Dr. Karen Buhler (biography and disclosures)
What I did before
As a family doctor in practice for 28 years providing maternity care, I thought I knew my patients well. I cared for them through young womanhood, pregnancies, and childbearing with numerous opportunities for therapeutic encounters. I spend a lot of time talking with and listening to my patients. Although I am well aware that usual care by family doctors fails to recognize 30-50% of depressed patients, I was sure this did not apply to my practice. When screening for depression at 28-32 weeks with the Edinburgh Depression Scale was incorporated into the BC Prenatal Record over a year ago, like most of my colleagues feeling short of time at the office, I never got around to administering it.
What changed my practice
I had recently completed a project with an interdisciplinary group creating the BC Maternity Care Pathway, which reviewed and summarized guidelines for routine prenatal care based on current evidence. Since I was one of the authors I decided I had better implement all of the recommendations into my practice. With an inward sigh I gave the EDS to every pregnant woman I saw between 28 and 32 weeks. The very first week I used it I was humbled to discover two cases of severe mood disorder.
The first was a 26 year old woman pregnant for the second time. She had had an exhausting and strenuous 3 years with her first child who had a “difficult” temperament. However, other than fatigue and the expected stress, I thought she was coping quite well. I handed her the EDS and got back a score of 24 out of a possible 30, which on this scale is “severe”. My eyebrows raised and I asked, “Can you tell me more about feeling very low?” She immediately burst into tears and poured out a story of insomnia, fear, anxiety, guilt, and despair going back to a childhood of extreme neglect and abuse. I was shocked that I didn’t know any of this and realized she must have suffered silently during her first pregnancy. When asked if she would like help with this, she was relieved.
The next day a similar patient interaction with a 36 yr old nulliparous woman, resulted in an EDS with a very high score for anxiety. Again the unexpected revelation of distress in this high functioning woman surprised me. I had inquired about mood throughout the pregnancy, without ever identifying that which was revealed to me via the EDS.
Mental illness is common in pregnancy and the postpartum period affecting as many as 25% of women, with depression and anxiety being the most common problems. Some investigators have reported obstetric complications associated with depression in pregnancy such as an increase in preterm labour, substance misuse, both high and low weight gain, and poorer performance on neonatal assessment tests. Infants of depressed mothers show delayed neurologic, cognitive, psychological, and motor development. When the mother’s mental illness is in remission the child’s behavioral and cognitive disorders improve. In women with perinatal mental illness there is an associated increase in poor socioeconomic status (no educational qualifications, unmarried, unemployed) and increased intimate partner violence (IPV). Antenatal depression is associated with an increased incidence of postnatal depression and thus early identification can help women and their care-providers plan for extra support and surveillance . Women with a prior history of perinatal depression have a 30-50% chance of recurrence with a subsequent pregnancy. These are the women at greatest risk of suicide. It is therefore compelling to recognize and treat women with perinatal mental illness. Due to frequent contact with health care providers, pregnancy is an ideal time to provide support, treatment, and close monitoring.
The EDS is a highly sensitive screening tool administered in less than 10 minutes and can be distributed before the encounter. It has been validated in pregnancy. The questions on the EDS make it suitable for screening in pregnancy, as there is less focus on somatic symptoms. The evidence that screening and providing treatment for perinatal mental illness improves outcomes remains equivocal. However ACOG, NICE (UK), U.S. Preventive Services Task Force and the Perinatal Services of BC in the Maternity Care Pathway all recommend formal screening for depression in pregnancy due to its serious morbidity and the potential for benefit to an individual woman and her family.
What I do now
Since that first week of using the EDS I now employ it on all my patients and continue to discover far more symptomatology than I did before. For some women the questionnaire is an education tool and they become aware of the extent of their distress and re-examine their lifestyle and supports. For others it offers an important opportunity to make the practitioner aware of problems and thus be able to assist in treatment, identify co-morbidities such as IPV, and hopefully prevent further progression. I no longer trust that I “know” my patients and utilize formal screening for antenatal mental health. Next I am implementing the alcohol-screening tool TACE routinely!
Edinburgh Postnatal Depression Scale 1 (EPDS) http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf
BC Maternity Care Pathway http://www.bcprenatalscreening.ca/sites/prenatal2/files/Guideline_19.pdf
BC Clinical Practice Guidelines (CPG’s) http://www.perinatalservicesbc.ca/Guidelines/default.htm
References: (Note: Article requests might require a login ID with the BC College of Physicians website or UBC)
- Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med 1995; 4:99-105 (View article with CPSBC or UBC)
- June C. Carroll, Anthony J. Reid, Anne Biringer. Effectiveness of the Antenatal Psychosocial Health Assessment (ALPHA) form in detecting psychosocial concerns: a randomized controlled trial. CMAJ • AUG. 2, 2005; 173 (3)
- Evans J, Heron J, Francomb H, et al. Cohort study of depressed mood during pregnancy and after childbirth. BMJ 2001;323:257-60 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC35345/pdf/257.pdf)
- Gaynes BN, Gavin N, Meltzer-Brody S, et al. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evid Rep Technol Assess (Summ) 2005; Number 119:1-8 (http://www.ncbi.nlm.nih.gov/books/NBK37740/)
- Gjerdingen DK, Yarn BP. Postpartum depression screening importance, methods, barriers and recommendations for practice. J. Am Board Fam Med 2007; 20:280-8 (http://www.jabfm.org/content/20/3/280.full.pdf+html)
- Weissman, MM, Pilowsky DJ, Wickramaratne, PJ, Talati A, Wisniewski SR, Fava M, et al. Remissions in maternal depression and child psychopathology: a STAR*D-child report. STAR*D-Child Team [published erratum appears in JAMA 2006:296:1234]. JAMA 2006:295:1389-98 (View article with CPSBC or UBC)
- Wilson LM, Reid AJ, Beringer A, Carroll JC, Stewart DE. Antenatal psychosocial risk factors associated with adverse postpartum family outcomes. Canadian Medical Association Journal 1996; 154: 785-99 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1487795/pdf/cmaj00090-0043.pdf)
- Lewis G, Drife J, editors. Why mothers die 1997-1999: the fifth report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press; 2001 (Book- available at Woodward library: WA900.FA1 W499 1998)
- Murray D, Cox JL. Screening for Depression during pregnancy using the Edinburgh depression Scale. Journal of Reproductive and Infant Psychology 1990; 8:99-107 (IK Barber Learning Centre ASRS Storage BF719 .J687)
- Cochrane review 2008, Antenatal psychosocial assessment for reducing perinatal mental health morbidity http://www2.cochrane.org/reviews/en/ab005124.html (View article with CPSBC or UBC)
- Committee Opinion No. 453: Screening for Depression During and After Pregnancy. Obstetrics & Gynecology: February 2010 – Volume 115 – Issue 2, Part 1 – pg 394-395 (View article with CPSBC or UBC)
- NICE Clinical guideline: Antenatal Care: Routine care for the healthy pregnant woman. National collaboration /Center for Women’s and Children’s Health, Clinical Guideline; March 2008, chapter 7.6 Psychiatric screening. P.118 (http://www.nice.org.uk/nicemedia/pdf/CG062NICEguideline.pdf scroll or search for ‘sec2:118’)