Abstract
Introduction
According to the World Health Organization: “Maternal mental health is fundamental to achieving global health targets relating to women and children because of its direct and potentially long-term impact on their general well-being and social and economic participation.” 1 More specifically, the American Academy of Pediatricians, among others, has stressed the negative implications of postpartum depression (PPD) for the child’s physical, cognitive and emotional development.2-6 Maternal depression is particularly detrimental in the early months of life, when the mother is the primary caretaker and focus of the infant’s developing interpersonal skills.7,8 PPD is defined as a major depressive episode, with onset during pregnancy or within 4 weeks following delivery, typified by a combination of specific symptoms, including depressed mood and/or loss of interest or pleasure (most of the day); as well as at least 4 other symptoms, including change in appetite, insomnia or hypersomnia, loss of energy or fatigue (not related to child care); psychomotor retardation or agitation; sense of worthlessness or guilt; impaired concentration or indecisiveness; recurrent thoughts of death or suicidal ideation or attempt. The symptoms cause significant distress or impairment and last for at least 2 weeks. 9 In the primary care setting, depressed mothers have reported triple the risk of serious emotional problems in their children, and increased likelihood of these problems being left untreated. 10 Many studies have reported PPD rates in the 10% to 20% range, in both Western countries11,12 and in countries as varied as Turkey (15.3%), 13 Tunisia (12.9%), 14 Malaysia (14.3%), 15 Dubai (18%), 16 and Japan (16.9%). 17 In Israel, reported rates have ranged from 12.2% to 16.3% among Jews and Arabs, respectively, in northern Israel,18,19 to 30% and more among Bedouin in southern Israel.20,21 Other studies have reported a wider range of PPD rates, and this is evidently due to differences in definitions, timing of measurement, reporting methods and cultural aspects. 22 However, most cases are not identified, thus do not seek and/or receive help.7,23-25
Several national reports and initiatives stress the role of primary care physicians (PCPs) in screening for depression in general, and PPD specifically.2,26,27 In Israel, perinatal mental health is considered an important public health issue. 28 In 2012, the Ministry of Health issued a Directive mandating PPD screening with the Edinburgh Postnatal Depression Scale antenatally and postpartum. 29 This directive is primarily aimed at well-baby clinic nurses. While these nurses have a crucial role in identifying women suffering PPD, the PCP—family practitioner or pediatrician—is also well placed to identify the signs of PPD and could provide an adjunct for women who do not attend well-baby clinics or who prefer not to discuss their emotions with the nurse. Regarding maternal mental health, pediatricians and family practitioners differ in training and focus; while the family practitioner regards the woman as a primary patient, the pediatrician views her solely in the context of the child as patient. Since women in the postpartum period are likely to have multiple contacts with PCPs and have expressed favorable attitudes toward being screened during visits to such providers,30,31 screening in these frameworks has been suggested and found feasible.32-34 Nevertheless most providers do not take steps to identify or treat PPD. 35
Screening should be prefaced by awareness of the consequences of PPD and knowledge of its signs. The present study is the first to inquire about Israeli PCPs’ attitudes and practice regarding maternal mental health, and compares the responses of pediatricians and family practitioners.
Data and Methods
In this cross-sectional study, an Internet survey was sent to all 345 pediatricians and family practitioners of Clalit Health Services in all 8 Clalit regions throughout the country. Israel’s National Health Insurance Law entitles every citizen free access to health care, provided by four non–profit-making health maintenance organizations (HMOs). 36 Clalit is Israel’s largest HMO, serving approximately 55% of the population. Responses were received from 224 physicians (response rate 65%). The survey included items about attitudes and practice regarding behavioral problems of children (survey items available on request), and demographic data and information regarding professional training. Three questions were appended to the survey concerning PPD among mothers of infants in their practice. These were preceded by the clarification: “. . . postpartum depression is defined as symptoms of moderate-to-severe depression that have continued for at least two weeks, as distinct from ‘postpartum blues,’ which is characterized by milder symptoms lasting for under two weeks.”
Analysis was conducted using SAS v9.2 software. Discrete variables were analyzed by chi-square, with a P value <.05 considered significant.
Clalit exempted the study from institutional review board approval, as this was an in-house survey only among primary physicians employed by the organization. Participants were guaranteed anonymity with no identifying data included.
