5
Screening for Depression in Parents

SUMMARY

Primary Care Settings

  • Studies show that primary care screening of adults increases the recognition of depressed individuals (two- to three-fold) and has a small effect on the persistence of depression; however, depressive symptoms in adults are more likely to improve when screening is accompanied by a systematic approach that provides further evaluation and treatment than with screening alone.

  • Studies that have examined the mental health outcomes of adult depression screening in primary care settings rarely identify if the adult is a parent; have not addressed its impact on parental function; do not inquire about comorbid conditions (e.g., anxiety disorders, substance use); rarely assess adult treatment preferences; and rarely consider barriers to utilization of services or the two-generation impact of depression.

  • Evidence shows that effective brief depression screening tools are available for adults. Professional organizations and experts recommend routine use of these screening tools for adults in primary care and obstetric settings if systematic follow-up is in place. However, parents are not routinely screened in clinical practice and screened adults are generally only identified as parents during the perinatal period.

  • A variety of programs have focused on screening mothers during



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5 Screening for Depression in Parents SUMMARY Primary Care Settings • Studies show that primary care screening of adults increases the recognition of depressed individuals (two- to three-fold) and has a small effect on the persistence of depression; however, depressive symptoms in adults are more likely to improve when screening is accompanied by a systematic approach that provides further evalu- ation and treatment than with screening alone. • Studies that have examined the mental health outcomes of adult depression screening in primary care settings rarely identify if the adult is a parent; have not addressed its impact on parental func- tion; do not inquire about comorbid conditions (e.g., anxiety disor- ders, substance use); rarely assess adult treatment preferences; and rarely consider barriers to utilization of services or the two-genera- tion impact of depression. • Evidence shows that effective brief depression screening tools are available for adults. Professional organizations and experts recom- mend routine use of these screening tools for adults in primary care and obstetric settings if systematic follow-up is in place. However, parents are not routinely screened in clinical practice and screened adults are generally only identified as parents during the perinatal period. • A variety of programs have focused on screening mothers during 

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN routine pregnancy and postpartum clinical visits and other child health visits. These approaches provide opportunities to identify in- dividuals who are at a higher risk for depression, provide education and support, assess parental function, and link child development screening with maternal depression screening. Other Settings • Studies have examined screening for depression in parents—par- ticularly mothers—in existing community programs (e.g., early Head Start, those serving homeless women, substance use disorder treatment, home visitation), where individuals who are at higher risk of depression are seen. Although these settings and programs offer opportunities to reach parents and their children at greater risk for depression, screening is not routine. Implementation • Little information is available in either public or private settings about the complex process of implementing a systematic approach to maternal or paternal depression screening and follow-up, includ- ing time, resources needed, workforce and training competency and capacity, and the impact of engagement and education of depressed parents on the parents as well as their children. ____________________ This chapter addresses screening parents for depression in primary care and other health and community programs. First, the evidence basis for screening adults for depression and the use of brief clinical screening tools is discussed. Next, this chapter discusses the current research on parental depression screening at both maternal postpartum and well-child visits. When available, the discussion includes comparison to other informal and diagnostic approaches to the assessment of depression in these settings. Be- cause successful screening and intervention involve a systematic approach, rather than only a questionnaire, the chapter discusses the challenges in implementation of screening with attention to parental, health provider, and health care system issues. Screening is the initial step in a systematic approach to detection and treating parents with depression. Finally, we consider promising approaches to parental depression screening and as- sessment in public health settings and with high-risk populations served by homeless, home visitation and substance use programs. In addressing the impact that depression has on children, the com-

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 SCREENING FOR DEPRESSION IN PARENTS mittee considered screening for other factors, such as poor developmental outcomes or parenting impairment. Linking developmental screening of the young child to parental depression screening is one option that is discussed. However, screening for parental skills is conducted in research settings with longer instruments (i.e., Parenting Stress Index, Abidin, 1995) with young children. Clinical studies are not available that use screening tools to ad- dress the issue of parental skills for children of multiple ages in the context of depression. PRIMARY CARE SETTINGS The substantial numbers of adults with depression who are untreated, along with the underrecognition of depression by primary care providers, has led to examination of the use of brief screening procedures for depres- sive symptoms to address this problem. Review of the research evidence by the U.S. Preventive Services Task Force has shown that, with screening of patients in the primary care setting and provision of this information to the clinician, the number of patients recognized as depressed increases 2–3 times (Pignone et al., 2002). Meta-analysis of studies with screening and feedback showed that this strategy significantly decreased the risk for persistent depression 6 months later by 9 percent (relative risk, RR = 0.9; confidence interval, CI = 0.82–0.98) (Pignone et al., 2002). Many of the screening studies assessed later depression status but did not consider pa- tient factors (e.g., acceptance of diagnosis, treatment preferences). Clinical outcomes were most likely to improve in studies in which screening was accompanied by a systematic approach, beyond the actual screening mea- sures, to improve the quality of depression care, including patient education and follow-up. Thus, although screening alone will increase recognition, the best outcomes occurred when primary care settings implemented qual- ity improvement programs that supported patient education and initiation of therapy. As a result of its evidence-based review, the U.S. Preventive Services Task Force (USPSTF) in 2002 recommended primary care screening for depression, with a brief measure or two verbal questions, combined with a systematic approach, to assist those who screen positive with further evalu- ation and assistance (U.S. Preventive Services Task Force, 2002). When applying these recommendations to the specific issue of parental depres- sion, however, there are limitations. None of the studies reviewed by the USPSTF identified status as a parent during screening, and women in the postpartum period were excluded from the studies reviewed. The potential two-generation benefit to the parent, usually the mother, and her children from identification of depressive symptoms and assistance to reduce their impact has not been considered in the reviews of the benefits of screening.

