Anna M. Georgiopoulos, MD

Postpartum depression (PPD) is a serious, common, and treatable condition seen frequently in the primary care setting.^1-3 The effects can be devastating for the entire family. The couple’s relationship often suffers,⁴ and women afflicted with PPD are at high risk for recurrent depression.⁵ Children of depressed mothers have been reported to have impaired cognitive development⁶ and behavioral disturbances.^7,8 Despite the serious consequences and the availability of highly effective pharmacologic and nonpharmacologic therapies,^9-11 PPD often remains unrecognized and untreated.^12,13

Routine office-based screening and the initiation of office systems have been shown to increase recognition and treatment of common conditions with high rates of missed diagnostic and treatment opportunities.¹⁴ Despite the availability of specific validated tools,^{15 17} routine screening for postpartum depression is not common in the United States. Although several population-based studies of PPD screening are available from other countries,^18,19 most studies in the United States have been completed in university settings or among high-risk populations.^20,21 Little published information is available on the effectiveness of routine postpartum screening in a community’s health care practice.²²

In 1997-98, we undertook a 9-month study of routine screening for PPD using the Edinburgh Postnatal Depression Scale (EPDS)¹⁵ at the 6-week postpartum visit in all clinical departments providing postpartum care in the Olmsted Medical Center and the Mayo Clinic, both in Rochester, Minnesota. The EPDS¹⁵ is a self-report scale that has 10 items relating to symptoms of depression and was developed to counter the limitations of other well-established depression scales used to screen postpartum women.^15,17 The scale is brief, easy to use, and avoids interpreting such common postpartum changes as fatigue, poor appetite, and altered sleep patterns as evidence of depression.^15,23

We evaluated changes in the 1-year postdelivery rates of the diagnosis and treatment of PPD before and after the introduction of universal office-based screening with the EPDS. The information obtained should be useful to other communities in determining how to address postpartum depression identification and the potential value of routine screening for PPD.

Methods

The 180 subjects for our study were all women who participated in the routine EPDS screening project, were residents of Olmsted County, and had EPDS scores of 10 or higher (n=172) or scores lower than 10 and an indication of any suicidal ideation (n=8). Nine women with scores of 10 or higher or suicidal ideation refused the general medical records research authorization required by Minnesota statute and could not be included in our study. That left 171 subjects with abnormal EPDS screening results plus an equal number of optimally matched²⁴ women with scores less than 10 and no indication of suicidal ideation for a total of 342 women studied. The matching was based on the age of the mother (±1.5 years) and month of delivery (±2 months).

Olmsted County is a metropolitan statistical area with a population of approximately 106,000 of whom 92% were white non-Hispanic with socioeconomic and educational levels slightly above the average for white citizens in the United States. There are approximately 1750 deliveries annually of Olmsted County women within Olmsted County hospitals. All in-hospital births in Olmsted County (99.5% of all county births) occur at Olmsted Medical Center or Rochester Methodist Hospital. Postpartum care for county residents is delivered at the Olmsted Medical Center, the Mayo Clinic, and their satellite practices, allowing screening of virtually all (98%) postpartum women in Olmsted County using only 2 institutions.²⁵

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.

Follow-up appointments to monitor confirmed or probable depression were suggested for 57 of the women, including 52 with EPDS scores of 10 or higher. In approximately a third of the cases (21, 37%) the follow-up appointment was with the same clinician. The other two thirds were scheduled to see a psychologist or psychiatrist. Follow-up visits were encouraged for 2.9% (5 of 171) of the women with EPDS scores lower than 10, for 23.5% (16 of 68) of the women with EPDS scores of 10 or 11, and for 45.3% (43 of 95) of the women with EPDS scores of 12 or higher (P for trend <.001).

Postpartum depression was diagnosed in 16 women at follow-up appointments initiated by the postpartum care provider. Altogether, 58 women were diagnosed with postpartum depression at visits clearly related to the 6-week postpartum visit. Most diagnoses of postpartum depression occurred within 90 days of delivery (65%).

