Nursing professionals regularly care for families experiencing the phenomena of maternal depression in a variety of settings: primary, tertiary, and community and must have confidence and competence in the assessment and implementation of appropriate interventions to address this issue. Pediatric health care professionals (PHCPs), specifically pediatric nurses, are ideally situated to identify and refer mothers experiencing maternal depression because many mothers interact more frequently and consistently with PHCPs than any other health provider during their child's early years (American Academy of Pediatrics, 2000; Heneghan et al., 2000; Mandl et al., 1999). For nursing professionals, screening with appropriate triage for maternal depression is congruent with the complimentary goals of actively promoting children's health and well-being (Edelbohls & Ecklund, 2002; Lau, 2000; Nickolson & Clayfield, 2004). Screening, identification, and intervention can prevent the long-term negative child outcomes as well as acute postpartum psychotic episodes associated with suicidal ideation and infanticide.
For women, depression is the leading cause of disease burden worldwide (World Health Organization, 2001), and mothering young children increases the risk of depression (Murray & Lopez, 1996). Maternal depression is a serious condition occurring in approximately 10% to 20% of women in the United States within 6 months of delivery (Miller, 2002) and has lasting effects on women (Beck, 1999; Greenberg et al., 2003), children (Casey et al., 2004; Weissman et al., 2004), families (Lopez & Murray, 1998; National Institute of Mental Health, 1998), and society at large (Kramer et al., 1998; Murray & Lopez, 1996). Although the most prevalent and treatable mental health problem, maternal depression, is generally undetected and untreated (Mandl, Tronick, Brennan, Alpert, & Homer, 1999), this missed diagnosis is important to pediatric health care given the enormous effect that parental well being has on children (Osofsky, 2004). To provide care for the overall physical and emotional
health of children, pediatric providers must have a comprehensive understanding of the children's home life, including physical and mental stresses.
Maternal depression is typically associated with disruptions in mother-child interactions and attachment and has profound consequences for infant development. Research indicates that depressive symptoms in mothers place their children at risk for developmental delay, somatic symptoms (colic, sleep and feeding disorders), behavioral difficulties (NICHD Early Child Care Research Network, 1999; Zuckerman & Beardslee, 1987), injury, and high use of medical facilities (Mahdi et al., 1999). Maternal depression results in serious functional impairment, placing a significant burden on families (Lopez & Murray, 1998; National Institute of Mental Health, 1998), and often leading to increased utilization of medical and mental health services for women and their children and overall increased medical costs (Klerman & Weissman, 1992; Minkovitz et al., 2005; National Institute of Mental Health, 1998). Nevertheless, the US Surgeon General's Report on Mental Health (1999) points out that the impact of maternal mental health on children is under recognized. Improving efforts at early recognition and treatment of maternal depression will benefit women, their children and families, and society at large.
Pediatric health care providers (PHCPs) are concerned about maternal depression because of its prevalence, with rates of 12% to 60% experienced throughout the child-bearing years (Heneghan, Silver, Bauman, & Stein, 2000) and the associated negative affects on mothers and children. PHCPs care for about four-fifths of children younger than 5 years of age (American Academy of Pediatrics, 2001) and many mothers interact more frequently and consistently with PHCPs than any other health provider during their child's early years (American Academy of Pediatrics, 2000; Heneghan et al., 2000; Mandl et al., 1999). For example, during the first 2 years of a child's life, women and their children come into frequent contact with health care providers through standard pediatric practice and recommended immunization schedules. Because parents often develop a rapport with their service provider, an honest and forthcoming dialogue about maternal depression might not be difficult, especially if it is framed in terms of the relevance to the children (Kahn et al., 1999; Olson et al., 2005). Therefore, pediatric settings provide a unique opportunity for the recognition of and intervention for maternal depression.
Pediatric guidelines emphasize that PHCPs should play a more active role in detecting family problems, especially depression (Green, 1994). Screening for family problems can increase the effectiveness of providers in dealing with and preventing a variety of childhood problems (Heneghan, Mercer, & DeLeone, 2004; Kemper, 1992). Olson and colleagues' (2002) seminal national survey of pediatricians' attitudes and practices in screening for maternal depression addressed five specific areas: 1) the self-perceived roles and responsibilities of primary care pediatricians in the recognition and treatment of postpartum and other maternal depression, 2) their self-reported identification and management practices, 3) their confidence in diagnostic and treatment skills, 4) existing barriers to recognition and treatment skills, and 5) their willingness to use education or new approaches for recognition or management. Overall their findings indicated pediatrician attitudes and skills relevant to maternal depression limit their ability to play an effective role in recognition and management. Several studies have shown that attempts at screening mothers for depression or other psychosocial factors in pediatric settings have been successful, especially when the screening is presented as a routine part of the care provided (Chaudron, Szilagyi, Kitzman, Wadkins, & Conwell, 2004; Kemper & Babonis, 1992).