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN Currently, the American College of Obstetrics and Gynecology and the American Academy of Family Practice follow the recommendations of the task force for adult depression screening. National guidelines by the Ameri- can Academy of Pediatrics and other national groups address screening for maternal depression and its impact on child development only in infancy, with a focus on the postpartum period (Hagen, Shaw, and Duncan, 2008; Jellinek, Patel, and Froehle, 2002). The main thrust of screening activities at pediatric well-child visits has been directed to detection of developmental delays in young children. The use of formal screening measures for devel- opmental delays at three time periods in infancy and early childhood, with particular attention to language and social delays, is now recommended by the American Academy of Pediatrics (American Academy of Pediatrics and Council on Children with Disabilities, 2006). Although maternal de- pression is associated with child developmental and behavioral outcomes, as discussed in Chapter 4, these recommendations do not mention either screening for maternal depressive symptoms with developmental screening or screening mothers when developmental delays are found. Depression is prevalent among women in the childbearing years, but, for many healthy women, their most frequent contact with health care pro- fessionals may be through their perinatal care or the care of their children. Thus, screening for depression, in addition to being provided during adult primary care, may need to access parents during obstetrical and pediatric care encounters. The available evidence about screening of parents in these settings needs to be examined. Community services that serve parents at higher risk for depression also offer the opportunity for screening and are discussed in this chapter. The Screening Process It has been shown that clinicians do not detect depressive symptoms in nearly half of mothers when they use informal inquiry to screen (Evins, Theofrastous, and Galvin, 2000; Heneghan et al., 2000; Olson et al., 2005). Inconsistent inquiry, the use of less specific questions, and the use of global impression rather than diagnostic criteria are some of the reasons (Olson et al., 2002). To enhance clinician detection of depressive symptoms, vari- ous measures have been used for depression screening, ranging from two- item questionnaires to structured clinical interviews. Generally, the tools that are most useful in busy clinical settings are brief, directly address symp- toms found in the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV), are adaptable to specific patient populations (based on age, education, and ethnicity), and are capable of measuring the change in severity over time. Specific maternal measures for the postpartum period have been de-

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 SCREENING FOR DEPRESSION IN PARENTS veloped. The performance characteristics of tools for postpartum depres- sion screening are summarized in a recent review (Boyd, Le, and Somberg, 2005). The Edinburgh Postpartum Depression Scale (EPDS) is the most widely used and has moderate to good reliability. It assesses symptoms of depression and anxiety rather than depression alone, as in other screening measures. The different cutoff scores used in studies limit comparisons of the EPDS with other measures (Gaynes et al., 2005). Screening adults with two questions1 about mood and anhedonia (low positive affect) has been found to perform as well as longer measures (Whooley et al., 1997). A three-question screen2 derived from an eight-item depression screen (Burnam et al., 1988) has been used clinically with mothers (Kemper and Babonis, 1992); however, the three-question screen has been validated against the eight-item instrument rather than a psychiatric interview. Small studies in high-risk populations have compared the EPDS with the Patient Health Questionnaire-2 (PHQ-2), but they have not used diagnostic inter- views as the gold standard (Cutler et al., 2007; Kabir, Sheeder, and Kelly, 2008). Table 5-1 lists four screening tools that are commonly used in clini- cal settings and available without cost. It is important to remember that, although a positive screen reveals depressive symptoms that might influence parenting, the positive predictive value for major depression is 35 to 50 percent with these screeners when validated by psychiatric interview (Boyd, Le, and Somberg, 2005; Kroenke, Spitzer, and Williams, 2003). Thus, posi- tive results on a screener indicate depressive symptoms and higher rates of minor (subthreshold) depression; individual patients need to be evaluated to determine if major depression is present. The screening process has been shown to be efficient, but it is more effective in clinical settings by using a two-step process. If a limited two- question screen is positive, then a nine-item diagnostic measure has then been administered. Both the PHQ-2 and the PHQ-9 have been evaluated by comparing the score with a clinical interview using DSM-IV criteria as well as scoring criteria developed to identify the presence and severity of depression (Kroenke, Spitzer, and Williams, 2003; Spitzer et al., 2000). Better case finding in primary care practice also occurred when follow-up questions asked whether the patient wanted help with the problem (Arroll et al., 2005). The use of a brief measure with simple scoring has the advan- tage of ease of implementation and less scoring error. Confirmation with a 1 The two questions asked were (1) “During the past month, have you often been bothered by feeling down, depressed, or hopeless?” and (2) “During the past month, have you often been bothered by little interest or pleasure in doing things?” (Whooley et al., 1997). 2 The three questions selected were: (1) “How much of the time in the past week has this statement been true for you? I feel depressed”; (2) “Have you had 2 or more years in your life when you felt depressed or sad on most days even if you felt ‘okay’ sometimes?”; and (3) unclear from the article (Kemper and Babonis, 1992).