An additional 46 subjects had later evaluation for postpartum depression which did not appear to be initiated by their postnatal care clinician. Only 10 of these women were given a diagnosis of depression. Sixteen of these women self-referred directly to a psychiatrist or psychologist, and the others were evaluated for depression during the course of a visit for another reason. The specialty of the other clinicians included family medicine (16), obstetrician/gynecologist or certified nurse-midwife (8), emergency department physician (2), and 1 each by a physiatrist, an endocrinologist, a nurse practitioner, and a physician’s assistant.

Treatment for women with diagnosed postpartum depression was universally documented. Antidepressant medications were prescribed for 49% of these women and counseling was given to 78%; many women received both (39%). In addition, one woman with a history of recurrent depression was started on an antidepressant immediately following delivery. She had no documented recurrence of depression in the postpartum period. None of the subjects in this study underwent electroconvulsive therapy during the first year postpartum. Three women were hospitalized for specific diagnoses of depression and 2 have been described previously. Another woman was hospitalized on a medical service at 4 months postpartum for fatigue, arthralgias, and other nonspecific symptoms that were eventually diagnosed as an unusual presentation of postpartum depression. Her EPDS score was 13 near 6 weeks postpartum, and she had a history of depression, including a pre-pregnancy attempted suicide.

Discussion

Routine screening for postpartum depression with the EPDS was associated with more-than-doubling the rate of physician-diagnosed postpartum depression in this community-based population. Many of the diagnoses of depression (85%) were made at a visit that could be directly linked to the 6-week postpartum visit during which the screening was completed. Depression-related care was offered in all women with the diagnosis of PPD. Consistent with other work,^15,17,18 women with an elevated EPDS score were 7 times more likely to be diagnosed with PPD. Although only an intermediate outcome measure, receiving treatment for PPD is the first step in effecting more patient-oriented outcomes, such as improved ability to carry out usual activities, ability to care for the new infant, and prevention of suicide.¹³

Most of the diagnoses of postpartum depression were made by the physician or midlevel practitioner who cared for the woman at her 6-week postpartum visit, and most were made within 3 months of delivery. These primary care physicians and obstetrical care providers both diagnosed the condition and provided care for many of the women. The importance of primary care physicians in the recognition and treatment of all types of depression has previously been confirmed.^13,14,29,30

The pattern of diagnosis early in the postpartum period is similar to that reported in other studies^2,15,12 with most women receiving the diagnosis within 6 months of delivery. During evaluation for their depression, many women with PPD reported that symptoms began within weeks of delivery and were simply tolerated until the diagnosis was made. Screening for depression at the 6-week postpartum visit is most likely to identify these women with early onset of symptoms.

EPDS screening is done at a single point in time, and not all postpartum depression is evident at or before this time. It is therefore important to continue to consider PPD as a diagnosis for women who have no signs or symptoms at the 6-week postpartum visit but present at a later time with findings that may be consistent with depression.¹⁷ In our study, it is impossible to determine whether the women ultimately diagnosed with PPD but had low EPDS scores near 6 weeks postpartum represent false-negative depression screens or whether these women were not symptomatic at the time of the EPDS screening.

The information documented in the medical records suggests that for some of the women with elevated EPDS scores, at the postpartum visits may have been missed opportunities to diagnose depression. Some women who had a first diagnosis of PPD at 3 to 9 months after delivery mentioned that symptoms had been present since the baby was aged younger than 1 month and had elevated EPDS screening scores. These women may represent the enhanced clarity of hindsight, the failure of the physician to address EPDS scores, the limited ability of the clinician to adequately evaluate depression,^5,31-33 or the failure of the women to disclose the severity of their symptoms.¹² The importance of reducing missed opportunities is exemplified by the woman with no documented response to a high EPDS score followed by a suicide attempt at approximately 3 months postpartum. The ICU record completed at the time of hospitalization for treatment of an attempted suicide by overdose states she had been symptomatic since shortly after the birth of the baby.

The lack of documented response to suicidal ideation indicated on the EPDS of several women is disturbing. It is not clear if the clinicians did not see the response, did not respond, or did not document their response (ie, unreported telephone follow-up). All clinicians received the same information about the program including written material and a presentation at a meeting of each department providing postnatal care. Each clinician was notified of any EPDS indication of thoughts of self-harm.

