Pediatric Clinicians Miss Depression in Mothers

Symptoms of depression were often overlooked among mothers whose children were treated in an inner-city general pediatric clinic, according to a new study.

Pediatric researcher Amy Heneghan, M.D., found a 40 percent rate of depression in mothers who brought their children to a pediatrician or pediatric practitioner for a visit. She also found that these clinicians recognized only 29 percent of the mothers with high levels of depressive symptoms.

“These findings showed me that there is an enormous need for intervention,” said Heneghan, “and that there is clearly a need to better prepare pediatricians to identify the most prevalent mental illness among mothers.” The study’s findings are published in the December 2000 issue of Pediatrics.

Heneghan, who is an assistant professor of pediatrics at Case Western Reserve University and Rainbow Babies and Children’s Hospital in Cleveland and director of the Rainbow Office-Based Research Network, believes such intervention is necessary because “maternal depression outside of the postpartum period has a wide-reaching negative impact on children.”

She also believes that many mothers may not have their own doctors and that the pediatrician’s office would be a logical referral point for the mothers to get help for depression.

Heneghan and her colleagues surveyed a random sample of 388 mothers bringing their children to a Bronx, N.Y., pediatric clinic. They gathered demographic information and assessed the mothers’ levels of depressive symptoms. The researchers used the Psychiatric Symptom Index (PSI) to rate the mothers’ depression. Mothers in the sample were mostly black or Hispanic, and more than half of the mothers were single. Almost 80 percent were unemployed.

The researchers also surveyed the pediatric clinicians, including attending pediatricians, pediatric trainees, and pediatric nurse practitioners on the child, maternal, and family functioning of their study subjects. The pediatric clinicians were also asked to document any depressive symptoms in the mothers.

Mothers who scored 20 or higher on the PSI were considered by researchers to have a high level of depressive symptoms, while those mothers with a score of 30 or higher would be likely to receive a diagnosis of major depressive disorder. While only 29 percent of the mothers with a high level of symptoms were identified by pediatric clinicians, only a slightly higher rate—34 percent—of the mothers who would warrant a diagnosis of major depressive disorder were identified as having the symptoms by these clinicians.

Predictably, mothers who had high PSI scores and who were assessed by the child’s regular primary care provider or were known by the provider because it was not the child’s first visit, were identified more often. “Continuity of care for mother and child may makes it easier for the mother to communicate with the child’s doctor,” Heneghan said.

Mothers whose children were seen by a pediatric trainee or a nurse practitioner were less likely to have depressive symptoms identified.

Heneghan recently received a grant to conduct focus groups among mothers and pediatric health care providers, and she expects that both groups will discuss some of the barriers to identification of depression. “Mothers in the focus groups might reveal that they pull themselves together when they bring their child in for a medical visit,” said Heneghan, who noted that in her experience, mothers tend to be composed in the pediatrician’s office.

Heneghan does not necessarily view the inattention of pediatric clinicians to mothers’ mental status as a matter of inadequate training. “I can’t really say that this kind of training is lacking from all residency programs. I teach in a residency training program, and I stress the importance of attention to the family milieu all the time.”

She believes that clinical experience is one of the best sources of learning. “That’s why the more experienced pediatricians were able to put the child in the context of his or her family and see the larger picture.” ▪