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 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN TABLE 5-1 Summary of Brief Paper-Based Depression Screening Tools Tool Validation Time Description Edinburgh Sensitivity = 5–10 minutes Has been the subject of a Postpartum 0.86 Self-administered, number of psychometric Depression Specificity = could be self- studies that provide support Screen 0.78 scored if scoring for its accuracy, validity, and (EPDS) For positive instructions standardization in Britain, screen ≥ 10 are provided to Canada, and the United patient States. The EPDS consists of 10 multiple-choice items that produce a “possible depression” score and a single question focusing on potential suicidal ideation. Downloadable from http:// www.dbpeds.org/articles/detail. cfm?TextID=485. Patient Health Sensitivity = 5–10 minutes The nine-item questionnaire Questionnaire 0.88 Self-administered is a diagnostic measure that (PHQ-9) Specificity = and self-scored, assesses DSM-IV symptoms 0.88 patient can present in the past 2 weeks. For positive access this online It can be used both for diagnosis screen ≥ 10 through http:// and monitoring symptom www.pfizer.com severity during treatment. Can or can obtain it be downloaded from http:// from physician www.depression-primarycare. org/. or http://www.pfizer. com/pfizer/download/do/phq- 9.pdf. Laminated copies can be obtained from Pfizer, Inc. (the company holding the copyright on all versions). < 1 minute PHQ-2 Sensitivity = See above. The two questions 2-question 0.83 Self-administered or from the PHQ-9 for mood and screen Specificity = can be asked anhedonia are used. Scored 1–3 0.92 for each question and summed. For positive Recommended that the physician screen ≥ 3 follow up with a more comprehensive screening tool. < 1 minute RAND Sensitivity = This is a three-item adaptation 3-question 1.00 Self-administered (Kemper and Babonis, 1992) screen Specificity = of the eight-item depression 0.88 screener developed by RAND For positive (Burnam et al., 1988) from screen—see longer screening instruments. footnote 2 in The eight-item measure has chapter been validated by psychiatric interview (sensitivity 0.70– 0.71, specificity 0.91–0.96). The reported sensitivity and specificity for the three-item screen are not against the psychiatric interview but a comparison between the three- and eight-item instruments.

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9 SCREENING FOR DEPRESSION IN PARENTS second step reduces the false positive rate and leads to appropriate referrals when mental health resources are limited. Clinicians can also be assisted in understanding severity and making treatment plans when follow-up questions ask about the functional impact on daily life. Although impact on activities of daily living at work or at home is one of the criteria for clinical depressive disorder, the adult studies of screening measures have not considered functional status as a parent in their assessment. One study of parents found over three-quarters of par- ents screening positive with the PHQ-9 felt their function as a parent was affected (Grupp-Phelan, Whitaker, and Naish, 2003). We could find no studies of depression screening in the adult care setting that addressed the two-generation impact of parental depression. Screening Selected Parental Populations in Health Settings When addressing depression in parents, mothers, as the primary care- giver of young children, have been the prime focus of screening in the perinatal period and beyond. Targeted screening of mothers at higher risk for depression or adverse outcomes is one approach to depression screen- ing that has been taken. The postpartum period for mothers has received attention as a specific time to screen. The unique triggers and social issues of this time period have led to recommendations for pediatricians, obstetri- cians, and family physicians to screen postpartum women. It is particularly during this period of parenting that depression has been widely recognized as impacting the parenting and nurturance of the child. Publicity about severe cases of postpartum depression has led to increased awareness and promotion of screening and education. Most of the data on women who screen positive for depressive symp- toms has come from population surveys, not clinical populations. A meta- analysis of studies (O’Hara and Swain, 1996) reported an average rate of postpartum depression of 13 percent. It found the rate differed by client his- tory. For women with a history of depression, the rate was estimated to be 25 percent. For women with depression during pregnancy, the postpartum rate was about 50 percent. Women who were unmarried, had an unplanned pregnancy, had little social support or inadequate financial resources were more likely to be depressed. Among these stressors, low-income status has been shown to be one of the strongest predictors of postpartum depression (Segre et al., 2007). Domestic violence and marital maladjustment also increase the incidence of postpartum depression. The Centers for Disease Control and Prevention has recently completed a study of maternal recall of postpartum depressive symptoms at 6 months postpartum in 17 states during 2004–2005. The prevalence of self-reported postpartum depression ranged from 11.7 percent in Maine to 20.4 percent in New Mexico. The

