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Study used pediatricians to screen mothers

Pediatricians usually focus on kids and leave the welfare of their mothers to obgyns. But Ardis Olson, M.D., an associate professor of pediatrics at DMS, believes that identifying signs of depression in mothers is a vital step in protecting the health and wellbeing of children.

According to Olson, the children of mothers with persistent depressive symptoms are four times as likely to exhibit behavior problems. Such children are also more prone to experience sleep problems and injuries. And, as they grow up, they are at increased risk of depression themselves. Among children with one parent who is clinically depressed, 40% are likely to develop symptoms of depression by age 20. That number increases to 60% by age 25.

Questions: In a study published in the June issue of the Journal of Developmental and Behavioral Pediatrics, Olson and her coauthors found that asking two key questions during well-child visits can help pediatricians identify at-risk mothers. "This is part of a move to screen all adults for depression, as recommended by the U.S. Preventive Services Task Force," explains Olson, adding that mothers of young children generally have more contact with a pediatrician than with any other health-care provider.

Designed to test the efficiency of screening in this setting, as well as the relative efficacy of different types of screening, Olson's study was conducted at four practices in rural communities in New Hampshire and Maine. A total of 473 mothers, with children ranging in age from two weeks to 16 years, took part. (The number of fathers accompanying children to visits was so small that their results were not included.)

The questions recommended by the Preventive Services Task Force—"In the past couple of weeks, have you been in a depressed mood most of the time?" followed by "During the past couple of weeks, have you often had little interest or pleasure in doing things?"—were posed in two different formats. In one group, 250 mothers were interviewed by the

pediatrician, who asked the questions in the context of a scripted discussion about family issues. In the second group, 223 mothers were given a paper questionnaire, which described depression as "a common but treatable illness in parents," explained the importance of screening for it, and then asked participants to check "yes" or "no" in response to the same two questions.

Among those interviewed in person, 5.7% screened positive—that is, they answered yes to both questions, indicating that they were at high risk for depression. That interview screen, plus subsequent discussions triggered by it, revealed depressive symptoms or other mental health concerns in a total of 8.8%. The detection rate among mothers responding to the paper questionnaire was significantly higher. In that group, 22.9% screened positive, with subsequent discussions revealing depressive symptoms or other mental health concerns in a total of 27%.

Specific: The primary reason for the difference, Olson suggests, is that adults are generally more comfortable revealing sensitive information on paper or to a computer than during a face-to-face interview. But the study showed that either method of screening is more effective than the pediatrician merely observing a depressed affect, which missed 54% of the mothers who had a positive screen. Similarly, asking general questions about stress and mood was not as useful as asking these two specific questions.

The 11 participating pediatricians felt the screenings were well worth the one or two minutes they took to administer. All four practices were prepared to follow up positive screens with referrals and other resources. The pediatricians saw their role as educating and motivating mothers, not diagnosing a depressive disorder. About 40% of the screenpositive mothers in both groups who were not already being treated accepted a referral for further assessment or mental health care.

"Many parents don't recognize that they're depressed," Olson says. "They think it's

Pediatrician Ardis Olson found that well-child visits are a good setting to screen for maternal depression.

normal to feel stress and have difficulties. They're not aware of crossing the line into depression."

Earlier studies have shown that depressed mothers don't do well at parenting. "One of the main problems is that they're inconsistent," Olson explains. "Sometimes they are withdrawn, and sometimes they are overly obtrusive. The children don't know what to expect." Depressed mothers often lack the energy to interact positively with their children—by reading to them, for example. Thus it isn't surprising that the children often grow into depressed adults, as well. As Olson points out, "Their behavior models are depressed people."

Follow-up: Olson is now working on a sixmonth follow-up of the practices involved in this study, and she looks forward to conducting further assessments of the processes and outcomes of maternal screening in a variety of settings.

Catherine Tudish

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