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Objective: To determine risk factors for a positive postpartum depression screen among women with private health insurance and 24/7 access to care.Study design: Retrospective cohort study of all patients delivered by a single MFM practice from April 2015 to September 2016. All patients had private health insurance and 24/7 access to care. All patients were scheduled to undergo the Edinburgh Postnatal Depression Scale (EPDS) at their 6-week postpartum visit and a positive screen was defined as a score of 10 or higher, or a score greater than zero on question 10 (thoughts of selfharm). Using logistic regression, risk factors for postpartum depression were compared between women with and without a positive screen.Results: Of the 1237 patients delivered, 1113 (90%) were screened with the EPDS. 81 patients (7.3, 95%CI 5.9-9.0%) of those tested had a positive screen. On regression analysis, risk factors associated with a positive screen were nulliparity (aOR 1.8, 95%CI 1.1, 2.9), cesarean delivery (aOR 1.7, 95%CI 1.1, 2.8), non-White race (aOR 2.0, 95%CI 1.1, 3.5), and a history of depression or anxiety (aOR 4.6, 95%CI 2.6, 8.1). Among the 100 women with a history of depression or anxiety, selective serotonin reuptake inhibitor (SSRI) use in the postpartum period was not associated with a reduced risk of a positive screen (25.5% in those taking an SSRI versus 18.4% of those not taking an SSRI, p = .39).Conclusions: Among women with private health insurance and access to care, the incidence of a positive screen for postpartum depression is approximately 7%. The use of an SSRI did not eliminate this risk. All women should be screened for postpartum depression.
postpartum depression screen
Background: Up to 50% of all cases of postpartum depression go undetected. The Edinburgh Postnatal Depression Scale (EPDS) has been the only instrument available that was specifically designed to screen for this mood disorder. None of the items on the EPDS, however, are written in the context of new motherhood.
Method: A total sample of 150 mothers within 12 weeks postpartum participated in the study. Each mother completed in random order three questionnaires: The PDSS, EPDS, and The Beck Depression Inventory-II (BDI-II). Immediately after completing these three questionnaires, each woman was interviewed by a nurse psychotherapist using the Structural Clinical Interview for DSM-IV Axis 1 Disorders.
Results: Twelve percent (n = 18) of the mothers were diagnosed with major postpartum depression, 19% (n = 28) with minor postpartum depression, and 69% (n = 104) with no depression. The PDSS was strongly correlated with both the BDI-II (r = 0.81) and the EPDS (r = 0.79). The ability of the PDSS to explain variance in diagnostic classification of postpartum depression above that explained by the BDI-II and EPDS (i.e., incremental validity) was assessed using hierarchical regression. After explaining variance in group classification by the other two depression instruments, the PDSS explained an additional 9% of the variance in depression diagnosis. Using receiver operating characteristic (ROC) curves, a PDSS cut-off score of 80 (sensitivity 94% and specificity 98%) is recommended for major postpartum depression and a cut-off score of 60 (sensitivity 91% and specificity 72%) for major or minor depression.
Postpartum Support International (PSI) recommends universal screening for the presence of prenatal or postpartum mood and anxiety disorders, using an evidence-based tool such as the Edinburgh Postnatal Depression Screen (EPDS) or Patient Health Questionnaire (PHQ-9).
PSI recommends universal screening in prenatal, postnatal, and pediatric settings. Settings for maternal mental health screening may include but are not limited to: health care providers (primary care, OB, midwifery, and pediatric), public health, addictions and mental health, community social services, and early childhood programs.
Screening must exist in a system of care that includes educated providers, social support for families, and a protocol to follow up with those who have screened above the cut-off score on an evidence-based screening tool, aligned with the ACOG and USPSTF recommendations. It is the goal of PSI to develop and nurture an integrated system of care that creates a safety net for parents and providers. All women should be screened routinely by their healthcare providers during and in the months following pregnancy, and ideally should have access to reproductive psychiatric specialists in their community who can treat and follow them, and coordinate care with OB providers, midwives, and pediatricians.
