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SPECIAL ARTICLE

Legal and Ethical Considerations: Risks and Benefits

of Postpartum Depression Screening at Well-Child

Visits

Linda H. Chaudron, MD, MSa,b,c, Peter G. Szilagyi, MD, MPHb, Amy T. Campbell, JD, MBEd,e, Kyle O. Mounts, MDf,g, Thomas K. McInerny, MDb

Departments ofaPsychiatry,bPediatrics, andcObstetrics and Gynecology anddDivision of Medical Humanities, University of Rochester School of Medicine and Dentistry,

Rochester, New York;eRegional Early Childhood Direction Center, Rochester, New York;fNewborn Care Physicians of SE Wisconsin, Milwaukee, Wisconsin;gDepartment

of Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin

Financial Disclosure: Dr Chaudron is on the speakers bureau of Wyeth Pharmaceuticals and has received grant support from Forest Laboratories. Drs Szilagyi, Mounts, and McInerny and Ms Campbell have indicated they have no financial relationships relevant to this article to disclose.

ABSTRACT

Pediatric professionals are being asked to provide an increasing array of services during well-child visits, including screening for psychosocial and family issues that may directly or indirectly affect their pediatric patients. One such service is routine screening for postpartum depression at pediatric visits. Postpartum depression is an example of a parental condition that can have serious negative effects for the child. Because it is a maternal condition, it raises a host of ethical and legal questions about the boundaries of pediatric care and the pediatric provider’s responsibility and liability. In this article we discuss the ethical and legal considerations of, and outline the risks of screening or not screening for, postpartum depression at pediatric visits. We make recommendations for pediatric provider education and for the roles of national professional organizations in guiding the process of defining the boundaries of pediatric care.

www.pediatrics.org/cgi/doi/10.1542/ peds.2006-2122

doi:10.1542/peds.2006-2122

Key Words

postpartum depression, screening tools, well-child care

Abbreviations

AAP—American Academy of Pediatrics USPSTF—US Preventive Services Task Forces

Accepted for publication Sep 25, 2006

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W

HEN A PEDIATRICIANor pediatric health care pro-vider walks into an examination room for a well-child visit, who is the patient? It is the well-child, of course, but within the context of the family.1 A child who is exposed to stress, abuse, neglect, domestic violence, pa-rental tobacco or substance use, extreme poverty, envi-ronmental toxins, or parental mental illness may be negatively affected. Pediatric providers should become aware of these conditions because they affect the child’s health and because they might be amenable to preven-tion or treatment. Furthermore, pediatric providers may be the sole health care professional with whom the family has frequent contact. If not the pediatric provider, then who?

Herein lies an ethical and legal conundrum of well-child care within the context of family-centered care: where do we draw the boundaries of pediatric care? Should pediatric providers routinely be screening par-ents for mental health problems and social and environ-mental risk factors? If so, which problems should be systematically addressed, and what should the providers do with the information that is obtained?

Practical issues such as feasibility and reimbursement have dominated this debate. Pediatric providers are asked to provide an increasing array of services during well-child visits, and at the same time, the very core of well-child care is under intense scrutiny because of the dearth of evidence-based practices.2As pediatrics rede-signs well-child visits,3 we believe that it is critical to consider the ethical and legal dimensions of the bound-aries of pediatric care.

Although a wide range of parental mental health issues—maternal depression, anxiety, substance use, personality disorders— can impact parenting practices and child health outcomes, we chose to consider one major clinical condition that has received increased at-tention with regard to routine screening within pediatric visits: postpartum depression. In hopes of stimulating a broader discussion of the boundaries of pediatric care, we use this specific disorder to discuss legal consider-ations that evolve from the US health care system and ethical considerations that are universal.

DEFINITION OF POSTPARTUM DEPRESSION

Postpartum depression is a term that is used in the literature and in clinical practice to describe a range of depressive symptoms and syndromes that women may experience after childbirth. Debate exists regarding whether postpartum depression is a distinct diagnostic disorder. To date, the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) does not recognize postpartum depression as a discrete diagnosis but applies the term “postpartum onset” as a specifier to major depression to explain the context and the time frame (ie, onset within 4 weeks of childbirth) in which the depression occurs.4In clinical practice, and in

many studies, the DSM-IV-TR definition is viewed as too narrow in both its application of “postpartum onset” to only major psychiatric disorders (major depression, bi-polar disorder, brief psychotic disorder) and its time frame for the postpartum period. Many studies define “postpartum” at a minimum of 3 months to a maximum of 1 year after childbirth and include a range of depres-sive symptom severity. In this discussion, the term “post-partum depression” implies the broader time frame (up to 1 year) and range of symptom severity.