Other studies of psychiatric screening tools in primary care have found similar results. In their evaluation of the Primary Care Evaluation of Mental Disorders (PRIME-MD), Spitzer and colleagues³⁴ reported that although 80% of clinicians introduced to this diagnostic screening tool supported routine psychiatric screening in primary care settings, only 32% of patients given new diagnoses by screening had new management actions initiated or planned. Among 74 patients in their study with previously unrecognized major depression, 22% were scheduled for follow-up visits, 10% received antidepressant prescriptions, and 5% were referred to a mental health care provider.³⁴ Routine use of the EPDS at 6 weeks postpartum can help to diagnose depression, but it is clearly not a sufficient intervention by itself.

Antidepressant therapy was not universally documented for this group of women. This may reflect the available spectrum of treatment choices and patient and physician preferences noted in the medical literature.⁹ In addition, antidepressant therapy may be discouraged if women are breastfeeding.³⁵ We were unable to make this distinction in most of the women with depression; however, the issue of medication crossing into breast milk was raised in at least 5 medical records and on at least 2 occasions breastfeeding was listed as a reason not to use antidepressant therapy.

Limitations

Because we followed practice as it occurs, it is not possible to benchmark our results against those of clinical intervention trials in which all patients are assessed for the outcome. However, we can provide unique data on the changes in clinical practice following the institution of screening for all women at the 6-week postpartum visit. Women were considered to have PPD on the basis of diagnoses recorded in the medical record. These diagnoses reflect the physicians’ judgment and may not exactly reflect the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, diagnostic criteria for depression. However, it is the diagnoses that physicians and other clinicians make that are the basis for treatment provided to women. Therefore, this type of study offers important information regarding the clinical effectiveness of universal screening with the EPDS. When added to studies of the psychometric properties and the efficacy of the instrument, effectiveness data can help identify barriers that occur in the practice-based implementation of trial programs.

Olmsted County women represent a diversity of socioeconomic status with 22% of pregnancies being covered by Medicaid insurance. Although the screening tool has been validated in multiple racial groups,^17-19 racially diverse groups may respond differently to their physician’s discussion of signs and symptoms of depression. Therefore, our results may not be generalizable to all women in the United States. However, middle-class white women are often considered at low risk for psychosocial problems and may therefore fail to be evaluated for PPD, making this an important group in which to assess this mass screening program.

Conclusions

Universal screening for PPD using the EPDS can be successfully implemented in primary care practices and may be associated with a significant increase in the rate of recognition, diagnosis, and treatment of postpartum depression.

Related Resources

• WebMD
• National Institute of Mental Health (NIMH)
• National Mental Health Association (NMHA)
• Mental Health Online

Postpartum depression (PPD) is a serious, common, and treatable condition seen frequently in the primary care setting.^1-3 The effects can be devastating for the entire family. The couple’s relationship often suffers,⁴ and women afflicted with PPD are at high risk for recurrent depression.⁵ Children of depressed mothers have been reported to have impaired cognitive development⁶ and behavioral disturbances.^7,8 Despite the serious consequences and the availability of highly effective pharmacologic and nonpharmacologic therapies,^9-11 PPD often remains unrecognized and untreated.^12,13

Routine office-based screening and the initiation of office systems have been shown to increase recognition and treatment of common conditions with high rates of missed diagnostic and treatment opportunities.¹⁴ Despite the availability of specific validated tools,^{15 17} routine screening for postpartum depression is not common in the United States. Although several population-based studies of PPD screening are available from other countries,^18,19 most studies in the United States have been completed in university settings or among high-risk populations.^20,21 Little published information is available on the effectiveness of routine postpartum screening in a community’s health care practice.²²

In 1997-98, we undertook a 9-month study of routine screening for PPD using the Edinburgh Postnatal Depression Scale (EPDS)¹⁵ at the 6-week postpartum visit in all clinical departments providing postpartum care in the Olmsted Medical Center and the Mayo Clinic, both in Rochester, Minnesota. The EPDS¹⁵ is a self-report scale that has 10 items relating to symptoms of depression and was developed to counter the limitations of other well-established depression scales used to screen postpartum women.^15,17 The scale is brief, easy to use, and avoids interpreting such common postpartum changes as fatigue, poor appetite, and altered sleep patterns as evidence of depression.^15,23

We evaluated changes in the 1-year postdelivery rates of the diagnosis and treatment of PPD before and after the introduction of universal office-based screening with the EPDS. The information obtained should be useful to other communities in determining how to address postpartum depression identification and the potential value of routine screening for PPD.

