The screening process as well as the demographic data and scores for the women screened have been described previously.26 Each woman’s screening results were available to her clinician at the time of her 6-week postpartum visit. Women who did not schedule a visit by 6 weeks postpartum were sent the survey by mail, and the results were given to the clinician who supervised her delivery. As required by the institutional review board, we notified the clinician of any EPDS score of 12 or higher or any indication of suicidal ideation on the EPDS, whether completed at the clinic or by mail. All care of the women remained at the discretion of the individual clinician.
Data Collection
All Olmsted Medical Center and Mayo Clinic records of each subject were reviewed for the period of 1 year postpartum. Linking women to all sources of health care is possible because the Rochester Epidemiology Project maintains a database of all health care utilization of all Olmsted County residents.27 The data we collected included any medical record documentation of the EPDS scores, evaluation for depression, referrals to psychiatry or psychology, and any psychiatric diagnoses made during the 1-year period. Documented treatment of depression with reassurance, social services support, counseling/therapy, medications, electroconvulsive therapy, partial or inpatient psychiatric hospitalization, or other modalities was also collected. We recorded remissions and recurrences of depression and suicide attempts. Other basic demographic information was also collected, including gravity, parity, and gestational age at delivery, as well as documented previous affective disorders and previous postpartum depression.
Data Analysis
We calculated simple descriptive statistics. Comparison of depression-related evaluations, treatments, and diagnoses for those with EPDS scores of 12 or higher, scores of 10 or 11, and scores lower than 10 with and without suicidal ideation were completed using Mantel-Haenzel chi-square testing and tests for trends. The number of diagnoses of depression for the entire population of the 909 subjects screened with the EPDS was estimated by applying the rate of diagnosed depression in the 171 women with EPDS scores lower than 10 to the other 558 women with scores of lower than 10. This estimate was based on the assumption that the 558 women with EPDS scores less than 10 whose medical records were not reviewed had similar rates of diagnosed depression as the women with EPDS scores less than 10 whose medical records were reviewed. This assumption appeared justified, since both groups had similar demographic characteristics and similar distributions of EPDS scores from 0 to 9. We compared the post-EPDS screening rates of PPD diagnosis with the prescreening rates obtained from a previous study of the same community28 using the chi-squared statistic.
The institutional review boards of the Olmsted Medical Center and the Mayo Clinic approved our study design.
Results
The mean age at delivery of the 342 women (171 with normal EPDS scores and 171 women with elevated scores) whose medical records were reviewed was 29 years (range=16-46 years). On average this was the second pregnancy for these women, and most (94%) delivered at more than 36 weeks’ gestation. Ninety-two percent (315) of women made a postpartum visit, while 8% (27) did not and received the EPDS by mail. Eighty-two percent of the women saw a physician, and 18% saw a nurse practitioner or nurse midwife for the postpartum visit. The demographic data for the women in this study is similar to that for the entire group of 909 who completed the EPDS during the 9-month study.
Overall, 68 women were diagnosed with postpartum depression Figure 1. The rate of diagnosis of PPD varied by the EPDS score and was highest in women with scores of Ž12 compared with scores of 10 or 11 and <10 (P for trend=.01). When weighted for the whole population of women screened, the community rate of diagnosed PPD was estimated to be 10.7%.
Documentation of mental health evaluations and referrals was not universal and differed between those with normal and elevated EPDS scores Table 1. More than three fourths (77%) of the women with some level of suicidal ideation indicated on the EPDS had no documentation of further immediate evaluation or scheduled follow-up concerning the risk for suicide. This included 5 women whose EPDS scores indicated “sometimes” thinking about suicide and another 28 who “occasionally” thought about suicide.
In the 3 women with documented clinician concern regarding risk of self-harm, immediate action was also documented. All 3 of these women had indicated that they had experienced suicidal ideation during the previous week, according to their EPDS sheets. One of these women was admitted to an inpatient mental health unit for short-term evaluation and initiation of therapy. The others were started on outpatient medical therapy. Two suicide attempts were recorded in the medical records of the study cohort. One woman who expressed sometimes thinking of self-harm but had no documentation of further evaluation made a suicide attempt (by overdose of over-the-counter medications) approximately 1 month after her postpartum visit and EPDS screening. She was hospitalized in the intensive care unit (ICU) for medical stabilization and was later transferred to an inpatient mental health unit. Another suicide attempt in this cohort involved a woman with no thoughts of suicide reproted on the EPDS at 6 weeks postpartum.