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 (Ž10) 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.
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