Implementing Maternal Depression Screening

Abstract

To the Editor.—We welcomed the articles by Dubowitz et al1 and Heneghan et al2 on screening for maternal depression in the March 2007 issue of Pediatrics. These articles confirmed earlier findings that brief screening is feasible in pediatric clinics and that despite the availability of reliable screening instruments that can be completed by mothers and easily scored, few pediatricians routinely use them without specific training and support.3–5What can help us fill the gap between what we know we should do (depression screening is recommended by the US Preventive Services Task Force) and what actually happens in practice? Several steps are likely necessary. First, education of clinicians and their staff is essential. Pediatricians have reported that lack of time and training are barriers to screening and engagement. Changes in medical school, residency training, and continuing medical education programs are important first steps but seem unlikely to remedy these problems by themselves. Key issues such as the extent of the pediatricians' role, appropriate educational materials, how to help with depression-related parenting issues, and an efficient referral process need to be addressed during training.At least as importantly, ongoing improvements in reimbursement for assessment activities will be necessary. Recent changes in payment for maternal depression screening services, such as those in Illinois that resulted in payment of $14 per patient screened, may make the time invested in screening (and subsequent actions when screen results are positive) worthwhile for pediatric practitioners. This is a testable hypothesis. As states individually pass legislation that enables payment for postpartum and other maternal depression screening (as well as Early Periodic Screening, Diagnostic, and Treatment–type screening), an opportunity emerges for a large comparative cohort trial. Does payment affect performance in screening as it does in most other human endeavors?Likewise, technologic advances improve the feasibility and efficiency of screening (scoring, interpretation, transcription onto the medical chart, and listing of available relevant resources) online, at computer kiosks, or on laptop or handheld computers in the community or in waiting rooms before pediatric health supervision visits. Although a growing number of studies point out the attraction of such technologies for patients and health systems, questions remain about which technologies are feasible and cost-effective and if they improve the quality of care (and ultimately the health of children).We embrace the American Academy of Pediatrics' consideration of the whole family when treating children, and we urge it and its members to advocate for federal funding to research questions about ways to decrease barriers and enhance the effectiveness of maternal mental health screening. We do not want to wait another 15 years to see more studies showing that screening for maternal depression (or other psychosocial problems) is feasible but no one is doing it. We want to see the effectiveness of interventions to improve the situation.