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90 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN risk factors associated with reporting depressive symptoms included using tobacco during the last 3 months of pregnancy, physical abuse before or during pregnancy, partner-related stress during pregnancy, and financial stress during pregnancy (Pregnancy Risk Assessment Monitoring System Working Group and the Centers for Disease Control and Prevention Preg- nancy Risk Assessment Monitoring System Team, 2008). The studies of screening for postpartum depression often involve small study populations, and confirmation of a diagnosis of depression is limited. A careful meta-analysis has examined perinatal screening studies in which validation by psychiatric interview was available (Gaynes et al., 2005). The results show that women in the postpartum year were not at greater risk for a major depressive disorder than other women in their childbearing years. However, they did have higher rates of new-onset, subthreshold depressive symptoms in the first 3 months after birth. Gaynes et al. found that 14.5 percent of women had a new episode of major or minor depression during pregnancy and 14.5 percent of women in the first 3 months’ postpartum. About half, or 7 percent, had major depression and half had subthreshold depressive symptoms. The evidence thus far shows that, in the postpartum period targeted by many programs, depressive symptoms, but not major depression, are more prevalent than at other times of parenthood. Some public health programs have initiated comprehensive programs to address maternal depression. Several state health departments have pro- grams that support screening, provider training, and parental supports. New Jersey, since 2006, has had a law requiring screening, education, and referral. Illinois provides additional clinician payment for conducting post- partum screening. Screening programs can have an educational role that decreases stigma as well as provides support to individuals in their parent- ing role. When screening is implemented the pressure to provide follow-up resources can stimulate treatment resources, such as depression support groups. In Washington state, with the advent of depression screening in the state’s Maternal Support “First Steps” Program, the number of postpar- tum depression groups have more than doubled. In Australia, over 40,000 women have been screened antepartum or postpartum in a wide range of clinical and public health programs with the EPDS. Clinical outcomes from these public health–supported depression screening programs have not been published. This public momentum has emphasized women’s increased risk for depression in this time period. Despite the public attention to perinatal maternal depression, overall screening rates in both obstetrical and pediatric care settings are low. For- mal screening during routine postpartum care is infrequent, with detection rates of 3.7 percent (Georgiopoulos et al., 2001) to 6.3 percent (Evins, Theofrastous, and Galvin, 2000). In a survey of obstetricians, 44 percent re- ported that they screened for depression, but less than a quarter used a vali-

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9 SCREENING FOR DEPRESSION IN PARENTS dated written screen or interview (LaRocco-Cockburn et al., 2003). Among family physicians surveyed in one state, 31 percent self-reported that they always screen at postpartum visits and 13 percent always screen mothers at well-child visits. The use of written screening tools was rare, with 82 percent using an interview (Seehusen et al., 2005). Pediatricians report that observation or informal inquiry is the most common method of detecting maternal depression, and only 4 percent usually use a screening measure, despite recognizing the impact of maternal depression on children’s health (Heneghan, Morton, and DeLeone, 2006; Olson et al., 2002). Another approach is to extend screening beyond the initial postpar- tum visit and screen the parent during other child health visits. Thus far, there are only a few studies suggesting the yield and feasibility of this approach. A study in an urban primary care pediatric practice with primarily black, low-income mothers sought to screen at all infant well visits in the first year. Half of the mothers were screened, and 27 percent had an EPDS score greater than 10 (Chaudron et al., 2004). Maternal depression screening in a disadvantaged, urban, pediatric, clinic setting during well-child visits for children under age 6 showed that 27 percent of mothers screened positive using a yes or no response for the PHQ-2, and 12 percent screened positive with the Beck Depression Inventory (BDI) (Dubowitz et al., 2007). Mothers who presented their children for either acute care or well-child visits in an urban setting were screened with the PHQ-9; 9–10 percent screened positive for major depression, and 8 percent for subthreshold depression (Grupp-Phelan, Whitaker, and Naish, 2003). In pediatric practices in rural communities with predominantly white populations, routine brief parental screening conducted at all well- child visits showed that 17 percent of mothers screened positive on the PHQ-2 when scored with the method used by Dubowitz et al. There were substantially lower rates of positive depression screens (6 percent) using a newer PHQ-2 scoring, which determined severity of symptoms (Olson et al., 2006). Although these studies are limited to small populations, they show that a substantial number of mothers presenting at well-child visits have depressive symptoms when routine depression screening is conducted. The results vary by clinical settings, and sites taking care of primarily disadvantaged populations will have more mothers in need of further evaluation and assistance. The current national recommendations for routine developmental screening of young children require clinical practices to develop organized systems to administer developmental screening measures during infancy and early childhood as well as to arrange appropriate follow-up. This provides the opportunity to target a high-risk population, children with developmen- tal delays, for parental depression screening. Whether delays result from

