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Practice problem
At the pediatric clinic in this project, mothers are seen often in the first months after birth, but they are not screened for depression. Staff say they "would notice if a mom was struggling," and the clinic has no referral pathway for maternal mental health. The clinic and its figures are illustrative.
Significance
The US Preventive Services Task Force (2019) notes that perinatal depression affects as many as 1 in 7 women and is one of the most common complications of pregnancy and the postpartum period, with adverse short- and long-term effects on both the woman and child. The American Academy of Pediatrics describes postpartum depression as an adverse childhood experience with potential long-term consequences for the infant and family, and recommends that pediatric medical homes screen mothers for postpartum depression at the 1-, 2-, 4- and 6-month well-child visits, use community resources for treatment and referral, and support the mother–infant relationship (Earls et al., 2019).
The screening tool
The Edinburgh Postnatal Depression Scale (EPDS) is a 10-item self-report scale developed to screen for postnatal depression in the community. In its validation study with 84 mothers, it showed satisfactory sensitivity and specificity, was sensitive to changes in severity over time and could be completed in about 5 minutes (Cox et al., 1987). Its final item asks about thoughts of self-harm, so the workflow must include an immediate safety response.
PICOT question
Among mothers attending well-baby visits at 1, 2, 4 and 6 months (P), does a standardized EPDS screening and referral workflow (I), compared with no routine screening (C), increase the percentage of eligible visits with a completed screen and the percentage of positive screens with a completed referral (O) over 16 weeks (T)?
Project objectives
- At least 80% of eligible well-baby visits will include a completed EPDS by week 8.
- At least 90% of mothers with a positive screen will receive a same-day discussion and an offered referral.
- All mothers with a positive response to the self-harm item will receive a same-day safety assessment.
Intervention
| Component | Detail |
|---|---|
| Screening | EPDS on a tablet at check-in, in English or Spanish, at 1-, 2-, 4- and 6-month visits |
| Positive screen | Pediatric provider or nurse discusses results privately, using a script, and offers referral |
| Self-harm item | Immediate safety assessment by a trained clinician, with emergency pathway if needed |
| Referral | Warm handoff to an integrated behavioral health clinician or partner counseling service; information about the National Maternal Mental Health Hotline |
| Prevention | Mothers at increased risk are offered counseling, such as cognitive behavioral therapy or interpersonal therapy, which the USPSTF (2019) recommends (B recommendation) |
Implementation and evaluation
The project uses Plan-Do-Study-Act cycles: cycle 1 tests the workflow with two providers for 2 weeks, cycle 2 extends to the whole clinic, and cycle 3 adds the Spanish version and behavioral health warm handoffs. Measures are tracked weekly on run charts:
- Process: screening completion rate; referral rate after positive screens.
- Outcome: percentage of referred mothers who attend a first counseling visit within 30 days.
- Balancing: visit length; staff-reported workload.
Ethical and practical considerations
Mothers aren't the clinic's registered patients, so the project will confirm documentation and billing procedures with the clinic's compliance officer and explain to mothers why the clinic asks about their well-being. Privacy matters: the EPDS will be discussed only with the mother, not in front of other family members, unless she chooses.
References
Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150(6), 782–786. https://doi.org/10.1192/bjp.150.6.782
Earls, M. F., Yogman, M. W., Mattson, G., Rafferty, J., & Committee on Psychosocial Aspects of Child and Family Health. (2019). Incorporating recognition and management of perinatal depression into pediatric practice. Pediatrics, 143(1), Article e20183259. https://doi.org/10.1542/peds.2018-3259
US Preventive Services Task Force. (2019). Interventions to prevent perinatal depression: US Preventive Services Task Force recommendation statement. JAMA, 321(6), 580–587. https://doi.org/10.1001/jama.2019.0007
