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Efficacy and Safety of Screening for Postpartum Depression
Comparative Effectiveness Reviews, No. 106
Investigators: Evan R Myers, MD, MPH, Nicki Aubuchon-Endsley, PhD, Lori A Bastian, MD, Jennifer M Gierisch, PhD, MPH, Alex R Kemper, MD, MPH, MS, Geeta K Swamy, MD, Marla F Wald, MD, Amanda J McBroom, PhD, Kathryn R Lallinger, MSLS, Rebecca N Gray, DPhil, Cindy Green, PhD, and Gillian D Sanders, PhD.
Author Information and AffiliationsStructured Abstract
Objectives:
To describe the benefits and harms of specific tools and strategies for screening for postpartum depression.
Data sources:
We searched PubMed®, Embase®, PsycINFO®, and the Cochrane Database of Systematic Reviews for relevant English-language studies published from January 1, 2004, to July 24, 2012, that evaluated the performance of screening instruments for postpartum depression, potential benefits and harms of screening, and impact on appropriate postscreening actions.
Review methods:
Two investigators screened each abstract and full-text article for inclusion; abstracted data; and performed quality ratings, applicability ratings, and evidence grading. A simulation model was used to estimate the effects of screening for postpartum depression on the overall balance of benefits and harms.
Results:
Forty studies (represented by 45 articles) were identified as relevant to this review. Eighteen studies provided sensitivity and specificity data on 9 screening instruments: 11 on the Edinburgh Postnatal Depression Scale, 4 on the Postpartum Depression Screening Scale, 4 on different versions of the Beck Depression Inventory, 2 on a “two-question” screen, and 1 each on 5 other instruments. Heterogeneity in setting, patient population, and choice of threshold prevented formal synthesis. For most tests in most studies, sensitivity and specificity were in the 80–90 percent range, with higher sensitivity associated with lower specificity; the two-question screen had 100 percent sensitivity but specificities of 45–65 percent. Fifteen studies analyzed the association between risk factors and postpartum depression. Although adverse pregnancy outcomes and chronic medical conditions (low strength of evidence) and past history of depression, poor relationship quality, and poor social support (moderate strength of evidence) were all associated with an increased risk of postpartum depression, only two studies directly reported an effect on test results. (Sensitivity was nonsignificantly increased in primigravidas compared with multigravidas.) Based on two studies, there was insufficient evidence to evaluate whether timing relative to delivery, setting, or provider affected test characteristics of screening instruments. Based on five studies, there was low to moderate strength of evidence that screening resulted in decreased depressive symptoms and improved mental health; in four of these studies, improvement in depressive symptoms was not accompanied by improvement in measures of parenting stress. Rates of referral and treatment for women with positive screening results were substantially higher in two studies where screening, diagnosis, and treatment were provided in the same setting; referral rates in other studies were all 50 percent or less. Modeling suggests that serial testing with a two-question screen followed by a second more specific instrument for those who have a positive result may be a reasonable strategy to reduce false positives while minimizing false negatives.
Conclusions:
The potential effectiveness of screening for postpartum depression appears to be related to the availability of systems to ensure adequate followup of women with positive results. The ideal characteristics of a screening test for postpartum depression, including sensitivity, specificity, timing, and frequency, have not been defined. Because the balance of benefits and harms, at both the individual level and health system level, is highly dependent on these characteristics, broad consensus on these characteristics is needed.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Introduction
- Results of Literature Searches
- Description of Included Studies
- Key Question 1 Performance Characteristics of Screening Instruments
- Key Question 2 Effect of Individual Subject Factors on Screening Performance
- Key Question 3 Effect of Testing Variables on Screening Performance
- Key Question 4 Comparative Benefits of Screening
- Key Question 5 Comparative Harms of Screening
- Key Question 6 Factors Affecting the Likelihood of an Appropriate Action After a Positive Screening Result
- Discussion
- Conclusions
- References
- Abbreviations
- Appendix A Exact Search Strings
- Appendix B Data Abstraction Elements
- Appendix C Included Studies
- Appendix D Excluded Studies
- Appendix E Study Characteristics Table
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10066-I, Prepared by: Duke Evidence-based Practice Center, Durham, NC
Suggested citation:
Myers ER, Aubuchon-Endsley N, Bastian LA, Gierisch JM, Kemper AR, Swamy GK, Wald MF, McBroom AJ, Lallinger KR, Gray RN, Green C, Sanders GD. Efficacy and Safety of Screening for Postpartum Depression. Comparative Effectiveness Review 106. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2007-10066-I.) AHRQ Publication No. 13-EHC064-EF. Rockville, MD: Agency for Healthcare Research and Quality; April 2013. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Duke Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10066-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
- 1
540 Gaither Road, Rockville, MD 20850; www
.ahrq.gov
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