Results
Participants
Participants included 122 pediatricians and 102 family practitioners (Table 1). More than half were male (57.9%), and a similar proportion were 51 years of age or older. A majority (56.6%) had studied medicine outside of Israel, most in the former Soviet Union; however, a larger proportion (87.8%) completed their specialization in Israel.
Descriptive Characteristics of Respondents (N = 224).
Abbreviations: FSU, former Soviet Union; HMO, health maintenance organization.
Not including missing values.
Responses
Most respondents (98.0%) answered in the affirmative (Table 2), including all family practitioners, all those whose medical training was outside Israel (P = .02), who specialized outside Israel, and who had private practices. There were no differences between physicians by HMO region or between males and females when comparing all respondents, as well as comparing within medical specialty (P > .05).
Responses to Questions Regarding Postpartum Depression.
Abbreviations: FSU, former Soviet Union; PPD, postpartum depression.
Not including missing data.
Most respondents (89.8%) noted that in such a case, they would become somewhat involved: clarifying the situation, keeping attentive, consulting with colleagues, and/or referring the mother to another professional. Six respondents, all family practitioners, stated that they would treat the case themselves (P = .01). A higher proportion of those whose training was outside Israel would avoid getting involved in these cases, compared with those who had studied in Israel (P = .04). There were no differences between physicians by HMO region or between males and females when comparing all respondents, as well as comparing within medical specialty (P > .05).
Three-quarters of the respondents (76.5%) would use such a questionnaire—family practitioners more so than pediatricians (91.2% vs 64.6%; P < .0001). There were no differences between physicians by HMO region or between males and females when comparing all respondents, as well as comparing within medical specialty (P > .05).
Discussion
This report presents responses to a brief questionnaire regarding PCPs attitude and practice regarding signs of PPD in mothers of children in their care. Studies have shown that, overall, PCPs perceive that it is their responsibility to recognize PPD symptoms.37-40 In this study, most respondents indicated the importance with which they view being able to recognize signs of PPD, with no significant difference between family practitioners and pediatricians. This is similar to the 90% rate reported by Leiferman et al, 38 who compared attitudes of family physicians and pediatricians. However, in contrast to our findings they found that family physicians were more likely to feel responsible for recognizing maternal depression and confident in discussing depressive symptoms and treating PPD. Heneghan et al 41 surveyed pediatricians and found that all respondents believed it appropriate to ask mothers about their own well-being, albeit preferring observational cues of distress, such as tearfulness, to formally asking mothers if they were depressed. Most of these pediatricians believed that mothers would react well if they were asked about their emotional well-being; however, 39% stated that they felt that a pediatric visit was not the best setting for discussing mothers’ emotional well-being, due to the child’s presence and other disruptions. Park et al 40 reported that 59% of the pediatricians in their study believed that they should be responsible for identification of maternal depression, similar to the rate reported by Olson et al. 42
There is a clear difference between considering the importance of recognizing signs of PPD and acting on them. In the present study, most respondents of both specialties would refer mothers’ depressive symptoms to mental health professionals. However only the family practitioners, albeit a minority of them, would actually treat maternal depression. Similarly, Park et al 40 reported that while most pediatricians surveyed believed that they should be responsible for referring to other providers, few believed that they themselves should be responsible for treating maternal depression. This is similar to the 7% reported by Olson et al 42 regarding treatment. Leiferman et al 38 reported that while 40% of family practitioners actually referred women for treatment for depression, fewer than 10% of pediatricians did so. Among pediatricians, Heneghan et al, 43 found that those who were older, who worked in settings with mental health providers, and who considered maternal depression to have an extreme effect on children’s mental health, were more likely to state that they identified and managed mothers with depression. In our study, no such distinction was found, as nearly all of the pediatricians expressed willingness to be somewhat involved (clarify, consult, or refer), but none were willing to treat.
