Objective
Determine whether depression screen results are consistent across successive pregnancies.
Study Design
The Edinburgh Postnatal Depression Scale was administered in 2 successive pregnancies to 2116 women. A woman was “screen-positive” if she scored ≥12 at 24-28 weeks’ or 6-weeks’ postpartum. Screen-positive women were assessed by telephone and triaged by mental health professionals.
Results
Most women (87.9%) were screen-negative in both pregnancies; 1.7% screened successively positive, 5.9% screened positive in only the first pregnancy; 4.5% screened positive in only the second pregnancy. Unpartnered, nonwhite, and publicly insured women were each likelier to screen positive in either or both pregnancies ( P < .0001). Gestational age at delivery was significantly greater in women who never screened positive ( P < .05). A majority (63%) of screen-positive women in both pregnancies reported no history of mood disorder.
Conclusion
There is sufficient variability in depression screening results between successive gestations to warrant screening during each pregnancy.
Depression is considered a common complication of pregnancy. Its prevalence, coupled with the availability of easily administered and validated screening tools has led to support for universal screening among obstetricians and legislatures. However, routine screening and systematic triage are not yet commonplace. As a result, most studies of depression risk have examined unselected groups of individual pregnancies and their corresponding postpartum timeframes. Other limitations in this literature include underrepresentation of minority subjects and those individuals who are uninsured or Medicaid enrollees. A systematic review by the Agency for Healthcare Research and Quality called for studies to parse out screening differences using these demographic variables to identify relevant cohorts and their unique attributes.
Depression screens analyzed in the current study were administered in the context of a comprehensive program for universal perinatal depression screening and mental health referral. Since 2003, the program has included centralized processing of all screening, a 24/7 crisis hotline, a network of community-based mental health professionals and an educational program for obstetricians and nurse midwives. In a prior study reporting on 1584 patients screened once during pregnancy and again at 6-weeks’ postpartum, we observed that unique screen-positive cohorts were identified before and after delivery, suggesting that screening status was not necessarily static over time in a single pregnancy. A related question is whether depressive risk is sustained between pregnancies and our program data provided the opportunity to address this issue by studying screening patterns across 2 successive gestations in the same patients.
Materials and Methods
The Edinburgh Postnatal Depression Scale (EPDS) was chosen for its validity in both the antepartum and postpartum timeframes. The EDPS is a self-report instrument that does not provide a clinical diagnosis of a perinatal mood disorder but does identify at-risk patients. A validated version of the EPDS was administered to patients at 24-28 weeks’ gestation and 6-weeks’ postpartum. These screening times were based on the potential onset of perinatal mood disorders and also to coincide with routine clinical activities (ie, glucose tolerance testing and the postpartum check-up).
Completed screens were e-faxed from the outpatient office to a confidential email account that was monitored daily. Scored screens were inputted into the electronic medical record and linked to the corresponding demographic and perinatal data. EPDS screens were designated “positive” for scores ≥12 or for a response other than “never” to the question describing thoughts of harming oneself based on recommendations for use of the EPDS. Screen-positive patients received a telephone call from a mental health professional and were referred to mental health resources as indicated. An interpretative language telephone line allowed for evaluation in each woman’s primary language and women were reminded about the availability of the crisis hotline. Institutional review board (IRB) approval was obtained for this study. We followed our IRB-approved protocol that specified presenting all screened women the opportunity to give written permission to be approached about research participation at a future date. In this study, we did not rely on additional patient contact and the data were deidentified before analysis. Therefore, the IRB exempted us from further consent requirements for this protocol.
Women who were screened at least once in 2 successive pregnancies (yielding a total of 2, 3, or 4 screens per subject) formed the basis for this study. A woman was defined as “positive” within each pregnancy if she screened positive at 24-28 weeks’ gestation and/or 6-weeks’ postpartum. Women were further categorized into concordant cases across 2 pregnancies (negative/negative or positive/positive) and discordant cases (negative/positive or positive/negative). Corresponding demographic, perinatal, and mental health variables were analyzed to determine factors that might be associated with the serial screening results. Statistical analysis was conducted using SAS 9.2 (SAS Institute, Cary, NC). A χ 2 was used to assess association between categorical covariates and the 4 screening phenotypes. Post hoc pairwise comparisons were Bonferroni corrected. Nonparametric methods (Wilcoxon rank sum test and Kruskal-Wallis test) were used to assess between-group difference with respect to continuous covariates, and post hoc pairwise comparisons were adjusted via permutation test.
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