January 19, 2018
Publish date: November 22, 2017
Over the last several years, there’s been increasing interest and ultimately a growing number of mandates across dozens of states to screen women for postpartum depression (PPD). As PPD is the most common, and often devastating, complication in modern obstetrics, screening for it is a movement that I fully support.
What’s been challenging is how to roll out screening in a widespread fashion using a standardized tool that is both easy to use and to score, and that has only a modest number of false positives (i.e., it has good specificity).
My colleagues and I at the Massachusetts General Hospital (MGH) Ammon-Pinizzotto Center for Women’s Mental Health have made significant progress toward these goals with the development of a new iPhone application. The MGH Perinatal Depression Scale (MGHPDS) is an app that screens for postpartum depression during and after pregnancy, and is currently available at the iTunes App Store for iOS devices.
The first version of the MGHPDS app combines the Edinburgh Postpartum Depression Scale (EPDS) – the most commonly used screen for PPD – with screening tools that measure sleep disturbance, anxiety, and stress. And while the Edinburgh scale has been an enormous contribution to psychiatry, its implementation in obstetric settings and community settings using pen and pencil has been a challenge at times given the inclusion of some questions that are “reverse scored”; other problems when the EPDS has been scaled for use in large settings include rates of false positives as high as 25%.
Our app, which gives users an opportunity to let us review their scores after giving informed consent, ultimately will lead to the development of a shortened set of questions that zero in on the symptoms most commonly associated with PPD. That information will derive from a validation study looking at how well the questions on the MGHPDS correlate with major depression; we hope to launch version 2.0 in mid-2018. The second version of the app is likely to include some items from the Edinburgh scale and also selected symptoms of anxiety, sleep problems, and perceived stress. Thus, the goal of the second version will be realized: a more specific scale with targeted symptoms that correlate with the clinical diagnosis of depression.
Automatic scoring of the questionnaires leads to an app-generated result across a spectrum from “no evidence of depressive symptoms,” to a message noting concern and instructing the user to seek medical attention. There are also links to educational resources about PPD within the app.
Equally as exciting as a precise and user-friendly digital screening tool for PPD is the opportunity that digital technology affords when identification of illness is coupled with delivery of evidence-based therapies via a smartphone or tablet. With almost no systematic evidence that initiatives to promote PPD screening have led to women getting referrals to treatment or to ultimate remission of PPD, there is now growing interest in developing evidence-based psychotherapies that can be delivered digitally, including cognitive-behavioral therapy, mindfulness-based cognitive therapy, and behavioral activation. Providing women with other information and resources about pharmacologic options for treatment all on one digital platform like a smartphone or tablet may help to bridge the distance from identification of those suffering from PPD to greater numbers of women recovering from a disabling disorder.
The task of referring women with PPD for treatment and then getting them well is a huge undertaking, and one where we currently are falling short. I have been heartened across the last decade to see the focus land on the issue of PPD screening, but failing to couple screening with evidence-based treatment is an incomplete victory. So with the next version of the app, we want to include treatment tools and a way to track women over time, looking at whether they were treated and if they got well.
We want clinicians to be aware of our app and to share it with their patients. But even more importantly, we want to reach out directly to women because they will lead the way on this effort.
The stakes for unrecognized and untreated PPD are simply too great for women, children, and their families.
Lee Cohen, MD
Dr. Cohen is the director of the Ammon-Pinizzotto Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications.