March 15, 2010
March 2010, ObGyn News, Lee S. Cohen, M.D.
Postpartum depression is a highly prevalent illness, with multiple studies consistently reporting rates of about 7%-10%, which include both minor and major depression. In some countries such as the United Kingdom, screening for postpartum depression is part of standard health care. In the United States, screening is highly variable, although there has been increasing awareness of this illness and the potential value of screening.
Screening for postpartum depression (PPD) has been recommended as part of routine postpartum care by the American College of Obstetricians and Gynecologists (Obstet. Gynecol. 2010;115(pt. 1):394-5). Several states, including New Jersey, have initiated mandated screening programs in a variety of settings to identify women suffering with postpartum depression. In Maine, an interesting pilot project has been launched, supported by the state’s psychiatric association, which entails screening women for postpartum depression by a spectrum of clinicians including obstetricians and primary care physicians, with psychiatric backup by a group of psychiatrists with subspecialty expertise in the management of postpartum depression.
Few would argue about the theoretical value of screening for postpartum depression, particularly when it leads to effective treatment, but very few studies have looked at whether screening is really cost effective. Specifically, it remains unclear whether screening for PPD leads to effective treatment of the illness (remission) and whether over time those treated do better clinically than those who are not identified or treated.
But a study conducted at the University of York (England), took a critical look at the extent to which screening for postpartum depression in a primary care setting was cost effective when a standardized postnatal depression or generic depression screening tool was used. The analysis, using an economic model and a hypothetical population of women seen at 6 weeks post partum in a primary care setting, determined that screening for PPD was not cost effective and therefore, could not be supported by the National Health Service, based on screening criteria established by that organization (BMJ 2009;339:b5203). The authors determined that the main reason screening was not cost effective was the cost of care for women with false-positive screening results. They concluded that the results did not meet the criteria required for formally adopting such a screening program.
The analysis did not factor in the associated costs of untreated postpartum depression, including the effect on the family and the child, despite the extensive literature on the toll of untreated PPD, including the risk for chronic maternal depression, recurrent postpartum depression, and adverse effects on infant and child development associated with untreated puerperal mood disturbance.
This study, although of interest, was conducted in a country with a national health care system that cannot be entirely extrapolated to the United States. But cost effectiveness and other issues surrounding the feasibility and overall value of screening for postpartum depression are still relevant issues that need to be considered in this country, as screening increasingly becomes a part of routine postpartum care and as more of these programs are recommended by professional organizations, if not mandated by given states.
For those of us who treat this illness, the question is not whether we can effectively screen for PPD, because screening is a simple process that can be accomplished with well-validated and readily available instruments. And there are extremely effective modalities for getting patients well, including nonpharmacologic interventions, such as certain psychotherapies, and pharmacologic interventions, such as antidepressants. Therefore, the problem that looms largest with respect to instituting screening programs is not what is the most appropriate screen or how to identify women with the illness. Rather, the most challenging aspect of screening for PPD in the United States centers on what follows identification of illness. How do clinicians ensure that identified patients have access to treatment that restores euthymia?
In the United Kingdom, primary care physicians routinely manage postpartum depression with regional backup from clinicians with expertise in reproductive psychiatry. In the United States, some primary care physicians treat postpartum depression, but others may be reluctant to do so, which highlights the contention that until a system is in place that ensures treatment of the illness following screening, then it may not be advisable to rush to institute such a program.
A critical questions also yet to be addressed is whether early identification of postpartum depression translates into a positive long-term outcome. We need to collect data on what happens after women are diagnosed, whether they get treated, and if so, how they are treated—with psychotherapy or pharmacotherapy. Data are also needed on who provides treatment and what types of treatment appear to be most effective for which types of patients. And when patients do get well, we need to look at data on whether the improvement is sustained. The precise value of screening is impossible to determine until we have these data.
If there ever is a national mandate to screen for postpartum depression, then it is critical to demonstrate that we have a treatment model in place that not only identifies patients who suffer from the illness, but that such a system includes delivery of effective treatment. Lastly, while it currently may not be possible to quantify the benefits of a screening program for PPD, what is clear is that such a program might help to de-stigmatize mental illness and prompt patients to seek treatment from a variety of care providers, including primary care physicians and obstetricians. Perhaps with greater opportunities to receive effective treatment from a variety of clinicians, the morbidity of postpartum mood disturbance could be vastly limited.