- Email: [email protected]
Depression in Mothers of Children Presenting for Emergency and Primary Care: Impact on Mothers' Perceptions of Caring for Their Children
Depression in Mothers of Children Presenting for Emergency and Primary Care: Impact on Mothers’ Perceptions of Caring for Their Children Jacqueline Grupp-Phelan, MD, MPH; Robert C. Whitaker, MD, MPH; Aimee B. Naish, BS Context.—Maternal mental health conditions may influence how mothers utilize emergency health care for their children. However, little is known about the prevalence of depression among mothers of children presenting for emergency health care and how maternal depression affects a mother’s perception of how difficult it is to care for her children. Objectives.—To screen for maternal depression and to examine whether mothers with depressive symptoms perceive that these symptoms interfere with their roles in caring for their children. Design.—Cross-sectional survey. Setting.—An urban, tertiary-care, children’s hospital. Participants.—Mothers bringing their children, aged 6 months to 18 years, to an emergency department for lowacuity illness (n 5 243) or to a pediatric primary care clinic (n 5 249) for well-child care. Main Outcome Measure.—Positive screening tests for depression using the Prime MD Patient Health Questionnaire. Results.—The prevalence of positive screening tests for depression was similar in both emergency and primary care settings, with 18% of mothers having either major (9%) or subthreshold (9%) depression and 5% percent having suicidal ideation. Seventy-six percent of mothers with a positive screen for major depression and 17% of those with a negative screen for depression reported that their mental health symptoms made it difficult to care for their children. Mothers with a positive screen for depression reported poorer health status for themselves (P 5 .014) but not for their children (P 5 .37). Conclusions.—Screening questionnaires in both primary care and emergency care settings with sociodemographically similar groups of mothers produced similar rates of depression. The high rates of depressive symptoms and of mothers’ reports that these symptoms cause them difficulty in caring for their children indicate that resources to screen for and address depressive symptoms in mothers should receive higher priority in pediatric health care settings. KEY WORDS:
maternal depression; maternal role functioning
Ambulatory Pediatrics 2003;3:142 146
M
ental illness imposes a substantial burden on the individual, the family, and society.1,2 Women of childbearing age are at a high risk of first onset depression.3,4 The number of people with mental health disorders is much greater than the number treated. This discrepancy exists, in part, because mental health disorders are often unrecognized, even by health care providers3,5,6 and, once identified, are often not treated.5 This underrecognition may be highest in mothers with young children because these mothers may lack their own source of primary care7 and are stressed by the demands of child rearing. Furthermore, when children are brought to emergency departments (EDs) for care, maternal mental health problems are likely to go undetected because of the high patient volume and the problem-focused approach to care
in that setting. These occasions represent a lost opportunity for the identification and referral of mothers with mental health problems and, perhaps, the chance to alter a root cause of their children’s distress and the health care utilization pattern8 that may arise from that distress. As such, the pediatric ED presents a unique and important setting to identify and intervene in mothers’ mental health. Approximately 1 in 5 mothers screens positive for depressive symptoms in primary care settings.5,9 However, no study has analyzed rates of maternal depression in an ED setting. Furthermore, no study has assessed mothers’ perceptions of how their depressive symptoms affect their ability to care for their children. The purpose of this study was to measure rates of maternal depression in 2 groups of women and to describe how depressed women perceive the level of difficulty in caring for their children. METHODS
From the Divisions of Emergency Medicine (Dr Grupp-Phelan and Ms Naish); and General and Community Pediatrics (Dr Whitaker), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio. Address correspondence to Jacqueline Grupp-Phelan, MD, MPH, Division of Emergency Medicine, Children’s Hospital Medical Center, 3333 Burnet Ave, ML 2008, Cincinnati, OH 45213 (e-mail: [email protected]). Received for publication June 14, 2002; accepted December 30, 2002. AMBULATORY PEDIATRICS Copyright q 2003 by Ambulatory Pediatric Association
Overview Between April and July of 2000, we asked mothers to complete a validated, self-administered questionnaire containing items about their mental health symptoms. The questionnaires were given to mothers bringing their children to an ED for low-acuity illnesses. As a comparison, we also administered questionnaires to a sociodemograph-
142
Volume 3, Number 3 May–June 2003
AMBULATORY PEDIATRICS
ically similar group of mothers bringing their children to a primary care clinic for well-child care. The Institutional Review Board at the Cincinnati Children’s Hospital Medical Center (CCHMC) in Cincinnati, Ohio, approved the study protocol. Setting CCHMC is an urban, tertiary-care medical center that is the major provider of pediatric emergency care to children living in the 8 surrounding counties of southern Ohio, northern Kentucky, and southeastern Indiana. It is also the major provider of primary care for the neighborhoods surrounding the hospital. The hospital’s ED has approximately 86 000 visits each year, and the hospital’s Pediatric Primary Care Clinic (PPC) has approximately 30 000 visits each year. The study was conducted in 2 settings at CCHMC that see predominately low-income children living near the hospital, the PPC, and in the satellite ED (SED), which is the part of the ED that sees children presenting with low-acuity problems. In the CCHMC ED, patients are triaged upon presentation and are sent to the adjoining SED if they are clinically stable and not ill appearing. These nonurgent patients are evaluated as soon as possible but are judged at triage to be at no risk of clinical deterioration over the course of the next 2 hours. Typical diagnoses in the SED include colds, rashes, earaches, sore throats, and minor injuries. Participants To avoid sampling bias, mothers were recruited during specific hours on Tuesdays and Thursdays in both sites— afternoon well-child clinic in PPC and evening hours (5 pm to midnight) in the SED. During these sampling periods, all biologic mothers arriving with children 6 months to 18 years of age were asked to participate in the study. We excluded mothers who were less than 18 years of age. We also excluded those who did not speak English because they make up a small minority of the patient population (,1%). Of the 502 eligible mothers asked to participate, only 10 (1.9%) declined. Mothers were given a $5 incentive to complete the questionnaire. Because there was a question regarding suicidal ideation, the consent form explicitly stated that we would be obligated to make further inquiry, and immediate or short-term referral as necessary, if suicidal ideation were reported on the questionnaire. Of the 492 mothers in the study, 249 were enrolled in the SED and 243 in the PPC. Although 36% of the mothers in the SED also reported receiving some primary care services at PPC, no mother completed the survey at both sites. Questionnaire Informed consent was obtained after the mother registered at the SED or PPC but before seeing the physician. We screened mothers for mental health disorders using the Prime MD Patient Health Questionnaire (PHQ). The PHQ is a 4-page, self-administered questionnaire10 that screens for 3 ‘‘threshold disorders’’ that correspond to specific
