Using a well-child visit to screen for postpartum depression 2 months after delivery will catch the majority of women likely to develop the condition within the first 6 postpartum months, new research suggests.
Investigators at the University of Colorado Denver School of Medicine also found that using cues embedded in the electronic medical records of infants 0 to 6 months of age to remind physicians to screen new mothers is an effective method of detecting and referring those at risk.
No Optimal Screening Interval Identified
Postpartum depression is the most common medical problem new mothers face and is associated with a wide range of maternal and child health problems. It can develop any time during the first postpartum year, and while pediatric visits have been identified as an ideal setting in which to screen women, there is no evidence to support an optimal screening interval, the authors note.
The purpose of the study was to assess the feasibility of using electronically generated reminders to detect and refer at-risk women and to look at the prevalence and incidence of maternal depression assessed at well-child visits during the first 6 months after birth.
The study included 204 mothers and 413 electronic depression–screening cues. These prompts appeared automatically when the medical records of children 0 to 6 months old were opened and reminded medical staff to administer the 10-item Edinburgh Postpartum Depression Scale (EPDS) to new mothers.
Providers were unable to close the children's medical records until they had entered the EPDS score or 1 of the precoded reasons for not administering the EPDS.
An EPDS of 10 or greater was considered a positive result, and providers could not close the medical record until a management plan or referral was recorded.
The providers administered the EPDS 98% of the time and always referred mothers with positive scores. Overall, 20.1% of the women who completed the EPDS at 2 weeks, 2 months, 4 months, or 6 months had positive scores.
EPDS scores indicated that the prevalence of depressive symptoms varied from 17.0% at 2 weeks to 16.5% at 2 months.
Screening Before 2 Months Not Useful The researchers also found that screening for depression during the first 3 weeks was so unreliable that it could not consistently identify the same mothers as being at risk for depression. This finding, the researchers note, argues against routine, universal postpartum depression screening before 2 months.
After 3 weeks, the prevalence and incidence of positive EPDS scores decreased from 16.5% at 2 months to 10.3% and 5.7% respectively at 4 months. However, prevalence increased to 18.5% at the 6-month visit and incidence decreased to 1.9%, the investigators report.
If women had been screened only at the 2-month postpartum time point, only 2 of the 35 mothers with positive EPDS scores at 6 months would have been missed. Both of those mothers completed the EPDS within 3 weeks after delivery, but neither crossed the referral threshold.
Clinical ContextAll new mothers should be screened periodically for postpartum depression because it is treatable and common and has the potential to cause child health problems. Postpartum depression can occur any time during the first year, and the best screening interval and strategy have not yet been identified. Also, the prevalence and accuracy of screening at different times after delivery are not well reported.
This is a study of a screening program using electronic cues to providers of well-child visits in a pediatric clinic to examine the efficacy of the cue on screening for postpartum depression and the prevalence of postpartum depression in adolescent new mothers in the first 6 months after delivery.
Study Highlights
• The Colorado Adolescent Maternity Program is a comprehensive prenatal delivery and postnatal care program for 12- to 21-year-old mothers in 1 US state located in an urban hospital, serving a low-income population.
• Providers of well-child care were a pediatrician and 2 mid-level providers with training in adolescent medicine.
• An electronic medical record system is used for practice improvement, and all child health records were flagged electronically with prompts to providers to administer the EPDS to mothers of children at well-child visits.
• The EPDS is a 10-item validated and reliable scale with a score of 10 or higher reliably identifying 90% of cases in other studies.
• Responses were on a 4-point scale with a score range from 0 to 30, with higher scores indicating higher depressive symptoms.
• Mothers were given a pencil-and-paper version of the EPDS to complete while waiting for their child to be seen.
• Providers collected and scored the EPDS forms, discussed results with mothers, and recorded the scores in the children's electronic medical records.
• After 5 months, providers were unable to close the children's electronic records unless they had administered the EPDS at least once or given a reason why it was not administered.
• During the study period, providers saw 418 electronic screening cues for the EPDS associated with 204 mothers.
• In 5 cases, mothers were not with the child; of the remaining cues, providers responded to 99%.
• None of the mothers refused to complete the EPDS.
• Mean age of mothers was 18 years, 36% were black and 44% were Hispanic, 87% were Medicaid recipients, mean parity was 1.4, and 51% were living with a biological parent.
• Overall, 20.1% of mothers who completed the EPDS at 2 weeks and at 2, 4, and 6-month well-child visits met the referral criteria of a score of 10 or higher on the EPDS.
• The prevalence of depressive symptoms ranged from 17.0% at 2 weeks to 16.5% at 2 months to 10.3% at 4 months and 18.5% at 6 months.
• Although the prevalence was highest at the 2-week visit, this was the least reliable measurement because only 12% of mothers met depression referral criteria at 2 visits, and 8% resolved the symptoms at the following visit.
• The incidence of depressive symptoms decreased from 16.5% at 2 months to 5.7% at 4 months and 1.9% at 6 months, with only 2 cases that would have been missed if the mothers had been screened only once.
• 94.5% of the mothers who met the referral criteria did so at the first screening.
• The authors recommended that screening at 2 months identifies most mothers who develop postpartum depression and that screening at 6 months was preferable to screening at 4 months.
• Of 40 mothers who met referral criterion, 8.6% were 22 years or older.
• They were referred for further evaluation and treatment.
• The authors concluded that screening of mothers at the well-child visit in the first 6 months was feasible and was associated with an accurate diagnosis of postpartum depressive symptoms.
Clinical Implications
• Use of an electronic cue to providers for screening for postpartum depression using the EPDS in mothers at well-child visits is associated with high compliance by providers and mothers.
• The EPDS used at the well-child visit at 2 and 6 months is helpful for diagnosing depressive symptoms in new mothers.
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