Should you screen for postpartum depression?

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Should you screen for postpartum depression?

J Fam Pract. 2013 November;62(11):E1-E3

By

Andrew H. Slattengren, DO

Shailendra Prasad, MBBS, MPH

M. Altaf Kaiseruddin, MD

Yes. Evidence suggests that screening new moms for depression leads to better outcomes, and should be routine.

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References

1. Yawn BP, Dietrich AJ, Wollan P, et al; TRIPPD practices. TRIPPD: a practice-based network effectiveness study of postpartum depression screening and management. Ann Fam Med. 2012;10:320-329.

2. Horowitz JA, Murphy CA, Gregory KE, et al. Best practices: community-based postpartum depression screening: results from the CARE study. Psychiatr Serv. 2009;60:1432-1434.

3. Gaynes BN, Gavin N, Meltzer-Brody S, et al. Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes: Summary. AHRQ Evidence Report Summaries. Rockville, MD: Agency for Healthcare Research and Quality; Feb, 2005.

4. Murray L, Cooper PJ. The impact of postpartum depression on child development. In: Goodyer I, ed. Aetiological Mechanisms in Developmental Psychopathology. Oxford, England: Oxford University Press; 2003.

5. Goodman SH, Gotlib IH. Risk for psychopathology in the children of depressed mothers: a developmental model for understanding mechanisms of transmission. Psychol Rev. 1999;106:458-490.

6. Pearlstein T, Howard M, Salisbury A, et al. Postpartum depression. Am J Obstet Gynecol. 2009;200:357-364.

7. Yonkers KA, Smith MV, Lin H, et al. Depression screening of perinatal women: an evaluation of the healthy start depression initiative. Psychiatr Serv. 2009;60:322-328.

8. American College of Obstetricians and Gynecologists. Committee on Obstetric Practice. Committee opinion no. 453: Screening for depression during and after pregnancy. Obstet Gynecol. 2010;115(2 pt 1):394-395.

9. Löwe B, Kroenke K, Herzog W, et al. Measuring depression outcome with a brief self-report instrument: sensitivity to change of the Patient Health Questionnaire (PHQ-9). J Affect Disord. 2004;81:61-66.

10. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–613.

11. Ribisl KM, Walton MA, Mowbray CT, et al. Minimizing participant attrition in panel studies through the use of effective retention and tracking strategies: review and recommendations. Eval Program Planning. 1996;19:1-25.

12. Dolbier CL, Rush TE, Sahadeo LS, et al; Community Health Network Investigators. Relationships of race and socioeconomic status to postpartum depressive symptoms in rural african american and non-Hispanic white women. Matern Child Health J. 2013;17:1277-1287.

13. Centers for Medicare and Medicaid Services. The Affordable Care Act: Helping Providers Help Patients. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/downloads/ACO-Menu-Of-Options.pdf. Accessed September 6, 2013.

Practice changer

Make depression screening a routine part of the postpartum visit.¹

Strength of recommendation

B: Based on a single blinded randomized controlled trial (RCT).

Yawn BP, Dietrich AJ, Wollan P, et al. TRIPPD practices. TRIPPD: a practice-based network effectiveness study of postpartum depression screening and management. Ann Fam Med. 2012;10:320-329.

Illustrative case

A 20-year-old patient comes in at 6 weeks’ postpartum for routine care. Should you screen her for postpartum depression?

The incidence of depression in the first 3 months’ postpartum is estimated at about 14%,^2,3 and the consequences can be severe. A new mom with a mood disorder in the first year of her child’s life can disrupt the mother-infant relationship, thereby contributing to both short- and long-term adverse outcomes for the child. These include behavior problems, low self-esteem, poor self-regulation, and an increased risk of impaired mental and motor development.^4,5

Postpartum depression often goes undetected

Despite this correlation, postpartum depression is both under-recognized and undertreated.⁶ A prospective randomized study of 5169 women who were screened for postpartum depression bears this out. Researchers found that about one in 4 (26%) of the 674 mothers who had positive screens were not asked about their emotional state by their clinicians.²

This may be due to a lack of evidence of the efficacy of screening for postpartum depression. In the Healthy Start Depression Initiative (n=1336), universal screening—with referrals to mental health care outside of the primary care physicians’ offices—did not alter either the level of depressive symptoms over a 10-month period or depression treatment.⁷

The American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice noted in 2010 (and reaffirmed in 2012) that there is insufficient evidence to support a firm recommendation for universal postpartum screening for depression.⁸ Neither the US Preventive Services Task Force nor the American Academy of Family Physicians has a specific recommendation regarding postpartum depression.

STUDY SUMMARY

Screening—with follow-up—leads to better outcomes

The study by Yawn et al included 28 family medicine practices in 21 states, randomized to either usual care or intervention.¹ Eligible practices had to have provided well-baby or maternity care to more than 30 patients in the previous year, but not to routinely screen for postpartum depression. A total of 2343 women aged 18 years or older—all of whom were between 5 and 12 weeks’ postpartum and planning on continuing care at the family medicine practice at the time they entered the study—were enrolled.

Staff at the 14 intervention sites received training in postpartum depression screening and diagnosis. They were also given a set of tools to facilitate management of postpartum depression, including an outline for follow-up visits and scripts for nurses to use for telephone calls relating to antidepressants. Therapy options were left to the discretion of the physician and the patient, with the help of tools that detailed the doses and adverse effects of various medications and described cognitive behavioral therapy.

Low socioeconomic status has been shown to be a strong risk factor for the development of postpartum depression.At the start of the study, participants at all 28 sites were given survey packets containing the Edinburgh Postnatal Depression Scale (EPDS) and the 9-item Patient Health Questionnaire (PHQ-9). Patients subsequently received surveys by mail at 6 and 12 months’ postpartum for self-reported outcomes. Clinicians at the intervention sites had routine access to the EPDS and PHQ-9 scores; those at the usual care sites did not.

The primary outcome was ≥5 point drop in the PHQ-9 score from baseline at 6 or 12 months’ postpartum, considered to be an indicator of clinical improvement and/or response to therapy. The PHQ-9 is a validated measure of depression severity, with the proven ability to detect changes over time.^9,10

Of the 2343 women initially enrolled in the study, 1897 (81%) provided outcome information and were included in the analysis. The rates of women with elevated depression scores (EPDS and/or PHQ-9 ≥10) at the start were comparable between the intervention and usual care groups (29.5% vs 25.8%, respectively).

Of those whose scores were initially elevated, 219 women in the intervention group and 178 women in the usual care group returned surveys at 12 months and were included in the final analysis. The results: 45% of those in the intervention group met the primary outcome—a decline in self-reported depressive symptom levels, as indicated by a PHQ-9 decrease ≥5 points—compared with 35% of the women in the usual care group (odds ratio, 1.8; 95% confidence interval, 1.14-2.9; P=.001). Not surprisingly, medical record review also indicated that those in the intervention group who initially had elevated depression scores were more likely to have received a diagnosis (66% vs 41%; P=.0006) and therapy (20% vs 11%; P=.02) for postpartum depression.