RATIONALE FOR POSTPARTUM DEPRESSION SCREENING IN PEDIATRICS

Pediatric providers are increasingly aware of the preva-lence of postpartum depression and its potential effects on children.5–7 In the United States, with heightened awareness has come a national call to improve identifi-cation of mothers at risk and those in need of treatment.8 For example, in Illinois and New Jersey, recommenda-tions, mandates, and even incentives (ie, reimburse-ment) are being given to primary care providers, in-cluding pediatric providers, to screen for maternal depression. In addition, the American Academy of Pedi-atrics (AAP) has described the scope of pediatricians’ responsibilities to include assessment and consideration of parental and family environmental factors that may affect children’s health,9maternal depression being one of these.

Although screening for postpartum depression may seem a simple task that pediatric providers could under-take easily, arguments for and against depression screen-ing should be considered carefully.10,11 In its report on screening for depression in adults, the US Preventive Services Task Forces (USPSTF) found sufficient evidence that screening for depression can improve clinical out-comes12and that the benefits of depression screening in primary care outweigh the risks. The USPSTF “recom-mends screening adults for depression in clinical prac-tices that have systems in place to assure accurate diag-nosis, effective treatment, and follow-up.”13

Whether this recommendation could, or should, be applied to postpartum depression and pediatric providers remains undecided. When weighing the risks and ben-efits of screening specifically for postpartum depression in pediatrics, it is important to determine if postpartum depression meets the criteria for a disease that should be periodically screened for at a preventive health visit. Key questions to consider are:

● Is the burden of suffering from postpartum depression sufficient to warrant a screening test?

● Do screening tests exist that are safe, inexpensive, feasible, simple, and have sufficient sensitivity and specificity?

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The Burden of Postpartum Depression Is Well Established

Postpartum depression affects⬃14% of new mothers14 and can have lasting effects on women, children, and families.15–17Among young and socioeconomically disad-vantaged mothers the prevalence rates are even greater: 1 in 4 women.18Studies have also found that if maternal mental health is impaired, children may be adversely affected. Children can suffer from the direct effects of depression such as impaired attachment19 or abuse or neglect.20–22They may also suffer from the indirect effects such as lack of attendance at well-child visits, parental inattention to preventive actions such as immunizations or use of car seats,23–26and maternal reluctance to engage in and continue breastfeeding.27

Safe, Inexpensive, Simple, Valid Screening Tools Exist

They have been used successfully in multiple settings, including pediatric settings, to screen mothers.18,28–30 Screening tools such as the Edinburgh Postnatal Depres-sion Scale31 and the Postpartum Depression Screening Scale32,33were designed specifically to screen for depres-sion in the postpartum period. These tools have been validated and tested in multiple community and ethni-cally diverse populations34–41 and have been shown to increase identification of postpartum depression in both obstetrical and pediatric settings. However, as with any screening tool, they should not be administered in a vacuum, and although feasible, implementation can be difficult in some systems.42Health care providers should be educated on the appropriate use of the screening tool, including its interpretation and limitations, and should have a set of guidelines for action based on the outcome of the screening test.

Effective Treatment for Postpartum Depression Exists

Both psychotherapy43,44 and antidepressants44,45 are ef-fective and generally acceptable and accessible treat-ments for postpartum depression. However, few studies have evaluated the direct connection between screening and increased identification and treatment outcomes.14 In 1 study, universal postpartum depression screening did increase referrals to social work,18 and in a more recent study, treatment of maternal mental health im-proved both maternal and child mental health out-comes.46

Because pediatric providers are not often the primary care providers for the mothers (unless the mother is an adolescent patient of the provider), a critical issue, as identified by the USPSTF, is ensuring adequate fol-low-up and treatment. Family practitioners, internists, and obstetricians/gynecologists may directly prescribe medication and/or refer mothers to mental health pro-viders, but even so, these primary care providers often receive little or no training on specific screening for or treatment of postpartum depression. Although family practitioners are in the unique position of being the

medical provider for both the mother and child, pedia-tricians, pediatric nurse practitioners, and pediatric phy-sician assistants are left in a “gray zone.” Most do not provide direct maternal care; however, they can refer women back to their primary care providers, offer infor-mation about local and national mental health re-sources, disseminate educational materials about post-partum depression, provide educational counseling on the effects of depression on children and families, and help track how mothers and children are doing. Al-though not a classic intervention, there is potential value in education of front-line providers and enhanced awareness of and access to other providers and commu-nity-based sources for care and support.

