Routine screening for postpartum depression

BACKGROUND: Postpartum depression (PPD) is a common and often overlooked condition. Validated screening tools for PPD exist but are not commonly used. We present the 1-year outcome of a project to implement universal PPD screening at the 6-week postpartum visit. METHODS: Universal screening with the Edinburgh Postnatal Depression Scale (EPDS) was implemented in all community postnatal care sites. One-year outcome assessments (diagnosis and treatment of PPD) were completed for a sample of the women screened using medical record review of all care they received during the first year postpartum. RESULTS: Sixty-eight (20%) of the 342 women whose medical records were reviewed had been given a documented diagnosis of postpartum depression, resulting in an estimated population rate of 10.7%. Depression was diagnosed in 35% of the women with elevated EPDS scores (> or =10) compared with 5% of the women with low EPDS scores (<10) in the first year postpartum. Treatment was provided for all women diagnosed with depression, including drug therapy for 49% and counseling for 78%. Four women were hospitalized for depression. Some degree of suicidal ideation was noted on the EPDS by 48 women but acknowledged in the chart of only 10 women, including 1 with an immediate hospitalization. The rate of diagnosis of postpartum depression in this community increased from 3.7% before the routine use of EPDS screening to 10.7% following screening. CONCLUSIONS: A high EPDS score was predictive of a diagnosis of postpartum depression, and the implementation of routine EPDS screening at 6 weeks postpartum was associated with an increase in the rate of diagnosed postpartum depression in this community.     

Implementation of Routine Postpartum Depression Screening and Care Initiation Across a Multispecialty Health Care Organization: An 18-Month Retrospective Analysis

Objectives Postpartum depression (PPD) affects approximately 10–20% of all mothers after giving birth. Adequate screening and follow-up care for the postpartum mother with depression is an essential component of quality care in this population. The purpose of this quality improvement project was to evaluate the quality and quantity of a postnatal PPD screening program and the subsequent initiation of needed PPD treatment in an integrated health system. Methods After implementing a standardized PPD screening process, we conducted an 18-month retrospective study of patient visits that required a PPD screen. Data were abstracted from medical records and analyzed to determine if postnatal PPD screening occurred, what quality of the screening was, and what follow-up measures were taken. Results Within the study timeframe, 28,389 postpartum and well-child visits were eligible for PPD screening. PPD screening occurred at 88% of eligible visits for approximately 5000 unique women. PPD was identified in 8.1% of screened women. Conclusions Of women with PPD, at least 44.8% were prescribed an SSRI and 21.4% attended a visit with a mental health professional, which is consistent with other studies. Screening can be successful through collaboration, although ongoing evaluation and process modification are necessary.     

Screening for Postpartum Depression in Well-Baby Care Settings: A Systematic Review

Introduction Postpartum depression (PPD) is a mental health problem frequently experienced by mothers in the first year postpartum. Early detection and treatment can help to reduce its negative effect on the development of the newborn child. Well-baby care (WBC) is a promising screening setting for early detection of PPD. This systematic review investigates the evidence of the effectiveness of screening for PPD in WBC settings regarding mother and child outcomes. Methods Three electronic databases were searched: SCOPUS, PsychINFO and CINAHL. Two reviewers independently performed the study selection. Data extraction was based on a predefined data extraction form. Results Six studies were included; a quality assessment rated two studies as strong and four as weak. Four studies measuring outcomes at process level showed improvement in detection, referral and/or treatment rates. Four studies, including the two strong ones, where screening and enhanced care were combined, showed improvements in the Edinburgh Postnatal Depression Scale scores of the mothers in the intervention groups. No improvements were reported on other outcomes at parent level or at child level. At child level, weight was the only outcome that was measured. Discussion This review provides limited yet positive evidence for the value of screening for PPD in a WBC setting. The outcomes are comparable with studies on screening for PPD in general. The evidence that we found is very promising but the small number of available studies shows a need for additional high-quality studies, to strengthen the evidence regarding the potential benefits of screening in a WBC setting.     