Methods

The 180 subjects for our study were all women who participated in the routine EPDS screening project, were residents of Olmsted County, and had EPDS scores of 10 or higher (n=172) or scores lower than 10 and an indication of any suicidal ideation (n=8). Nine women with scores of 10 or higher or suicidal ideation refused the general medical records research authorization required by Minnesota statute and could not be included in our study. That left 171 subjects with abnormal EPDS screening results plus an equal number of optimally matched²⁴ women with scores less than 10 and no indication of suicidal ideation for a total of 342 women studied. The matching was based on the age of the mother (±1.5 years) and month of delivery (±2 months).

Olmsted County is a metropolitan statistical area with a population of approximately 106,000 of whom 92% were white non-Hispanic with socioeconomic and educational levels slightly above the average for white citizens in the United States. There are approximately 1750 deliveries annually of Olmsted County women within Olmsted County hospitals. All in-hospital births in Olmsted County (99.5% of all county births) occur at Olmsted Medical Center or Rochester Methodist Hospital. Postpartum care for county residents is delivered at the Olmsted Medical Center, the Mayo Clinic, and their satellite practices, allowing screening of virtually all (98%) postpartum women in Olmsted County using only 2 institutions.²⁵

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.

Follow-up appointments to monitor confirmed or probable depression were suggested for 57 of the women, including 52 with EPDS scores of 10 or higher. In approximately a third of the cases (21, 37%) the follow-up appointment was with the same clinician. The other two thirds were scheduled to see a psychologist or psychiatrist. Follow-up visits were encouraged for 2.9% (5 of 171) of the women with EPDS scores lower than 10, for 23.5% (16 of 68) of the women with EPDS scores of 10 or 11, and for 45.3% (43 of 95) of the women with EPDS scores of 12 or higher (P for trend <.001).

Postpartum depression was diagnosed in 16 women at follow-up appointments initiated by the postpartum care provider. Altogether, 58 women were diagnosed with postpartum depression at visits clearly related to the 6-week postpartum visit. Most diagnoses of postpartum depression occurred within 90 days of delivery (65%).

An additional 46 subjects had later evaluation for postpartum depression which did not appear to be initiated by their postnatal care clinician. Only 10 of these women were given a diagnosis of depression. Sixteen of these women self-referred directly to a psychiatrist or psychologist, and the others were evaluated for depression during the course of a visit for another reason. The specialty of the other clinicians included family medicine (16), obstetrician/gynecologist or certified nurse-midwife (8), emergency department physician (2), and 1 each by a physiatrist, an endocrinologist, a nurse practitioner, and a physician’s assistant.

Treatment for women with diagnosed postpartum depression was universally documented. Antidepressant medications were prescribed for 49% of these women and counseling was given to 78%; many women received both (39%). In addition, one woman with a history of recurrent depression was started on an antidepressant immediately following delivery. She had no documented recurrence of depression in the postpartum period. None of the subjects in this study underwent electroconvulsive therapy during the first year postpartum. Three women were hospitalized for specific diagnoses of depression and 2 have been described previously. Another woman was hospitalized on a medical service at 4 months postpartum for fatigue, arthralgias, and other nonspecific symptoms that were eventually diagnosed as an unusual presentation of postpartum depression. Her EPDS score was 13 near 6 weeks postpartum, and she had a history of depression, including a pre-pregnancy attempted suicide.