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92 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN medical, social, or language conditions, coexisting maternal depression is likely to influence outcomes. A recent analysis at the Child and Adolescent Health Measurement Initiative conducted for this report provides information about maternal depression screening in the context of childhood developmental screening (Bethell, Peck, and Schor, 2001). The Promoting Healthy Development Sur- vey, which measures key aspects of the quality of delivery of preventive care for children under age 5 (Bethell, Peck, and Schor, 2001), was administered along with the Parents Evaluation of Developmental Status, a validated developmental and behavioral risk screener (Brothers, Glascoe, and Robert- shaw, 2008), including a three-question maternal depression screen (Kem- per and Babonis, 1992) to a sample of mothers of 4,654 Medicaid-insured children from seven states as well as a sample of mothers of 2,162 children receiving well-child care in the Kaiser Permanente Northwest health care system. Children were under 48 months of age. Depression screens were positive in 20 percent of mothers in the Med- icaid population and in 13.7 percent of mothers in the Kaiser Permanente population. Depression screen positive rates did not differ for different age subgroups (0–18 months, 19–36 months, and 37–48 months). These rates are similar to the smaller published screening studies in primary care and show that maternal depressive symptoms continue to be an issue beyond the postpartum period. Children who screened at risk for developmental or behavioral problems on the Parents’ Evaluation of Developmental Sta- tus were 1.93 times more likely to have a mother who screened at risk for depression (28.5 versus 20.5 percent). Parents with a positive depression screen were no more likely to have their clinician ask about depression in the health visit than parents with normal depression screens (20.4 versus 20.8 percent). These findings in the clinical setting are consistent with the research in Chapter 4 that shows increased developmental and behavioral con- sequences in young children with a depressed mother. A comprehensive approach that addresses both parental factors and child issues when devel- opmental delays occur is appropriate. Targeting the population of children with developmental or behavioral problems for maternal depression screen- ing is supported by these findings. SCREENING IN OTHER SETTINGS Parents, particularly women, with children who are at heightened risk for depression are served in other community programs that may provide the opportunity to screen for depression and offer further assessment and supports for treatment. Maternal depression is common among parents of Early Head Start programs, and depressive symptoms have been assessed as

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9 SCREENING FOR DEPRESSION IN PARENTS part of program evaluation. However, programs currently do not routinely screen mothers for depression. Mothers seen in programs for homeless families are at high risk for depression. Screening women served in homeless programs in western Massachusetts showed that 52 percent had depressive symptoms and received assistance (Weinreb et al., 2006). Promising new programs that are supported by the Commonwealth Fund’s Assuring Better Child Health and Development project, better known as ABCD, and that assist state maternal and child health program are being established. As a result, a statewide public health approach to developmental screening that incorporates family mental health screening in Iowa (the 1 to 5 Initiative) links screening in either primary care or early childhood service agencies (e.g., the Special Supplemental Nutrition Program for Women, Infants, and Children; Visiting Nurse Associations) with a community-level care coordi- nator to address the entire range of child and family issues. Screening in Substance Use Disorder Treatment Settings Since 1995, there have been an increased awareness and emphasis on providing depression screening, assessment and diagnosis, and treatment to patients enrolled in treatment programs for substance use disorders (SUDs). Based on data reported to the Substance Abuse and Mental Health Services Administration from the National Survey of Substance Abuse Treatment Services in 2006, the most recent data available, 58 percent of programs provided screening for mental health disorders, 42 percent provided com- prehensive assessment and diagnosis of mental health disorders, and 37 per- cent reported special programming for those with co-occurring disorders. Women in their childbearing years with substance use disorders often have co-occurring disorders, including depression and experience with in- terpersonal violence that results in posttraumatic stress disorder. Data on parents with substance use disorders and depression and other mental health disorders are largely limited to comprehensive SUD treatment programs for women, mostly those who are perinatal. Among mothers, 83–88 percent screened positive for depressive symptoms at treatment entry (Conners et al., 2006; Lincoln et al., 2006). Of the women screening positive for depressive symptoms, 64 percent received a depressive disorder diagnosis using an independent diagnosis assessment (Lincoln et al., 2006). It has been estimated that, among pregnant women with a substance use disorder, 56 percent have depressive symptoms (e.g., Fitzsimons et al., 2007); 48 percent of pregnant, drug-dependent women enrolled in a comprehensive SUD treatment program have a current major depressive disorder; and 54 percent have major depressive disorder with a concurrent anxiety disorder (Fitzsimons et al., 2007). Mothers and fathers with substance use disor- ders often suffer from multiple and complex co-occurring disorders and