For pediatric nurses, screening for maternal depression is congruent with the complimentary goals of actively promoting child health and well-being (Edelbohls & Ecklund, 2002; Lau, 2000; Nickolson & Clayfield, 2004). Yet, as Chaudron and associates (2004) point out, although screening for maternal depression in pediatric settings seems promising, a number of practical barriers to implementation continue to exist: 1) the mother is not the identified patient; 2) time limitations of the well child visit; and 3) under some health plans, providers are not able to refer mothers directly to mental health providers. Thus, getting providers to implement procedures outlined in national clinical guidelines, such as those for maternal depression, is challenging in an environment of shrinking healthcare dollars and increased competing demands (Tam, Newton, Dern, & Parry, 2002). There continues to be limited empirical evidence important for understanding PHCP attitudes and practices involved in executing such guidelines in systematic and routine ways. The purpose of this study was to expand existing knowledge by examining the current attitudes and practices regarding management of maternal depression in a sample of PHCPs. The specific aims were to: 1) examine frequencies of PHCPs' self-reported practices in recognizing and treating maternal depression; 2) examine PHCPs' plans for and perceived barriers to behavior change; and 3) examine and compare PHCPs' attitudes, practices and perceived barriers to change by confidence level.
Methods
A descriptive cross-sectional design was used for the study reported in this paper. A convenience sample of PHCPs, (physicians and advance practice nurses [APNs]) practicing in a large metropolitan area of Southern California and participating in the Partnership for Smoke-Free Families (PSF) provided the data for this study. PSF is a model designed to systematically screen pregnant women and new mothers for tobacco use and link them with appropriate interventions. This program has been described in detail elsewhere (Baker et al., 2004; Saks et al., 2001). Subsequent to approval from appropriate institutional review boards, a packet containing a written explanation of the project, survey, and a self-addressed stamped envelope was delivered to 290 PSF providers during August 2003. Two telephone calls followed the delivery at 1 and 2-week intervals. A follow-up mailing was conducted at 2 months. A total of 28 providers were classified as ineligible when they could not be reached through 2 mailings, had no forwarding address, and after two attempts did not answer their business telephone. Providers who completed the survey were entered into a drawing for a $50.00 gift certificate.
Sample. A convenience sample of 98 out of 262 eligible providers responded to the survey. Respondents were representative of the larger PSF sample with 59% female; 81% physicians, 19% APN; and in distribution across practice settings (75% group practices--including community clinics/other and 5% solo practices).
Measurement. The 48-item survey included items adapted from a national survey of U.S. primary care pediatricians conducted by Olson, Kemper, Kelleher, Hammond, Zuckerman and Dietrich (2002). Details of their survey development and piloting have been previously described (Olson et al., 2001). Questions elicited information about the provider's perceived responsibility for recognition and treatment of postpartum or maternal depression, provider confidence in his/her skills in diagnosis and treatment, and provider willingness to change his/her practices regarding postpartum or maternal depression. Based upon Olson and colleagues' survey (2002), PHCPs were asked to recall their last identified case of maternal depression to gain more specific data about identification and management of depression while limiting overgeneralization and social desirability in responses. Thus, the survey used in our study also included a series of questions inquiring about providers' specific behaviors or practices in identifying and addressing maternal depression in their last recalled case. Questions also inquired about the cues the PHCPs used in identifying the mother's depression. Providers could choose as many cues as applicable. In addition, because the use of screening tools has been recommended for use in primary care, items were included on whether the respondents used screening tools in their office setting for both mother and child conditions and whether or not they were used for family psychosocial issues.
Previous research has identified potential barriers to following guidelines and embedding quality of care initiatives into practice. In order to understand what barriers exist for the PHCPs in this study, a list of barriers was provided and the providers rated them on a range from 'limiting them a great deal' to 'not limiting them' in identifying and addressing maternal depression in their practice. Completion of the survey required approximately 10 to 15 minutes.
Statistical analysis. All analysis was conducted using SPSS statistical software, version 12.0. For the study reported here, data analyses included descriptive statistics (frequencies) and cross tabulations. The significance level was determined by Pearson chi square with a significance level <0.05. Five -point Likert scales were collapsed into 3 category variables (e.g., strongly agree and agree coded as agree, strongly disagree and disagree coded as disagree, neutral remained coded as neutral). Four-point Likert scales were collapsed into dichotomous variables (e.g., very and mostly confident coded as confident, somewhat and not confident coded as not confident). Lastly, the 3-point Likert scale for barriers was collapsed into a dichotomous variable (limited a great deal and limited somewhat coded as limited, did not limit remained coded as did not limit). The small sample of APNs participating in the study does not permit comparative analyses; however their responses are informative and are presented in Tables 1 through 3.
Results
Over two-thirds (67%) of the sample reported seeing 10 or fewer patients weekly for a 2-month well child visit, with the remaining 33% seeing more than 10 patients. Eighty-five percent of providers indicated screening for depression was a high priority, yet only 30% reported using questionnaires or screening instruments for family psychosocial issues and 20% for parental well-being. Less than one-third (28%) reported having a mental health professional available at their practice site (see Table 1).
Recognizing and treating maternal depression. Over 80% of the providers (APNS = 94%) agreed that recognizing maternal depression was their responsibility; on the other hand only 11% agreed that treating maternal depression was their responsibility. In fact they were more likely to disagree that treating maternal depression was their responsibility with almost 72% reporting that treating maternal depression was not within the scope of their responsibilities. When asked to recall the last mother seen in their office during a well child check-up whom they recognized as having maternal depression, 22% could not recall a maternal depression case.