Discussion

Routine screening for postpartum depression with the EPDS was associated with more-than-doubling the rate of physician-diagnosed postpartum depression in this community-based population. Many of the diagnoses of depression (85%) were made at a visit that could be directly linked to the 6-week postpartum visit during which the screening was completed. Depression-related care was offered in all women with the diagnosis of PPD. Consistent with other work,^15,17,18 women with an elevated EPDS score were 7 times more likely to be diagnosed with PPD. Although only an intermediate outcome measure, receiving treatment for PPD is the first step in effecting more patient-oriented outcomes, such as improved ability to carry out usual activities, ability to care for the new infant, and prevention of suicide.¹³

Most of the diagnoses of postpartum depression were made by the physician or midlevel practitioner who cared for the woman at her 6-week postpartum visit, and most were made within 3 months of delivery. These primary care physicians and obstetrical care providers both diagnosed the condition and provided care for many of the women. The importance of primary care physicians in the recognition and treatment of all types of depression has previously been confirmed.^13,14,29,30

The pattern of diagnosis early in the postpartum period is similar to that reported in other studies^2,15,12 with most women receiving the diagnosis within 6 months of delivery. During evaluation for their depression, many women with PPD reported that symptoms began within weeks of delivery and were simply tolerated until the diagnosis was made. Screening for depression at the 6-week postpartum visit is most likely to identify these women with early onset of symptoms.

EPDS screening is done at a single point in time, and not all postpartum depression is evident at or before this time. It is therefore important to continue to consider PPD as a diagnosis for women who have no signs or symptoms at the 6-week postpartum visit but present at a later time with findings that may be consistent with depression.¹⁷ In our study, it is impossible to determine whether the women ultimately diagnosed with PPD but had low EPDS scores near 6 weeks postpartum represent false-negative depression screens or whether these women were not symptomatic at the time of the EPDS screening.

The information documented in the medical records suggests that for some of the women with elevated EPDS scores, at the postpartum visits may have been missed opportunities to diagnose depression. Some women who had a first diagnosis of PPD at 3 to 9 months after delivery mentioned that symptoms had been present since the baby was aged younger than 1 month and had elevated EPDS screening scores. These women may represent the enhanced clarity of hindsight, the failure of the physician to address EPDS scores, the limited ability of the clinician to adequately evaluate depression,^5,31-33 or the failure of the women to disclose the severity of their symptoms.¹² The importance of reducing missed opportunities is exemplified by the woman with no documented response to a high EPDS score followed by a suicide attempt at approximately 3 months postpartum. The ICU record completed at the time of hospitalization for treatment of an attempted suicide by overdose states she had been symptomatic since shortly after the birth of the baby.

The lack of documented response to suicidal ideation indicated on the EPDS of several women is disturbing. It is not clear if the clinicians did not see the response, did not respond, or did not document their response (ie, unreported telephone follow-up). All clinicians received the same information about the program including written material and a presentation at a meeting of each department providing postnatal care. Each clinician was notified of any EPDS indication of thoughts of self-harm.

Other studies of psychiatric screening tools in primary care have found similar results. In their evaluation of the Primary Care Evaluation of Mental Disorders (PRIME-MD), Spitzer and colleagues³⁴ reported that although 80% of clinicians introduced to this diagnostic screening tool supported routine psychiatric screening in primary care settings, only 32% of patients given new diagnoses by screening had new management actions initiated or planned. Among 74 patients in their study with previously unrecognized major depression, 22% were scheduled for follow-up visits, 10% received antidepressant prescriptions, and 5% were referred to a mental health care provider.³⁴ Routine use of the EPDS at 6 weeks postpartum can help to diagnose depression, but it is clearly not a sufficient intervention by itself.

Antidepressant therapy was not universally documented for this group of women. This may reflect the available spectrum of treatment choices and patient and physician preferences noted in the medical literature.⁹ In addition, antidepressant therapy may be discouraged if women are breastfeeding.³⁵ We were unable to make this distinction in most of the women with depression; however, the issue of medication crossing into breast milk was raised in at least 5 medical records and on at least 2 occasions breastfeeding was listed as a reason not to use antidepressant therapy.

