Sixteen per cent of mothers who present their young infants to the emergency department with non-time-critical conditions screen positive for postnatal depression
- Centre for Emotional Health, Department of Psychology, Macquarie University, North Ryde, New South Wales, Australia
- Correspondence to: Catherine McMahon
Centre for Emotional Health, Department of Psychology, Macquarie University, Balaclava Road, North Ryde 2109, New South Wales, Australia;
Commentary on: Stock A, Chin L, Babl FE, et al. Postnatal depression in mothers bringing infants to the emergency department. Arch Dis Child 2013;98:36–40.
Implications for practice and research
Maternal mental health should be routinely assessed in paediatric settings where the presenting problem is the infant.
The emergency department (ED) setting is an opportune place for the identification of postnatal depression (PND) and referral for support.
Study findings should be replicated in other ED settings, with more socioeconomically diverse samples and confirmed through the use of diagnostic interviews.
PND is a common mental health problem with community prevalence estimates internationally ranging between 8% and 20%.1 A large body of research demonstrates ongoing adverse impacts on the mother, her family and the developing infant. In recent years, the Australian government has made significant investments in the prevention, early detection and better treatment of PND, culminating in the National Perinatal Depression Initiative (NPDI) launched in 20092 and the development of clinical practice guidelines for primary healthcare practitioners.1
This prospective observational study examined the prevalence of PND in ED settings with a convenience sample of 200 mothers who presented with infants (mean age 3.6 months) with non-time-critical conditions. The mothers provided demographic information, prior depressive symptom and treatment information, and whether they had been previously screened with the Edinburgh Postnatal Depression Scale (EPDS). The outcome measure was depression, defined as a score of >13 on the EPDS. Univariate associations with demographics, depression history and presenting infant problem were explored. The participants were socioeconomically at low risk: predominantly Australian born, living with a partner, well educated, and multiparous, with only three indigenous women.
A total of 16% screened positive, 53% indicated they had not been screened previously with the EPDS, and a further 5% were unsure. The majority (75%) who screened positive accepted a recommended consultation with a social worker. Screening positive for depression was most strongly associated with a history of depression, being a single parent, and a crying baby as the presenting problem. Although the researchers report indigenous status as a risk factor, statistical calculations with this small number are of questionable validity.
The results suggest that questions about maternal coping and mood should be routine when mothers of young infants present to the ED. Interestingly, less than half the mothers had been screened previously for depression. While awareness of PND, and, in principle, support for universal screening is now widespread in Australia, implementation in public health settings remains patchy, and many cases still remain undetected.3
In a study examining the barriers to identification and treatment of PND, many women indicated that they had reached ‘crisis point’ where they had no choice but to seek help BEFORE they engaged with health services.4 All mothers with an acutely ill or irritable infant are likely to be exhausted and stressed, and the ED may be an opportune time to reach those who might otherwise not engage with the health system.
The complex bidirectional association between an infant crying and postnatal mood disorders is well established. Depression prevalence of 30–60% has been reported in mothers attending residential care facilities for assistance with unsettled infant behaviour.5 In this study, while presentation with a crying baby was significantly associated with screening positive for depression, the majority of mothers who screened positive presented with reasons other than crying suggesting that assessment of maternal mental health should not be limited to mothers with crying or irritable babies.
Inadequate training and lack of clarity about resources available to women who screen positive have been identified as major barriers to screening for PND.3 If the researchers' recommendations are to be successfully implemented, adequate staff training, unambiguous screening protocols and clear referral pathways for women screening positive would need to be in place.