Universal screening for postpartum depression: an inquiry into provider attitudes and practice

Materials and Methods 

In the first phase of our study, we examined the electronic medical records of 512 postpartum patients seen from March 1, 2006, to July 17, 2006. All women who were seen for a postpartum visit were included, even if they had no dictated note. Women were excluded from the study if they were billed as a postpartum visit but were actually seen for some other reason. Demographic, medical, and psychiatric information was obtained through structured chart abstraction. When available, the EPDS score was recorded, as well as counseling and/or psychiatric referral.

We investigated whether women with a positive screen (score of > 10) were referred to our Psychiatry Department and whether this visit was attended. In the second phase of our study, we adapted a previously validated survey to e-mail format.6 This survey included open-ended and multiple-choice questions and was sent to 47 providers, including attending and resident physicians, certified nurse midwives (CNMs), and nurse practitioners (NPs).

Results 

Chart review 

Of 512 charts examined, 458 met inclusion criteria. The patient population studied was low risk, with 90% delivered at full term. Patients reported a 12% incidence of depression, 9% incidence of treatment with psychiatric medications either before or during their pregnancy, and < 1% incidence of a past history of PPD. Providers documented the EPDS score in 39% of visits and counseled patients on their score and/or depression in 35% of visits. Of patients with a documented EPDS, the mean score was 5.8 (Table 1).

TABLE 1. Results of the EPDS score

	EPDS score	n (%)
	0-9	146(82%)
	10-12	16(9%)
	> 12	16(9%)

EPDS, Edinburgh Postnatal Depression Scale. Delatte. Universal screening for postpartum depression. Am J Obstet Gynecol 2009.

There was a significant difference in documentation of the EPDS among the 4 provider types examined (P < .0001) (Table 2). Higher EPDS scores resulted in increased patient counseling (P < .003) (Table 3) and increased referral to psychiatry. Of patients with a normal score on the EPDS (< 10), 97% (143/146) were not referred to psychiatry. Of those with a very high score on the EPDS (≥ 13), 75% (12/16) were referred to psychiatry.

TABLE 2. Documentation

	Provider	n (%)
	Resident	20(17%)
	Attending	80(42%)
	CNM	65(67%)
	NP	16(94%)

P < .0001. CNM, certified nurse midwife; NP, nurse practitioner. Delatte. Universal screening for postpartum depression. Am J Obstet Gynecol 2009.

TABLE 3. Counseling

	Variable	Counseled, n (%)	Not counseled, n (%)
	Screen plus (EPDS > 10)	27(84%)	5(16%)
	Screen minus (EPDS < 10)	78(53%)	68(47%)

P < .003. EPDS, Edinburgh Postnatal Depression Scale. Delatte. Universal screening for postpartum depression. Am J Obstet Gynecol 2009.

Comment 

The burden of suffering associated with PPD warrants universal screening to facilitate prompt treatment. This study reveals that, although the Department of Obstetrics and Gynecology instituted a novel program to ensure universal screening in 2006, our providers are not using the EPDS to screen for PPD. Furthermore, use varied broadly according to the type of provider that saw the patient as well as the degree of severity of the EPDS score.

Our survey showed that providers feel responsible for and confident with screening for PPD using both clinical judgment and a screening tool. Prior studies have shown that instituting an organized approach to screening for PPD can make a difference in the rate of detection.7, 8, 9 A retrospective study is only as good as the documentation of providers. The true number of providers using the EPDS may be actually higher than what we were able to extract from the medical records. However, our study is the first to evaluate in a 2-part approach both providers' practices and their attitudes concerning screening for PPD. This allowed us to comprehensively assess and begin to remove the barriers to effective, universal screening for PPD.

This study defines the gap between what providers know should be done and what is actually being done at postpartum visits. By presenting the results of this study at a departmental meeting, we have increased provider awareness of the need for increased use of the EPDS. We plan to increase use of the EPDS additionally by having our nurses document the EPDS as a vital sign. We have increased communications between the Departments of Obstetrics and Gynecology and Psychiatry to facilitate continued referral of patients to the Perinatal Psychiatry Center. Future research may focus on whether these measures affect the use of the EPDS and referral patterns to the Perinatal Psychiatry Center.