TRIPPD: a practice-based network effectiveness study of postpartum depression screening and management

PURPOSE

Postpartum depression is common but inadequately recognized and undertreated. Continuing depressive symptoms are associated with adverse outcomes for the woman, her infant, and family. We wanted to determine the effect of a practice-based training program for screening, diagnosis, and management of depression in postpartum mothers.

METHODS

In this practice-based effectiveness study, 28 practices were randomized to usual care (n = 14) or intervention (n = 14), and 2,343 women were enrolled between 5 and 12 weeks’ postpartum. The intervention sites received education and tools for postpartum depression screening, diagnosis, initiation of therapy, and follow-up within their practices. Usual-care practices received a 30-minute presentation about postpartum depression. Screening information for the usual care was obtained from baseline surveys sent directly to the central site but was not available for patient care. Outcomes were based on patient-reported outcomes (level of depressive symptoms) from surveys at 6 and 12 months, plus medical record review (diagnosis and therapy initiation).

RESULTS

Among the 2,343 women enrolled, 1,897 (80.1%) provided outcome information, and were included in the analysis. Overall, 654 (34.5% of 1,897) women had elevated screening scores indicative of depression, with comparable rates in the intervention and usual-care groups. Among the 654 women with elevated postpartum depression screening scores, those in the intervention practices were more likely to receive a diagnosis (P = .0006) and therapy for postpartum depression (P = .002). They also had lower depressive symptom levels at 6 (P = .07) and 12 months’ (P=.001) postpartum.

CONCLUSIONS

Primary care–based screening, diagnosis, and management improved mother’s depression outcomes at 12 months. This practical approach could be implemented widely with modest resources.     

Are family physicians appropriately screening for postpartum depression?

PURPOSE: Despite the availability of screening tools for postpartum depression (PPD), there is a general consensus that the condition is underdiagnosed. This study was conducted to determine how frequently family physicians screen for PPD, what methods they use to screen, and what influences their screening frequency. METHODS: A survey of members of the Washington Academy of Family Physicians was conducted. Three hundred sixty-two (60.9%) mailed surveys were returned. The 298 physicians who saw postpartum women and children younger than 1 year of age were included in the study. RESULTS: Of the study population, 70.2% always or often screened for PPD at postpartum gynecologic examinations, and 46% always or often screened mothers at well-child visits. Of those who screened, 30.6% reported using a validated screening tool. Of those, only 18% used a tool specifically designed to screen for PPD. Logistic regression modeling showed that female sex [odds ratio (OR) = 2.2], training in PPD during residency (OR = 8.1), training in PPD through medical literature (OR = 2.1), and agreement that postpartum depression is common enough to warrant screening (OR = 1.9) were all significantly associated with more frequent screening at postpartum gynecologic visits. Agreement that screening takes too much effort was associated with less frequent screening (OR = 0.8). CONCLUSIONS: Although family physicians believe that PPD is serious, identifiable, and treatable; screening is not universal and use of screening tools designed for PPD is uncommon. Training in postpartum depression and female sex are the variables most strongly associated with frequent screening.     

Maternal Morbidities and Postpartum Depression: An Analysis Using the 2007 and 2008 Pregnancy Risk Assessment Monitoring System