Clinical cues. Table 2 presents the proportions of providers who could recall a last case of maternal depression, assessment strategies (e.g., clinical cues), management practices, and desire to change their practice. Based upon those respondents who could recall a case of maternal depression (n = 77), the majority of providers (88%) stated they predominately relied on the mother's behavior, appearance or complaints (e.g., appeared sad, cried, not sleeping) with the next most frequently cited cues of family dynamics (31%) and the child's presenting problem (e.g., failure to thrive, sleep problems, behavior, somatic complaints, injuries) (31%). Only 12 % of PHCPs reported that they routinely ask mothers about symptoms of depression in their practice, while almost one third of APNs (29%) routinely inquire.
Suicide assessment. Fifty percent of providers reported they assessed the mother's risk for suicide. The majority of providers who assessed for suicidality reported doing so by asking a direct question (63%), as compared to indirectly asking (37%), or the mother volunteering the information (3%). Of the PHCPs who assessed for suicide risk, 59% also assessed for other psychosocial issues, including the availability of a support network (84%), somatic symptoms (75%), and functional impairment (55%). More than three quarters of the APNs (79%) reported assessing for mother's risk of suicide, with 82% asking a direct question as compared to indirectly asking (18%), or the mother volunteering the information (9%). APNs also reported assessing for other psychosocial issues, including availability of support networks (90%), somatic symptoms (90%), and functional impairment (70%).
Diagnosis. Over two-thirds of the providers determined mother's depression based on their overall impression with inquiry about 1 or 2 symptoms (68%). Nine percent used formal diagnostic criteria (e.g., DSM-IV) for determining depression and 3% used a screening questionnaire. Reflecting upon their last case of maternal depression, 42% estimated the level of depression of the mother as mild, 53% as moderate, and 5% as severe. Almost three-quarters (74%) of providers told the mother they thought she was depressed by using the term depression in the conversation. The majority of APNs (93%) based their impression on inquiring about 1-2 symptoms, yet none reported using formal diagnostic criteria (e.g., DSM-IV), and only 7% used a screening questionnaire. For the estimation of depression severity, 21% estimated the level of depression of the mother as mild, 57% as moderate, and 21% as severe.
Intervention. Providers were also asked to report specific ways in which they intervened in the last case by providing treatment or by making referrals (see Table 2). The most common method of managing maternal depression was via referral to a primary care provider/mental health professional/ER (80%), followed by counseling by the provider for less than 5 minutes (36%). Almost half of APNs prescribed antidepressant medications.
Plan for behavior change. When providers were asked if they were inclined to change the way they access, recognize, or manage mothers with suspected depression and how likely they would be to implement specific strategies in the next 6 months, almost three-fourths (70%) were very likely or almost certain of changing their approach to the recognition and management of maternal depression. The providers seemed most willing to ask mothers about depression more frequently (73%) or consult mental health providers more often (59%), and almost half (43%) reported an interest and willingness to use a depression-screening tool in their practice. For APNS almost all (94%) reported being more likely to increase the frequency of asking mothers about depression or more frequently consulting mental health providers (88%).
Perceived barriers. Table 3 presents perceived barriers at the organizational, mother/child, and provider levels. The most commonly identified barriers that limited PHCPs at the organizational level were inadequate time for the provider to provide counseling/education (81%) and the appointment time was too short for an adequate history (78%). At the maternal/patient level, the medical problem of the child was more pressing (43%) and at the provider level, incomplete training to effectively diagnose/counsel mothers (53%) were the most commonly identified barriers. Somewhat surprisingly, the following factors were not described as limiting: difficult paper work for authorization procedures (24%), poor reimbursement for treatment (21%), and provider financial disincentives for mental health referrals (13%). Finally, lack of effective treatment for maternal depression was not a commonly cited barrier (19%). Interestingly, APNS identified four additional organizational barriers: mother's insurance limited treatment options (75%), unavailability of mental health resources (69%), mental health professionals not affordable (64%), and difficult paperwork/authorization procedures (54%).
Practice behaviors and perceived barriers by confidence level. Almost half (48%) of the providers reported being confident in recognizing maternal depression (see Table 2). However, only 16% reported being confident in treating maternal depression with medications and 12% reported being confident in treating with counseling.
Analyses were next conducted to examine practice behaviors by reported confidence (providers who were confident in recognizing maternal depression versus those who were not confident) (see Table 4). Not-confident providers were significantly more likely than confident providers to suspect maternal depression because the mother introduced the topic directly ([chi square] = 4.83(1), p < .05). Regarding treatment approaches, significantly more confident providers were likely to address the mother's maternal depression by counseling her for more than 5 minutes ([chi square] = 4.81(1), p < .05) while significantly more not confident PHCPs were likely to counsel the mother for less than 5 minutes ([chi square] = 4.58(1), p < .05).
