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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Is screening for PND with a very short instrument indicated?
Breaking down the time barrier
Screening for Postpartum Depression with the Patient Health Questionnaire (PHQ): A Commentary
Postpartum Depression Screening at Well-Child Visits: Validity of a 2-Question Screen and the PHQ-9
Importance of Screening
Postpartum Depression Screening at Well-Child Visits: Validity of a 2-Question Screen and the PHQ-9
Postpartum Depression Screening.
Time well spent
I wish screening had been available for me.
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Jeannette Milgrom, Melbourne, Australia Professor of Psychology, University of Melbourne & Parent-Infant Research Institute, Austin Health
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Screening for depression postpartum is important as women are often not identified and there are long-term consequences for the infant and the mother. The Gjerdingen et al study is timely and topical, and highlights the advantages of a brief 2-item tool with high sensitivity: i.e. more depressed women will have a positive result and not be missed. However, there is a balance to be struck against the low specificity of this 2-item tool: low specificity means more false-positive test results. Using the longer 9-item version with moderate sensitivity and high specificity may in the long run be the better screening device as it will result in fewer women who are not depressed scoring test positive. As a screening tool generally requires a further diagnostic assessment to confirm depression (and this is more time consuming), the 9-item screening version will mean fewer false positive test results and the longer assessment will therefore not be needed on as many women. Potential negative consequences of the 2-item version with high sensitivity and low specificity therefore include more women screening as at-risk of depression when they are not, the risk of health professionals using short-cuts and stopping at the two items (leaving some false positive and false negative test results un-resolved and women potentially labelled as depressed, or incorrectly labelled as “in the clear”); and the need to do a fuller assessment on more women. At the end of the day, however, practicalities are important as Seehusen & Evans point out and if there is only time to screen with 2 items, something may be better than nothing. Nevertheless this also highlights the importance of training: how and what to tell women. Importantly, as Boyd, Gjerdingen and Stuart highlight, screening is only the first part of the process and the subsequent management of women is the critical outcome. Finally, as the authors and Buist suggest there is merit in replicating results with a larger sample with better response rate and comparing the PHQ to the EPDS (which has reasonable balance between sensitivity and specificity – see Milgrom, Ericksen, Negri & Gemmill 2005). Whilst an ideal screening tool maximizes both sensitivity and specificity, arguments for using one or the other should also include data on acceptability (for instance the EPDS is highly acceptable to women - see Gemmill, Leigh, Ericksen & Milgrom 2006) as even a tool that is free, universally available and 100% accurate has its usefulness determined in direct proportion to its acceptability in the target population. References 1. Milgrom, J., Ericksen, J.E., Negri, L., & Gemmill, A.W. (2005). Screening for Postnatal Depression in Routine Primary Care: Properties of the Edinburgh Postnatal Depression Scale in an Australian Sample. Australian and New Zealand Journal of Psychiatry, 39(8), 745-751. 2. Gemmill, A.W., Leigh, B., Ericksen, J. & Milgrom, J. (2006). A Survey of the Clinical Acceptability of Screening for Postnatal Depression in Depressed and Non-depressed Women. BioMed Central Public Health, 6, 211. Competing interests: None declared |
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Dean A. Seehusen, Evans, GA Research Director, EAMC
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Postpartum depression is a disease that family physicians are extremely well-suited to deal with. The condition is common and has a significant impact on the entire family. The postpartum woman suffers the debilitating effects of the depression, their infants are adversely impacted, and even spouses seem to be put at risk for their own emotional problems. Postpartum depression can be screened for, diagnosed, and treated by family physicians. For me, its diagnosis and treatment is extremely rewarding. Despite all of this, detection rates continue to be low, mainly due to low screening rates. The barriers to screening and diagnosis are well documented in the literature. Chief among them is the lack of time busy clinicians face on a daily basis. This is why this study by Gjerdingen et al. is so important. The 2 question screen takes very little time to complete, does not require special training to administer or score, and is very sensitive. While there is legitimate reason to debate which screening method (EPDS or PHQ- 9) should follow, the real take home for me is that this two-step method might be more acceptable to providers because the first step is so easy. Breaking down the time barrier is crucial if screening rates are to rise. Perhaps this study will open the door to more universal screening. It is important for such simple, efficient methods such as this to find their way into common practice. One way to insure this is for educators to instill their importance early. Students and residents need to get the message that screening for postpartum depression is quick, easy, and mandatory. Competing interests: None declared |
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Rhonda C Boyd, Philadelphia, USA Assistant Professor, Children's Hospital of Philadelpha & University of Pennsylvania School of Medic