Maternal Depression and Effects on Role Functioning
143
diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)11—major depressive disorder, panic disorder, and anxiety disorder. It also screens for ‘‘subthreshold depressive disorder’’ whose criteria encompass fewer symptoms than are required for the DSM-IV diagnoses of major depressive disorder. Finally, the PHQ assesses the presence of somatic symptoms. Although depression was our disorder of interest, we were also interested in measuring the often comorbid diagnoses of anxiety, panic, and somatoform disorders. The PHQ is a screening tool and not a diagnostic tool. Thus, we refer to those screening positive for various disorders assessed by the PHQ as having a positive screen for a mental health problem rather than as having a mental illness diagnosis, per se. Although we did not perform any diagnostic interviews, the performance characteristics of the PHQ as a screening tool suggest that mothers screening positive are likely to have a mental health diagnosis. Analysis of data from both a general population and a population of patients with mental illness12 showed that there is good agreement between PHQ diagnoses and those of independent mental health professionals with an overall accuracy of 85%, a sensitivity of 75%, and a specificity of 90%. The PHQ has been used as a successful screen for depression and anxiety in various health care settings.13 In addition to answering questions about demographic characteristics we also asked mothers 2 questions about their perceived role functioning. First, we asked mothers who had reported any symptoms on the PHQ mental health inventory about the impact of these problems on their overall life (‘‘If you marked off any problems on this questionnaire, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?’’). In addition we asked mothers about how they perceived the impact of these problems on caring for their children (‘‘If you marked off any problems on this questionnaire, how difficult have these problems made it for you to take care of your children the way that you would like to?’’). For both these questions on perceived functioning, there were 4 possible responses—‘‘not difficult at all, somewhat difficult, very difficult,’’ and ‘‘extremely difficult.’’ Mothers were asked to rate their own and their child’s health as poor, fair, good, very good, or excellent. Analysis We used SPSS (Version 10; SPSS, Chicago, Ill) to perform statistical analysis. Chi-square tests were used to compare differences between PPC and SED settings in the proportion of mothers with and without mental health problems. We then used Chi-square tests to examine the relationship between maternal depression and the mothers’ 1) demographic characteristics, 2) rating of their own health status, 3) rating of their child’s health status, 4) reported difficulty with overall life functioning, and 5) reported difficulty taking care of their children. Power calculations were based on the ability to determine a difference in the prevalence of maternal depression in the PPC
144
Grupp-Phelan et al
AMBULATORY PEDIATRICS
Table 1. Sociodemographic Variables for Study Subjects by Study Site† Characteristic Age of mother (mean 6 SE, y)* Age of child (mean 6 SD, mo) Married (%)‡ Male child (%) High school education or less (%) Race*** White (%) Black (%) Other (%) Health insurance status* Medicaid, none, or selfpay (%) Commercial (%) Mental disorder Major depression (%) Subthreshold ideation (%) Suicidal ideation (%) Anxiety disorder (%) Panic disorder (%) $3 Somatic symptoms (%) Any mental health problem (%)§
PPC (n 5 249)
SED (n 5 243)
Total (n 5 492)
26 6 7
28 6 8
27 6 7
53 6 64 43 52
68 6 62 45 49
61 6 63 44 50
76
78
77
Table 2. Maternal Perception of Mother’s Role Functioning, Health, and Child’s Health by Maternal Depression Screening Status
Characteristic
25 72 3
90 10
28 71 1
78 22
9
10
8 6 6 2
8 5 4 5
21
20
30
29
27 71 2
84 16
†PPC indicates Pediatric Primary Care clinic; SED, Satellite Emergency Department. ‡ ‘‘Married ’’included those who selected the response ‘‘Not married but living together with someone as if married.’’ All those with suicidal ideation met criteria for major depression. §Includes those having a positive screen for either depression (major or substhreshold), anxiety disorder, panic disorder, or $3 somatic symptoms. Thirteen percent of mothers had a positive screen for more than 1 of these 4 mental health problems. *P , .002. ***P between .05 and .10.
and SED. Two-hundred fifty patients in each site were needed to detect a 10% difference in prevalence of maternal depressive symptoms, with a power of 80% and an alpha of 0.05. We assumed that 15% of mothers in the PPC would screen positive for depression. RESULTS Demographic Characteristics and Prevalence of Depression The mothers in the PPC and SED had similar sociodemographic characteristics, except that the mothers and their children were slightly younger in the PPC and were also less likely to have commercial insurance (Table 1). There were no significant differences between SED and PPC mothers in the percentage having a positive screen for any of the mental health disorders (Table 1). Across both sites, 18% of mothers had a positive screen for either major or subthreshold depression. Overall, 1 out of every 20 mothers reported suicidal ideation (‘‘Thoughts that you
Major Subthreshold Depression Depression (%) (%)
Not Depressed (%)
Difficulty in life functioning† Somewhat to extreme difficulty 87 No difficulty 13
62 38
32 68
Difficulty caring for child‡* Somewhat to extreme difficulty No difficulty
76 24
37 63
17 83
Own health§* Poor or fair Good to excellent
34 66
15 85
13 87
Child’s health§ Poor to fair Good to excellent
2 98
5 95
5 95
†In response to question ‘‘How difficult have these problems [refers to any mental health symptom reported] made it for you to do your work, take care of things at home, or get along with other people?’’ ‡In response to question ‘‘How difficult have these problems [refers to any mental health symptom reported] made it for you to take care of your children the way that you would like to?’’ §All differences across 3 categories of depression were evaluated using the Mantel Haenszel Chi-square. *P , .01.
