Support and Training to Enhance Primary Care for Postpartum Depression

Screening

Using a standardized tool along with follow-up clinical interview questions will ensure efficiency and consistency in screening. Some women may be willing to reveal and communicate experiences or symptoms related to depression directly to their provider during a patient visit. The use of a screening tool, however, gives shyer or more reticent women a more comfortable means of informing their providers that they may be experiencing depressive symptoms. The use of both methods , a screening tool and direct conversation between provider and patient, increases the chances for accurately identifying those women who have or are at risk for developing PPD.

Standardized self-report screening tools can help detect the presence and/or severity of common depressive symptoms. Because some women with atypical depression may present with anhedonia or irritability rather than depressed mood, screening every postpartum woman increases the likelihood that the depression will be detected and addressed. Keep in mind that effective provider-patient communication is the key to screening and assessing for PPD. The screening tool can facilitate the screening and assessment processes, but it cannot replace sensitive, one-on-one communication with women.

TOP

Standardized Tool

With a standardized screening tool, women can report their own symptoms in a structured questionnaire before or during a clinical visit; healthcare professionals score and interpret responses. This approach can help:

  • Alert the provider to points of concern that, can be addressed during the clinical visit
  • Give the patient language to use with the provider
  • Create an opportunity to discuss emotional health during the visit

The following steps are recommended for conducting effective screening in a time-efficient manner without placing undue burden on the physician or other providers follow:

  • Give each postpartum woman a screening tool to complete in the waiting room when she arrives
  • Have an administrative assistant, nurse, or other staff score the screening instrument, highlighting any positive responses to the “red flag” or critical items.
  • Put the scored screen on top of the patient file for the provider to review before or while meeting with the patient
  • Have the provider discuss the screen with the woman and ask follow-up clinical interview questions to adequately assess risk for PPD.

"Red flag" or critical items refer to those items that indicate suicidal ideation. Due to the serious nature of suicidal ideation and the potential consequences, women who endorse any red flag or critical items should be referred to a mental health specialist and may require immediate hospitalization. Click here for more information on how to assess a woman's suicide risk.

TOP

Selecting a Standardized Screening Tool

Three standardized tools are commonly used to screen patients for PPD in primary care settings. Each is widely used in research and practice, and all have been found to be valid and reliable in the measurement of PPD:

  • Edinburgh Postnatal Depression Scale (EDPS - Cox, Holden, & Sagovsky, 1987)
  • Patient Health Questionnaire (PHQ-9 - Spitzer, Kroenke, & Williams, 1999)
  • Postpartum Depression Screening Scale (PDSS - Beck & Gable, 2001)

Each of these tools has its own strengths and shortcomings. In terms of strengths the EPDS is the most widely studied and validated, and it is available in numerous languages. The PHQ-9 is often used in primary care settings because it can be used for depression outside the postpartum period and links with Diagnostic and Statistical Manual (DSM-IV-TR) criteria. Both the EPDS and PHQ-9 are available for free. The PDSS was developed with the input of women diagnosed with PPD and has a number of subscales. However, it is longer than the other two more commonly used tools and must be purchased.

The following chart summarizes the characteristics and the strengths and weaknesses of each of these tools.

Screening Tool Edinburgh Postnatal Depression Scale (EPDS) Postpartum Depression Screening Scale (PDSS) Patient Health Questionnaire (PHQ-9)

Basic Facts

Designed to detect PPD in healthcare settings, this 10-question screen can be completed in about 5 minutes.

This 35-item scale has subscales and a response validity indicator. It takes less than 10 minutes to complete, and the shorter, 7-item version takes less than 5 minutes to complete.