PurposePostpartum depression (PPD) is common and associated with significant health outcomes and other consequences. Identifying persons at risk may improve screening and detection of PPD. This exploratory study sought to identify the morbidities that associate with 1) PPD symptoms and 2) PPD diagnosis.MethodsData from the 2007 and 2008 Pregnancy Risk Assessment Monitoring System were analyzed from 23 states and 1 city (n = 61,733 pregnancies); 13 antenatal morbidities were included. To determine whether antenatal morbidity predictors of PPD would differ based on PPD symptoms versus a diagnosis, each of the 13 antenatal morbidities were examined in separate logistic regression models with each PPD outcome. For each objective, two samples were examined: 1) Women from all states and 2) women from Alaska and Maine, the two states that included both PPD symptoms and PPD diagnosis measures in their questionnaires. Control variables included demographic and sociodemographic variables, pregnancy variables, antenatal and postpartum health behaviors, and birth outcomes.Main FindingsHaving vaginal bleeding (odds ratio [OR], 1.42; OR, 1.76), kidney/bladder infection (OR, 1.59; OR, 1.63), nausea (OR, 1.50; OR, 1.80), preterm labor (OR, 1.54; OR, 1.51), or being on bed rest (OR, 1.34; OR, 1.56) associated with both PPD symptoms and PPD diagnosis, respectively. Being in a car accident associated with PPD symptoms only (OR, 1.65), whereas having hypertension (OR, 1.94) or a blood transfusion (OR, 2.98) was associated with PPD diagnosis only. Among women from Alaska or Maine, having preterm labor (OR, 2.54, 2.11) or nausea (OR, 2.15, 1.60) was associated with both PPD symptoms and PPD diagnosis, respectively. Having vaginal bleeding (OR, 1.65), kidney/bladder infection (OR, 1.74), a blood transfusion (OR, 3.30), or being on bed rest (OR, 1.87) was associated with PPD symptoms only, whereas having diabetes before pregnancy (OR, 5.65) was associated with PPD diagnosis only.ConclusionsThe findings of this exploratory study revealed differences in the antenatal morbidities that were associated with PPD symptoms versus diagnosis in both samples, and can assist prenatal care providers in prioritizing and screening for these morbidities that are associated with PPD during pregnancy. Additional research is warranted to confirm the results of this study in other samples and populations. Developing strategies to 1) improve general awareness of PPD and the appropriate antenatal morbidity risk factors to focus on in clinical settings, and 2) increase screening for the antenatal morbidities determined to be predictors of PPD in this study are warranted in preventing PPD.     

Improving maternal postpartum mental health screening guidelines requires assessment of post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) has a prevalence of 4–17% in the postpartum period and, like better known postpartum depression (PPD), is linked to reduced quality maternal-child interactions, decreased maternal sense of life satisfaction and functioning, and negative impacts on child development. Currently, provincial and public health organizations throughout Canada screen new mothers for PPD with the Edinburgh Postpartum Depression Scale, which while laudable does not capture PTSD. PTSD is highly associated with PPD, 65% of women with PTSD also present with PPD, presenting a significant gap in postpartum maternal mental health screening. Numerous self-report PTSD screening questionnaires are available that could be incorporated into routine maternal postpartum mental health care. Furthermore, across Canada, regional differences in availability of maternal mental health screening, services, and programs suggest a gap in one of the tenets of Canadian health care—lack of universality. Not only does Canada require national maternal mental health screening, service and program guidelines, but PTSD screening must be incorporated, in order to identify and treat new mothers experiencing mental health problems.     

The effects of primary care depression treatment on patients' clinical status and employment

OBJECTIVE: To evaluate the effects of depression treatment in primary care on patients' clinical status and employment, over six months. DATA SOURCES/STUDY SETTING: Data are from a randomized controlled trial of quality improvement for depression that included 938 adults with depressive disorder in 46 managed primary care clinics in five states. STUDY DESIGN: Observational analysis of the effects of evidence-based depression care over six months on health outcomes and employment. Selection into treatment is accounted for using instrumental variables techniques, with randomized assignment to the quality improvement intervention as the identifying instrument. DATA COLLECTION/EXTRACTION METHODS: Patient-reported clinical status, employment, health care use, and personal characteristics; health care use and costs from claims data. PRINCIPAL FINDINGS: At six months, patients with appropriate care, compared to those without it, had lower rates of depressive disorder (24 percent versus 70 percent), better mental health-related quality of life, and higher rates of employment (72 percent versus 53 percent), each p<.05. CONCLUSIONS: Appropriate treatment for depression provided in community-based primary care substantially improves clinical and quality of life outcomes and employment.     