Confidence level in relation to perceived barriers that limited care are shown in Table 5. Overall, providers who were not confident reported higher percentages of each barrier compared to providers who were confident, and about half of these differences were statistically significant based on chi-square analyses. At the organizational level significantly more not-confident providers endorsed appointment time was too short for adequate history ([chi square] = 5.63(1), p < .05) and mental health professional not affordable ([chi square] = 4.78(1), p <.05) than confident providers. At the maternal/patient level, significantly more not-confident providers indicated mother reluctant to see mental health professional ([chi square] = 7.64(1), p < .05), mother reluctant to accept diagnosis ([chi square] = 15.36(1), p < .05), and mother reluctant to begin antidepressant ([chi square] = 6.01(1), p < .05) as barriers that limited care than confident providers. At the provider level, significantly more not-confident providers endorsed incomplete training to effectively diagnose/counsel mothers, ([chi square] = 6.99(1), p < .05), incomplete knowledge of treatment ([chi square] = 12.22 (1), p < .05), and incomplete knowledge of DSM-IV ([chi square] = 8.99(1), p < .05) limited care than confident providers.
Discussion
Screening for maternal depression with appropriate intervention at well child visits has been emphasized through pediatric guidelines (American Academy of Pediatrics, 2000; Green, 1994), however, engaging providers to implement procedures remains challenging. Research has demonstrated pediatric health care providers are able to incorporate screening with referral for maternal depression in their practice, however it remains outside of usual care on a universal level. Fox and associates (1989) argue commitment and responsibility for a problem is required to influence clinical behavior. Further empirical data are needed to substantiate PHCPs' resolve to assess and intervene in maternal depression.
In our sample, the majority of respondents (85%) endorsed a responsibility for recognizing maternal depression, and for the APNs almost all (94%) reported professional responsibility. This perceived responsibility was reported by a greater percentage of PHCPs in our sample than that reported by Olson and colleagues (2002) based on their national survey of pediatricians (57%), and did not vary by gender or number of patients seen per week. Others have found a difference in primary care physicians screening for depression during the postpartum period by gender with female physicians screening more often then males (Seehusen, Baldwin, Runkle, & Clark, 2005). Only a very small sample of PHCPs reported routinely asking mothers about depression (12%) and even less use a screening tool in their offices (3%); almost a third of the APNs in our study reported routinely asking about depression yet only 5% used a screening tool. These rates are consistent with those reported by Seehusen and colleagues (2005) on screening for maternal depression during well child visits (13% always screen and 33% often screen) (Seehusen et al., 2005). Similar to those surveyed in the Olson study (81%), the PHCPs in this study (88%) relied on unstructured approaches that were highly dependent on the mothers' initiation of the topic or obvious features of her presentation, using such cues as mother's behavior, appearance, or complaints. Although the majority of our sample could recall one case of maternal depression, one-fifth of the sample could not recall one case which is concerning. This inability reinforces the clinical significance of not incorporating screening procedures into routine practice.
A total of 80% of the sample referred the mother to receive treatment from either a mental health or their primary care provider and one-third of the sample provided direct counseling to the mother. Our study's sample also differs from Olson et al.'s (2002) sample on PHCPs' treatment practices. Specifically, about one- half of the PHCPs (55%) reported referring mothers to mental health providers and 41% referring the mother to her primary care provider compared to 29% and 22% respectively in the Olson et al sample. These overall increases may reflect the increased emphasis in the pediatric health care community in recent years on the need to assess and intervene for maternal depression and resulting increases in educating providers through the pediatric literature, training, and continuing education programs.
Although the majority of the PHCPs reported a sense of responsibility in recognizing maternal depression, only half reported confidence in their ability to recognize maternal depression, which is consistent with the previous work of Olson and colleagues (2002). In addition, the majority of the respondents lacked confidence in their treatment skills with only 17% reporting confidence in medication treatment and 13% reporting confidence in counseling skills. Although overall, respondents reported a lack of confidence in their treatment skills, a greater percentage reported confidence than those in the Olson et al. (2002) national sample. Lastly, similar to Olson et al., respondents in our study perceived themselves as having an educational role with 92% discussing the etiology of depression, prognosis, treatment options, and/or side effects of treatment with mothers they suspected of having depression.
When comparing PHCPs by confidence level in recognizing maternal depression, some important findings were revealed. Notably, PHCPs did not differ on demographics by confidence level. They also did not differ on perceived responsibility for recognizing maternal depression or on their ratings of importance of screening for other important familial issues such as substance use or tobacco use. On the other hand, not-confident PHCPs were significantly more likely to rely on the mother introducing the topic of depression as a method of recognizing depression compared to the confident group. However, once depression was recognized, both groups reported similar practice behaviors, including discussing depression with the mother using the term depression, assessing for the risk of suicide, and conducting other psychosocial assessments (e.g., maternal history of sexual/physical abuse.). In addition, PHCPs provided similar types of patient educational activities regardless of their confidence level (e.g., discussing the etiology and treatment of depression), although confident PHCPs were more likely to provide direct counseling to the mother and provide treatment. Also, not-confident PHCPs reported significantly more perceived barriers in screening and treating maternal depression in routine care.
