KEY ACTIVITY #8:
Provide Dyadic Care: Screen for Postpartum Depression
This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; behavioral health integration.
Overview
California created a dyadic services Medi-Cal benefit effective January 2023. The dyadic services benefit allows Medi-Cal to cover behavioral health and wellness visits that focus on the individual child and their surrounding environment, including caregiver wellness, all within the context of the child’s medical appointment. Dyadic services provide reimbursement for evidence-based health promotion and primary prevention supports that can be brief in duration. Covered behavioral health services include screening for behavioral health problems, interpersonal safety, tobacco and substance misuse, and health-related social needs and referrals for appropriate follow-up care.
This foundational activity provides guidance on screening for postpartum depression (PPD) in a pediatric setting. Currently, the American Academy of Pediatrics (AAP) recommends that pediatric care providers screen mothers for postpartum depression at the infant's one-, two-, four-, and six-month well-child visits (WCVs). Repeated screening at these visits allows for a birthing person who may not be comfortable disclosing initially to do so at a later visit, and it maximizes the opportunity to engage a dyad that may miss one or more of the recommended well-infant visits. AAP also recommends use of community resources for the treatment and referral of the birthing person with depression and providing support for the maternal/child dyad relationship, including breastfeeding support. Of note, some advocates are encouraging screening the partner for postpartum depression as well.
Pediatric care providers have a crucial role in recognizing birthing people who may be experiencing PPD and referring them to appropriate treatment. When left unaddressed, depression can undermine a parent's capacity to form a strong bond with and provide proper care for their infant. This can result in the cessation of breastfeeding, disruptions within the family dynamic, and an elevated likelihood of child abuse and neglect. Moreover, untreated depression can adversely impact an infant's brain development, heightening the risk of toxic stress, which in turn hampers the timely development of language, cognitive skills, and socio-emotional abilities.
Nonetheless, a survey conducted in 2019 among members of the American Academy of Pediatrics (AAP) revealed that merely around half of pediatricians (53.9%) incorporate formal screening for maternal depression into their practices.
According to the AHA’s Institute for Diversity and Health Equity, PPD affects one in eight people and the risk is 1.6 times higher for Black people than white people. Yet Black people are less likely to receive help due to factors such as financial barriers, stigma associated with mental health struggles, structural racism, and a historical mistrust of the healthcare system. Reliable, culturally appropriate PPD screening and follow-up care is essential.
PPD causes intense long-lasting feelings of anxiety, sadness and fatigue, making it difficult for birthing people to care for themselves and/or their babies, as well as handle daily responsibilities.[1] Providing PPD screening and follow-up care, as well as other dyadic services, can identify potential barriers and challenges the perinatal population may face, with long-range impacts on birthing person and newborn outcomes.
Linkage of the birthing person’s prenatal and postpartum records to the infant’s record is often challenging in the EHR, and even more complicated for other children in the family. Care coordination applications are one opportunity to assure that the child’s care plan includes and addresses the birthing person’s concerns. Another approach is assuring that there is a place in the child’s record to store and update this information by more manual means.
Action steps and roles
1. Understand current recommendations for perinatal depression screening compared to the baseline screening rate.
This 2019 article in the American Academy of Pediatrics includes the current recommendations.
Establish a baseline by assessing the current PPD screening rate compared to the guideline (e.g., PPD screening was documented at 63% of the visits at one to six months). If these data are not available in a format amenable to a care gap report, consider gathering data prospectively by tracking how often PPD screening occurs during recommended visits over the next two to four weeks).
2. Flag all eligible patients for postpartum depression screening and administer screening.
To screen for depression, consider:
- During pregnancy: Patient Health Questionnaire-2 (PHQ-2) or Patient Health Questionnaire-9 (PHQ-9). (PHQ-2 In Spanish; PHQ-9 in Spanish.)
- During postpartum: Edinburgh Postnatal Depression Screen (EDPS). (EPDS in Spanish). Note this is included in some pediatric screening tools, including SWYC.
Care teams may administer depression screening in various ways: verbally by rooming staff, by paper screener at check-in, virtually through tablets at check-in, or as part of a pre-visit screening packet sent via text or email. Regardless of the method, clinic teams must have a process for reviewing the results in a timely fashion on the day of the visit and initiating the next step in the workflow, namely: if the score is positive, the rooming staff would hand off information to the medical or behavioral health staff.
Resources for empathic, trauma-informed screening and responding to positive screens are provided below:
- Postpartum depression and anxiety: How to start the conversation from the AAP.
- Empathic Connections: Follow-Up Conversations on Sensitive Screens.
3. Support access to postpartum mental health services.
If screening results are positive, the pediatric care provider can conduct an assessment or bring in a member of the behavioral health team to do an evaluation and discuss appropriate timing of the best next steps, including combination of the following:
- Watchful waiting.
- Behavioral health referral.
- Medication management.
Ensure staff can activate an immediate suicide risk assessment and response protocol, as needed, for patients with identified suicidal ideation, significant risk of harm to self and/or others, or psychosis. The PHMI People with Behavioral Health Conditions Guide provides more information about implementing a suicide response protocol.
Under the Medi-Cal dyadic care benefit, the caregiver does not need to be enrolled in Medi-Cal or have other coverage, so long as the care is for the direct benefit of the child. This benefit includes services provided to the caregiver during a child’s visit including brief emotional and behavioral assessment, depression screening, and psychiatric diagnostic evaluation. Other relevant dyadic benefits for postpartum depression include dyadic comprehensive community supports services to help the caregiver gain access to needed services and family therapy to improve parent/child relationships and encourage bonding, resolve conflicts, and create a positive home environment.
Case example: In response to a review of their practice’s data showing Hispanic patients were less likely to be screened for maternal PPD, a pediatric practice developed a campaign to better support these patients. Educational materials were created in Spanish to address frequently asked questions and concerns about depression and the need for depression screening, especially during the prenatal and postpartum periods. The screening workflow was altered, so the educational materials were provided alongside the paper screening tool when patients and their families checked in for their appointments. To improve reliability, the practice decided to administer the tool for all visits for children aged one to six months, including both WCVs and sick visits. Care teams were retrained on the process for PPD screening and referrals, including how to respond empathically to achieve positive results.