Limitations

Because we followed practice as it occurs, it is not possible to benchmark our results against those of clinical intervention trials in which all patients are assessed for the outcome. However, we can provide unique data on the changes in clinical practice following the institution of screening for all women at the 6-week postpartum visit. Women were considered to have PPD on the basis of diagnoses recorded in the medical record. These diagnoses reflect the physicians’ judgment and may not exactly reflect the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, diagnostic criteria for depression. However, it is the diagnoses that physicians and other clinicians make that are the basis for treatment provided to women. Therefore, this type of study offers important information regarding the clinical effectiveness of universal screening with the EPDS. When added to studies of the psychometric properties and the efficacy of the instrument, effectiveness data can help identify barriers that occur in the practice-based implementation of trial programs.

Olmsted County women represent a diversity of socioeconomic status with 22% of pregnancies being covered by Medicaid insurance. Although the screening tool has been validated in multiple racial groups,^17-19 racially diverse groups may respond differently to their physician’s discussion of signs and symptoms of depression. Therefore, our results may not be generalizable to all women in the United States. However, middle-class white women are often considered at low risk for psychosocial problems and may therefore fail to be evaluated for PPD, making this an important group in which to assess this mass screening program.

Conclusions

Universal screening for PPD using the EPDS can be successfully implemented in primary care practices and may be associated with a significant increase in the rate of recognition, diagnosis, and treatment of postpartum depression.

Related Resources

• WebMD
• National Institute of Mental Health (NIMH)
• National Mental Health Association (NMHA)
• Mental Health Online

Postpartum depression (PPD) is a serious, common, and treatable condition seen frequently in the primary care setting.^1-3 The effects can be devastating for the entire family. The couple’s relationship often suffers,⁴ and women afflicted with PPD are at high risk for recurrent depression.⁵ Children of depressed mothers have been reported to have impaired cognitive development⁶ and behavioral disturbances.^7,8 Despite the serious consequences and the availability of highly effective pharmacologic and nonpharmacologic therapies,^9-11 PPD often remains unrecognized and untreated.^12,13

Routine office-based screening and the initiation of office systems have been shown to increase recognition and treatment of common conditions with high rates of missed diagnostic and treatment opportunities.¹⁴ Despite the availability of specific validated tools,^{15 17} routine screening for postpartum depression is not common in the United States. Although several population-based studies of PPD screening are available from other countries,^18,19 most studies in the United States have been completed in university settings or among high-risk populations.^20,21 Little published information is available on the effectiveness of routine postpartum screening in a community’s health care practice.²²

In 1997-98, we undertook a 9-month study of routine screening for PPD using the Edinburgh Postnatal Depression Scale (EPDS)¹⁵ at the 6-week postpartum visit in all clinical departments providing postpartum care in the Olmsted Medical Center and the Mayo Clinic, both in Rochester, Minnesota. The EPDS¹⁵ is a self-report scale that has 10 items relating to symptoms of depression and was developed to counter the limitations of other well-established depression scales used to screen postpartum women.^15,17 The scale is brief, easy to use, and avoids interpreting such common postpartum changes as fatigue, poor appetite, and altered sleep patterns as evidence of depression.^15,23

We evaluated changes in the 1-year postdelivery rates of the diagnosis and treatment of PPD before and after the introduction of universal office-based screening with the EPDS. The information obtained should be useful to other communities in determining how to address postpartum depression identification and the potential value of routine screening for PPD.

Methods

The 180 subjects for our study were all women who participated in the routine EPDS screening project, were residents of Olmsted County, and had EPDS scores of 10 or higher (n=172) or scores lower than 10 and an indication of any suicidal ideation (n=8). Nine women with scores of 10 or higher or suicidal ideation refused the general medical records research authorization required by Minnesota statute and could not be included in our study. That left 171 subjects with abnormal EPDS screening results plus an equal number of optimally matched²⁴ women with scores less than 10 and no indication of suicidal ideation for a total of 342 women studied. The matching was based on the age of the mother (±1.5 years) and month of delivery (±2 months).

