Screening for Postpartum Depression in Well-Baby Care Settings: A Systematic Review

The characteristics of the six included studies are presented in Table 2. The settings of the studies (Yawn et al. 2012; Glavin 2012; Glavin et al. 2010; Chaudron et al. 2004; Leung et al. 2011; Carroll et al. 2013; Gerrard et al. 1993) differ in location and the professionals performing the screening. In the studies by Chaudron et al. (2004) and Carroll et al. (2013), care was delivered by the pediatric staff from a primary care center. In the Norwegian Glavin et al. study (2010, 2012), public health nurses screened the mothers at well-baby clinics, a comparable setting to that of the Leung et al. (2011) study in Hong Kong, where nurses screened the mothers at Maternal and Child Health Centers. The screening investigated by Gerrard et al. (1993) was carried out by trained health visitors at baby clinics in England. Yawn et al. (2012) focused on family medicine research network practices in 21 USA states; 22 of the included practices offered continuity to the mother and her child, and six only to the mother. Pediatrician offices offering services only to the child were excluded. Except for the six practices studied by Yawn et al., the other practices offered frequent appointments to both mother and child. In the first year postpartum the frequency varied from 7 to 10. The intention of the settings was to service the general population and to reach 90–100 % of the mothers of newborn children in their area. The frequency and outreach of the services in the Gerrard et al. study (1993) could not be verified.

The interventions offered in the various studies differed greatly. Those in the Chaudron et al. (2004) and Carroll et al. (2013) studies consisted mainly of incorporating screening questionnaires into the regular visits. In addition, Carroll et al. used a decision support system, incorporated in an electronic medical support system. Depending on the answers on the screening questionnaire, reminders were created by the system to guide clinicians during their visit. Four of the six studies (Yawn et al. 2012; Glavin et al. 2010; Leung et al. 2011; Gerrard et al. 1993) investigated an intervention consisting of both screening and enhanced care. In the Glavin et al. study (2010) screening was one of several components of the intervention and was followed by a standard supportive counseling session for all mothers with the Public Health Nurse. Depressed mothers received follow-up supportive counseling sessions. Yawn et al. (2012) compared a practice-based training program for screening, diagnosis, and management of mothers with PPD. Intervention practices were provided with a set of tools to facilitate each part of the process. Leung et al. (2011) also described the steps following screening: participants with a positive EPDS were directed to another nurse for counseling. During this session, subsequent management was recommended. This could be either non-directive counseling by a Maternal and Child Health Centre (MCHC) nurse or referral to the community psychiatric team. These steps were also offered to mothers clinically observed as depressed, and were therefore not limited to the intervention. Mothers with elevated EPDS scores in the post-training group of the Gerrard et al. study (1993) were offered 4–8 non-directive counselling visits by their health visitor.

Five studies used the EPDS as the screening instrument; four (Yawn et al. 2012; Glavin et al. 2010; Chaudron et al. 2004; Leung et al. 2011) had the same cut-off score of ≥10 and one, by Gerrard et al. (1993), selected 12 as the cut-off score. Glavin et al. (2010) and Chaudron et al. (2004) mentioned that clinical judgment should confirm the EPDS indication of a mother as probably being depressed. Leung et al. (2011) also considered a positive answer on question ten (suicidal ideation) as indicative. Carroll et al. (2013) adapted a validated two question depression screening tool into an existing pre-screening form. In the study by Yawn et al. (2012), mothers with an EPDS score of ≥10 were asked to complete the Patient Health Questionnaire (PHQ-9) as well. A mother was considered to have PPD if her PHQ-9 score was ≥10 and the physician’s evaluation revealed no other cause for the depressive symptoms. Carroll et al. (2013) reported the PHQ-9 was added as a hand-out to one of the two intervention arms to assist the physician in diagnosing depression but no PHQ-9 data were shown in the results. In the studies by Leung et al. (2011), Glavin et al. (2010) and Yawn et al. (2012), screening was performed once, at 2 months, 6 weeks and between 5–12 weeks postpartum, respectively. In the Chaudron et al. study (2004), mothers received the EPDS at each well-child visit during the child’s first year, starting with the routine 2 week visit. In the study by Carroll et al. (2013), mothers were screened every 3 months until the age of 15 months. Health visitors in the Gerrard et al. study (1993) were instructed to screen at 6–8 weeks and/or 10–12 weeks, depending on the number of training sessions attended by the health visitor.