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9 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN environmental challenges, including poverty or deprivation, homelessness, inability to afford or access dental or medical care, unemployment, a lack of vocational skills, interpersonal violence, and ineffective parenting skills. As such, brief screening instruments, followed by assessment and treatment when needed, are urgently needed for front-line substance abuse treatment staff to quickly and easily administer, to interpret the results, and to refer their clients for further assessment for mental health treatment (Lincoln et al., 2006). Although the rates of depression in parents who treated for substance use disorders are elusive, several promising programs that screen, assess, and treat depression in pregnant and parenting women who are also being treated for substance use disorders are highlighted below. Specific to pregnant women, the Center for Addiction and Pregnancy, located in Baltimore City on the campus of the Johns Hopkins Bayview Medical Center, is a comprehensive care model (Jansson et al., 1996, 2007). The center provides treatment for substance use disorders while concur- rently providing obstetrical, medical, and other psychiatric care to mothers and pediatric care to the children of patients. As a part of the center’s com- prehensive screening battery, a screen for mental health issues is included. Given the need to minimize paperwork and demands on patients and staff, a study comparing the utility of the Addiction Severity Index (ASI) to the BDI was conducted to see which instrument predicted mood disorders in this pregnant drug-dependent population. The ASI psychiatric severity rat- ing by the interviewer was found to have better sensitivity and specificity than the BDI for predicting mood disorders (Chisolm et al., in press). The ASI, which is a required intake tool for substance abuse treatment programs in many states, is now used for screening patients for the need for further psychiatric assessment by the center psychiatrist. The center’s research has also found that when using the Structured Clinical Interview for DSM Disorders, diagnosed depression in the absence of anxiety is especially prevalent (54 percent) in pregnant, drug-dependent patients (Fitzsimons et al., 2007). Two promising programs described in Chapter 6 treat mental health, interpersonal violence, and substance use disorders in mothers and fami- lies. The first model is the Boston Consortium of Services for Families in Recovery Model, which under the Boston Public Health Commission has an active collaborative system of services for women with substance use disorders as well as mental health and trauma issues (Amaro et al., 2005). The system, which routinely screens all new patients for mental health disorders, found that 88 percent of patients reported experiencing mental health symptoms in the month before treatment entry (Lincoln et al., 2006). The other model is part of PROTOTYPES, which also provides services for women with substance use disorders as well as a variety of mental illnesses and trauma issues (Brown, Rechberger, and Bjelajec, 2005).

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9 SCREENING FOR DEPRESSION IN PARENTS Screening in Home Visitation Programs Home visitation programs potentially provide an important, large- scale context in which to identify and intervene in parental depression and associated parenting difficulties. Home visitation programs typically serve young, low-income families with high levels of stress, histories of trauma, and marital problems. These high-risk families typically have low utiliza- tion rates for traditional center-based mental health services. The high rate of depressed mothers encountered by home visitation programs and the negative impacts that maternal depression has on the effectiveness of home visitation has led to a number of home visitation–based treatment interven- tions, which are described in Chapter 6. Another intervention strategy that has been employed is screening by the home visitor with referral to com- munity mental health services. National home visiting models, such as the Nurse-Family Partnership, operating in 26 states, and Healthy Families America, operating in 440 communities, use a battery of parent-report and home visitor–administrated measures to determine the types and intensity of services required by the families. Standard depression screens, such as the EPDS or BDI-II, have been included at some sites of several major programs, but are not univer- sally administered. In intervention studies reporting depression screening scores at baseline, positive screens occurred in 29 to 50 percent (Am- merman et al., 2009; Jacobs et al., 2005; Stevens et al., 2002). Thus, for mothers enrolled in home visiting programs, substantial numbers reported clinically significant depressive symptoms at entry to the study. Based on these rates of depression in the home visiting literature, routine screening can be expected to reach many high-risk families and to identify a large number of clinical cases. Although no randomized clinical trial outcomes have been published for the strategy of screening all new mothers through home visitation, several state programs are conducting screening programs in which home visitors administer and score a standardized depression screen and then refer mothers (or fathers) scoring above a predetermined clinical threshold to community mental health services for further evaluation and treatment as indicated. One promising example is the collaboration between the Ohio De- partment of Health’s Help-Me-Grow statewide home visitation program, implemented at a county level, and the Ohio Department of Mental Health. Help-Me-Grow home visitors administer the EPDS to new mothers with infants ages 4 to 20 weeks. They enter the EPDS score and demographic data into a web-based data system that automatically scores the EPDS and prompts the home visitor to make a referral for mothers who score 12 or above or who endorse item 10 (a suicide question) at a level 2 or higher.

