Screening for postpartum depression is a valuable safeguard. It is not, however, all we have to do.

There is little debate that our most reliable and valid screening tool for postpartum depression, the EPDS, is effective in identifying screen-positive women. Furthermore, universal screening for postpartum depression during well-child care visits has been shown to increase detection of PPD. What does seem to be missing, however, is an extensive understanding of the screening process itself, including limitations and potential harm of untrained health professional and inadequate follow up. Recently, Katherine Stone wrote a compelling piece on this topic.

Screening provides the opportunity to normalize the assessment of a woman’s emotional health after childbirth. When a healthcare provider asks the right questions, in the right way, it creates an environment in which postpartum women can begin to feel comfortable addressing how they feel. To my knowledge, women generally accept this opportunity with an open heart. That does not mean they are eager to disclose the nature of their dark thoughts or the depth of their anguish, and it certainly doesn’t mean they won’t lie about how they are feeling.  But by and large, they interpret these questions as a legitimate early intervention and recognize their value. (Although as Stone points out, many women today still report they are not being screened or evened asked about their emotional state). Questions focusing on mental health have also shown to convey the valuable message that one’s emotional state is an important part of recovery and that this is taken seriously by the particular healthcare provider asking the questions. It appears that any discomfort with this process reported by postpartum women, is not a function of the assessment itself; rather, it may be associated with their degree of distress. By normalizing the discussion of postpartum emotions, the screening process serves to help reduce the perceived stigma attached to mental health issues, particularly those associated with new motherhood.

That’s the good news.

The not-so-good news is that healthcare providers, eager to implement state and federal mandates and keep up with current awareness campaigns, are potentially missing some important information about the purpose of screening and how the results should be managed.

Timing

Some studies confirm that screening should place in the first 3 months postpartum, although most experts agree that the risk for postpartum depression remains high during the first postpartum year.

Various other screening points have been targeted by numerous studies, including 6 weeks postpartum, 6 months postpartum, 12 months postpartum and beyond.

Some experts claim that the risk of developing postpartum depression is greatest in the first 3 months postpartum, decreasing slightly in the fourth through the seventh month after delivery.  Most of us who study this population will agree that residual depressive symptoms often linger well into and beyond the first postpartum year.  

Still, others claim that screening for postpartum depression is recommended 6–8 weeks after delivery.

Moreever, it seems hospitals are beginning to screen postpartum women prior to discharge, which is generally 24-48 hours after delivery.

Have you ever asked a woman who gives birth how she feels 24 hours later? These results are highly likely to be skewed. In light of inconclusive timing recommendations, and without rigorous follow up protocol or a formal diagnostic procedure, this practice of immediately screening is most effective for postpartum psychosis symptoms and less so with major depressive disorders.

What are we telling women?

Is there potential harm in telling a woman with positive results that she is depressed? Yes, according to Jeanne Milgrom, lead author of Does postnatal depression screening work? Throwing out the bathwater, keeping the baby,

"A positive screen only indicates a higher than average chance of being found to be currently depressed by a second, diagnostic-stage test."

If we communicate to her that she is “at risk”, or “probably depressed”, we might be providing ambiguous or erroneous information. Milgrom explains that “at risk” implies she may be likely to develop depression in the future, which the EPDS does not establish and “probably depressed” is likely to imply a higher probability than is actually the case. The use of these phrases could contribute to the mother’s already agitated state. Similarly, a negative screen does not imply that the woman is free from depression. It only indicates a lower than average chance of a positive depression diagnosis, on a second-stage diagnostic test. False positive and false negative results are not always related to the instrument itself, rather, they can result from improper training or misinterpretations.

Milgrom compares this to other health screening instruments with similar effective rates. The majority of women who are called back for further testing after a routine mammogram screen, for example, are not diagnosed with breast cancer. Furthermore, these women should never be informed that they have cancer or that they are “at risk” for cancer and it makes sense that these same considerations should pertain to postpartum women being screened for depression.

I think it’s great that we are stepping up the screening process. But it will be a charade of good intentions unless we carry it out correctly. Just because it looks good on paper, or in policy or in brochures, does not mean we are providing the best practices for the postpartum women we are purportedly caring for.

In order for screening practices to be maximized, here are the key points:

  • The EPDS is not a diagnostic tool. It is an assessment tool.
  • No woman should be “labeled” as depressed solely on the basis of the EDPS screen.
  • Follow up screening is imperative.
  • Clinical interview is essential.
  • If hospitals routinely screen postpartum women prior to discharge, can they properly identify and differentiate a transitory emotional state from a depressive episode?
  • Who is doing the screening? Are they sufficiently trained? Are they familiar with the instrument and how some women misinterpret the questions, thereby skewing their responses? Do they know how to interpret the results properly? Are they helping the mother understand the screening questions if they are feeling overwhelmed or symptomatic? Are they saying the right things to the patients without misleading them?

Unfortunately we don’t have all the resources to screen well.  Too many facilities are handing out the screening tool just like they are handing out prescriptions for SSRIs, without adequate dialogues or ongoing assessment.  However, as Milgrom notes in her article, that is not to say we should not be screening. Of course we should. And it has been proven to make a difference in the identification of women with PPD. Still, can we do right? Can we be careful how we do it and what we say?

In an ideal world, screening for postpartum depression should be carried out by trained healthcare providers who understand the particular screening instrument (as well as its nuances) and who have the clinical skills to put it into practice with compassion and specialized expertise. Doctors, nurses, midwives, social workers, support staff and whomever is performing the screening should receive specialized training. It is simply not enough to hand over a piece of paper to postpartum women, especially, those who have just given birth 24 hours ago. After all, if we are going to spend this time, energy, and resources on behalf of postpartum women, shouldn't we be doing it right?

References:

Seehusen, D., Clark, G. (2007). Barriers to postpartum depression screening, diagnosis and treatment. In: Rosenfield AI, editor. New Research on Postpartum Depression. Nova Science Publishers, 59–68.

Gaynes, B., Gavin, N., Meltzer-Brody, S., et al. (2005). Evidence Report/ Technology Assessment No. 119 (Prepared by the RTI-University of North Carolina Evidence-Practice Center, under Contract No. 290-02-0016) AHRQ Publication No. 05-E006-2. Rockville, MD: Agency for Healthcare Research and Quality;Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes.

Milgrom, J., Mendelsohn, J., Gemmill, A.(2011). Does postnatal depression screening work? Throwing out the bathwater, keeping the baby. Journal of Affective Disorders, 132(3):301-10.

Cox, J., Holden, J., & Sagovsky, R. (1987). Detection of postnatal depression. Developmentof the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry,150, 782–786.

Beck, C. (2006).  Postpartum depression: It isn't just the blues. American Journal of Nursing, 106 ( 5), 40-50.

Glavin,. K, Smith, L., Sorum, R., et al. (2010). Redesigned community postpartum care to prevent and treat postpartum depression in women—a one-year follow-up study. Journal of Clinical Nursing,19 (21–22):3051–62.

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