Repeated Depression Screening During the First Postpartum Year

Barbara P. Yawn; Susan Bertram; Marge Kurland; Peter C. Wollan

doi:10.1370/afm.1777

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Importance of expanding mental health assessment in the peripartum period
Barbara P Yawn

Published on: 02 February 2016
The Case for Multi-disease Mental Health Screening
Bradley N. Gaynes

Published on: 26 January 2016
Author response: Continuing Need for Evidence?
Barbara P Yawn

Published on: 17 May 2015
Screening shouldn't be forgotten
Anne E. Buist

Published on: 13 May 2015

Published on: (2 February 2016)
Page navigation anchor for Importance of expanding mental health assessment in the peripartum period
Importance of expanding mental health assessment in the peripartum period
Barbara P Yawn, Adjunct Professor
We appreciate and agree with the comments of Dr. Gaynes and colleagues. While postpartum and peripartum depression is the focus of several studies both completed and ongoing, anxiety, Bipolar disorders, post traumatic stress disorder and other mental health conditions have not received adequate attention in this very important group of women. We believe our data has demonstrated, along with that of others noted in our...
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We appreciate and agree with the comments of Dr. Gaynes and colleagues. While postpartum and peripartum depression is the focus of several studies both completed and ongoing, anxiety, Bipolar disorders, post traumatic stress disorder and other mental health conditions have not received adequate attention in this very important group of women. We believe our data has demonstrated, along with that of others noted in our publication, that 'once and done' is not enough. Depression screening once during pregnancy or once postpartum will not identify all of the women, infants and families at risk for the burden and adverse outcomes of mental health conditions.
Indeed our data suggests that repeated screening does identify additional cases at 6 and 12 months postpartum and that anxiety appears to adversely affect the improvement of depressive symptoms. Dr. Gaynes and colleagues point to several other studies that highlight the rates of Bipolar disorder among those screening positive for depression and suggests important next steps.
We agree that broad, primary care based studies of feasibility and outcomes of broader mental health screening in the postpartum period are required. Using a 27 question tool will provide additional time barriers and the need to address multiple new mental health conditions with continuing limited numbers of mental health professionals is an important challenge that needs to be studied. Those studies should not be small studies of just the identified highest risk patients or those referred to hotlines or mental health sites but of the general population of pregnant and postpartum women cared for in family medicine, obstetrical and pediatric practices.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (26 January 2016)
Page navigation anchor for The Case for Multi-disease Mental Health Screening
The Case for Multi-disease Mental Health Screening
Bradley N. Gaynes, Professor of Psychiatry
Other Contributors:
January 26, 2016
To the Editor:
We read with great interest the report of Yawn et al concerning PHQ9 screening in the postpartum.[1] Yet perhaps even more interesting was authors advocating for adjunctive anxiety screening for this same group of postpartum patients.[2] The problem Yawn and associates brought to light in their Annals of Family Medicine report, i.e., that vigilance for depression in the postpart...
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January 26, 2016
To the Editor:
We read with great interest the report of Yawn et al concerning PHQ9 screening in the postpartum.[1] Yet perhaps even more interesting was authors advocating for adjunctive anxiety screening for this same group of postpartum patients.[2] The problem Yawn and associates brought to light in their Annals of Family Medicine report, i.e., that vigilance for depression in the postpartum needs to extend out to 6 months and beyond, may have been worked out to a degree in their later analysis. Anxiety was found to be partially predictive of the later-onset depressions uncovered in that study. We are very much in favor of multi-disease mental health screening, especially in this group of patients at this point in their life course. Correctly diagnosing mental health problems at this crucial time has the potential to positively impact the health of both the mother and her infant.
Other psychiatric diagnoses are not routinely detected in postpartum depression screening. Of particular interest in the perinatal population is Bipolar disorder (BD). Merrill, et al found 21.4% of patients screening positive for depression with the Edinburgh Postnatal Depression Scale (EPDS) were positive for BD on the Mood Disorder Questionnaire (MDQ).[3] Sharma, et al found that 54% of patients referred with a diagnosis of postpartum depression were later re-diagnosed with bipolar disorder.[4] Missing the signs and symptoms of BD can have profound implications, including the delayed initiation of appropriate treatment and the inappropriate prescription of antidepressants. These findings support the use of a mental health screening instrument with the broadest screening capability.
Elation, over-activation, and increased tolerance to sleep deprivation are all difficult to assess in the immediate postpartum period, as they may be readily mistaken-- absent careful measurement-- for normal adaptation to what is a very happy and activated time for many women. Might such "positive" mood deflections in the early postpartum also account for some of the late-onset depression noted in this group's study?
