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.
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