Description

Tools and Exemplary Approaches for Screening

Learning objectives

Recognize post-partum depression

Outline strategies to identify post-partum depression including use of screening questions, general history, and child focused complaints.

Know measures for detecting post-partum depression

Know measures such as the Beck Depression Inventory and the Edinburgh Postnatal Depression Scale.

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An estimated 10% to 20% of women struggle with major depression before, during and after delivery of a baby. Perinatal depression has substantial personal consequences and interferes with quality of child-rearing, adversely affecting parent-child interactions, maternal responsiveness to infant vocalizations and gestures and other stimulation essential for optimal child development. Early detection is disturbingly uncommon even though it is known to improve maternal well-being and child outcomes.

A recent review of randomized, controlled trials examining the effectiveness of screening for depression in primary care settings was conducted by the US Preventive Services Task Force who demonstrated that screening leads to treatment which is particularly effective when integrated models are in place. These include provider and/or patient education, access to case management and/or mental health care, telephone follow-up, and institutional commitment to quality improvement. Additional information and a review of research may be found in the USPSTF Screening statement. As part of their review, the USPSTF found a range of screens for depression equally effective, and did not recommend one particular measure above another. The review also supported studies using screens with only one or two items.

In this article, is a description of one State’s initiative to detect perinatal depression. Also included is a list of common symptoms and a description of various screening tools.

An Exemplary Model 

The State of Illinois in conjunction with the Illinois Chapter of the AAP recently backed up its recommendations for routine perinatal depression screening with reimbursement (of $14.60) and guided providers to use the 99420 procedure code with modifiers. The State approved several specific screens for reimbursement but allowed providers who supply appropriate psychometric documentation to seek approval for other instruments. Providers are encouraged to screen at several points including prenatal or postpartum visits, infant well-child or episodic visits. The State also set up a Perinatal Mental Health Consultation Service for providers.

A single toll-free number links primary care clinicians to psychiatrists and to information about medications that may be used in the management of perinatal depression both during and after pregnancy. Similarly patients have access to a toll-free helpline. The State’s website includes rich information about perinatal depression, patient handouts, a clinician guide to treatment decisions, an e-mail alert system so that providers can receive practice updates.

Much of the following material is drawn from their Perinatal Depression webpage. In addition, the Illinois AAP has a number of links on its site including the University of Illinois at Chicago’s Perinatal Depression Project which is designed to help providers and office staff and includes information about free workshops on recognition and treatment of perinatal depression.

Risk Factors Associated With Perinatal Depression 

Although there are risk factors associated with perinatal depression, even in their absence, use of a screening test is encouraged because many patients are reluctant to spontaneously describe their symptoms. Even so, awareness of risk factors may increase clinician vigilance:

Significant Predictors for Perinatal Depression	Other Predictors for Perinatal Depression
Prenatal depression	Difficult family relationships
Child care stress	Work stress / new job
Life stress	Severe financial difficulties
Poor social support	Recent stressful events
Prenatal anxiety	Victim of violence or abuse
Poor marital relationship	Low confidence as a parent
History of previous depression	Family history of postpartum depression
Difficult infant temperament	Teen or adolescent
Maternity blues	Complicated or difficult pregnancy
Single marital status	Thyroid problems or family history of thyroid problems
Previous postpartum depression	Poor diet or severe morning sickness
Severe premenstrual syndrome (PMS)	Oral-contraceptive use or Depo-Provera shot soon after delivery
Family history of depression	Early or recent loss of a parent
Taking excessive sick leave during pregnancy	Other psychiatric disorders
Frequent visits to doctor during pregnancy	Excessive lability of mood during pregnancy
Bereavement	Transient baby blue syndrome symptoms during first ten postpartum days
Prior stillborn

Early Detection Methods 

The following describes a range of screens, all administered by self-report and all brief enough to complete in a waiting or exam room. Measures included here all meet psychometric standards for screening tests in terms of sensitivity and specificity, standardization, reliability and validity.

Family Psychosocial Screen

The FPS (free download) includes a 4 item screen for depression as well as screens for substance abuse, domestic violence, and other risk factors (such as low socio-economic status, absence of social support, etc.). The FPS was developed by Dr. Kathi Kemper and is often used as a clinic intake form.  

Beck Depression Inventory-II

The BDI–II consists of 21 items to assess the intensity of depression in clinical and normal adults. Each item is a list of four statements arranged in increasing severity about a particular symptom of depression. Items correspond to DSM–IV criteria. Abundant psychometric studies support all dimensions of reliability and validity of the BDI-II. The BDI-II is available for $77.00 in English and Spanish from Psychological Corporation.

Edinburgh Postnatal Depression Scale1 (EPDS).

The authors of this scale freely give permission to use it in patient care. Copies in both English and Spanish can be found at Illinois Department of Public Aid. 

The Edinburgh has been the subject of a number of psychometric studies that provide support for its accuracy, validity, and standardization in Britain, Canada, and the US. The Edinburgh consists of 10 multiple choice items that produce a “possible depression” score and a single question focusing on potential suicidal ideation.

The Primary Care Evaluation of Mental Disorders (PRIME-MD)

This measure comes in various versions: a 2 item prescreen, which if positive should be followed by the 9 item version. There is also a 77 item measure that has been translated into Chinese, French, German, Greek, Italian, Spanish and Vietnamese and assesses a wide range of mental health issues, functional impairment and recent psychosocial stressors. All have substantive psychometric support. The two shorter versions may be downloaded at Mental Health CME. Laminated copies can be obtained from Pfizer, Inc (the company holding the copyright on all versions).  

Dr. Glascoe is a researcher focusing on developmental and behavioral screening tools. She is the AAP SODBP newsletter editor and co-edits www.dbpeds.org where this article is posted with live links to the various resources mentions.

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References

• Watt, Sword, Krueger, Sheehan. A cross-sectional study of early identification of postpartum depression: Implications for primary care providers from The Ontario Mother & Infant Survey. BMC Family Practice. 2002, 3:5 [274]
• Lembke, Anna. A Psychosocial Approach to Postpartum Depression. Psychiatric Times, June 2002; Vol. XIX, Issue 6. [278]
• Misri, S. A Review of Screening Tools. http://www.wellmother.com. Accessed 3/30/2005 [272]
• Misri, S., Duke, M. Depression During Pregnancy and Postpartum. Journal of the Society of Obstetrics & Gynecology of Canada 1995; 17:657-65 [271]
• Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786 [275]
• Wisner KL, Parry BL , Piontek CM. Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002, 194-199 [276]
• Nielsen, F., Videbech, P., Hedegaard, M. Postpartum depression: identification of women at risk. BJOB, 2000. Oct;107(10): 1210-7 [273]
• Beck, CT. Revision of the Postpartum Depression Predictors Inventory. JOGNN. 2001. Vol. 31 [213]
• Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999 Nov 10;282(18):1737-44 [277]

Keywords: depression,family system,mother baby,newborn,parenting,perinatal,postpartum,pregnancy,prenatal care,prevention,screening
Publication date: Jan 18, 2005
Revise date: Apr 1, 2005
TextID: 356

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