Author Affiliations: Department of Pediatrics, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts.
Screening for maternal depression in clinical and community settings has been the topic of numerous recent studies and an important component of the 2009 Institute of Medicine report Depression in Parents, Parenting, and Children.1 According to the report, however, studies of maternal depression screening have largely ignored the implications of comorbid mental health conditions on screening approaches and evaluation of screening effectiveness.1 One condition that may accompany—and complicate—maternal depression is posttraumatic stress disorder (PTSD).
Posttraumatic stress disorder and depression share several diagnostic criteria, and depression—when accompanied by posttraumatic stress symptoms—is less responsive to treatment.2 Whereas depression has an extensive evidence base for effective primary care–based treatment, PTSD typically requires mental health specialty services. In certain high-risk populations, therefore, it is important to understand the likelihood with which depression screening instruments identify mothers who may have PTSD.
We surveyed mothers of children aged 0 to 5 years from Women, Infants, and Children offices and Head Start centers in a single city. Research assistants approached all mothers in Women, Infants, and Children office waiting rooms; Head Start mothers were recruited through flyers and by Head Start staff unaware of the study's specific purpose. Ability to communicate in English or Spanish was the eligibility criterion.
Respondents answered a face-to-face questionnaire, which included the Patient Health Questionnaire–2 and the Modified PTSD Symptom Scale. The Patient Health Questionnaire–2 is a 2-item depression screening instrument with performance characteristics of 83% sensitivity and 92% specificity for major depression.3 The Modified PTSD Symptom Scale is a valid scale of PTSD symptomatology.4 Consistent with previous literature,5 we created a proxy variable for PTSD diagnosis by mapping individual Modified PTSD Symptom Scale items onto Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) diagnostic criteria. Data analysis was composed of descriptive statistics. The Boston Medical Center institutional review board approved this study.
From a total sampling frame of 5426 mothers, we surveyed 190 mothers. One hundred ten (58%) reported English as their primary language; 55 (30%), Spanish. Seventy-seven women (41%) self-identified as black and 75 (39%) as Latina. On average, the mothers had 2.16 children (SD, 1.27); most mothers were younger than 30 years old; and 43% worked outside the home.
Of 190 mothers, 56 (29%) screened positive for depression and 32 (17%) had symptoms consistent with DSM-IV criteria for PTSD. Of the 56 women with positive depression screens, 14 (25%) had symptoms consistent with PTSD. Thirty-one women had both positive depression screens and reported histories of trauma; of these, 45% had symptoms consistent with PTSD.
In our sample, 89 women (47%) reported having an unusually traumatic event in their lifetime. The most common traumas were sexual assault, physical assault, witnessing someone shot or killed, and witnessing the death of a family member. Among those having experienced a trauma, 32 (36%) had symptoms consistent with PTSD.
A screening test is indicated if it accurately identifies a condition, which can then be treated effectively. According to the US Preventive Services Task Force, adult depression fits these criteria, provided that appropriate systems exist to ensure accurate diagnosis and appropriate follow-up and treatment.6 However, when depression is comorbid with posttraumatic stress symptoms—as it appears to be in 25% of our sample—it is both more difficult to diagnose and more refractory to treatment. Among populations in which this comorbidity is highly prevalent, depression may no longer fit the paradigm for a good screening test, given current screening practices and availability of services.
To fulfill the US Preventive Services Task Force's criteria for diagnostic accuracy and appropriate follow-up and treatment, therefore, it may be that maternal depression screening in certain settings ought to be augmented with additional questions around trauma exposure or symptomatology and that more detailed screening—accompanied by algorithms for referral—may be warranted. Given the limited mental health resources for low-income populations, the high prevalence of maternal depression, and the benefits to children of treating depressed mothers, resolving these issues is of substantial public health importance.
Correspondence: Dr Silverstein, Boston Medical Center, 88 E Newton St, Vose 3, Boston, MA 02118 (email@example.com).
Author Contributions: Dr Silverstein had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Silverstein and Feinberg. Acquisition of data: Silverstein, Feinberg, Sauder, Egbert, and Stein. Analysis and interpretation of data: Silverstein and Feinberg. Drafting of the manuscript: Silverstein and Sauder. Critical revision of the manuscript for important intellectual content: Silverstein, Feinberg, Egbert, and Stein. Statistical analysis: Silverstein. Obtained funding: Silverstein and Feinberg. Administrative, technical, and material support: Silverstein, Feinberg, Sauder, Egbert, and Stein. Study supervision: Silverstein and Feinberg.
Funding/Support: Dr Silverstein is supported by grant K23MH074079 from the National Institute of Mental Health, grant R03HD058075 from the National Institute of Child Health and Human Development, the Hood Foundation, and the Robert Wood Johnson Foundation under its Physician Faculty Scholars Program.
Financial Disclosure: None reported.
Additional Contributions: Barry Zuckerman, MD, and Howard Bauchner, MD, reviewed the manuscript.
Thank you for submitting a comment on this article. It will be reviewed by JAMA Pediatrics editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 3
Customize your page view by dragging & repositioning the boxes below.
Users' Guides to the Medical Literature
All results at
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.