would be better off dead or of hurting yourself in some ways’’) on at least several days in the prior 2 weeks. Approximately 30% of mothers in each group had a positive screen for 1 of 4 mental health problems: depression (either major or subthreshold), anxiety disorder, panic disorder, or somatic complaints (3 or more complaints). Overall, 13% of mothers had a positive screen for more than 1 of these 4 mental health problems. For example, 61% of those mothers with positive screens for depression also had 3 or more somatic complaints. Being married, uninsured, and having no more than a high school education were all associated with having a positive screen for at least one mental health problem (data not shown). We categorized mothers with depressive symptoms into 3 groups according to the outcome of their depression screen on the PHQ: not depressed, subthreshold depression, and major depression. We then investigated the relationship between depressive symptom severity and the mother’s perceptions of her own role functioning, her own health status, and her child’s health status. As symptoms of depression increased in severity, so did maternal reports of difficulty in their overall life functioning and, specifically, in caring for their children (Table 2). More than three quarters of mothers with symptoms of major depression reported that the mental health symptoms they noted on the PHQ had resulted in ‘‘somewhat’’ to ‘‘extreme’’ difficulty in taking care of their children. This was also true for over one third of mothers with subthreshold depression. Nearly 90% of mothers with a positive screen for major depression felt that their mental health symp-
AMBULATORY PEDIATRICS
toms caused them ‘‘somewhat’’ to ‘‘extreme’’ difficulty in their overall role functioning (at work, home, or in their relationships). Although mothers with more severe depressive symptoms were less likely to report their own health as good or excellent, there was no apparent relationship between maternal depressive symptoms and how they rated child’s health. The majority of mothers interviewed felt ‘‘not uncomfortable at all’’ with the questions in the survey (80%) and most also felt that the questions asked would be ‘‘somewhat to extremely helpful’’ to the health care professionals caring for their children (74%). DISCUSSION This is the first study to examine the prevalence of maternal mental health problems among mothers bringing their children to a pediatric ED for evaluation of lowacuity illnesses. We found that the prevalence of maternal mental health problems in this setting was similar to that in an urban pediatric PPC serving a sociodemographically similar population at the same institution. In both settings, almost 1 in 5 mothers had a positive screen for depression (major or subthreshold depression), with 1 in 20 reporting suicidal ideation on several or more days in the prior 2 weeks. The rates of positive screens for maternal depressive symptoms in our study are similar to those obtained in studies in other urban, pediatric PPCs, 5,7,14–16 in nonurban pediatric practices,17 and from a national sample of lowincome mothers.18 The difference in rates across studies could largely result from the use of varied screening instruments and their associated cut-points for establishing positive screens. The PHQ was used to screen over 3000 pregnant women receiving obstetrical care in 7 clinics in 5 US cities. The rates of positive screens for major depression (6%, range 22% to 14%) and for subthreshold depression (6%, range 24% to 17%) were very similar to those discovered in our study.13 The major contribution of this study was to describe how mothers perceive that their own mental health symptoms affect their role functioning in caring for their children. Maternal depression is known to affect many aspects of maternal role functioning and maternal-child interactions.19–24 However, we are not aware of any other study that has specifically assessed whether mothers themselves believe that their symptoms are making it difficult for them to take care of their children the way that they would like to. Although services for mothers with depression are still lacking, we believe that mothers with depression would use available services if they perceived, as they do, impaired functioning in their role as parents. We suspect that any social desirability bias in the response to the question on parental role functioning would lead to an underestimate of these difficulties. As anticipated, mothers more often reported these difficulties, along with difficulties in their overall role functioning, as the severity of depressive symptoms increased (major vs subthreshold depression). Our findings are consistent with those of other studies showing that even subthreshold depression25 has significant effects on adult functioning. These effects on
Maternal Depression and Effects on Role Functioning
145
functioning are comparable to those caused by major chronic illnesses.26 Nine percent of mothers in our study, for example, screened positive for subthreshold depression, and two thirds of this group reported some difficulty with overall role functioning, compared to one third of those with a negative depression screen. Because screening for suicidal ideation and other sensitive questions may bring about discomfort among mothers interviewed, during this study we asked mothers how they felt about answering these questions in the PPC and ED settings. The majority of the mothers were comfortable being asked these questions. Furthermore, the great majority of mothers felt that their answers to the mental health screening questions would be helpful to those health professionals caring for their children. These findings are consistent with those of Kahn et al,7 who found that the vast majority of mothers would either ‘‘welcome’’ or ‘‘not mind at all’’ having their child’s health care provider make inquiries about maternal depressive symptoms and referrals to adult providers. Consistent with other studies in the literature, those adults who screened positive for major depression were more likely to report poorer general health 27 and more somatic complaints.28 Despite this connection between self-assessed physical well-being and depression in mothers, we, like others,29,30 found no evidence that maternal depression alone negatively affected a mother’s perception of her child’s health. We did not confirm positive screens with a formal diagnostic interview. Nonetheless, among mothers bringing their children to an urban, pediatric ED for evaluation of low-acuity illnesses, we have shown what other investigators have shown in different settings: high rates of depressive symptoms, comorbid somatic symptoms, a relation between self-reported health and depressive symptoms, no relation between the perception of the child’s health and depressive symptoms, and an openness to being asked by child health care providers about maternal mental health symptoms. Beyond that, we have documented a high rate of suicidal ideation and a strong relationship between a mother’s depressive symptoms and her perceived functioning in caring for her child. A mother’s perceptions about mental health symptoms affecting her role functioning leads to concern for child health care providers, regardless of whether the mother is ultimately found to meet formal diagnostic criteria for a mental health disorder. High rates of maternal depressive symptoms, the reported impact of these symptoms on caring for their children, mothers’ willingness to accept screening and referral,7 and effective treatments for depression31 all indicate that resources to screen for and address maternal mental health problems, particularly depression, should receive higher priority in child health care settings.32 The recent Surgeon General’s Report on Mental Health33 highlighted the impact of mental health disorders on adult functioning and economic productivity, the failure of the current health care system to detect and treat these disorders, and the possible reasons for this failure.
