In a recently released issue of Pediatrics, Dr. van der Zee-van der Berg and colleagues report from the Netherlands on the “Post-up” study ( 10.1542/peds.2017-0110), which examined the impact of maternal postpartum depression screening on maternal and child outcomes. The authors used a prospective, quasi-experimental design to compare “Care as Usual”, which did not typically include maternal depression screening, with screening of mothers using the well-validated 10 question Edinburgh Postpartum Depression Scale at 1, 3 and 6 months postpartum. Meaningful strengths of this study included active referral for treatment of screen-positive mothers, and a primary outcome, the rate of maternal depression at 9 months postpartum, that was directly assessed with a structured diagnostic interview. Additionally, the authors were able to enroll and follow an appropriately large population sample, with 1465 and 1009 of mothers in the intervention and Care as Usual groups, representing 80% and 81% of the original cohort, respectively, completing the 9 month assessment.  The short version of their results is a resounding “yes!” – postpartum depression screening followed by treatment referral significantly reduces risk of maternal depression at 9 months postpartum. The authors’ careful work contributes important information, and strengthens recommendations that pediatric providers should both screen for postpartum depression and refer mothers for treatment if screen-positive.  Details in the article, as well as child outcomes, and are more informative than the short version given here!

 

The relevant AAP guidance (reaffirmed December 2014), in concert with Bright Futures recommendations (https://brightfutures.aap.org), recommends screening mothers with one of the two methods recommended by the US Preventive Task Force: (1) the EPDS (can be viewed at https://psychology-tools.com/epds/) or (2) two-question screening, administered at 1, 2, 4 and 6 months postpartum, with follow up referral for resources and treatment.1,2  For those unfamiliar, the relevant queries for 2 question screening are: “Over the past two weeks, have you felt down, depressed or hopeless?” and “Over the past two weeks, have you felt little interest or pleasure in doing things?”; any “yes” response is a positive screen. The EPDS incorporates risk of suicide (question #10), and our regional standard (CPRN- Cleveland Regional Perinatal Network at https://crpn.net/training/perinatal/) is to add a 3rdquestion to “2 question screening” that assesses homicidal and suicidal thinking (‘Have you had any thoughts of hurting yourself or the baby?”).

 

The Post-up Study by Dr. van der Zee-van der Berg and colleagues assumed a postpartum depression prevalence rate of 6%, and found a rate of 8.4% at 9 months in the Care as Usual group.  The Centers for Disease Control and Prevention report an overall US rate of postpartum depression of approximately 11.1% (“1 in 9 mothers”); among mothers burdened by poverty, low educational level and social isolation, rates of postpartum depression are higher.3,4 Specifically, “…prevalence [of postpartum depression] was highest among new mothers who 1) were aged ≤19 years or 20–24 years, 2) were of American Indian/Alaska Native or Asian/Pacific Islander race/ethnicity, 3) had ≤12 years of education, 4) were unmarried, 5) were postpartum smokers, 6) had three or more stressful life events in the year before birth, 7) gave birth to term, low-birthweight infants, and 8) had infants requiring neonatal intensive care unit admission at birth;” rates ranged up to 24% for high-risk mothers.3  This relationship between postpartum depression and maternal descriptors associated with poverty and social stress emphasizes to me that screening is likely to be especially impactful and critical among underserved populations.4 Particularly in practices serving inner-city, rural or specific minority populations, both training and re-training for consistency in screening, and use of a written protocol for timely and “closed loop” referrals (quick intake and feedback to providers) are key (https://crpn.net/wp-content/uploads/2015/02/Guidelinesrev2-15.pdf ).  

 

Congratulations to Dr. van der Zee-van der Berg and colleagues for bringing excellent data on this important topic to all of us.