Our findings are consistent with a study of general practitioners, which found that those who lacked self-confidence in managing depressed patients were more likely to identify barriers (Richards, Ryan, McCabe, Groom, & Hickie, 2004). These findings suggest that a provider's perceived confidence may impact their practice behaviors negatively. Previous research has indicated that confidence to assess for and treat depression was associated with training (Kaplan, Adamek, & Martin, 2001) and change in behaviors were only found when educational methods included practical assessment tools with the specific skills to use them (Kutcher, Lauria-Horner, MacLaren, Bujas-Bobanovic, & Karlovic, 2003). Interestingly, perceived responsibility in recognizing maternal depression was not an issue in our sample, but rather as in other recent studies confidence in treatment skills is an issue and should now be targeted. It is noteworthy that confident and not-confident PHCPs in the current sample reported similar levels of willingness to implement new strategies regarding maternal depression (e.g., attend CME, use depression screening instruments). Of note is that few practitioners reported assessing for the often co-occurring problems of intimate partner violence or substance use. With the increasing awareness of comorbidity of maternal depression, violence, and substance use and their important link to child health and well being, there is the need for an effective response across a variety of disciplines. Such findings together suggest a need for continuing education to increase the amount of pediatric provider training specific to maternal depression, including the use of specific validated screening tools and treatment guidelines.
The findings, however, should be considered in relation to the study's limitations. First, the sample was a purposive convenience sample that was relatively homogeneous and not randomly selected or matched. This nonrandom procedure may influence the findings through self-selection bias. Second, the small sample size, the limited number of PHCPs responding to our survey, and the cross sectional design limit generalizability. Finally, the results of our study may reflect that our sample felt a commitment and responsibility for a problem that influences clinical behaviors (Fox, Mazmanian, & Putnam, 1989). The PHCPs surveyed in our study were already engaged in a program designed to increase assessment and intervention with families targeted for smoking cessation. This may have predisposed them to more readily acknowledge a responsibility to recognize maternal depression in conjunction with other psychosocial issues that may influence smoking cessation. Or it may demonstrate the seamless nature of integrating such assessment into clinical practice based upon experience. Despite these limitations, the results contribute to our understanding of the need to continue emphasizing the importance of education to increase screening and treatment of maternal depression in pediatric settings.
Although the small number of APNs participating in our study prevents comparative analyses, an examination of their responses is of interest. Almost all of the APNs perceived a responsibility to recognize maternal depression, half reported confidence in recognizing the phenomena, and almost one-third routinely asked about depression, however only 5% used a screening instrument. They also demonstrated an ability to treat depressive symptomotology with three-quarters referring to other professionals and almost half prescribing antidepressant medications. Furthermore, almost all reported they would inquire about maternal depression more frequently. The PHNs also identified more organizational and maternal/child barriers than the other providers taken as a whole. These findings may reflect the imbedded skill integral to APNS, such as expertise in holistic assessment necessary to comprehensively and sensitively address client physical and mental health needs. Nursing professionals are poised to intervene at the person, family, and community level and can make unique contributions to interprofessional collaborative efforts needed to intervene with maternal depression.
Conclusions
Pediatric health care providers report a high sense of responsibility to recognize and address maternal depression during routine well child care. However, few are currently screening for depression regularly and their current practices towards depression are influenced by their confidence level in recognizing it. Additionally, it has been suggested elsewhere that confidence levels are related to the amount and types of training experiences. Therefore, efforts to increase routine screening for maternal depression in pediatric settings should involve providing PHCPs with direct training experiences in the identification, use, and application of screening tools and specific treatment guidelines for addressing or referring their identified patients for intervention.
Acknowledgements: Support for this work comes from National Institute on Drug Abuse Mentored Research Scientist Development Award K01-DA 15145 (C.D.C.). National Institute of Mental Health Mentored Research Scientist Development Award K01-MH69665 (M.B), National Institute of Mental Health Mentored Research Scientist Development Award K01-MH65454 (A.L.H.), and the Trilateral Partnership (Rady Children's Hospital and Health Center, Scripps and Sharp Healthcare--San Diego). The authors thank Donald Slymen, PhD, for statistical consultation; Phyllis Hartigan, MPH, and Nicole Howard, MPH, for assistance with survey development and administration. We also gratefully acknowledge the contributions of the fieldwork staff and the participants in the study.
References
American Academy of Pediatrics. (2000). Committee on Practice and Ambulatory Medicine. Recommendations for preventative pediatric health care. Pediatrics, 105, 645-646.
American Academy of Pediatrics. (2001, October). National Ambulatory Medical Care Survey (NAMCS) and Periodic Survey # 42-2000. American Academy of Pediatrics New Research Update Column.
Baker, M., Hartigan, P., Howard, N., Mueggenborg, M., Wilke, T., & King, M. (2004). Partnership for Women's Health Program: Overview and results of pilot study. Report presented to the Trilateral Partnership, March 2004.
Beck, C. T. (1999). Postpartum depression. Stopping the thief that steals motherhood. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) Lifelines, 3(4), 41-44.
Casey, P., Goolsby, S., Berkowitz, C., Frank, D., Cook, J., Cutts, D., Black, M.M., Zaldivar, N., Levenson, S., Heeren, T., & Meyers, A. (2004). Maternal depression, changing public assistance, food security, and child health status. Pediatrics, 113(2), 298-304.