An often-voiced concern is that in many communi-ties, mental health resources are limited or mothers may not have adequate health insurance coverage to access needed mental health services. This is a challenge for all health care providers and is not limited to women with postpartum depression; in fact, pediatric providers often encounter similar dilemmas with their own patients. Hence, although accessibility to maternal mental health care is a challenge, it is not an absolute limitation.

Beyond the above-mentioned challenges, it is impor-tant to consider the ethical and legal considerations of screening for postpartum depression.

What Are the Risks of screening?

Many clinicians’ primary concerns involve a combina-tion of ethical and legal consideracombina-tions. Pediatric pro-viders may be concerned that mothers will find these questions intrusive or stigmatizing; in response, mothers may not seek care for their children. In this way, as a pediatric provider whose primary obligation is to the child, they run the risk of “harming” children by imple-menting screening. The acceptability of screening for maternal mental health issues at pediatric visits is mixed and requires further exploration.28,47Alternately, to the extent that the mother’s health affects the child, simply doing nothing might be a “harm” in and of itself. Fur-thermore, if providers do identify women who are at risk but whom they do not treat and, with due diligence, educate and refer women for care, what is the pediatric provider’s responsibility for follow-up with the mother? If the mother chooses not to seek care or injures the child in the context of an identified mental illness, does the pediatric provider face any liability? Clarifying the “best interests of the patient” (child) is critical for this debate. These issues are not insurmountable but cer-tainly highlight the need for an incremental and empir-ical approach to adoption of screening.

What Are the Risks of Not Screening?

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receive help if possible? That is, at what point does having the knowledge, means, and ability to detect post-partum depression cross a line to reach a “standard of care” that we should expect primary care providers to meet? And then, is the standard to simply screen or do more? Furthermore, if clinicians do not proactively at-tempt to identify a disorder about which they have knowledge and expertise to inform the mother and refer her for help, are primary care providers exposing them-selves to potential liability?

With these questions in mind, it is important to ad-dress the “practical” and legal issues that would likely arise in an effort to craft national guidelines and build an evidence base that might shift the “standard of care” to routine screening for postpartum depression. Among these issues are confidentiality, medical charts/docu-mentation, liability, and scope of practice.

Confidentiality, Medical Charts, and Documentation

The Health Insurance Portability and Accountability Act of 1996 (HIPAA)48 impacts the ability of multiple pro-viders to share information and the ability to share information within families. In this instance, it is impor-tant to remember that the child is the pediatric provid-er’s patient, which limits the health care pediatric pro-vider’s ability to obtain information about the mother. Family practitioners who treat both the mother and the infant would not have the same limitations. HIPAA is not a bar to sharing, but it requires consent of the mother before proceeding. Health care providers should work across disciplines and, with the full involvement of the mother/family, create data-sharing agreements for certain information that impacts the health of the child and mother. Because of heightened confidentiality related to mental health records, extra attention should be paid to the extent of documentation of maternal mental health issues in the pediatric record. It is impor-tant to record a note in the child’s chart that a screening for postpartum depression took place and, if necessary, that a referral was made. However, what takes place when the mother seeks care after such referral is part of the mother’s record, not the child’s record.

Liability

Liability is a complicated issue that often depends on “standard of care.” At this time, because of the lack of evidence behind a single screening tool and lack of adop-tion in practice of sufficient scope, a standard of care does not yet exist that would obligate a pediatric pro-vider to conduct a screening. However, as data accumu-late and guidelines are put into practice, the standard of care will likely shift. Even if screening is considered standard of care in certain areas or practices and if pro-viders are currently screening, liability issues to consider also include the quality and context of the screening

assessment, the nature of the referral, and follow-up after identification and referral.