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Screening for postpartum depression (PPD) has been recommended and implemented, however, screening efforts are greatly affected by the availability of valid and reliable measures. Sensitivity and positive predictive value (PPV) are particularly important for screening. Gjerdingen and colleagues demonstrated that the modified PHQ-2 screener has excellent sensitivity and low PPV while the PHQ-9 simple scoring showed good sensitivity and low PPV using the gold standard, a diagnostic interview. There have been two recently published articles examining the PHQ with postpartum samples. These articles were published after the Boyd and colleagues review(1) in which the PHQ-9 was not considered. The modified PHQ-2 screener has been shown to demonstrate good sensitivity and low PPV with the Edinburgh Postnatal Depression Scale (EPDS) as the criterion for postpartum women(2). However, Hanusa et al.(3) found that the PHQ-9 simple scoring demonstrated good PPV but correctly identified only 31% of the women with Major Depressive Disorder. Their main findings provided support for use of the EPDS in comparison to the PHQ-9. Taken together, these studies do not provide convincing psychometric evidence for the use of the PHQ in PPD screening, however more research is needed. The Gjerdingen et al. article raises several issues concerning the implementation of PPD screening at well-child visits. First, the use of the complex scoring of the PHQ-9 resulted in reduced sensitivity of the measure. It is likely that clinical judgment is needed for the complex scoring and this may compromise the validity for detecting true depressive symptoms. Second, the PHQ-2 sceener showed a higher sensitivity when compared to the PHQ-2 providing support for the screener. Third, in busy practice settings, it is potentially burdensome for physicians or clinic staff to conduct two separate screenings even with brief measures. Screening procedures should be simple and practical for the staff implementing them. Moreover, there is no discussion of which staff at the well-child visit could be responsible for screening for PPD. Fourth, the women who dropped out of the study were those with the least resources (e.g., positive depression screen, lower income, less likely to be married) but are likely the most in need of postpartum support. Similarly, other studies have shown greater depressive symptoms in low- income women(4). Finally, it is critical to discuss mental health referral and treatment as a part of the screening process. References
Competing interests: None declared |
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Dwenda K. Gjerdingen, St. Paul, MN physician, professor, University of Minnesota
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It is good to hear from Dr. Anne Buist and Dr. Donna Stewart, both of whom have made important contributions to women's mental health research. Dr. Buist is correct - the EPDS is a very widely used and acceptable screen for postpartum depression, and in fact in the most commonly used screen for PPD worldwide. We wanted to validate the PHQ-9 in a postpartum sample, as it is becoming an increasingly popular tool in general depression research and practice, and is considered a diagnostic instrument, in that it contains all of the diagnostic criteria for depression. I hope that at some time the PHQ-9 and the EPDS will be compared head-to-head in a large postpartum depression study. Importantly though, either tool would be useful in identifying depressed mothers. Regarding the participant numbers for references 12 and 13, I agree that the "860,479" figure was misleading, and it would have been clearer if the text had read "860 and 479." I apologize for the confusion. The 860 figure came from the abstract of reference #12, which states that 860 postnatal women were surveyed. I agree wholeheartedly with Dr. Stewart's comment, that positive screens need to be followed by clinical assessment and treatment, and that to screen without ensuring this type of follow-up is unethical and futile! Competing interests: None declared |
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Anne E Buist, West Heidelberg, Australia Professor of Psychiatry University of Melbourne
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Screening for postnatal depression has been the source of ongoing debate, first in the UK with Judy Shakespeare's review highlighting the high level of data and research required in the ideal world before a routine screening should be introduced, and over the last few years taken up by our group when beyondblue (a not for profit organisation) funded a large project in part research and in part a public health initiative (references 12 and 13 in this article refer to the beyondblue project). As the Director of this earlier project, I agree with the authors of this article that screening is important; we have shown it to be acceptable and feasable and the Australian government had supported our bid to have it introduced as "routine". Each state government is having to look at how to implement this however, and there remains controversy. A initial easier step (in this case the two questions) would be attractive if introducing screening on such a large scale. I think in our case however, the world wide use, acceptability and simplicity of the EPDS (EDINBURGH POSTNATAL DEPRESSION SCALE)would make this the obvious second step. Also, just to clarify; I am uncertain where the authors got 860,479 women from references 12 and 13. In my report on acceptability 860 women were approached and 501 responded; overall the project screened just over 40,000 women (though information was given to over 100,000. Competing interests: None declared |
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Dwenda Gjerdingen, St. Paul, MN, USA physician, first author of article
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I appreciate the comments of Susan McRoberts and Pam Stenhjem. Pam was wise and perhaps a little unusual in being able to diagnose her own postpartum depression, because of her friend's previous depression and her own self-education. Most women with postpartum depression are not so fortunate and rely on health care providers to recognize the problem, which may not work if the provider doesn't screen, or if screening doesn't coincide with depressive symptoms. This article describes an efficient, validated method for making the diagnosis, but we also need to remember to give effective, consistent care and follow up to women who are diagnosed. Competing interests: None declared |