Chaudron, L.H., Szilagyi, P.G., Kitzman, H.J., Wadkins, H.I., & Conwell, Y. (2004). Detection of postpartum depressive symptoms by screening at well-child visits. Pediatrics, 113(3 Pt 1), 551-558.
Edebohls, L., & Ecklund, C. (2002). Commentary on Andrea Yates Postpartum depression: Practical advice from two nurse practitioners. Pediatric Nursing, 22(3), 298-299.
Fox, R.D., Mazmanian, RE., & Putnam, R.W. (1989). Changing and learning in the lives of physicians. New York: Praeger.
Green, M. (1994). Diagnosis, management, and implications of maternal depression for children and pediatricians. Current Opinion in Pediatrics, 6(5), 525-529.
Greenberg, P., Kessler, R., Birnbaum, H., Leong, S., Lowe, S.W., Berglund, P.A., & Corey-Lisle, P.K. (2003). The economic burden of depression in the United States: How did it change between 1990 and 2000? Journal of Clinical Psychiatry, 64(12), 1465-1475.
Heneghan, A.M., Mercer, M., & DeLeone, N.L. (2004). Will mothers discuss parenting stress and depressive symptoms with their child's pediatrician? Pediatrics, 113(3 Pt 1), 460-467.
Heneghan, A.M., Silver, E.J., Bauman, L.J., & Stein, R.E. (2000). Do pediatricians recognize mothers with depressive symptoms? Pediatrics, 106(6), 1367-1373.
Kahn, R.S., Wise, RH., Finkelstein, J.A., Bernstein, H.H., Lowe, J.A., & Homer, C.J. (1999). The scope of unmet maternal health needs in pediatric settings. Pediatrics, 103(3) 576-581.
Kaplan, M.S., Adamek, M.E., & Martin, J.L. (2001). Confidence of primary care physicians in assessing the suicidality of geriatric patients. International Journal of Geriatric Psychiatry, 16(7), 728-734.
Kemper, K.J. (1992). Self-administered questionnaire for structured psychosocial screening in pediatrics. Pediatrics, 89(3), 433-436.
Kemper, K.J., & Babonis, T.R. (1992). Screening for maternal depression in pediatric clinics. American Journal of Diseases of Children, 146(7), 876-878.
Klerman, G.L., & Weissman, M.M. (1992). The course, morbidity, and costs of depression. Archives of General Psychiatry, 49(10), 831-834.
Kramer, R.A., Warner, V., Olfson, M., Ebanks, C.M., Chaput, F., & Weissman, MM. (1998). General medical problems among the offspring of depressed parents: a 10-year follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 37(6), 602-611.
Kutcher, S., Lauria-Horner, B., MacLaren, C., Bujas-Bobanovic, M., & Karlovic, Z. (2003). Short-term educational intervention improves family physicians' knowledge of depression. Journal of Continuing Education in the Health Professions, 23(4), 239-243.
Lopez, A.D., & Murray, C.C. (1998). The global burden of disease, 1990-2020. Nature Medicine, 4(11), 1241-1243.
Lau, B. (2002). Stress in children: Can nurses help? Pediatric Nursing, 28(1), 13-19.
Mandl, K.D., Tronick, E Z., Brennan, T.A., Alpert, H.R., & Homer, C.J. (1999). Infant health care use and maternal depression. Archives of Pediatrics and Adolescent Medicine, 153(8), 808-813.
Miller, L.J. (2002). Postpartum depression. Journal of the American Medical Association, 287(6), 762-765.
Minkovitz, C.S., Strobino, D., Scharfstein, D., Hou, W., Miller, T., Mistry, K.B., & Swartz, K. (2005). Maternal depressive symptoms and children's receipt of health care in the first 3 years of life. Pediatrics, 115(2), 306-314.
Murray, C.J.L., & Lopez, A.D. (1996). The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard University Press.
National Institute of Mental Health. (1998). (Report No. 98-4321) Rockville, MD: NIMH.
NICHD Early Child Care Research Network. (1999). Chronicity of maternal depressive symptoms, maternal sensitivity, and child functioning at 36 months. Developmental Psychology, 35(5), 1297-1310.
Nicholson, J., & Clayfield, J. (2004). Responding to depression in pa rents. Pediatric Nursing, 20(2), 136-142.
Olson, A.L., Dietrich, A.J., Prazar, G., Hurley, J., Tuddenham, A., Hedberg, V., & Naspinsky, D.A. (2005). Two approaches to maternal depression screening during well child visits. Journal of Developmental and Behavioral Pediatrics, 26(3), 169-176.
Olson, A.L., Kelleher, K.J., Kemper, K.J., Zuckerman, B.S., Hammond, C.S., & Dietrich, A.J. (2001). Primary care pediatricians' roles and perceived responsibilities in the identification and management of depression in children and adolescents. Ambulatory Pediatrics, 1(2), 91-98.
Olson, A.L., Kemper, K.J., Kelleher, K.J., Hammond, C.S., Zuckerman, B.S., & Dietrich, A.J. (2002). Primary care pediatricians' roles and perceived responsibilities in the identification and management of maternal depression. Pediatrics, 110(6), 1169-1176.