Postpartum Support International exists to help families and providers become informed and find resources they need to adequately screen, assess, refer, and follow up. Contact PSI www.postpartum.net or 800-944-4PPD for up-to-date information, support, training, and resources.
Mandatory depression screening of pregnant and postpartum women is now recommended by an increasing number of professional organizations: the American College of Obstetrics and Gynecology (ACOG, 2015), the American Academy of Pediatrics (2010), and the American Medical Association, following the 2016 recommendation from the United States Preventive Services Task Force (2016).
In May 2015, ACOG recommended that screening for perinatal mood changes take place at least once during the perinatal period including pregnancy and 12 months postpartum. This was a shift for ACOG and speaks to the evolving research regarding perinatal mood disorders. In addition to screening with a validated tool, ACOG acknowledges that screening by itself does not improve outcomes. It is necessary to have a system in place that couples screening with appropriate follow-up and treatment. The recommendation included training front-line OB providers to recognize PMADs and be prepared to initiate treatment and referral to behavioral health providers.
Additionally, in January 2016, the U.S. Preventive Services Task Force (USPSTF, 2016) updated its 2009 recommendation related to screening for depression to include pregnant and postpartum women, adding to the consensus on screening in the perinatal period and the recommendation of PSI.
Earls MF; Committee on Psychosocial Aspects of Child and Family Health. American Academy of Pediatrics. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics 2010;126(5):1032-9.
Purpose: Postpartum depression affects up to 22% of women who have recently given birth. Most mothers are not screened for this condition, and an ideal screening tool has not been identified. This study investigated (1) the validity of a 2-question screen and the 9-item Patient Health Questionnaire (PHQ-9) for identifying postpartum depression and (2) the feasibility of screening for postpartum depression during well-child visits.
Methods: Study participants were English-literate mothers registering their 0- to 1-month-old infants for well-child visits at 7 family medicine or pediatric clinics. They were asked to complete questionnaires during well-child visits at 0 to 1, 2, 4, 6, and 9 months postpartum. Each questionnaire included 2 depression screens: the 2-question screen and the PHQ-9. The mothers also completed the depression component of the Structured Clinical Interview for DSM-IV (SCID) initially, and again at a subsequent interval if either screening result was positive for depression.
Results: The response rate was 33%. Of the 506 women who participated, 45 (8.9%) had major depression (ie, they had a positive result on the SCID). The screen sensitivities/specificities over the course of the study were 100%/44% with the 2-question screen, 82%/84% with the PHQ-9 using simple scoring, and 67%/92% with the PHQ-9 using complex scoring. In addition, the corresponding values for the first 2 items of the PHQ-9 (ie, the 2-item Patient Health Questionnaire or PHQ-2) were 84%/79%. Some 38% of women completed their 2- to 6-month questionnaires during well-child visits; the rest completed them by mail (29%) or telephone (33%).
Conclusions: The 2-question screen was highly sensitive and the PHQ-9 was highly specific for identifying postpartum depression. These results suggest the value of a 2-stage procedure for screening for postpartum depression, whereby a 2-question screen that is positive for depression is followed by a PHQ-9. These screens can be easily administered in primary care clinics; feasibility of screening during well-child visits was moderate but may be better in clinics using a mass-screening approach.
Register for alerts If you have registered for alerts, you should use your registered email address as your username Citation toolsDownload this article to citation manager Brooke Levis postdoctoral research fellow, Zelalem Negeri postdoctoral research fellow, Ying Sun research coordinator, Andrea Benedetti associate professor, View ORCID ProfileBrett D Thombs professor Levis B, Negeri Z, Sun Y, Benedetti A, Thombs B D. Accuracy of the Edinburgh Postnatal Depression Scale (EPDS) for screening to detect major depression among pregnant and postpartum women: systematic review and meta-analysis of individual participant data BMJ 2020; 371 :m4022 doi:10.1136/bmj.m4022 BibTeX (win & mac)Download
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