Should you screen for postpartum depression?

,; ,; ,

PURLs

Should you screen for postpartum depression?

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

PDF Download

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.

WHAT'S NEW?

We now have evidence of the efficacy of postpartum screening

This is the first large study of a primary care-based approach to screening, diagnosis, and management of postpartum depression to show any improvement in maternal outcomes at 12 months. Prior universal screening and referral support in the Healthy Start program was done by paraprofessionals, who referred women with positive screens for mental health care outside of the primary care setting and did not reduce the rate of depression in perinatal women.⁷

CAVEATS

Dropout rate, socioeconomic status may affect results

Among the women who initially were found to be positive for postpartum depression, 38% did not return questionnaires at 12 months’ postpartum. While this loss to follow-up is high, it is comparable to that of most effectiveness trials¹¹with similar rates in the intervention and usual care groups.

Within the intervention group, there was no statistical difference between women who did and did not return the questionnaires with regard to marital status, history of depression, income, or uninsured status. However, women in the usual care group who did not return the 12-month questionnaire were more likely to be poor (89% vs 57%; P<.01) and uninsured (49% vs 29%; P<.01) than those who did return the questionnaire.

The impact of these differences and the loss to follow-up in this study is unknown. However, low socioeconomic status has been shown to be a strong risk factor for the development of postpartum depression.¹² The authors of the study suggest (and we agree) that the difference in socioeconomic status in women who did not return the questionnaire may underestimate the positive impact of this screening approach.

CHALLENGES TO IMPLEMENTATION

Screening requires extra work

Personnel at the intervention sites received a half day of training in postpartum depression screening, diagnosis, and nursing telephone follow-up. The workload at these sites also increased, as most women found to have postpartum depression received one to 2 follow-up telephone calls and an average of one to 2 follow-up visits after the start of therapy. These measures, while seemingly modest, could pose a challenge to implementation. This could potentially be alleviated by the additional payments for care coordination promised in the Patient Protection and Affordable Care Act.¹³

ACKNOWLEDGEMENT

The PURLs Surveillance System was developed in part by Grant Number UL1RR024999 from the National Center for Research Resources, a Clinical Translational Science Award to The University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center of Research Resources or the National Institutes of Health.