Electronic reminder systems increase screening for postpartum depression

Sheeder J, Kabir K, Stafford B. Screening for postpartum depression at well-child visits: Is once enough during the first 6 months of life? Pediatrics 2009;123:e982-8.

Question 

Is an electronic reminder system effective in promoting detection and referral of postpartum depression at well-child visits? What is the incidence of maternal depression at well-child visits during the first 6 months of life?

Design 

Population-based study.

Setting 

Adolescent-oriented maternity program in an urban Colorado teaching hospital.

Participants 

Mothers of 0- to 6-month-old infants seen for well-child visits.

Intervention 

Completion of the Edinburgh Postpartum Depression Scale.

Outcomes 

Incident cases represented mothers who crossed the referral threshold (score of ≥10) after the first screening.

Main Results 

Mothers usually brought their infants to the clinic, and none refused screening. Providers saw 418 electronic cues for screening 204 mothers; they administered the Edinburgh Postpartum Depression Scale 98% of the time and always referred mothers with scores of ≥10. Overall, 20% of the mothers scored ≥10. Scores were unstable at ≤3 postpartum weeks (κ = 0.2). Thereafter, the prevalence and incidence of scores of ≥10 decreased from 16.5% and 16.5% at 2 months to 10.3% and 5.7%, respectively, at 4 months. Prevalence increased to 18.5% at the 6-month visit, and incidence decreased to 1.9%. Repeat screening detected only 2 mothers (5.7%) with scores of ≥10.

Conclusions 

Electronic cueing improved compliance with the detection and referral phases of screening for maternal depression at well-child visits. Screening 2 months after delivery detects most mothers who become depressed during the first 6 postpartum months, and screening at the 6-month well-child visit is preferable to screening at the 4-month visit.

Commentary 

Pediatric health care providers are in a unique position to screen for maternal depression across the first postpartum year. Screening is done with validated instruments such as the Edinburgh Postpartum Depression Scale or Patient Health Questionnaire–2. This study adds new information about the frequently neglected high-risk population of young mothers. The work demonstrates the effectiveness of mandatory reminders within the electronic medical record to ensure consistent care across providers and suggests additional improvements such as mandatory entry of the suicidality item score. The authors suggest that screening during the first 2 to 3 weeks postpartum yields inconsistent results and thus may not be an ideal time to screen. This instability reflects the normal resolution of somatic discomfort and “baby blues” by 10 days. Despite the instability at this time, early postpartum screening demonstrates that the pediatric provider cares about the mother's health, encourages discussions about the link between maternal and child health, and may even open discussion about other maternal mental health conditions. Rather than not screening before 3 weeks, perhaps early screening should only lead to referral if there is suicidality, the score is very high, or there is a history of depression; otherwise, repeat screening can be done at the next well or sick visit. The reported incidence of depression declined from 2- to 4- to 6-month visits in this population. However, only 2.5% (5/199) and 26% of mothers in this study brought their infants for all 4 or at least 3 (respectively) of the recommended well visits, and more than half only came for a single visit. Therefore it is likely that the low incidence of depression at the 4 and 6 month visits are underestimates. Munk-Olsen et al1 demonstrated that the increased risk for postpartum depression persists for the first 5 months. The ultimate goal of screening is to improve both maternal and child outcomes through engagement in effective behavioral health treatment strategies. This remains to be demonstrated.