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9 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN The database can email a copy of the client’s EPDS and pertinent refer- ral information, or the referral can be printed and mailed or faxed to the mental health agency. Once a referral is made, the database automatically prompts a monitor to contact the mental health agency at 30 and 90 days to see if an appointment was made and whether it was kept. This program is currently operating in 17 Ohio counties around the state and is slated to increase to 40 counties in 2010. Unpublished results indicate that 20 per- cent of screened mothers met the EPDS clinical threshold and 68 percent of positive screens accepted the home visitor’s offer of a facilitated mental health referral. Follow-up at 30 days found that 37 percent of referred mothers had actually kept their mental health appointments. No data are collected on treatment outcomes. CHALLENGES IN THE IMPLEMENTATION OF SCREENING FOR DEPRESSION For depression screening to be feasible in more primary care settings, more information about the details of implementing screening programs in different settings is needed for practices to plan for adequate time and support resources. For example, only one study provides information about the impact on the time spent by clinicians with routine depression screen- ing (Olson et al., 2006). There has been little published evidence shedding light on the entire process of screening and systematic follow-up in different types of clinical settings. This is an issue for routine screening of adults in primary care and obstetric settings as well as pediatric health care settings (Chaudron et al., 2007). The lack of information about the results of screening programs is another barrier to implementation. Data on program cost and effectiveness are rarely available. One example is a study in Florida (Gadsden County) that estimated a cost of $466 per client for 224 women screened. The num- ber screening positive was 89 clients, or 36 percent. Since this county has a large number of families living in poverty, the rates of depression were higher. In all, 51 percent of the positive cases accepted treatment, and the average cost ($100 per treatment visit) was $2,229 for each client treated (Lynch and Harrington, 2003). This type of evaluation needs to occur in a variety of public and private health care settings. A further barrier to implementation of screening programs for paren- tal depression is that primary care providers report that they are not well enough prepared to deal with the mental health issue of depression, or they perceive inadequate resources in their community to provide treatment for clients. In a recent survey of pediatricians, those from the Midwest were five times more likely than in other regions to identify and manage mothers with depression. Michigan, Wisconsin, and Illinois have all implemented initia-

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9 SCREENING FOR DEPRESSION IN PARENTS tives to increase public awareness about maternal depression (Heneghan et al., 2007). The state of Illinois has developed a comprehensive support system for providers dealing with perinatal clients. The system provides accessible information on the Internet and makes professional consultation easily accessible (Wiedmann and Garfield, 2007). Furthermore, there are challenges in screening in home visitation programs. The major problem raised by routine screening is how to provide effective services for the large number of depressed parents who are likely to be identified. In addition to needing local capacity to treat these newly recognized cases, several studies indicate that home visitors as a group are not good at connecting families with community-based services for depression, domestic violence, and sub- stance abuse (Hebbeler and Gerlach-Downie, 2002; Tandon et al., 2005). Although there are no empirical studies of the reasons why this is so, it is thought in these programs that their concern about discussing sensitive is- sues may alienate families and undermine the effectiveness of the primary home visitation services. It is challenging to implement depression screening and to ensure that individuals receive assistance. Although inadequacies of systems of care are often emphasized, there are other barriers at the patient level. Difficulty in engaging women to recognize and act on symptoms has been identified as a barrier to better outcomes. For example, in one study, when patients in perinatal care were willing to be screened for depression, many did not agree to further assessment or contact (Carter et al., 2005). In several stud- ies, investigators have reported resistance to treatment services because of the stigma associated with mental illness and the fear of having their children removed because of the mother’s function (Beeber, Perreira, and Schwartz, 2008; Lazear et al., 2008; Miranda et al., 2006). In addition, low-income and immigrant populations identified the following barriers to services: domestic violence; isolation; language problems; difficulties with public systems; lack of access to quality, culturally competent care; reliance primarily on informal systems of care; lack of insurance; and the attitudes of providers. Engagement with a trusted clinician is important for mothers to dis- cuss such issues as stress and depression (Heneghan, Mercer, and DeLeone, 2004). Screening in the child’s health visit can provide a supportive set- ting for discussion, assistance, and referral. When screening occurred in the context of the infant’s visit, Chaudron et al. reported that half of the depression screen positives were referred and 88 percent were seen by on- site social workers (Chaudron et al., 2004). In children’s well-child visits, nearly half of the mothers with a positive depression screen thought they might be depressed and were willing to take action after discussion with the pediatrician (Olson et al., 2006). In clinical screening programs, it is desir- able to also include an educational component. It is important to initiate a

