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 studies2,15,12 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.