, MD, FAAP Co-Director, PCMH-Kids Pediatrician, Waterman Pediatrics/Coastal Medical, Inc. April 26, 2017

2. AAP Clinical Report – Pediatrics Vol 126, Number 5, November 2010, pp1032-1039Incorporating Recognition and Management of Perinatal and Postpartum Depression in Pediatric Practice • Perinatal depression is the most underdiagnosed obstetrical complication in America • Post Partum Depression leads to – • Increased costs of medical care • Inappropriate medical care • Child abuse and neglect • Discontinuation of breastfeeding • Family dysfunction • And adversely affects early brain development

3. Breastfeeding • The depressed mother is – • less likely to breastfeed • more likely to nurse for shorter durations • have more negative emotions and experiences towards breastfeeding New mothers experiencing breastfeeding difficulties may be more likely to be suffering from postpartum depression.

4. Post Partum Depression affects Infant Brain Development • Threatens the mother-child relationship of attachment and bonding • An infant living in an emotionally neglectful environment can have adverse changes visible on brain MRI • Impaired social interaction • Delays in physical development and language acquisition Without early intervention these delays become less responsive to intervention over time. As early as 2 months the infant looks at the depressed mother less often, shows less interest in objects, exhibits lower activity level and has poor state regulation.

5. Paternal Post Partum Depression • Estimated at 6% of all fathers • In one study of children in Early Head Start, 18% of fathers had symptoms • Depressed fathers have higher substance abuse rates • Rate of paternal depression is higher when the mother has postpartum depression, which compounds the effect on children • Conversely, a non-depressed father has a protective effect on children, acting as a factor in resilience.

6. The pediatric medical home is uniquely positioned - • To establish a system of post partum depression screening • To identify and use community resources for treatment • To refer the depressed mother (or father) to these resources • To increase local awareness of the need for screening in obstetrical and pediatric care schedules • To ensure payment for post partum depression screening

7. Why Pediatricians? • New Moms often only have 1-2 postpartum visits with their OB and post partum depression symptoms may not be present at those times • New babies often have up to 6 visits in the first six months, so pediatricians see the infant-mother dyad much more often • Also, the nature and longevity of the pediatrician-patient (mother) relationship, and the frequency of visits allows mothers to develop a certain level of trust, thus more likely to speak about issues affecting the child’s health, environment and well being • Studies have shown that up to 80% of mothers are comfortable with the idea of being screened for depression

8. Primary Care Pediatrician • We are often the first clinicians to see the infant-mother dyad after birth • We have a continuity with the infant and family • BUT – the infant is our patient • Therefore, it is our role to provide guidance, support, referrals and follow up for the infant and the dyad relationship to optimize the child’s healthy development and the healthy functioning of the family

9. Perceived Barriers to Implementation • Lack of time • Incomplete training to diagnose and counsel • Lack of adequate mental health referral sources • Fear that screening means ownership of the problem • Lack of payment • Fear of liability

10. Pediatrician studies • The majority of pediatricians agree that screening for perinatal depression is in the scope of pediatric practice Pediatrics, 2002:110(6): 1169-1176 • Few pediatricians felt responsible for the diagnosis and management of post partum depression but the majority reported they had provided brief intervention Pediatrics, 2006;118(1):207-216 • Chaudron et al - “We believe that from the perspective of feasibility and now from the legal and ethical standpoints, the benefits of screening outweighs the risks.” Pediatrics, 2007;119(1):123-128.

11. Endorsements • US Preventative Services Task Force endorses the Edinburgh Postnatal Depression Scale as well as the general 2-question screen for depression • US Surgeon General’s office recognizes and calls for early identification and treatment • May 11, 2016 – CMS released an informational bulletin • Maternal Depression Screening and Treatment – A Critical Role for Medicaid in the Care of Mothers and Children • Asks states’ Medicaid to support screening and treatment in EPSDT benefit • “Maternal depression screening during the well-child visit is considered pediatric best practice.” (Early and Periodic Screening, Diagnostic and Treatment)

12. Bright Futures • The Pediatricians’ standard for well child care • Guidelines include surveillance regarding parental social-emotional well being • Bright Futures 4 (2017) • recommends post partum depression screening at well child visits – age 1 month, 2 month, 4 month, 6 month

13. Coding aappublications.org/new/2016/11/04/coding110416 • 99420 deleted for 2017 • 96161 – administration of caregiver-focused health risk assessment instrument for the benefit of the patient, with scoring and documentation, per standardized instrument (i.e. Edinburgh postnatal depression scale billed under baby) • Aka – use of a standardized instrument to screen for health risks on the caregiver for the benefit of the patient. It is intended that the code 96161 will be reported to the patient’s health plan as it is a service for the benefit of the patient. • RVU 0.13 x 2017 Medicare Conversion Factor $35.89 = $4.67

14. RIAAP Pediatric Council • 2008 – post partum depression screening on first agenda • Payment was variable but increasingly consistent • Depending on patient’s plan, the screening may drop to the family’s deductible • 2017 – and the discussion continues • The new CPT code has presented coverage and payment glitches • One insurer bulletin notes that post partum depression screening is a covered service but not separately paid

15. Waterman Pediatrics’ Work flow • Many years of experience screening for post partum depression with the Edinburgh 2-question screener • Clipboard, pen, screening questionnaire, Bright Futures page and VIS handed to parents in the exam room at the visit start • Pediatrician reviews the screen with the mother at the visit, the data is entered into structured EHR fields and the paper is scanned into the chart • We choose to administer screen at each baby visit up to 6 months • To create awareness of the topic with parents • To capture any family member involved in this baby’s life • Dad is often only at the first visit or two, and Grandma may attend other visits • To show support of the mother right from the start