Postpartum Depression Screening
Postpartum Depression Screening
Background: Postpartum depression occurs in 10% to 20% of women who have recently given birth, but fewer than half of cases are recognized. The purpose of this review is to discuss the potential benefit of mass screening for improving postpartum depression recognition and outcomes.
Methods: A review of the literature was conducted by searching MEDLINE, using the key words "depression," "postpartum depression," and "mass screening." The Cochrane database was also searched for reviews on depression and postpartum depression.
Results: Opportunities for routine postpartum depression screening include mothers' postpartum office visits and their infants' well-child visits. Although several depression screens have been used in postpartum women, additional studies using large representative samples are needed to identify the ideal screening tool. Depression screening plus "high-risk" feedback to providers improves the recognition of depression. However, for screening to positively impact clinical outcomes, it needs to be combined with systems-based enhanced depression care that provides accurate diagnoses, strong collaborative relationships between primary care and mental health providers, and longitudinal case management, to assure appropriate treatment and follow-up.
Conclusions: Postpartum depression screening improves recognition of the disorder, but improvement in clinical outcomes requires enhanced care that ensures adequate treatment and follow-up.
Depression is common and costly, particularly for women in their childbearing years. The World Health Organization has identified major depression as the fourth leading cause of burden among all diseases, and the leading cause of years lived with disability. It is estimated that depression costs the United States $30 billion to $50 billion in lost productivity and direct medical costs each year. By 2020, depressive illness is expected to be the second leading cause of disability in the world. The burden is greatest for women, with a lifetime risk for major depressive disorder of 20% to 25%, approximately twice the 7% to 12% rate seen with men. In the first 3 months after childbirth, 14.5% of women have a new episode of major or minor depression, and 10% to 20% of mothers are believed to suffer with depression sometime during their postpartum course, making postpartum depression the most common serious postpartum disorder.
There is some controversy about whether rates of depression increase after delivery, and whether postpartum depression is a distinct entity from nonpostpartum depression. A British case-control study of mothers from 4 general practices found a 3-fold higher incidence of depression within 5 weeks after childbirth. Similarly, a Norwegian study comparing postpartum with nonpostpartum women found a 1.8-fold greater risk for depression in postpartum women. However, other researchers have not found the risk of depression to be an higher in postpartum women, compared with other young women, suggesting that postpartum depression may not be a distinct condition but merely major depression recognized at a time of potential stress. Investigators have also looked for differences in natural history or recurrence rates that would suggest postpartum depression to be a unique condition. Studies looking for biochemical associates with postpartum depression such as thyroid antibodies are interesting but seem to identify only a small group of women who will develop postpartum depression. Estrogen and progesterone fluctuations have not been shown to predict or follow postpartum depression. Recent studies investigating a broader spectrum of hormones seem promising, but are unlikely to provide clinically useful biochemical screening or prediction tools for many years. Whether postpartum depression is a separate type of depression or simply an important time to identify depression in women may be of little practical importance.
The clinical presentation of postpartum depression is like that of other major depressive disorders, with symptoms of depressed mood, diminished pleasure, marked change in appetite and sleep, psychomotor agitation or retardation, fatigue, feelings of worthlessness or inappropriate guilt, decreased concentration, and recurrent thoughts of death or suicide. The presence of maternal depressive symptoms at a critical time for infant and family has additional adverse effects, such as marital distress, problems with mother-infant interaction and attachment, and adverse behavioral and cognitive effects in the child. Although the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) specifies that the symptoms of postpartum depression must begin within 4 weeks after delivery, many experts believe that women remain at increased risk for depression for up to 1 year after delivery.
Children of depressed mothers are more likely to have delayed psychological, cognitive, neurological, and motor development, and are at higher risk of avoidance and distressed behavior. In fact, depressed mothers, compared with nondepressed mothers, report a 3-fold greater risk of serious emotional problems in their children and a 10-fold greater risk of having poor mother-child relations. The withdrawn, unresponsive, or negative behavior of a depressed mother early in the infant's life seems to affect maternal-infant attachment and result in fussier infants who vocalize less and make fewer positive facial expressions than infants of mothers who are not depressed. The abnormal patterns of mother-infant interactions associated with maternal depression have been described as a vicious cycle that increases the likelihood of chronic mental health, emotional, and family function problems. Children's behavioral difficulties associated with maternal depression may continue through at least ages 4 to 8 years. In addition, these children tend to use more health care resources for a broad spectrum of concerns. Fortunately, remission of maternal depression is associated with reductions in children's mental and behavioral disorders.
Given the potentially serious consequences of postpartum depression, it is unfortunate that the rates of diagnosis and treatment of this serious problem are low, primarily because of lack of recognition. This paper focuses on the recognition of postpartum depression through depression screening, current screening practices and methodologies, and barriers to postpartum depression screening and treatment. Recommendations for postpartum depression screening and future research are presented.