Scope of Practice

Finally there exist concerns over the scope of practice of pediatric providers, including fears that already time-limited sessions will now have mental health interven-tions for mothers added on and that pediatric providers will not be reimbursed for the time spent addressing maternal mental health issues. Some of these issues are echoed in the concerns of the American Academy of Family Physicians, which are stated in their position paper on general mental health issues in family prac-tice.49Pediatric providers should clarify that screens are performed with the purpose—in their role as the child’s health care provider— of enhancing that child’s well-being. Pediatric providers should be cautious in over-stepping the bounds of their role and leave ongoing adult care and therapy to qualified professionals. Moth-ers should recognize that the pediatric provider’s pri-mary obligation is not to them but to their children and should be approached with screens as tools to enhance their ability to care for their children in a way that is supportive and not punitive.

From this risk/benefit assessment, we believe that from both ethical and legal perspectives, the benefits of screening for postpartum depression outweigh the risks. Yet, this does not discount the limited data available to guide pediatric practitioners and the need to proceed with caution to create policies, practices, and guidelines that are supported by evidence from studies. To ade-quately address these issues, studies must be conducted among diverse populations (ie, diverse cultures, ethnic groups, and socioeconomic groups) as well as among diverse pediatric settings (ie, urban versus rural, com-munity health centers versus private practitioner offices, etc).

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min-imal number of times to screen and at which pediatric visit(s) and standardizing documentation to record out-comes of the screening process, education or counseling of the mother, safety issues assessed and addressed, re-ferrals, refusals, and any follow-up attempted. Finally, pediatric providers should gather information about lo-cal and national mental health resources so that they can provide this information directly to the mothers and potentially collaborate directly with their mental health providers.

NEXT STEPS FOR POLICY MAKERS

More research must be conducted and evidence must be gathered to support development of evidence-based screening tools that are culturally sensitive and that are easy to implement in pediatric settings. Professional or-ganizations such as the AAP, the American Academy of Family Physicians, and the National Association of Pediatric Nurse Associates and Practitioners should con-sider the boundaries of pediatric care and develop guide-lines for practitioners that address the roles, responsibil-ities, and limits of the pediatric provider’s role with regard to the mother’s mental health needs. For exam-ple, the AAP’s Mental Health Task Force is currently developing a statement that will include recommenda-tions for screening for postpartum depression. The task force will need to consider the boundary issues described herein to help define the scope of practice and the needs of pediatric practitioners to effectively help mothers.

In addition, pediatric professional organizations should work collaboratively with mental health professional or-ganizations such as the American Psychiatric Association and the American Psychological Association to develop appropriate tools to educate pediatric providers and to develop guidelines for screening for postpartum depres-sion. Regulatory agencies, insurers, and other payers also will need to address how to break down barriers to support pediatric providers in this “new role” and to facilitate ef-fective collaboration between primary care providers and maternal mental health providers, systems that tradition-ally have very little, if any, interaction.

CONCLUSIONS

With apologies to Benjamin Franklin, we believe that we should acknowledge that an ounce of secondary prevention is worth a pound of tertiary cure and develop the systems required to support pediatric providers in screening mothers for postpartum depression. We be-lieve that from the perspective of feasibility, and now from the legal and ethical standpoints, the benefits of screening outweigh the risks. Implementation, however, must be seen as an iterative process, one that relies on additional studies to improve the feasibility of the screening process and the ability of pediatric providers to help mothers with postpartum depression. Although it challenges the pediatric profession to consider the

boundaries of pediatric care, implementing screening for postpartum depression in a systematic, comprehensive approach is critical to the ultimate well-being of children and families.

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DOI: 10.1542/peds.2006-2122

2007;119;123

Pediatrics

Thomas K. McInerny

Linda H. Chaudron, Peter G. Szilagyi, Amy T. Campbell, Kyle O. Mounts and

Screening at Well-Child Visits

Legal and Ethical Considerations: Risks and Benefits of Postpartum Depression

Services

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DOI: 10.1542/peds.2006-2122

2007;119;123

Pediatrics

Thomas K. McInerny

Linda H. Chaudron, Peter G. Szilagyi, Amy T. Campbell, Kyle O. Mounts and

Screening at Well-Child Visits

Legal and Ethical Considerations: Risks and Benefits of Postpartum Depression

http://pediatrics.aappublications.org/content/119/1/123

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