146
Grupp-Phelan et al
The findings of our study emphasize several of these points as they relate to maternal and child health. First, mothers with depressive symptoms report that these symptoms affect how well they function in part of their work—caring for their children. Second, maternal mental health screening and systems of referral need to be incorporated into all settings in which health care is provided to children, including EDs. Third, providing this service to mothers is part of good care for their children, a point that was recognized many years ago.24 If the mother mediates a prescribed prevention or treatment plan, it is necessary to consider whether maternal mental health problems will interfere with her ability to understand and execute that plan.34 Increased understanding about the impact in adulthood of childhood exposure to parental mental health problems35 may also increase attention with regard to helping child health care providers extend their practice to detect and refer parents with mental health problems.
AMBULATORY PEDIATRICS
14.
15.
16.
17.
18.
19. 20.
21.
ACKNOWLEDGMENTS We would like to thank Thomas G. DeWitt, MD, and Richard M. Ruddy, MD, for their support of this project. We would like to acknowledge the important intellectual contribution of Robert Kahn, MD, who helped us develop the question for this study on mothers’ perceptions of their ability to care for their children. Dr. Whitaker’s efforts on this project were supported, in part, by the Center for Health and Wellbeing, Woodrow Wilson School of Public and International Affairs, Princeton University.
22. 23.
24. 25.
REFERENCES 1. Bland RC. Psychiatry and the burden of mental illness. Can J Psychiatr. 1998;43:801–810. 2. Jenkins R. Reducing the burden of mental illness. Lancet. 1997; 349:611–612. 3. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12month prevalence of DSM-III-R psychiatric disorders in the United States. Arch Gen Psychiatr. 1994;51:8–19. 4. Weissman MM, John K, Merikangas KR, et al. Depressed parents and their children. General health, social, and psychiatric problems. Am J Dis Child. 1986;140:801–805. 5. Kemper KJ, Babonis TR. Screening for maternal depression in pediatric clinics. Am J Dis Child. 1992;146:876–878. 6. Cross National Collaborative Group. The changing rate of major depression. JAMA. 1992;268:3098–3105. 7. Kahn RS, Wise PH, Finkelstein JA, et al. The scope of unmet maternal health needs in pediatric settings. Pediatrics. 1999; 103:576–581. 8. Mandl KD, Tronick EZ, Brennan TA, et al. Infant health care use and maternal depression. Arch Pediatr Adolesc Med. 1999; 153:808–813. 9. Mulrow CD. Case-finding instruments for depression in primary care settings. Ann Intern Med. 1995;122:913–921. 10. Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. JAMA. 1994;272:1749–1756. 11. First MB, ed. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000. 12. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999;282:1737–1744. 13. Spitzer RL, Williams JB, Kroenke K, et al. Validity and utility of the PRIME-MD patient health questionnaire in assessment
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
of 3000 obstetric-gynecologic patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study. Am J Obstet Gynecol. 2000;183:759–769. Hall LA, Williams CA, Greenberg RS. Supports, stressors, and depressive symptoms in low-income mothers of young children. Am J Public Health. 1985;75:518–522. Heneghan AM, Silver EJ, Bauman LJ, et al. Do pediatricians recognize mothers with depressive symptoms? Pediatrics. 2000; 106:1367–1373. Orr ST, James S. Maternal depression in an urban pediatric practice: implications for health care delivery. Am J Public Health. 1984;74:363–365. Olson AL, DiBrigida LA. Depressive symptoms and work role satisfaction in mothers of toddlers. Pediatrics. 1994;94:363– 367. Lanzi RG, Pascoe JM, Keltner B, et al. Correlates of maternal depressive symptoms in a national Head Start program sample. Arch Pediatr Adolesc Med. 1999;153:801–807. Beck CT. Maternal depression and child behaviour problems: a meta-analysis. J Adv Nurs. 1999;29:623–629. Cogill SR, Caplan HL, Alexandra H, et al. Impact of maternal postnatal depression on cognitive development of young children. Br Med J (Clin Res Ed). 1986;292:1165–1167. Fergusson DM, Lynskey MT. The effects of maternal depression on child conduct disorder and attention deficit behaviours. Soc Psychiatr Epidemiol. 1993;28:116–123. Field T. Maternal depression effects on infants and early interventions. Prev Med. 1998;27:200–203. Weinberg MK, Tronick EZ. Emotional characteristics of infants associated with maternal depression and anxiety. Pediatrics. 1998;102:1298–1304. Zuckerman BS, Beardslee WR. Maternal depression: a concern for pediatricians. Pediatrics. 1987;79:110–117. Judd LL, Rapaport MH, Paulus MP, et al. Subsyndromal symptomatic depression: a new mood disorder? J Clin Psychiatr. 1994;55(suppl):18–28. Wells KB, Stewart A, Hays RD, et al. The functioning and wellbeing of depressed patients. Results from the Medical Outcomes Study. JAMA. 1989;262:914–919. Heneghan AM, Silver EJ, Bauman LJ, et al. Depressive symptoms in inner-city mothers of young children: who is at risk? Pediatrics. 1998;102:1394–1400. Simon GE, VonKorff M, Piccinelli M, et al. An international study of the relation between somatic symptoms and depression. N Engl J Med. 1999;341:1329–1335. Dadds MR, Stein RE, Silver EJ. The role of maternal psychological adjustment in the measurement of children’s functional status. J Pediatr Psychol. 1995;20:527–544. McCormick MC, Brooks-Gunn J, Shorter T, et al. Factors associated with maternal rating of infant health in central Harlem. J Dev Behav Pediatr. 1989;10:139–144. Agency for Health Care Policy and Research. Treatment of Depression: Newer Pharmacotherapies: Evidence Report/Technology Assessment Number 7. Rockville, Md: Agency for Health Care Policy and Research; 1999. US Department of Health and Human Services. Healthy Children 2000. Washington, DC: US Department of Health and Human Services; 1991. US Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, Md: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999. Zuckerman BS, Kahn RS. Pathways to early child health and development. In: Securing the Future. New York: Russell Sage Foundation; 2000:330. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14:245–258.