Olmsted County is a metropolitan statistical area with a population of approximately 106,000 of whom 92% were white non-Hispanic with socioeconomic and educational levels slightly above the average for white citizens in the United States. There are approximately 1750 deliveries annually of Olmsted County women within Olmsted County hospitals. All in-hospital births in Olmsted County (99.5% of all county births) occur at Olmsted Medical Center or Rochester Methodist Hospital. Postpartum care for county residents is delivered at the Olmsted Medical Center, the Mayo Clinic, and their satellite practices, allowing screening of virtually all (98%) postpartum women in Olmsted County using only 2 institutions.²⁵

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.

Follow-up appointments to monitor confirmed or probable depression were suggested for 57 of the women, including 52 with EPDS scores of 10 or higher. In approximately a third of the cases (21, 37%) the follow-up appointment was with the same clinician. The other two thirds were scheduled to see a psychologist or psychiatrist. Follow-up visits were encouraged for 2.9% (5 of 171) of the women with EPDS scores lower than 10, for 23.5% (16 of 68) of the women with EPDS scores of 10 or 11, and for 45.3% (43 of 95) of the women with EPDS scores of 12 or higher (P for trend <.001).

Postpartum depression was diagnosed in 16 women at follow-up appointments initiated by the postpartum care provider. Altogether, 58 women were diagnosed with postpartum depression at visits clearly related to the 6-week postpartum visit. Most diagnoses of postpartum depression occurred within 90 days of delivery (65%).

An additional 46 subjects had later evaluation for postpartum depression which did not appear to be initiated by their postnatal care clinician. Only 10 of these women were given a diagnosis of depression. Sixteen of these women self-referred directly to a psychiatrist or psychologist, and the others were evaluated for depression during the course of a visit for another reason. The specialty of the other clinicians included family medicine (16), obstetrician/gynecologist or certified nurse-midwife (8), emergency department physician (2), and 1 each by a physiatrist, an endocrinologist, a nurse practitioner, and a physician’s assistant.

Treatment for women with diagnosed postpartum depression was universally documented. Antidepressant medications were prescribed for 49% of these women and counseling was given to 78%; many women received both (39%). In addition, one woman with a history of recurrent depression was started on an antidepressant immediately following delivery. She had no documented recurrence of depression in the postpartum period. None of the subjects in this study underwent electroconvulsive therapy during the first year postpartum. Three women were hospitalized for specific diagnoses of depression and 2 have been described previously. Another woman was hospitalized on a medical service at 4 months postpartum for fatigue, arthralgias, and other nonspecific symptoms that were eventually diagnosed as an unusual presentation of postpartum depression. Her EPDS score was 13 near 6 weeks postpartum, and she had a history of depression, including a pre-pregnancy attempted suicide.

Discussion

Routine screening for postpartum depression with the EPDS was associated with more-than-doubling the rate of physician-diagnosed postpartum depression in this community-based population. Many of the diagnoses of depression (85%) were made at a visit that could be directly linked to the 6-week postpartum visit during which the screening was completed. Depression-related care was offered in all women with the diagnosis of PPD. Consistent with other work,^15,17,18 women with an elevated EPDS score were 7 times more likely to be diagnosed with PPD. Although only an intermediate outcome measure, receiving treatment for PPD is the first step in effecting more patient-oriented outcomes, such as improved ability to carry out usual activities, ability to care for the new infant, and prevention of suicide.¹³

Most of the diagnoses of postpartum depression were made by the physician or midlevel practitioner who cared for the woman at her 6-week postpartum visit, and most were made within 3 months of delivery. These primary care physicians and obstetrical care providers both diagnosed the condition and provided care for many of the women. The importance of primary care physicians in the recognition and treatment of all types of depression has previously been confirmed.^13,14,29,30

The pattern of diagnosis early in the postpartum period is similar to that reported in other studies^2,15,12 with most women receiving the diagnosis within 6 months of delivery. During evaluation for their depression, many women with PPD reported that symptoms began within weeks of delivery and were simply tolerated until the diagnosis was made. Screening for depression at the 6-week postpartum visit is most likely to identify these women with early onset of symptoms.