The M3 is a screening tool, validated in a report in this same journal in 2010,[5] that can screen for depression, anxiety disorders, PTSD and bipolar disorder with one 27-item self-rated screen. The M3's sensitivity and specificity was found to be equal to those of four comparator mono-diagnostic instruments (including the PHQ9, GAD7 and MDQ). It also queries patients about alcohol and substance misuse. It has a computer and smartphone interface that makes its completion supportable both in-office and remotely and its scoring is fully automated. We appreciate that Yawn et al have brought much needed attention to the dimensional aspect of postpartum mood and anxiety disturbances. A broadly tuned screening instrument needs to be tested in this important group of patients.
Notes: [1]Yawn BP, Bertram S, Kurland M, Wollan PC. Repeated depression screening during the first postpartum year. Ann Fam Med 13(3) 2015; 228-34.
[2]Yawn BP, Bertram S, Kurland M, Wollan PC. Anxiety assessment should be added to postpartum depression screening: a research letter. J Womens Health 24(8); 2015, 689-90.
[3]Merrill L, Mittal L, Nicolaro J, et al: Screening for bipolar disorder during pregnancy. Arch Womens Ment Health 18(5); 2015, 579-83.
[4]Sharma V, Burt VK, Ritchie HL. Bipolar II postpartum depression: detection, diagnosis, and treatment. Am J Psychiatry 166(11); 2009, 1217-21.
[5]Gaynes BN, DeVeaugh-Geiss J, Weir S, et al. Feasibility and diagnostic validity of the M-3 checklist: a brief, self-rated screen for depression, bipolar, anxiety, and post-traumatic stress disorders in primary care. Ann Fam Med 8(2); 2010, 160-169.
Sincerely,
Bradley N. Gaynes, MD, MPH Professor of Psychiatry, Associate Chair of Research Training and Education, Department of Psychiatry, University of North Carolina School of Medicine Chapel Hill, NC 27599
Joanne DeVeaugh-Geiss, PhD Adjunct Assistant Professor, Department of Psychiatry, University of North Carolina School of Medicine Chapel Hill, NC 27599
Sam Weir, MD Associate Professor of Family Medicine, Director, Faculty Development Fellowship Department of Family Medicine, University of North Carolina School of Medicine Chapel Hill, NC 27599
Competing interests: None declared
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Competing Interests: None declared.
Published on: (17 May 2015)
Page navigation anchor for Author response: Continuing Need for Evidence?
Author response: Continuing Need for Evidence?
Barbara P Yawn, Director of Research
Dr Buist points out the long history of groups like hers working to promote and indeed demand screening for postpartum depression. It has been almost 15 years since we published our first article demonstrating routine screening for postpartum depression did increase recognition, diagnosis and treatment initiation. However, it has been a relatively short time since we demonstrated that we could improve outcomes by screen...
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Dr Buist points out the long history of groups like hers working to promote and indeed demand screening for postpartum depression. It has been almost 15 years since we published our first article demonstrating routine screening for postpartum depression did increase recognition, diagnosis and treatment initiation. However, it has been a relatively short time since we demonstrated that we could improve outcomes by screening and follow up. To date few other programs have demonstrated improved outcomes for mom, baby or the family. Screening with referrals that don't actually occur is of unknown and probably limited help. But there are programs out there that seem to be doing more than just referring and hoping for action.
I urge Dr. Buist and her colleagues to continue publishing results from the large Australian experiment and hope to see others publish their results demonstrating that we are not able to just find women at high risk of depression (those with high screening scores) but are able to go beyond that to improve their lives with treatment, support and ongoing care.
Barbara P. Yawn, MD MSc
Competing interests: None declared
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Competing Interests: None declared.
Published on: (13 May 2015)
Page navigation anchor for Screening shouldn't be forgotten
Screening shouldn't be forgotten
Anne E. Buist, psychiatrist
It is now a decade since the beyondblue team which I headed at the time finished their evaluation of the benefits and acceptance of screening for ppd, recommendations to do so being taken up by the Federal government. It is somewhat dismaying to still find places don't believe it is worthwhile, so articles like this are timely: you don't ask and 50% will be missed, and as the authors note, asking once may not be enough. H...
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It is now a decade since the beyondblue team which I headed at the time finished their evaluation of the benefits and acceptance of screening for ppd, recommendations to do so being taken up by the Federal government. It is somewhat dismaying to still find places don't believe it is worthwhile, so articles like this are timely: you don't ask and 50% will be missed, and as the authors note, asking once may not be enough. Health professionals dealing with perinatal women need to keep depression and its costs in their mind at every visit.
Competing interests: None declared
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Competing Interests: None declared.