maternal depression; maternal role functioning
Ambulatory Pediatrics 2003;3:142 146
M
ental illness imposes a substantial burden on the individual, the family, and society.1,2 Women of childbearing age are at a high risk of first onset depression.3,4 The number of people with mental health disorders is much greater than the number treated. This discrepancy exists, in part, because mental health disorders are often unrecognized, even by health care providers3,5,6 and, once identified, are often not treated.5 This underrecognition may be highest in mothers with young children because these mothers may lack their own source of primary care7 and are stressed by the demands of child rearing. Furthermore, when children are brought to emergency departments (EDs) for care, maternal mental health problems are likely to go undetected because of the high patient volume and the problem-focused approach to care
in that setting. These occasions represent a lost opportunity for the identification and referral of mothers with mental health problems and, perhaps, the chance to alter a root cause of their children’s distress and the health care utilization pattern8 that may arise from that distress. As such, the pediatric ED presents a unique and important setting to identify and intervene in mothers’ mental health. Approximately 1 in 5 mothers screens positive for depressive symptoms in primary care settings.5,9 However, no study has analyzed rates of maternal depression in an ED setting. Furthermore, no study has assessed mothers’ perceptions of how their depressive symptoms affect their ability to care for their children. The purpose of this study was to measure rates of maternal depression in 2 groups of women and to describe how depressed women perceive the level of difficulty in caring for their children. METHODS
From the Divisions of Emergency Medicine (Dr Grupp-Phelan and Ms Naish); and General and Community Pediatrics (Dr Whitaker), Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio. Address correspondence to Jacqueline Grupp-Phelan, MD, MPH, Division of Emergency Medicine, Children’s Hospital Medical Center, 3333 Burnet Ave, ML 2008, Cincinnati, OH 45213 (e-mail: [email protected]). Received for publication June 14, 2002; accepted December 30, 2002. AMBULATORY PEDIATRICS Copyright q 2003 by Ambulatory Pediatric Association
Overview Between April and July of 2000, we asked mothers to complete a validated, self-administered questionnaire containing items about their mental health symptoms. The questionnaires were given to mothers bringing their children to an ED for low-acuity illnesses. As a comparison, we also administered questionnaires to a sociodemograph-
142
Volume 3, Number 3 May–June 2003
AMBULATORY PEDIATRICS
ically similar group of mothers bringing their children to a primary care clinic for well-child care. The Institutional Review Board at the Cincinnati Children’s Hospital Medical Center (CCHMC) in Cincinnati, Ohio, approved the study protocol. Setting CCHMC is an urban, tertiary-care medical center that is the major provider of pediatric emergency care to children living in the 8 surrounding counties of southern Ohio, northern Kentucky, and southeastern Indiana. It is also the major provider of primary care for the neighborhoods surrounding the hospital. The hospital’s ED has approximately 86 000 visits each year, and the hospital’s Pediatric Primary Care Clinic (PPC) has approximately 30 000 visits each year. The study was conducted in 2 settings at CCHMC that see predominately low-income children living near the hospital, the PPC, and in the satellite ED (SED), which is the part of the ED that sees children presenting with low-acuity problems. In the CCHMC ED, patients are triaged upon presentation and are sent to the adjoining SED if they are clinically stable and not ill appearing. These nonurgent patients are evaluated as soon as possible but are judged at triage to be at no risk of clinical deterioration over the course of the next 2 hours. Typical diagnoses in the SED include colds, rashes, earaches, sore throats, and minor injuries. Participants To avoid sampling bias, mothers were recruited during specific hours on Tuesdays and Thursdays in both sites— afternoon well-child clinic in PPC and evening hours (5 pm to midnight) in the SED. During these sampling periods, all biologic mothers arriving with children 6 months to 18 years of age were asked to participate in the study. We excluded mothers who were less than 18 years of age. We also excluded those who did not speak English because they make up a small minority of the patient population (,1%). Of the 502 eligible mothers asked to participate, only 10 (1.9%) declined. Mothers were given a $5 incentive to complete the questionnaire. Because there was a question regarding suicidal ideation, the consent form explicitly stated that we would be obligated to make further inquiry, and immediate or short-term referral as necessary, if suicidal ideation were reported on the questionnaire. Of the 492 mothers in the study, 249 were enrolled in the SED and 243 in the PPC. Although 36% of the mothers in the SED also reported receiving some primary care services at PPC, no mother completed the survey at both sites. Questionnaire Informed consent was obtained after the mother registered at the SED or PPC but before seeing the physician. We screened mothers for mental health disorders using the Prime MD Patient Health Questionnaire (PHQ). The PHQ is a 4-page, self-administered questionnaire10 that screens for 3 ‘‘threshold disorders’’ that correspond to specific
Maternal Depression and Effects on Role Functioning
143
diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)11—major depressive disorder, panic disorder, and anxiety disorder. It also screens for ‘‘subthreshold depressive disorder’’ whose criteria encompass fewer symptoms than are required for the DSM-IV diagnoses of major depressive disorder. Finally, the PHQ assesses the presence of somatic symptoms. Although depression was our disorder of interest, we were also interested in measuring the often comorbid diagnoses of anxiety, panic, and somatoform disorders. The PHQ is a screening tool and not a diagnostic tool. Thus, we refer to those screening positive for various disorders assessed by the PHQ as having a positive screen for a mental health problem rather than as having a mental illness diagnosis, per se. Although we did not perform any diagnostic interviews, the performance characteristics of the PHQ as a screening tool suggest that mothers screening positive are likely to have a mental health diagnosis. Analysis of data from both a general population and a population of patients with mental illness12 showed that there is good agreement between PHQ diagnoses and those of independent mental health professionals with an overall accuracy of 85%, a sensitivity of 75%, and a specificity of 90%. The PHQ has been used as a successful screen for depression and anxiety in various health care settings.13 In addition to answering questions about demographic characteristics we also asked mothers 2 questions about their perceived role functioning. First, we asked mothers who had reported any symptoms on the PHQ mental health inventory about the impact of these problems on their overall life (‘‘If you marked off any problems on this questionnaire, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?’’). In addition we asked mothers about how they perceived the impact of these problems on caring for their children (‘‘If you marked off any problems on this questionnaire, how difficult have these problems made it for you to take care of your children the way that you would like to?’’). For both these questions on perceived functioning, there were 4 possible responses—‘‘not difficult at all, somewhat difficult, very difficult,’’ and ‘‘extremely difficult.’’ Mothers were asked to rate their own and their child’s health as poor, fair, good, very good, or excellent. Analysis We used SPSS (Version 10; SPSS, Chicago, Ill) to perform statistical analysis. Chi-square tests were used to compare differences between PPC and SED settings in the proportion of mothers with and without mental health problems. We then used Chi-square tests to examine the relationship between maternal depression and the mothers’ 1) demographic characteristics, 2) rating of their own health status, 3) rating of their child’s health status, 4) reported difficulty with overall life functioning, and 5) reported difficulty taking care of their children. Power calculations were based on the ability to determine a difference in the prevalence of maternal depression in the PPC
144
Grupp-Phelan et al
AMBULATORY PEDIATRICS
Table 1. Sociodemographic Variables for Study Subjects by Study Site† Characteristic Age of mother (mean 6 SE, y)* Age of child (mean 6 SD, mo) Married (%)‡ Male child (%) High school education or less (%) Race*** White (%) Black (%) Other (%) Health insurance status* Medicaid, none, or selfpay (%) Commercial (%) Mental disorder Major depression (%) Subthreshold ideation (%) Suicidal ideation (%) Anxiety disorder (%) Panic disorder (%) $3 Somatic symptoms (%) Any mental health problem (%)§
PPC (n 5 249)
SED (n 5 243)
Total (n 5 492)
26 6 7
28 6 8
27 6 7
53 6 64 43 52
68 6 62 45 49
61 6 63 44 50
76
78
77
Table 2. Maternal Perception of Mother’s Role Functioning, Health, and Child’s Health by Maternal Depression Screening Status
Characteristic
25 72 3
90 10
28 71 1
78 22
9
10
8 6 6 2
8 5 4 5
21
20
30
29
27 71 2
84 16
†PPC indicates Pediatric Primary Care clinic; SED, Satellite Emergency Department. ‡ ‘‘Married ’’included those who selected the response ‘‘Not married but living together with someone as if married.’’ All those with suicidal ideation met criteria for major depression. §Includes those having a positive screen for either depression (major or substhreshold), anxiety disorder, panic disorder, or $3 somatic symptoms. Thirteen percent of mothers had a positive screen for more than 1 of these 4 mental health problems. *P , .002. ***P between .05 and .10.
and SED. Two-hundred fifty patients in each site were needed to detect a 10% difference in prevalence of maternal depressive symptoms, with a power of 80% and an alpha of 0.05. We assumed that 15% of mothers in the PPC would screen positive for depression. RESULTS Demographic Characteristics and Prevalence of Depression The mothers in the PPC and SED had similar sociodemographic characteristics, except that the mothers and their children were slightly younger in the PPC and were also less likely to have commercial insurance (Table 1). There were no significant differences between SED and PPC mothers in the percentage having a positive screen for any of the mental health disorders (Table 1). Across both sites, 18% of mothers had a positive screen for either major or subthreshold depression. Overall, 1 out of every 20 mothers reported suicidal ideation (‘‘Thoughts that you
Major Subthreshold Depression Depression (%) (%)
Not Depressed (%)
Difficulty in life functioning† Somewhat to extreme difficulty 87 No difficulty 13
62 38
32 68
Difficulty caring for child‡* Somewhat to extreme difficulty No difficulty
76 24
37 63
17 83
Own health§* Poor or fair Good to excellent
34 66
15 85
13 87
Child’s health§ Poor to fair Good to excellent
2 98
5 95
5 95
†In response to question ‘‘How difficult have these problems [refers to any mental health symptom reported] made it for you to do your work, take care of things at home, or get along with other people?’’ ‡In response to question ‘‘How difficult have these problems [refers to any mental health symptom reported] made it for you to take care of your children the way that you would like to?’’ §All differences across 3 categories of depression were evaluated using the Mantel Haenszel Chi-square. *P , .01.