The types of primary outcomes depended on the study design. Studies examining screening without enhanced care (Chaudron et al. 2004; Carroll et al. 2013) used documented depressive symptoms and referrals, indicated in Table 2 as primary outcomes at process level. Five studies (Yawn et al. 2012; Glavin et al. 2010; Chaudron et al. 2004; Leung et al. 2011; Carroll et al. 2013) reported the rates of the elevated scores on their screening instrument at the moment of intervention. None of the studies used a golden standard to confirm the PPD diagnosis. The four studies (Yawn et al. 2012; Glavin et al. 2010; Leung et al. 2011; Gerrard et al. 1993), which examined screening combined with enhanced care, used the screening instrument of their intervention also as a primary outcome measure for maternal depressive symptoms later in the postpartum year. Regarding secondary outcomes, different outcome measures were used. Three (Yawn et al. 2012; Glavin et al. 2010; Leung et al. 2011) of those studies used the Parenting Stress Index (PSI). The only secondary outcome at child level was the child’s body weight at 6 and 18 months presented by Leung et al. (2011).

Table 3shows the outcomes of the Quality Assessment tool for Quantitative Studies (Armijo-Olivo et al. 2012).

Four (Glavin et al. 2010; Chaudron et al. 2004; Carroll et al. 2013; Gerrard et al. 1993) of the six studies were globally rated as weak, according to this Quality Assessment tool. All four studies had a weak score on description and control of possible confounders. In both Chaudron’s (Chaudron et al. 2004) and Carroll’s (Carroll et al. 2013) study the data collection methods were weak as their data were based on health care provider documentations, which were incomplete and not based on valid instruments in the control groups.

Four studies presented screening outcomes at process level (Table 2) (Yawn et al. 2012; Chaudron et al. 2004; Leung et al. 2011; Carroll et al. 2013). The effect on the detection rate when screening for PPD was quantified in three of the six studies (Chaudron et al. 2004; Leung et al. 2011; Carroll et al. 2013). The calculated RRs for detection of PPD in the studies by Chaudron et al. (2004) and Leung et al. (2011) were, respectively, 5.3 (8.5 %/1.6 %) and 4.8 (29 %/6 %). Improvement in the rate of referral in the study by Carroll et al. (2013) was presented with an OR of 2.06 (95 % confidence interval (CI) 1.08–3.93). We calculated the RRs for the other three studies: for the referral to a social worker in the study by Chaudron et al. (2004) the RR was 18 (3.6/0.2), for receiving treatment in the study by Leung et al. (2011) the RR was 4.9 (23.8/4.8), and for being diagnosed as PPD in the study by Yawn et al. (2012) the RR was 1.6 (66 %/41 %). Carroll et al. (2013) mentioned that adding handouts to the screening process resulted in earlier referral, but no data were presented.

Four of the six studies (Yawn et al. 2012; Glavin et al. 2010; Leung et al. 2011; Gerrard et al. 1993) (including the two strong studies) in which screening and enhanced care were combined in the intervention, showed significant improvement of depression scores later in the postpartum year in the intervention arms. In the Leung et al. study (2011), mothers in the intervention group had an RR of 0.59 (95 % CI 0.39–0.89) for having an elevated EPDS (≥10) at 6 months postpartum. In the Glavin et al. study (2010), mothers in the intervention group had an OR of 0.5 (95 % CI 0.3–0.8) for having an elevated EPDS (≥10) and in the Gerrard et al. study (1993) the post-training group had an RR of 0.51 (9.8 %/19.3 %) for an EPDS of 12 or above. Mothers in the intervention group in the Yawn et al. (2012) study had an OR of 1.74 (95 % CI 1.05–2.86) for having a ≥5-point drop in PHQ-9 score between baseline and 12 months postpartum. Of the mothers in the study of Glavin et al. (2010) who had an EPDS score of 10 or above at 6 weeks postpartum, those in the intervention group had a larger improvement in EPDS scores from 6 weeks to 12 months postpartum compared to the those in the control group (effect size 0.53). We could not create a summarized effect size as the measurement moments and outcome measures in the included six studies varied too much.

Regarding secondary outcomes, there were no results on child development or social-emotional wellbeing. No significant difference was found with respect to the child’s weight in the Leung et al. study (2011). At parent level, no statistical significant differences were found in secondary outcomes regarding measuring long-term effects (Table 2), except in the study by Glavin et al. (2010). The intervention group’s PSI Health subscale 12 months postpartum demonstrated a better score.