Osofsky, J. (2004) Statement presented before the Subcommittee on Substance Abuse and Mental Health Services Committee on Health, Education, Labor, and Pensions. Retreived April 7, 2005 at www.zerotothree.org/policy.
Richards, J.C., Ryan, R, McCabe, M.P., Groom, G., & Hickie, I.B. (2004). Barriers to the effective management of depression in general practice. Australian and New Zealand Journal of Psychiatry, 38(10), 795-803.
Saks, N.P., Hartigan, P., Howard, N., Schneider, J.M., Nathan, G., Fidler, C., & Beck, C.H. Jr. (2001). Collaboration to implement smoking cessation guidelines during the childbirth continuum. Joint Commission Journal on Quality Improvement, 27(12), 664-672.
Seehusen, D.A., Baldwin, LM., Runkle, G.P., & Clark, G. (2005). Are family physicians appropriately screening for postpartum depression? Journal of the American Board of Family Practice, 18(2), 104-112.
Tam, L.W., Newton, R.P., Dern, M., & Parry, B.L. (2002). Screening Women for Postpartum Depression at Well Baby Visits: Resistance Encountered and Recommendations. Archives of Women's Mental Health, 5(2), 79-82.
U.S. Department of Health and Human Services. (1999). Mental health: A report of the surgeon general. Rockville, MD: US Department of Health and Human Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.
Weissman, M.M., Feder, A., Pilowsky, D.J., Olfson, M., Fuentes, M., Blanco, C., Lantigua, R., Gameroff, M. J., & Shea, S. (2004). Depressed mothers coming to primary care: Maternal reports of problems with their children. Journal of Affective Disorders, 78(2), 93-100.
World Health Organization. (2001). A message from the Director General. Retrieved April 12, 2005 at www. who.int/whr/2001/dg_message/ en/index.html.
Zuckerman, B.S., & Beardslee, W.R. (1987). Maternal depression: A concern for pediatricians. Pediatrics, 79(1), 110-117.
Cynthia D. Connelly, PhD, FAAN, is Research Scientist, Child and Adolescent Services Research Center, Rady Children's Hospital and Health Center, and Professor, Hahn School of Nursing and Health Science, University of San Diego, San Diego, CA.
Mary J. Baker, PhD, is Research Scientist, Child and Adolescent Services Research Center, Rady Children's Hospital and Health Center, and Adjunct Assistant Clinical Professor, Department of Psychiatry, University of California San Diego, San Diego, CA.
Andrea L. Hazen, PhD, is Research Scientist, Child and Adolescent Services Research Center, Rady Children's Hospital and Health Center, and Adjunct Professor, Department of Psychology, San Diego State University, San Diego, CA.
Mary G. Mueggenborg, MSW, is Project Coordinator, Child and Adolescent Services Research Center, Rady Children's Hospital and Health Center, San Diego, CA.
The Practice Applications of Research section presents reports of research that are clinically focused and discuss the nursing application of the findings. If you are interested in author guidelines and/or assistance, contact Janice S. Hayes, PhD, RN; Section Editor; Pediatric Nursing; East Holly Avenue Box 56; Pitman, NJ 08071-0056; (856) 256-2300 or FAX (856) 256-2345.
Table 1. Respondent Profile Provider Type PHCP (a) APN (b) MD (c) N (%) n (%) n (%) 98 19 (19.3) 79 (80.6) Gender (Female) 58 (59.1) 16 (84.2) 42 (53.1) Practice Structure Group practice 93 (94.8) 19 (100) 74 (93.6) Solo practice 5 (5.1) 0 5 (6.3) Patients Seen Per Week 10 or fewer 66 (67.3) 14 (73.7) 52 (65.8) More than 10 31 (31.6) 5 (26.3) 26 (32.9) Questionnaire Use (Yes) Family psychosocial issues 29 (29.5) 20 (25.3) Parental well-being 20 (20.4) 9 (47.5) 14 (17.7) Do not routinely use any 6 (31.6) screening instruments 27 (27.5) 22 (27.8) Mental Health Professional 27 (27.5) 5 (26.3) 22 (27.8) Available--(Yes) 5 (26.3) Depression Screen Priority--High 83 (84.6) 18 (94.7) 65 (82.2) Note: (a) PHCP = Pediatric Health Care Provider; (b) APN = Advance Practice Nurse; c MD = Pediatrician Table 2. Recognition and Management of Maternal Depression, Provider Confidence, & Desire to Change Practice by Pediatric Health Care Providers based on Their Last Recalled Case of Maternal Depression PHCP APN MD n = 77 n = 14 n = 63 Assessment % % % Mother's behavior, appearance, complaints 88.3 92.6 87.3 Depression suspected because of family dynamics 31.2 35.7 30.2 Child's presenting problem is associated with maternal depression 31.2 35.7 30.2 Mother introduced topic directly 26.0 42.9 22.2 History of depression or psychiatric illness 18.2 21.4 17.5 Mother said currently being treated for depression 13.0 21.4 11.1 Mothers routinely asked about depressive symptoms 11.7 28.6 7.9 Family member concerned about depression 10.4 14.3 9.5 History of excessive alcohol/drug use or self-destructive