Abstract and Introduction
Abstract
Background: Postpartum depression occurs in 10% to 20% of women who have recently given birth, but fewer than half of cases are recognized. The purpose of this review is to discuss the potential benefit of mass screening for improving postpartum depression recognition and outcomes.
Methods: A review of the literature was conducted by searching MEDLINE, using the key words "depression," "postpartum depression," and "mass screening." The Cochrane database was also searched for reviews on depression and postpartum depression.
Results: Opportunities for routine postpartum depression screening include mothers' postpartum office visits and their infants' well-child visits. Although several depression screens have been used in postpartum women, additional studies using large representative samples are needed to identify the ideal screening tool. Depression screening plus "high-risk" feedback to providers improves the recognition of depression. However, for screening to positively impact clinical outcomes, it needs to be combined with systems-based enhanced depression care that provides accurate diagnoses, strong collaborative relationships between primary care and mental health providers, and longitudinal case management, to assure appropriate treatment and follow-up.
Conclusions: Postpartum depression screening improves recognition of the disorder, but improvement in clinical outcomes requires enhanced care that ensures adequate treatment and follow-up.
Introduction
Depression is common and costly, particularly for women in their childbearing years. The World Health Organization has identified major depression as the fourth leading cause of burden among all diseases, and the leading cause of years lived with disability. It is estimated that depression costs the United States $30 billion to $50 billion in lost productivity and direct medical costs each year. By 2020, depressive illness is expected to be the second leading cause of disability in the world. The burden is greatest for women, with a lifetime risk for major depressive disorder of 20% to 25%, approximately twice the 7% to 12% rate seen with men. In the first 3 months after childbirth, 14.5% of women have a new episode of major or minor depression, and 10% to 20% of mothers are believed to suffer with depression sometime during their postpartum course, making postpartum depression the most common serious postpartum disorder.
There is some controversy about whether rates of depression increase after delivery, and whether postpartum depression is a distinct entity from nonpostpartum depression. A British case-control study of mothers from 4 general practices found a 3-fold higher incidence of depression within 5 weeks after childbirth. Similarly, a Norwegian study comparing postpartum with nonpostpartum women found a 1.8-fold greater risk for depression in postpartum women. However, other researchers have not found the risk of depression to be an higher in postpartum women, compared with other young women, suggesting that postpartum depression may not be a distinct condition but merely major depression recognized at a time of potential stress. Investigators have also looked for differences in natural history or recurrence rates that would suggest postpartum depression to be a unique condition. Studies looking for biochemical associates with postpartum depression such as thyroid antibodies are interesting but seem to identify only a small group of women who will develop postpartum depression. Estrogen and progesterone fluctuations have not been shown to predict or follow postpartum depression. Recent studies investigating a broader spectrum of hormones seem promising, but are unlikely to provide clinically useful biochemical screening or prediction tools for many years. Whether postpartum depression is a separate type of depression or simply an important time to identify depression in women may be of little practical importance.
The clinical presentation of postpartum depression is like that of other major depressive disorders, with symptoms of depressed mood, diminished pleasure, marked change in appetite and sleep, psychomotor agitation or retardation, fatigue, feelings of worthlessness or inappropriate guilt, decreased concentration, and recurrent thoughts of death or suicide. The presence of maternal depressive symptoms at a critical time for infant and family has additional adverse effects, such as marital distress, problems with mother-infant interaction and attachment, and adverse behavioral and cognitive effects in the child. Although the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) specifies that the symptoms of postpartum depression must begin within 4 weeks after delivery, many experts believe that women remain at increased risk for depression for up to 1 year after delivery.
Children of depressed mothers are more likely to have delayed psychological, cognitive, neurological, and motor development, and are at higher risk of avoidance and distressed behavior. In fact, depressed mothers, compared with nondepressed mothers, report a 3-fold greater risk of serious emotional problems in their children and a 10-fold greater risk of having poor mother-child relations. The withdrawn, unresponsive, or negative behavior of a depressed mother early in the infant's life seems to affect maternal-infant attachment and result in fussier infants who vocalize less and make fewer positive facial expressions than infants of mothers who are not depressed. The abnormal patterns of mother-infant interactions associated with maternal depression have been described as a vicious cycle that increases the likelihood of chronic mental health, emotional, and family function problems. Children's behavioral difficulties associated with maternal depression may continue through at least ages 4 to 8 years. In addition, these children tend to use more health care resources for a broad spectrum of concerns. Fortunately, remission of maternal depression is associated with reductions in children's mental and behavioral disorders.
Given the potentially serious consequences of postpartum depression, it is unfortunate that the rates of diagnosis and treatment of this serious problem are low, primarily because of lack of recognition. This paper focuses on the recognition of postpartum depression through depression screening, current screening practices and methodologies, and barriers to postpartum depression screening and treatment. Recommendations for postpartum depression screening and future research are presented.
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