Three-quarters of this study’s respondents expressed willingness to screen for PPD, significantly more of the family practitioners than pediatricians, among whom the rate was less than two-thirds. In actual practice, the compliance rate with the PPD screening program initiated by Wichman et al 44 in a multispecialty clinic (47.6%) was similar for pediatricians and family practitioners. In a survey by Wiley et al, 45 half of the pediatricians thought it feasible to screen for PPD, and 58% said they would use a short screening tool for PPD; however, only 7% were familiar with any such tool, and most reported having little or no knowledge about PPD. Other studies have also indicated that many pediatricians feel it is their responsibility to recognize PPD or inquire about it, but not formally with a screening tool, rather through nonverbal observational cues.41,45
The disparity found here between family practitioners and pediatricians has been reflected in other findings. Leiferman et al, 38 considering actual practice, found that 70% of family practitioners actively assessed women, compared to 30% of the pediatricians surveyed. The question of “who is the patient?” may be pivotal in this context, since in pediatric practice the mother is not the primary focus. Indeed Thomas et al, 46 who surveyed family practitioners and obstetrician/gynecologists, found that the vast majority (97%) felt it was their responsibility to diagnose PPD, and 88% felt that treating it was also their responsibility. Strengthening this view was the finding of Seehusen et al 39 that the general belief of most family practitioners in their study was that PPD is a common and serious condition, and that screening at every postpartum or well-child visit would be effective. The respondents noted that while screening at every well-child visit—at which the infant is the focus—would take considerable effort, screening at every woman’s postpartum visit would be more feasible. Studies have demonstrated that during the postpartum period, women with PPD see their physicians for health-related issues to a greater extent than do nondepressed postpartum women. 47 Family practitioners may therefore play a significant role in a woman’s postpartum life, hence placing them in a pivotal position to screen postpartum women for depression. While the focus on family physicians is intuitive, the reality is that in the year following childbirth women frequently visit pediatricians for well-baby and acute care—perhaps more frequently than they visit an internist/family practitioner. Indeed, Brown et al. found that mothers reported higher satisfaction with their child’s PCP when their own stress was discussed during pediatric visits. 48
Although not included in the present study, obstetricians/gynecologists also have an important role to play in this aspect of health care. With reforms in Israeli health care in recent years, women are increasingly turning to HMO Women’s Community Health Clinics for perinatal follow-up care, thus it is important that these professionals also be informed, and be able to identify and respond appropriately (with support and/or referrals) to emotional distress of women in their care. Indeed, the American College of Obstetricians and Gynecologists has issued a Committee Opinion encouraging screening for perinatal depression with appropriate systems in place for follow-up and treatment, as necessary. 49
Barriers to managing PPD screening both in pediatric as well as in family practitioner settings include lack of time, lack of training to recognize and discuss emotional well-being, and lack of knowledge of appropriate referral resources.41,42,45,50 Although in the present study the respondents’ age was not significantly related to willingness to address PPD, in the study by Head et al, 51 pediatricians in practice for five or more years reported more barriers to dealing with maternal depression than did current residents. This bodes well for the hope that with increasing awareness of the close association between physical and mental well-being, medical education will emphasize mental health issues as part of a holistic approach to the profession.
Limitations of the present study were the necessary brevity of the questionnaire and a possible ceiling effect of responses regarding the importance of recognizing signs of PPD. This effect might be due to response bias, with those more interested in the issue of maternal mental health being more likely to respond. Despite the fact that anonymity was guaranteed, social-desirability bias might have affected the findings because women’s mental health has gained “political correctness” in recent years. On the other hand, particularly regarding actual practice and willingness to screen, the responses were not uniform. Nevertheless, attempt to correct for these limitations should be made in future research.
A strength of the study is that pediatricians and family practitioners responded in nearly equal numbers, with a good response rate, 52 thus it was possible to gain a fair picture of the attitudes of both subgroups. Furthermore, Clalit being the country’s largest HMO, with the largest number of PCPs, is dominant in both size and influence, 36 leading many aspects of health care policy.
It seems that family practitioners have more favorable attitudes than do pediatricians; however screening in pediatric facilities is at least as important. The American Academy of Pediatrics’ report states that “Pediatric practices, as medical homes, can establish a system to implement postpartum depression screening and to identify and use community resources for the treatment and referral of the depressed mother and support for the mother-child (dyad) relationship.” 2 For PCPs to routinely screen for PPD and treat or refer women for treatment, it is crucial to be aware of their attitudes toward the matter. 40
Although the present study was conducted in Israel, reports from other countries indicate that this is a global issue and that its results and implications for PCPs reflect those worldwide. Hopefully, future research will offer more specific directions relating to medical education and health policy for family practitioners and pediatricians, as well as obstetricians/gynecologists, to meet the challenge of early identification and treatment of postpartum depression for the benefit of the women, infants, and families.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.