Repeated Depression Screening During the First Postpartum Year

PURPOSE

Postpartum depression (PPD) screening at 4 to 12 weeks’ postpartum can improve outcomes for women when linked to in-practice management programs. The benefit of repeated PPD screening during the first year postpartum remains unclear.

METHODS

We report a substudy of a large pragmatic trial of early PPD screening and practice management, the Translating Research into Practice for Postpartum Depression (TRIPPD) study. Outcome analyses were based on demographic information and Patient Health Questionnaire (PHQ-9) screening scores from questionnaires mailed to all enrolled women at baseline (4 to 12 weeks’ postpartum) and again at 6 and at 12 months’ postpartum. The main outcomes of this substudy were the 6- and 12-month rates of PHQ-9 scores that were 10 or greater for women whose baseline PHQ-9 scores were less than 10. Women whose scores were 10 or greater would be considered at high risk of PPD and appropriate for further evaluation.

RESULTS

At 6 months, 134 (10.9%) of the 1,235 women who did not have PHQ-9 scores greater than 10 at baseline had elevated scores appropriate for further evaluation. At 12 months, 59 (6.1%) of the 969 women who did not have PHQ-9 scores greater than 10 at baseline or at 6 months had elevated scores. Together the 6- and 12-month repeated screenings identified 193 women at high risk of depression. This finding represents 13.5% of the 1,432 women whose screening results were negative for PPD at baseline.

CONCLUSIONS

Repeated PPD screening at 6 and 12 months’ postpartum increases the percentage of women identified as being at high risk of PPD. Further work will be required to understand the impact of this repeated screening on patient outcomes.     

Development of a prenatal psychosocial screening tool for post-partum depression and anxiety

McDonald S, Wall J, Forbes K, Kingston D, Kehler H, Vekved M, Tough S. Development of a prenatal psychosocial screening tool for post‐partum depression and anxiety. Paediatric and Perinatal Epidemiology 2012; ?? : ??–??. Background: Post‐partum depression (PPD) is the most common complication of pregnancy in developed countries, affecting 10–15% of new mothers. There has been a shift in thinking less in terms of PPD per se to a broader consideration of poor mental health, including anxiety after giving birth. Some risk factors for poor mental health in the post‐partum period can be identified prenatally; however prenatal screening tools developed to date have had poor sensitivity and specificity. The objective of this study was to develop a screening tool that identifies women at risk of distress, operationalized by elevated symptoms of depression and anxiety in the post‐partum period using information collected in the prenatal period. Methods: Using data from the All Our Babies Study, a prospective cohort study of pregnant women living in Calgary, Alberta (N = 1578), we developed an integer score‐based prediction rule for the prevalence of PPD, as defined as scoring 10 or higher on the Edinburgh Postnatal Depression Scale (EPDS) at 4‐months postpartum. Results: The best fit model included known risk factors for PPD: depression and stress in late pregnancy, history of abuse, and poor relationship quality with partner. Comparison of the screening tool with the EPDS in late pregnancy showed that our tool had significantly better performance for sensitivity. Further validation of our tool was seen in its utility for identifying elevated symptoms of postpartum anxiety. Conclusion: This research heeds the call for further development and validation work using psychosocial factors identified prenatally for identifying poor mental health in the post‐partum period.     