would be better off dead or of hurting yourself in some ways’’) on at least several days in the prior 2 weeks. Approximately 30% of mothers in each group had a positive screen for 1 of 4 mental health problems: depression (either major or subthreshold), anxiety disorder, panic disorder, or somatic complaints (3 or more complaints). Overall, 13% of mothers had a positive screen for more than 1 of these 4 mental health problems. For example, 61% of those mothers with positive screens for depression also had 3 or more somatic complaints. Being married, uninsured, and having no more than a high school education were all associated with having a positive screen for at least one mental health problem (data not shown). We categorized mothers with depressive symptoms into 3 groups according to the outcome of their depression screen on the PHQ: not depressed, subthreshold depression, and major depression. We then investigated the relationship between depressive symptom severity and the mother’s perceptions of her own role functioning, her own health status, and her child’s health status. As symptoms of depression increased in severity, so did maternal reports of difficulty in their overall life functioning and, specifically, in caring for their children (Table 2). More than three quarters of mothers with symptoms of major depression reported that the mental health symptoms they noted on the PHQ had resulted in ‘‘somewhat’’ to ‘‘extreme’’ difficulty in taking care of their children. This was also true for over one third of mothers with subthreshold depression. Nearly 90% of mothers with a positive screen for major depression felt that their mental health symp-
AMBULATORY PEDIATRICS
toms caused them ‘‘somewhat’’ to ‘‘extreme’’ difficulty in their overall role functioning (at work, home, or in their relationships). Although mothers with more severe depressive symptoms were less likely to report their own health as good or excellent, there was no apparent relationship between maternal depressive symptoms and how they rated child’s health. The majority of mothers interviewed felt ‘‘not uncomfortable at all’’ with the questions in the survey (80%) and most also felt that the questions asked would be ‘‘somewhat to extremely helpful’’ to the health care professionals caring for their children (74%). DISCUSSION This is the first study to examine the prevalence of maternal mental health problems among mothers bringing their children to a pediatric ED for evaluation of lowacuity illnesses. We found that the prevalence of maternal mental health problems in this setting was similar to that in an urban pediatric PPC serving a sociodemographically similar population at the same institution. In both settings, almost 1 in 5 mothers had a positive screen for depression (major or subthreshold depression), with 1 in 20 reporting suicidal ideation on several or more days in the prior 2 weeks. The rates of positive screens for maternal depressive symptoms in our study are similar to those obtained in studies in other urban, pediatric PPCs, 5,7,14–16 in nonurban pediatric practices,17 and from a national sample of lowincome mothers.18 The difference in rates across studies could largely result from the use of varied screening instruments and their associated cut-points for establishing positive screens. The PHQ was used to screen over 3000 pregnant women receiving obstetrical care in 7 clinics in 5 US cities. The rates of positive screens for major depression (6%, range 22% to 14%) and for subthreshold depression (6%, range 24% to 17%) were very similar to those discovered in our study.13 The major contribution of this study was to describe how mothers perceive that their own mental health symptoms affect their role functioning in caring for their children. Maternal depression is known to affect many aspects of maternal role functioning and maternal-child interactions.19–24 However, we are not aware of any other study that has specifically assessed whether mothers themselves believe that their symptoms are making it difficult for them to take care of their children the way that they would like to. Although services for mothers with depression are still lacking, we believe that mothers with depression would use available services if they perceived, as they do, impaired functioning in their role as parents. We suspect that any social desirability bias in the response to the question on parental role functioning would lead to an underestimate of these difficulties. As anticipated, mothers more often reported these difficulties, along with difficulties in their overall role functioning, as the severity of depressive symptoms increased (major vs subthreshold depression). Our findings are consistent with those of other studies showing that even subthreshold depression25 has significant effects on adult functioning. These effects on
Maternal Depression and Effects on Role Functioning
145
functioning are comparable to those caused by major chronic illnesses.26 Nine percent of mothers in our study, for example, screened positive for subthreshold depression, and two thirds of this group reported some difficulty with overall role functioning, compared to one third of those with a negative depression screen. Because screening for suicidal ideation and other sensitive questions may bring about discomfort among mothers interviewed, during this study we asked mothers how they felt about answering these questions in the PPC and ED settings. The majority of the mothers were comfortable being asked these questions. Furthermore, the great majority of mothers felt that their answers to the mental health screening questions would be helpful to those health professionals caring for their children. These findings are consistent with those of Kahn et al,7 who found that the vast majority of mothers would either ‘‘welcome’’ or ‘‘not mind at all’’ having their child’s health care provider make inquiries about maternal depressive symptoms and referrals to adult providers. Consistent with other studies in the literature, those adults who screened positive for major depression were more likely to report poorer general health 27 and more somatic complaints.28 Despite this connection between self-assessed physical well-being and depression in mothers, we, like others,29,30 found no evidence that maternal depression alone negatively affected a mother’s perception of her child’s health. We did not confirm positive screens with a formal diagnostic interview. Nonetheless, among mothers bringing their children to an urban, pediatric ED for evaluation of low-acuity illnesses, we have shown what other investigators have shown in different settings: high rates of depressive symptoms, comorbid somatic symptoms, a relation between self-reported health and depressive symptoms, no relation between the perception of the child’s health and depressive symptoms, and an openness to being asked by child health care providers about maternal mental health symptoms. Beyond that, we have documented a high rate of suicidal ideation and a strong relationship between a mother’s depressive symptoms and her perceived functioning in caring for her child. A mother’s perceptions about mental health symptoms affecting her role functioning leads to concern for child health care providers, regardless of whether the mother is ultimately found to meet formal diagnostic criteria for a mental health disorder. High rates of maternal depressive symptoms, the reported impact of these symptoms on caring for their children, mothers’ willingness to accept screening and referral,7 and effective treatments for depression31 all indicate that resources to screen for and address maternal mental health problems, particularly depression, should receive higher priority in child health care settings.32 The recent Surgeon General’s Report on Mental Health33 highlighted the impact of mental health disorders on adult functioning and economic productivity, the failure of the current health care system to detect and treat these disorders, and the possible reasons for this failure.