behavior 9.1 21.4 6.3 Formal diagnostic criteria 9.3 -- 11.5 Screening Instrument 2.7 5.3 1.6 Management/intervention Referred to PCP/mental health professional/ER 79.5 76.9 80.0 Counseled by provider <5 minutes 35.6 30.8 36.7 Recommended changes in lifestyle 23.3 15.4 25.0 Scheduled with provider more often 19.2 15.4 20.0 Involved family members 17.8 30.8 15.0 Counseled by provider >5 minutes 16.4 15.4 16.7 Prescribed antidepressant medication 12.3 46.2 5.0 Referred to self help/support group 8.2 15.4 6.7 Not involved/watchful waiting 5.5 7.7 5.0 Confidence in Recognition & Treatment I can recognize maternal depression 51.0 44.4 52.7 I can treat maternal depression with medications 16.8 16.7 16.9 I can treat maternal depression with counseling 13.6 22.3 11.4 Overall, I can manage maternal depression 15.9 16.7 15.7 Plans to Change Plan to change in upcoming 6 months 75.0 77.8 74.3 Inquire about maternal depression more frequently 72.5 94.1 67.1 Use depression screening tool 42.6 41.2 43.1 Table 3. Identified Barriers that Limited Care of Pediatric Health Providers in Last Recalled Case of Maternal Depression PHCP APN MD n = 77 n = 14 n = 63 Organizational Barriers % % % Inadequate time to provide counseling/education 80.8 78.6 81.4 Appointment time too short for adequate history 78.1 78.6 78.0 Mother's insurance limited treatment options 42.0 75.0 35.1 Mental health professionals not affordable 35.2 64.3 28.0 Unavailability of mental health resources 33.8 69.1 25.9 Difficult paperwork/authorization procedures 24.3 53.8 17.5 Poor reimbursement for treatment 20.6 18.2 21.1 Physician financial disincentives for mental health referrals 13.2 16.7 12.5 Maternal and Patient Barriers Medical problems of the child were more pressing 43.1 64.3 37.9 Mother reluctant to see mental health professional 34.7 57.1 29.3 Mother reluctant to accept diagnosis 29.2 50.0 24.1 Mother reluctant to begin antidepressants 20.0 50.0 13.8 Symptoms explained by other medical illness 15.5 7.7 17.2 Provider Barriers Incomplete training to diagnose/counsel 53.4 42.9 55.9 Incomplete knowledge of treatment for depression 34.7 28.6 36.2 Incomplete knowledge of DSM-IV diagnostic criteria 34.7 35.7 34.5 Lack of effective treatments 18.6 23.1 17.5 Table 4. Pediatric Health Care Provider Practice Behaviors by Confidence Level Confident Not-Confident (n = 40) (n = 35) Assessment % % Mother's behavior, appearance, complaints 90.0 85.7 Depression suspected because of family dynamics 30.0 31.4 Child's presenting problem is associated with maternal depression 22.5 42.9 Mother introduced topic directly * 15.0 37.1 History of depression or psychiatric illness 20.0 17.1 Mother said currently being treated for depression 12.5 14.3 Mothers routinely asked about depressive symptoms 15.0 5.7 Family member concerned about depression 10.0 11.4 History of excessive alcohol/drug use or self-destructive behavior 7.5 8.6 Management/intervention Referred to PCP/mental health professional/ER 78.4 80.0 Counseled by provider < 5 minutes * 24.3 48.6 Recommended changes in lifestyle 21.6 25.7 Scheduled with provider more often 16.2 20.0 Involved family members 21.6 11.4 Counseled by provider > 5 minutes * 24.3 5.7 Prescribed antidepressant medication 10.8 11.4 Referred to self help/support group 8.1 5.7 Not involved/watchful waiting 8.1 2.9 * p < .05; p values arise from a Chi square test for contingency tables. Table 5. Identified Barriers that Limited Care of Pediatric Health Care Providers in Last Recalled Case of Maternal Depression by Confidence Level Confident Not-Confident (n = 40) (n = 35) Organizational Barriers % % Inadequate time to provide counseling/education 76.3 88.2 Appointment time too short for adequate history 68.4 * 91.2 Mother's insurance limited treatment options 32.4 53.1 Mental health professionals not affordable 22.2 * 47.1 Unavailability of mental health resources 27.0 42.4 Difficult paperwork/authorization procedures 16.7 30.3 Poor reimbursement for treatment 11.4 30.3 Physician financial disincentives for mental health referrals 11.1 15.6 Maternal and Patient Barriers Medical problems of the child were more pressing 37.8 50.0 Mother reluctant to see mental health professional 18.9 * 50.0 Mother reluctant to accept diagnosis 8.1 * 50.0 Mother reluctant to begin antidepressants 8.1 * 31.3 Symptoms explained by other medical illness 13.5 18.2 Provider Barriers Incomplete training to diagnose/counsel 39.5 * 70.6 Incomplete knowledge of treatment for depression 16.2 * 55.9 Incomplete knowledge of DSM-IV diagnostic criteria 18.9 * 52.9 Lack of effective treatments 13.5 * 25.0 * p < .05; p values arise from a Chi square test for contingency tables.