“I keep it to myself”: A qualitative meta‐interpretive synthesis of experiences of postpartum depression among marginalised women

Postpartum depression (PPD) is a significant public health concern due to the physical, emotional, economic, and life course outcomes. Rates of PPD are significantly higher for marginalised populations and can impact low‐income, minority, and/or immigrant women differently when compared to white middle‐class women. Commonly studied negative effects of PPD include poor health outcomes, mother–child bonding challenges, and negative child educational outcomes. However, research surveying the postpartum experience and negative outcomes among marginalised women is sparse. This study implemented a qualitative meta‐interpretive synthesis (QIMS) methodology to synthesise themes across 12 qualitative research articles surveying postpartum experiences of marginalised women in North American countries. Articles included in the QIMS were extracted from online databases from a 10‐year window spanning January 2008–2018. The guiding research question was “What are the PPD experiences of women belonging to marginalized populations?” Constant comparative analysis was used with coding in atlas.ti and themes were synthesised with input of all three authors. Five main themes emerged. The themes are (a) intersections of PPD and poverty, (b) culture and PPD, (c) pressures of mothering, (d) strengths and coping, and (e) abuse affects my PPD experience. Subthemes such as “I keep it to myself” relating to cultural response to PPD and idealised mothering were also discovered. Implications for social workers, nurses, and future research are discussed.     

Factors Associated With Postpartum Depression in Chilean Women

The purpose of this study was to assess the prevalence of postpartum depression in a regular clinical setting among Chilean women. The Postpartum Depression Screening Scale, Spanish Version was used to assess symptoms of depression. Chilean women (45%) reported depressive symptoms including suicidal thoughts, sleeping/eating disturbances, and emotional stability. Factors that predicted the probability of PPD included attitudes concerning pregnancy, social support, and tobacco use. Routine screening for PPD could make a difference in prevention, prompt diagnosis, and management of postpartum depression in developing countries.     

Factors associated with postpartum depression in Chilean women

The purpose of this study was to assess the prevalence of postpartum depression in a regular clinical setting among Chilean women. The Postpartum Depression Screening Scale, Spanish Version was used to assess symptoms of depression. Chilean women (45%) reported depressive symptoms including suicidal thoughts, sleeping/eating disturbances, and emotional stability. Factors that predicted the probability of PPD included attitudes concerning pregnancy, social support, and tobacco use. Routine screening for PPD could make a difference in prevention, prompt diagnosis, and management of postpartum depression in developing countries.     

Building Capacity for Behavioral Health Services and Clinical Research in a Rural Primary Care Clinic: A Case Study

Integrating sustainable, evidence-based, and collaborative depression screening and follow-up treatment into primary care clinics is a significant challenge in health care. In this article a case study approach is used to describe the process of building capacity for a depression screening program in a rural federally qualified health center (FQHC). A conceptual framework addressing the clinical, operational, and financial perspectives of a primary care setting is applied restrospectively to identify 1) the barriers and facilitating factors associated with integrating a depression screening program into standard practice and 2) how the program was leveraged to conduct clinical research to improve self-management in patients with diabetes and elevated depressive symptoms.     

Rates and Predictors of Postpartum Depression by Race and Ethnicity: Results from the 2004 to 2007 New York City PRAMS Survey (Pregnancy Risk Assessment Monitoring System)

The objective of this study was to examine racial/ethnic disparities in the diagnosis of postpartum depression (PPD) by: (1) identifying predictors that account for prevalence rate differences across groups, and (2) comparing the strength of predictors across groups. 3,732 White, African American, Hispanic, and Asian/Pacific Islander women from the New York City area completed the Pregnancy Risk Assessment Monitoring System from 2004 to 2007, a population-based survey that assessed sociodemographic risk factors, maternal stressors, psycho-education provided regarding depression, and prenatal and postpartum depression diagnoses. Sociodemographic and maternal stressors accounted for increased rates in PPD among Blacks and Hispanics compared to Whites, whereas Asian/Pacific Islander women were still 3.2 times more likely to receive a diagnosis after controlling for these variables. Asian/Pacific Islanders were more likely to receive a diagnosis after their providers talked to them about depressed mood, but were less likely than other groups to have had this conversation. Prenatal depression diagnoses increased the likelihood for PPD diagnoses for women across groups. Gestational diabetes decreased the likelihood for a PPD diagnosis for African Americans; a trend was observed in the association between having given birth to a female infant and increased rates of PPD diagnosis for Asian/Pacific Islanders and Whites. The risk factors that account for prevalence rate differences in postpartum diagnoses depend on the race/ethnic groups being compared. Prenatal depression is confirmed to be a major predictor for postpartum depression diagnosis for all groups studied; however, the associations between other postpartum depression risk factors and diagnosis vary by race/ethnic group.     