146
Grupp-Phelan et al
The findings of our study emphasize several of these points as they relate to maternal and child health. First, mothers with depressive symptoms report that these symptoms affect how well they function in part of their work—caring for their children. Second, maternal mental health screening and systems of referral need to be incorporated into all settings in which health care is provided to children, including EDs. Third, providing this service to mothers is part of good care for their children, a point that was recognized many years ago.24 If the mother mediates a prescribed prevention or treatment plan, it is necessary to consider whether maternal mental health problems will interfere with her ability to understand and execute that plan.34 Increased understanding about the impact in adulthood of childhood exposure to parental mental health problems35 may also increase attention with regard to helping child health care providers extend their practice to detect and refer parents with mental health problems.
AMBULATORY PEDIATRICS
14.
15.
16.
17.
18.
19. 20.
21.
ACKNOWLEDGMENTS We would like to thank Thomas G. DeWitt, MD, and Richard M. Ruddy, MD, for their support of this project. We would like to acknowledge the important intellectual contribution of Robert Kahn, MD, who helped us develop the question for this study on mothers’ perceptions of their ability to care for their children. Dr. Whitaker’s efforts on this project were supported, in part, by the Center for Health and Wellbeing, Woodrow Wilson School of Public and International Affairs, Princeton University.
22. 23.
24. 25.
REFERENCES 1. Bland RC. Psychiatry and the burden of mental illness. Can J Psychiatr. 1998;43:801–810. 2. Jenkins R. Reducing the burden of mental illness. Lancet. 1997; 349:611–612. 3. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12month prevalence of DSM-III-R psychiatric disorders in the United States. Arch Gen Psychiatr. 1994;51:8–19. 4. Weissman MM, John K, Merikangas KR, et al. Depressed parents and their children. General health, social, and psychiatric problems. Am J Dis Child. 1986;140:801–805. 5. Kemper KJ, Babonis TR. Screening for maternal depression in pediatric clinics. Am J Dis Child. 1992;146:876–878. 6. Cross National Collaborative Group. The changing rate of major depression. JAMA. 1992;268:3098–3105. 7. Kahn RS, Wise PH, Finkelstein JA, et al. The scope of unmet maternal health needs in pediatric settings. Pediatrics. 1999; 103:576–581. 8. Mandl KD, Tronick EZ, Brennan TA, et al. Infant health care use and maternal depression. Arch Pediatr Adolesc Med. 1999; 153:808–813. 9. Mulrow CD. Case-finding instruments for depression in primary care settings. Ann Intern Med. 1995;122:913–921. 10. Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care. JAMA. 1994;272:1749–1756. 11. First MB, ed. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000. 12. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999;282:1737–1744. 13. Spitzer RL, Williams JB, Kroenke K, et al. Validity and utility of the PRIME-MD patient health questionnaire in assessment
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
of 3000 obstetric-gynecologic patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study. Am J Obstet Gynecol. 2000;183:759–769. Hall LA, Williams CA, Greenberg RS. Supports, stressors, and depressive symptoms in low-income mothers of young children. Am J Public Health. 1985;75:518–522. Heneghan AM, Silver EJ, Bauman LJ, et al. Do pediatricians recognize mothers with depressive symptoms? Pediatrics. 2000; 106:1367–1373. Orr ST, James S. Maternal depression in an urban pediatric practice: implications for health care delivery. Am J Public Health. 1984;74:363–365. Olson AL, DiBrigida LA. Depressive symptoms and work role satisfaction in mothers of toddlers. Pediatrics. 1994;94:363– 367. Lanzi RG, Pascoe JM, Keltner B, et al. Correlates of maternal depressive symptoms in a national Head Start program sample. Arch Pediatr Adolesc Med. 1999;153:801–807. Beck CT. Maternal depression and child behaviour problems: a meta-analysis. J Adv Nurs. 1999;29:623–629. Cogill SR, Caplan HL, Alexandra H, et al. Impact of maternal postnatal depression on cognitive development of young children. Br Med J (Clin Res Ed). 1986;292:1165–1167. Fergusson DM, Lynskey MT. The effects of maternal depression on child conduct disorder and attention deficit behaviours. Soc Psychiatr Epidemiol. 1993;28:116–123. Field T. Maternal depression effects on infants and early interventions. Prev Med. 1998;27:200–203. Weinberg MK, Tronick EZ. Emotional characteristics of infants associated with maternal depression and anxiety. Pediatrics. 1998;102:1298–1304. Zuckerman BS, Beardslee WR. Maternal depression: a concern for pediatricians. Pediatrics. 1987;79:110–117. Judd LL, Rapaport MH, Paulus MP, et al. Subsyndromal symptomatic depression: a new mood disorder? J Clin Psychiatr. 1994;55(suppl):18–28. Wells KB, Stewart A, Hays RD, et al. The functioning and wellbeing of depressed patients. Results from the Medical Outcomes Study. JAMA. 1989;262:914–919. Heneghan AM, Silver EJ, Bauman LJ, et al. Depressive symptoms in inner-city mothers of young children: who is at risk? Pediatrics. 1998;102:1394–1400. Simon GE, VonKorff M, Piccinelli M, et al. An international study of the relation between somatic symptoms and depression. N Engl J Med. 1999;341:1329–1335. Dadds MR, Stein RE, Silver EJ. The role of maternal psychological adjustment in the measurement of children’s functional status. J Pediatr Psychol. 1995;20:527–544. McCormick MC, Brooks-Gunn J, Shorter T, et al. Factors associated with maternal rating of infant health in central Harlem. J Dev Behav Pediatr. 1989;10:139–144. Agency for Health Care Policy and Research. Treatment of Depression: Newer Pharmacotherapies: Evidence Report/Technology Assessment Number 7. Rockville, Md: Agency for Health Care Policy and Research; 1999. US Department of Health and Human Services. Healthy Children 2000. Washington, DC: US Department of Health and Human Services; 1991. US Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, Md: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999. Zuckerman BS, Kahn RS. Pathways to early child health and development. In: Securing the Future. New York: Russell Sage Foundation; 2000:330. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14:245–258.