About ten years ago, we ran a collaborative project with our obstetrics department here at MGH where we screened all new mothers for postpartum depression. The screening went well. Nearly all the women completed the Edinburgh Postnatal Depression Scale (EPDS) at their 6-week postpartum visit. We contacted the women with scores on the EPDS suggestive of postpartum depression. Everything seemed like it was going smoothly.
But how many women actually came in for treatment? Very few. There were many reasons that women provided — too far to travel, no childcare, no insurance, no interest. Our experience was by no means unique. In a study of 400 pregnant women carried out in New Zealand, 92.5% completed the EPDS; of the 49 women who screened positive, only 30.6% agreed to mental health assessment. Of those, less than half followed through with assessment, and only 2 women accepted any form of treatment
This is obviously a problem. We know that about 15% of women suffer from depression during pregnancy or the postpartum period But what we don’t know is how to best identify these women and to then ensure that they get the support and treatment they need. Certainly handing them a questionnaire when they visit their OB is not going to do the trick.
Earlier this year, the American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice published an opinion on screening for perinatal depression, recommending that “clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standard, validated tool.” Having the backing of ACOG is certainly a big step in the right direction. But as we move toward universal screening, we must make sure that screening is seamless connected to folow-up and treatment.
Dr. Nancy Byatt and colleagues published an analysis of intervention studies that may help us to improve the delivery of care to this population. In this report, they analyzed 17 studies where women were screened for perinatal depression, and they assessed levels of subsequent treatment.
If you look at the women who were screened for depression but received no additional intervention, rates of treatment were low. An average of 22% (13.8-33.0%) of women who screened positive for depression received at least one mental health visit.
The authors noted that use of mental health services increased two to fourfold when screening was combined with additional interventions geared to decrease potential barriers to treatment. For example, studies including interventions offering systematic follow-up, supportive therapy, or support groups were associated with an average mental health care use rate of 31% Use of mental health services was even better when these interventions targeted both patient- and health care provider-derived barriers to treatment by using patient engagement strategies (44%, 29.0–90.0%), on-site assessments (49%, 25.2–90.0%), and perinatal care provider training (54%, 1.0–90.0%).
One of these interventions, the Perinatal Depression Management Program developed by Dr. Laura Miller, deserves special attention and may serve as a model for the multidisciplinary care and treatment of women with perinatal depression. This intervention includes on-site screening and same-day evaluation by a perinatal care provider, training and support of perinatal healthcare providers, and patient engagement strategies.
This program was implemented in an urban community health center in Chicago serving a predominantly Hispanic population. The Patient Health Questionnaire (PHQ-9) was administered during perinatal visits. Women who had positive screens were followed up at the same visit by a brief diagnostic assessment and engagement strategies.
Before the intervention, 10% of women with positive screens received on-site assessment. None of the patients with identified perinatal depression entered into treatment. After implementation of the program, significantly more women (93.5%) completed the PHQ-9 screening, and of patients with positive screens, 84.8% received an on-site assessment. Among patients diagnosed with major depression and offered treatment, 90% entered treatment.
It is clear that screening for perinatal depression substantially improves detection; however, screening alone does not improve rates of treatment or outcomes. We clearly need to do more.
Ruta Nonacs, MD PhD
Byatt N, Levin LL, Ziedonis D, Moore Simas TA, Allison J. Enhancing Participation in Depression Care in Outpatient Perinatal Care Settings: A Systematic Review. Obstet Gynecol. 2015 Oct 5. [Epub ahead of print]
Miller L, Shade M, Vasireddy V. Beyond screening: assessment of perinatal depression in a perinatal care setting. Arch Womens Ment Health 2009;12:329–34.
Miller LJ, McGlynn A, Suberlak K, Rubin LH, Miller M, Pirec V. Now what? Effects of on-site assessment on treatment entry after perinatal depression screening. J Womens Health (Larchmt) 2012;21:1046–52.