Changing laws, guidelines expand screening for postpartum depression

July 06--Postpartum depression can catch many families off guard and become worrisome not just for the mom experiencing it but for the baby whose mother might have excessive worries about that baby's safety or feel a lack of connection to her baby.

That maternal bond is important in the first few years of life as babies learn that if I smile at you, you smile back. If I cry because I'm hungry, you feed me.

"When a baby is parented by a depressed or anxious mother, there is some evidence that long-term exposure can lead to a learning disability, cognitive delays or motor delays," says Elaine Cavazos, a licensed social worker who specializes in postpartum depression. She is also an adjunct professor at the University of Texas and the clinical director of the Pregnancy and Postpartum Health Alliance of Texas.

Postpartum depression rates vary from 10 percent to 20 percent of postpartum women. It depends on what study you cite.

In May, the American College of Obstetricians and Gynecologists recommended that doctors offer more postpartum care for women by adding follow-up within the first three weeks of delivery in addition to a comprehensive visit within 12 weeks of delivery. Part of that recommendation is a response to recognizing that symptoms of postpartum depression often happen before the traditional six-week checkup.

Mothers actually see their child's pediatrician more regularly throughout that first year than their own doctors. Usually within a few days of birth, then at 1 month, 2 months, 4 months, 6 months, 9 months and 1 year.

"One of the critical things is we have access to the moms because we have access to the babies at a pretty high frequency," says pediatrician Louis Appel.

Recognizing that, the 2017 Texas Legislature passed House Bill 2466 that allows pediatricians to charge Medicaid and child health plan programs for the screening of mothers for depression within the first year of a child's life, even if the mother isn't covered by those programs but the child is. Medicaid covers mothers with low incomes while they are pregnant until 60 days after delivery, at which point they might not have the insurance to be screened for postpartum depression. Now they can still get screened after 60 days by going through the child's pediatrician and insurance.

Once screened, pediatricians can refer mothers to mental health services.

Appel says about seven years ago, pediatricians where he works, at People's Community Clinic, began doing the screenings because they were looking at what they could do to help with early brain development.

"The thing we landed on was screening for postpartum depression," he says. "That early bonding is so important to early brain development in children."

People's Community Clinic screens by having the nurse or doctor ask two questions, known as the Patient Health Questionnaire 2:

1. During the past month, have you often been bothered by feeling down, depressed or hopeless?

2. During the past month, have you often been bothered by having little interest or pleasure in doing things?

If they answer yes to those things or if there is a noticeable lack of interaction between Mom or baby or an anxiousness around that interaction, the patient would be given a longer 10-question form to fill out.

Doctors and nurses then refer patients to the clinic's social workers, sometimes in person that day or by phone later. If Appel didn't have those in-house resources, he says he would refer the mom to her primary care physician, to other community health resources or to the national crisis line for postpartum depression. Pregnancy and Postpartum Health Alliance of Texas also keeps a list of providers and what insurance companies they take.

It's not just moms who can get postpartum depression. It can happen to dads, too -- the Centers for Disease Control and Prevention estimates that about 4 percent of new fathers experience it. Cavazos says that in her practice, she sees dads as well as adoptive parents.

Last week, the American Academy of Pediatrics recommended that parents actually have a prenatal visit with pediatricians. This can help pediatricians anticipate postpartum depression by looking for any perinatal depression as well as give guidelines for those first few weeks of infant care. It also helps establish a partnership between the doctor and the family, and for the doctor to get a sense of pregnancy complications, family medical histories and any exposure that baby might have had to drugs or alcohol while in the womb.

Cavazos says the hallmark of postpartum depression is intrusive thoughts that something awful is going to happen to the baby, that they are going to do something awful to the baby or that they are going to do something awful to themselves and the baby. The mom becomes super vigilant about the baby's care and won't let anyone else care for the baby, or she is unable to engage with the baby because she's afraid she'll do something wrong.

Cavazos says it's like she is thinking, "What's the very worst thing that can happen to her?" and she's playing it over and over again in her head.

Her family will take note that she just doesn't seem like herself.

With postpartum depression, Cavazos will ask the mom if she's sleeping and that will get a laugh. She worries if women are getting less than five hours of sleep a day combined. She also wants to know about whether they have access to nutritious food and are eating. She might want them to have their vitamin D and thyroid levels checked to rule out other possibilities.

Sometimes antidepressants will be necessary. Even for moms who are nursing, "the general consensus is if the mom is depressed, the benefits far outweigh the risks of the medication," Appel says.

Other times, the treatment is self-care and talk therapy.

Cavazos will work on what feelings the moms have about the baby, what things cause them to become overwhelmed with the baby's care and what resources they have to get help, and also normalize what they are feeling.

Often moms don't stay long in therapy, usually four to eight visits, because of the amount of bandwidth they have. After all, they have a new baby, but sometimes they will make therapy part of their self-care regimen. Sometimes Cavazos will recommend a support group or some sort of parenting group to help the mom not feel so alone. And she'll help reassure moms that they have good parenting skills and find ways to strengthen those skills.

Appel encourages a mom's partner or support system to help as much as possible and to "give new moms permission to ... take any help people can give," he says. That whole "sleep when baby sleeps" is important. "You should not be doing the laundry or cleaning the house," he says.

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