This is a 10-item scale designed to compare depressive symptoms against DSM-IV-TR criteria items in a healthcare setting

Efficacy, PPV (positive predictive value), and NPV (negative predictive value) 12 13 48 71

Sensitivity: 78%
Specificity: 99%
PPV: 93%
NPV: 96%

Sensitivity: 91%–94%
Specificity: 72%–98%
PPV: 59%–90%
NPV: 95%–99%

Sensitivity: 88%
Specificity: 88%
Predictive values unknown

Pros

  • Validated for use with PPD
  • Most widely studied
  • Available in more than 20 languages
  • Free
  • PPD-specific
  • Validated
  • Questions based on interviews with postpartum women
  • Questions reflect DSM-IV criteria to aid diagnosis
  • Validated for use with PPD 71 117
  • Free

Cons

  • No parenting-specific questions
  • Self-report measures subject to woman's perceptions
  • Length of the tool may make it less feasible for clinical use
  • Self-report
  • Must purchase
  • Not diagnostic, despite reflecting diagnostic criteria
  • Not specific to PPD
  • Self-report

Authors

J. L. Cox, J. M. Holden, and R. Sagovsky 40

C. T. Beck and R. K. Gable 13

R. L. Spitzer, and K. Kroenke, J. B. Williams 116

How to obtain

Available for download in resources section

Available from Western Psychological Services
(800) 648-8857
WPS Web site: PDSS orders

Available on-line at
pfizer.com

TOP

Scoring and Interpreting the Screens

The total score for each screening tool is the arithmetic sum of the number circled for each individual item. The "cutoff" value and interpretation of the score varies for each tool. Details for each are provided below.

It is important to note that scores are not diagnostic, but rather guidelines for further assessment. Individuals not meeting the cutoff scores may still meet depression diagnostic criteria; clinical judgment should be used in all cases. Also, each tool has at least one “red flag” question addressing suicidal thoughts; affirmative answers to these questions qualify as a positive screen regardless of the score. When evaluating the score, look at both the overall score and responses to these “red flag” questions to evaluate the amount of follow-up needed.

For specific information on how to score and interpret each screener, click on the tool name below:

  • EPDS: A total score of 10 or greater typically indicates the presence of depressive symptoms, with a score of 13 or greater indicating a high likelihood of major depression. A score of 2 or higher on question #10 also qualifies as a positive screen, as this indicates the possible presence of suicidal ideation. 51
  • PHQ-9: A total score of 10 or greater indicates that the woman is at a significant risk of having or developing depression. In addition, a score of 1 or more on question #9 is considered a positive screen, as this indicates a possible presence of suicidal ideation.
  • PDSS:

    Full Form: A total score of 60 or greater typically indicates the presence of depressive symptoms, and a score of 81 or higher indicates a high likelihood of major depression. A score of 6 or greater on the SUI**(suicidal thoughts) subscale also qualifies as a positive screen, as this indicates a possible presence of suicidal ideation.

    Short Form: A total score of 14 or greater indicates a high risk of major depression. A score of 2 or greater on question #7 also qualifies as a positive screen, as this indicates a possible presence of suicidal ideation.

TOP

Reviewing the Screening Results

Before reviewing the screening results with the patient, you may want to explain that your clinic screens every woman who visits your office within the first postpartum year, and views depression as a serious issue.

For those with a positive screen (total score above the cutoff and/or one or more red flag items endorsed), explain to the patient that she is considered at risk for having or developing depression, and you would like to ask a few questions about how she has been feeling.

For those with a negative screen (total score below cutoff, and no red flag items endorsed), explain to the patient that the results of the screen indicate she is at low risk for depression, but you want to ask a few questions about how she has been feeling.

For women with negative screens, you should ask the following questions:

  • Since having your baby, have you ever felt down, depressed, or sad? (Listen for terms like “depressed,” “down,” “not myself,” or other terms indicating a depressed mood)
  • Since having your baby, have you little interest or pleasure in doing things? (Listen for indications that the mother cannot find pleasure in things or does not partake in pleasurable activities.)

For women who had a positive screen (total score above the cutoff, and/or one or more red flag items endorsed), continue with the assessment procedure below, regardless of her response to these questions.

If a woman'’'s response to either of the two questions above indicates that she could be experiencing depressive symptoms, continue with the more thorough assessment (described in the clinical interview section).

For women with a negative screen (total score below cutoff, and no red flag items endorsed) who did not endorse responses indicative of depression on either of these questions, provide written literature on PPD (Visit the Resources section and download the patient brochure) and explain that PPD is not uncommon among new mothers. Instruct them to call you or come back for a visit if they begin to feel any of these symptoms.

TOP