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9 DEPRESSION IN PARENTS, PARENTING, AND CHILDREN discussion of symptoms of depression that provides anticipatory guidance to help the child and motivates the parent to seek support and use exist- ing resources. The educational role of screening linked with discussion is demonstrated in the Australian postpartum depression screening program, in which the women screened were more likely to identify symptoms as clinical depression when they had depression screening and discussion by health staff (Buist et al., 2006). RESEARCH GAPS Although evidence supports the effectiveness of brief screening mea- sures for adult depression in clinical and community settings, there remain many unanswered questions. For example, more evidence is needed on the effectiveness of universal screening of parents with depression, including moving beyond the perinatal period. And, more research is needed to de- velop brief clinical screening measures for key parenting skills that relate to depression. More specifically, studies are needed that measure depression in parents with both diagnostic interviews and with symptom scales and that examine differences in parenting and in child functioning that might be related to measurement approach, severity, impairment, and other clinical characteristics of depression. In terms of outcomes, research is lacking on the outcomes of screening parents as part of a two-generation comprehensive depression care program that addresses issues for both parent and child. The next stage is trans- lational research to determine if comprehensive screening programs can ultimately influence parental mental health, parenting, or adverse outcomes in child development. More specifically, effectiveness of the implementation of programs, rather than efficacy studies, are needed in community and clinical settings. They should examine the impact of each step in the care process from screening, education, and parent engagement, through parent treatment preferences and choices made, to referrals made and completed, and to clinical outcomes. More research is needed to determine the optimal ways to integrate parental depression screening with the assessment of parenting and child developmental and behavioral status for all children but especially in high- risk populations (i.e., with substance use disorders, low-income status, at risk for abuse). CONCLUSION Effective brief screening measures are available—and recommended— for recognizing depressed adults in a variety of clinical settings and exist- ing community programs. However, depressive symptoms are more likely

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99 SCREENING FOR DEPRESSION IN PARENTS to improve when screening is accompanied by education and initiation of treatment. Most adult screening studies assess only changes in depressive symptoms and provide little information about patient or system variables that influence treatment choices or effectiveness. However, these screening studies do not inquire about parental status, do not examine how depres- sion affects areas of functioning as a parent, and do not inquire about comorbid conditions (e.g., anxiety and substance use disorders). Rarely are screening programs integrated with service delivery. Mothers with elevated depressive symptoms as well as cases of clinical depression have been suc- cessfully identified primarily through screening programs in perinatal health care settings and, to a limited extent, in other private and public primary care settings. Depression in fathers has not been the focus of screening programs. Some programs providing early childhood services to high-risk populations have conducted screening and offer an opportunity to screen parents for depression and parenting function. Despite the promise of screening programs, current approaches to parental depression screening have not been integrated with assessment of parental function or child development. As national initiatives by organi- zations and state agencies proceed to promote routine developmental and behavioral screening of young children, it is important to recognize that developmental or behavioral problems in this age group may be related to parenting difficulties and depression and should be assessed. Furthermore, a number of barriers exist in implementing a comprehen- sive screening program. For screening to be effective, the paths to further care must be clear and accessible for both the providers who identify the depression and the families so that available clinical and community re- sources to address issues are used. Limited or poorly organized community resources, or lack of knowledge of existing resources, may decrease willing- ness to screen. Linking depression screening to existing screening efforts—such as pre- natal assessment during pregnancy and child developmental screening, at entry into programs serving high-risk parents (e.g., home visiting, homeless, and substance use programs), and other existing treatment or prevention programs—is a first step that could address depression in parents and its impact on their families. REFERENCES Abidin, R. (1995). Parenting Stress Index: Professional Manual (2nd ed.). Lutz, FL: Psycho- logical Assessment Resources. Amaro, H., McGraw, S., Larson, M.J., Lopez, L., Nieves, R., and Marshall, B. (2005). Boston Consortium of Services for Families in Recovery: A trauma-informed intervention model for women’s alcohol and drug addiction treatment. Alcoholism Treatment Quarterly, 22, 95–119.

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