A universal screening program increased the number of women diagnosed and treated for depression during and after pregnancy and resulted in significant relief from their symptoms,according to two Kaiser Permanente studies published online today in the journal Obstetrics and Gynecology.
Perinatal depression (before and after birth) occurs in 12 to 20 percent of pregnancies, according to the U.S. Centers for Disease Control and Prevention. The consequences can include premature delivery, decreased maternal-child interactions, child behavior problems, and in severe cases, even suicide or infanticide. The American College of Obstetrics and Gynecologists and the U.S. Preventive Services Task Force recently recommended that clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms, using a validated screening tool.
Kaiser Permanente in Northern California initiated the development of a universal screening program in 2007. Women were screened with the PHQ-9, a validated nine-question survey, at three times during the perinatal period: the first prenatal visit, at 24 to 28 weeks of gestation, and at three to eight weeks following birth. Each woman’s obstetrician reviewed the results and, when depressive symptoms were present, offered treatment and referrals for classes, support groups, individual counseling or prescribed medication.
“We identified best practices, empowered advocates on site to help educate obstetricians, streamlined the work flow for screening during obstetric office visits and used data to continuously improve the program,” said Tracy Flanagan, MD, director of women’s health for Kaiser Permanente in Northern California, clinical lead of the screening program and lead author of the first study.
At full implementation, the program screened 98 percent of pregnant and postpartum women at least once during and after pregnancy, and an average of 2.5 times per pregnancy. Based on their scores, 15 percent of the pregnant women screened positive for depression symptoms and 6 percent screened positive for severe depression symptoms. (A score of 10 or more indicates depression, and a score of 15 or more indicates severe depression.)
Researchers compared outcomes before, during and after implementation of the screening program for nearly 98,000 pregnancies between 2007 and 2014. In 2014, at full implementation, the program included more than 80,000 screenings.
Among the women diagnosed with depression, 82 percent had scores less than 10 by six months postpartum, and 60 percent had symptoms that improved a minimum of 50 percent. Among women diagnosed with depression and severe symptoms, 57 percent had mild symptoms with scores less than 10 by six months postpartum and 56 percent had symptoms that improved by 50 percent or more.
“Our studies provide evidence for the effectiveness of universal screening for perinatal depression in enhancing identification and treatment and, ultimately, improvement of outcomes,” said Lyndsay Ammon Avalos, PhD, MPH, lead author of the second study and a research scientist in the Kaiser Permanente Northern California Division of Research.
“Through collaborations with mental health professionals, the implementation of universal screening in routine obstetric care can provide significant improvements in identifying and treating perinatal depression,” Flanagan said.
Flanagan and Avalos were co-authors of the first study. Co-authors of the second study were Avalos, Flanagan, Tina Raine-Bennett, MD, MPH, Hong Chen, MPH, and Alyce S. Adams, PhD, of the Kaiser Permanente Division of Research.
Avalos received funding for this study from the National Institute of Mental Health and the University of California, San Francisco/Kaiser Permanente Building Interdisciplinary Research Careers in Women’s Health Program.