Postpartum depression: a review

Postpartum depression is a disorder that is often unrecognized and undertreated. Many psychosocial stressors may have an impact on the development of postpartum depression. The greater risk of postpartum depression is a history of major depression and those who have experienced depression during past pregnancies. Untreated maternal depression can have a negative effect on child development, mother-infant bonding, and risk of anxiety or depressive symptoms in infants later in life. Management of postpartum depression is a vital part of adequate medical care. The obstetrician and pediatrician can serve important roles in screening for and treating postpartum depression. To prevent adverse outcomes associated with depression and its impact on the child, it is important that all health care professionals and nurse practitioners are aware of specific signs and symptoms, appropriate screening methods, and proper treatment. This review article covers major traits of postpartum depression.     

Controlled trial of a collaborative primary care team model for patients with diabetes and depression: Rationale and design for a comprehensive evaluation

ABSTRACT: BACKGROUND: When depression accompanies diabetes, it complicates treatment, portends worse outcomes and increases health care costs. A collaborative care case-management model, previously tested in an urban managed care organization in the US, achieved significant reduction of depressive symptoms, improved diabetes disease control and patient-reported outcomes, and saved money. While impressive, these findings need to be replicated and extended to other healthcare settings. Our objective is to comprehensively evaluate a collaborative care model for comorbid depression and type 2 diabetes within a Canadian primary care setting.Methods/designWe initiated the TeamCare model in four Primary Care Networks in Northern Alberta. The intervention involves a nurse care manager guiding patient-centered care with family physicians and consultant physician specialists to monitor progress and develop tailored care plans. Patients eligible for the intervention will be identified using the Patient Health Questionnaire-9 as a screen for depressive symptoms. Care managers will then guide patients through three phases: 1) improving depressive symptoms, 2) improving blood glucose, blood pressure and cholesterol, and 3) improving lifestyle behaviors. We will employ the RE-AIM framework for a comprehensive and mixed-methods approach to our evaluation. Effectiveness will be assessed using a controlled "on-off" trial design, whereby eligible patients would be alternately enrolled in the TeamCare intervention or usual care on a monthly basis. All patients will be assessed at baseline, 6 and 12 months. Our primary analyses will be based on changes in two outcomes: depressive symptoms, and a multivariable, scaled marginal model for the combined outcome of global disease control (i.e., A1c, systolic blood pressure, LDL cholesterol). Our planned enrolment of 168 patients will provide greater than 80% power to observe clinically important improvements in all measured outcomes. Direct costing of all intervention components and measurement of all health care utilization using linked administrative databases will be used to determine the cost-effectiveness of the intervention relative to usual care. DISCUSSION: Our comprehensive evaluation will generate evidence to reliability, effectiveness and sustainability of this collaborative care model for patients with chronic diseases and depression.Trials registrationClintrials.gov Identifier: NCT01328639.     

Screening for postpartum depression: What influences participation?

Abstract

Routine screening for postpartum depression (PPD) is widespread; however not all women comply. In this prospective study, women who participated in a screening initiative in Israel were compared to those who did not, and factors associated with participation were examined. One-to-two days postpartum women completed a socio-demographic survey, and at 6-weeks postpartum 76% participated in a screening initiative. Having at least three children, a family history of depression, and more positive attitudes toward seeking help were associated with participation in the screening initiative. PPD screening procedures should be optimized to offer the most suitable and acceptable screening program to women from various socio-demographic backgrounds.