Screening and Detection of Postpartum Depression

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Postpartum depression (PPD) can be quickly treated and controlled. This makes it all the more crucial that it be identified as early as possible so as to reduce potentially negative outcomes, not just for the mother but for her developing infant as well (Gao et al., 2010).

It is estimated that at least 50% of postpartum depression cases go unrecognized (Peindl, Wisner & Hanusa, 2004) When postpartum depression is identified, it is most often the primary care provider who does so (41.3% of cases), followed by obstetricians (30.7%), then mental health providers (13.0%) (Dietz et al., 2007).  While psychiatrists are probably better equipped to identify and treat PPD, women are more likely to seek help from their OB/GYN, primary care physicians (Peindl, Wisner & Hanusa, 2004) or even their children’s pediatrician (Hadi & Hadi, 2015).

Because women tend to seek help from these primary care physicians, it is important therefore that these primary care physicians familiarize themselves with the symptoms, risk factors, and screening techniques of postpartum depression. There are several screens available, the most widely used currently being the PHQ-2 questionnaire (covering depressive and dysphoric mood nearly every day for at least two weeks) (Hadi & Hadi, 2015). While traditionally a “yes” or “no” questionnaire, responses to the PHQ-2 can be quantified to more accurately assess a woman’s mood. It can also be extended beyond the DSM-IV time frame of four weeks as defining the postpartum period. But even with these adaptations, there is a major weakness in the PHQ-2 when applied to postpartum depression—it does not address the hallmark postpartum depression symptom of anxiety. It is only 83% sensitive with a cutoff score >3, and adapting it quantitatively and extending the time frame it covers has not been shown to benefit sensitivity (O’Hara, 2009). 

One of the most successful screening tools specifically for postpartum depression is the Edinburgh Postpartum Depression Scale (EPDS), developed by Kendell et al. in Edinburgh Scotland as the result of the first major research on postpartum depression over 30 years ago (Coast et al., 2012). It represents a 10-item questionnaire (scored 0-3) with varying levels of specificity and sensitivity, depending on where the cutoff score falls. Sensitivity increases with lower cutoff scores, but at the cost of specificity. For instance, at a cutoff of 12, the EPDS has an 86 % sensitivity and 78 % specificity. One study showed that women with EPDS scores of 5-9 are 68 times more likely to develop postpartum depression than women with scores of 0-4 in the first five months postpartum. This has led to the proposal of campaigns to have physicians educate mothers, monitor symptoms, and possibly initiate treatment, if their scores are > 9. Currently, most clinics employing the EPDS use 10 as the cutoff score, which identifies more than 90% of women with postpartum depression (Wolf, 2010).

Notwithstanding where the cutoff score falls, the evidence supporting the use of the EPDS is irrefutable. When used in a residency program in 2004, the EPDS increased detection of postpartum depression from 6.3% of identified cases to 35.4%. Then, implemented into a community program as part of the same study, detection increased from 3.7% to 10.7%. While many cases remained undiagnosed, the EPDS vastly improved the outcome for those whom it did identify (Weiss, Sheehan, & Gushwa, 2009).

The success of the EPDS is most likely due to its focus on psychological rather than somatic aspects of depression. It explores two distinct domains of negative affect—depression and anxiety. In fact, the EPDS-3 (a subset of the EPDS questions specifically addressing anxiety) has been shown to have an even better performance than the EPDS in its entirety! (Hadi & Hadi, 2015). With a sensitivity of 95% and specificity of 98%, the EPDS-3 identified 16% more mothers with postpartum depression than the EPDS-10.5. In addition, the EPDS-3 is much faster to complete and lessens any time constraints on both physician and patient.

Because a woman’s history of depression is such a significant risk factor, the prenatal and early postpartum periods are probably the most ideal times to begin screening women for potential risk factors for postpartum depression in order to intervene as early as possible. In one study, 54.2% of women with postpartum depression reported that their symptoms actually began during pregnancy (Hegadoren et al., 2009). It is therefore recommended that the EPDS should be used within two to three days postpartum or at the first after-delivery pediatric visit. 

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