EPDS screening is done at a single point in time, and not all postpartum depression is evident at or before this time. It is therefore important to continue to consider PPD as a diagnosis for women who have no signs or symptoms at the 6-week postpartum visit but present at a later time with findings that may be consistent with depression.¹⁷ In our study, it is impossible to determine whether the women ultimately diagnosed with PPD but had low EPDS scores near 6 weeks postpartum represent false-negative depression screens or whether these women were not symptomatic at the time of the EPDS screening.

The information documented in the medical records suggests that for some of the women with elevated EPDS scores, at the postpartum visits may have been missed opportunities to diagnose depression. Some women who had a first diagnosis of PPD at 3 to 9 months after delivery mentioned that symptoms had been present since the baby was aged younger than 1 month and had elevated EPDS screening scores. These women may represent the enhanced clarity of hindsight, the failure of the physician to address EPDS scores, the limited ability of the clinician to adequately evaluate depression,^5,31-33 or the failure of the women to disclose the severity of their symptoms.¹² The importance of reducing missed opportunities is exemplified by the woman with no documented response to a high EPDS score followed by a suicide attempt at approximately 3 months postpartum. The ICU record completed at the time of hospitalization for treatment of an attempted suicide by overdose states she had been symptomatic since shortly after the birth of the baby.

The lack of documented response to suicidal ideation indicated on the EPDS of several women is disturbing. It is not clear if the clinicians did not see the response, did not respond, or did not document their response (ie, unreported telephone follow-up). All clinicians received the same information about the program including written material and a presentation at a meeting of each department providing postnatal care. Each clinician was notified of any EPDS indication of thoughts of self-harm.

Other studies of psychiatric screening tools in primary care have found similar results. In their evaluation of the Primary Care Evaluation of Mental Disorders (PRIME-MD), Spitzer and colleagues³⁴ reported that although 80% of clinicians introduced to this diagnostic screening tool supported routine psychiatric screening in primary care settings, only 32% of patients given new diagnoses by screening had new management actions initiated or planned. Among 74 patients in their study with previously unrecognized major depression, 22% were scheduled for follow-up visits, 10% received antidepressant prescriptions, and 5% were referred to a mental health care provider.³⁴ Routine use of the EPDS at 6 weeks postpartum can help to diagnose depression, but it is clearly not a sufficient intervention by itself.

Antidepressant therapy was not universally documented for this group of women. This may reflect the available spectrum of treatment choices and patient and physician preferences noted in the medical literature.⁹ In addition, antidepressant therapy may be discouraged if women are breastfeeding.³⁵ We were unable to make this distinction in most of the women with depression; however, the issue of medication crossing into breast milk was raised in at least 5 medical records and on at least 2 occasions breastfeeding was listed as a reason not to use antidepressant therapy.

Limitations

Because we followed practice as it occurs, it is not possible to benchmark our results against those of clinical intervention trials in which all patients are assessed for the outcome. However, we can provide unique data on the changes in clinical practice following the institution of screening for all women at the 6-week postpartum visit. Women were considered to have PPD on the basis of diagnoses recorded in the medical record. These diagnoses reflect the physicians’ judgment and may not exactly reflect the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, diagnostic criteria for depression. However, it is the diagnoses that physicians and other clinicians make that are the basis for treatment provided to women. Therefore, this type of study offers important information regarding the clinical effectiveness of universal screening with the EPDS. When added to studies of the psychometric properties and the efficacy of the instrument, effectiveness data can help identify barriers that occur in the practice-based implementation of trial programs.

Olmsted County women represent a diversity of socioeconomic status with 22% of pregnancies being covered by Medicaid insurance. Although the screening tool has been validated in multiple racial groups,^17-19 racially diverse groups may respond differently to their physician’s discussion of signs and symptoms of depression. Therefore, our results may not be generalizable to all women in the United States. However, middle-class white women are often considered at low risk for psychosocial problems and may therefore fail to be evaluated for PPD, making this an important group in which to assess this mass screening program.

Conclusions

Universal screening for PPD using the EPDS can be successfully implemented in primary care practices and may be associated with a significant increase in the rate of recognition, diagnosis, and treatment of postpartum depression.

Related Resources

• WebMD
• National Institute of Mental Health (NIMH)
• National Mental Health Association (NMHA)
• Mental Health Online