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Donna E. Stewart, Toronto, Ontario, Canada University Professor and Chair of Women's Health
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Perinatal depression is a serious public health problem.Depression during pregnancy worsens maternal and fetal outcomes and is a strong predictor for postpartum depression, which has deleterious effects for the mother, her infant and family. Gjerdingen et al in this issue of Annals of Family Medicine have demonstrated the feasibility and validity of administering a 2-question screen, followed by the PHQ-9 when indicated, to identify postpartum depression during well-child visits in family medicine and pediatric practices. Although the 2-question screen had previously been validated in other populations, the current study is the first to do in a postpartum sample. Despite the limited response rate (33%), the study makes an important contribution to clinical practice. The 2-question screen had 100% sensitivity and 44% specificity and the PHQ-9 (complex scoring) led to sensitivity/specificity of 67%/92% respectively, when compared to the Structural Clinical Interview for DSM IV (SCID). Importantly, the lack of specificity on the 2-question screen could be remedied by administering the PHQ-9 to women screening positive on either of the 2 screening questions. These results suggest that a time efficient 2 stage screening can readily be conducted in both family medicine and pediatric practices. What should not be forgotten, however, is that women with positive results should be clinically assessed and appropriate treatment plans implemented. To screen without appropriate follow-up is unethical and futile! Competing interests: Scientific Advisory Board, Eli Lilly,Wyeth, Boelinger I. |
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Susan A McRoberts, Greenwood, USA Author and speaker on postpartum depression
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I think that the 2 question screen is a fantastic way to look for postpartum issues in women. The PHQ-9 is an invaluable tool in digging deeper into what is going on. Speaking from experience, it is excruciating to share the details of depression and anxiety with a doctor, even one you fully trust. These tools give women the words they need when they can't find them. It's easier to answer these questions than it is to come to the doctor with a list of symptoms. It's less intimidating and takes the pressure off the mother. Because someone already has the symptoms listed, it validates the woman's issues, causes her to feel like she isn't making it all up and like she isn't the first person to experience these scary things. These are tools that doctors should be using. These are not time consuming tests and can alter the course of a woman's postpartum health. I think that is time well spent. Competing interests: None declared |
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Pam Stenhjem, Minneapolis, MN Research Fellow, University of Minnesota
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I am the mother of a beautiful seven year old boy. I developed severe postpartum depression, obsessive compulsive thought disorder, and anxiety within two weeks of his birth. I had an unremarkable pregnancy and was over joyed that I was having a baby. I've been told by many that I was an exceptionally happy pregnant woman. I also had an unremarkable birth - induced, eight hours of labor, and a baby that scored 10/10 on the Apgar test. I was in the hospital for two days and then went home for three months of maternity leave. My husband stayed home for the first month of maternity leave to help out with the baby, to run errands, and to do daily chores around the house. In my experience, the postpartum check up is not soon enough to screen for postpartum depression and related disorders. I saw my son's pediatrican within two weeks of leaving the hospital, and much more frequently than my own doctor. Had a postpartum depression screening been administered at those visits, I may have received assistance much earlier than I did. I was fortunate in that a friend of mine had postpartum depression while I was pregnant. As a researcher (and being naturally curious) I went on-line to learn more about this diagnosis and it's symptoms. When I noticed that I was exhibiting many of the symptoms of postpartum depression, I self-diagnosed and went in for an emergency consultation with my OBGYN. She did indeed diagnose me with postpartum depression and anxiety. I was also having thoughts of suicide and of harming my baby. I was put on several different medicines to combat the depression and anxiety, which I believe saved my life and that of my baby. I believe this study is extremely important and that more studies to validate the use of these instruments to screen new mothers at well child visits is critical. Many new mothers are embarrassed, afraid, humilated, and ashamed when they feel depressed, anxious, and less than perfect. It's very difficult to admit that anything might be wrong. However, if a screening were routinely done with ALL new mothers going to well-child visits, then we would all be in the same boat and no one would have to feel alone in this. It's perplexing to me that this condition and related disorders is not discussed during childbirth classes for pregnant women and their partners. You would think that preventive care and education of would be of primary importance. However, this was never mentioned in my class, or by any doctor, nurse, or other practitioner during my pregnancy. I strongly recommend the adaption of this practice within the pediatric system, as it will be much more effective in catching new mothers with depression and related disorders much earlier. It will allow for earlier and more proactive intervention. It may save a mother's life, as well as the life of her newborn. Competing interests: None declared |
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