Acceptability of routine screening for perinatal depression

Journal of Affective Disorders 93 (2006) 233 – 237 www.elsevier.com/locate/jad

Brief report

Acceptability of routine screening for perinatal depression☆ Anne Buist ⁎, John Condon, Janette Brooks, Craig Speelman, Jeannette Milgrom, Barbara Hayes, David Ellwood, Bryanne Barnett, Nick Kowalenko, Stephen Matthey, Marie-Paule Austin, Justin Bilszta University of Melbourne, Department of Psychiatry Austin Health, Repat Campus PO Box 5444, West Heidelberg, Victoria, 3061, Australia Received 8 December 2005; received in revised form 19 February 2006; accepted 21 February 2006 Available online 2 May 2006

Abstract Background: To assess the acceptability of routine screening for perinatal depression. Method: Postnatal women (n = 860) and health professionals (n = 916) were surveyed after 3 years of routine perinatal (antenatal and postnatal) use of the Edinburgh Postnatal Depression Scale (EPDS). Results: Over 90% of women had the screening explained to them and found the EPDS easy to complete; 85% had no difficulties completing it. Discomfort with screening was significantly related to having a higher EPDS score. A majority of health professionals using the EPDS was comfortable and found it useful. Limitations: The sample involved only maternity services supporting depression screening. In addition, the response rate from GPs was low. Conclusions: Routine screening with the EPDS is acceptable to most women and health professionals. Sensitive explanation, along with staff training and support, is essential in implementing depression screening. © 2006 Elsevier B.V. All rights reserved. Keywords: Postnatal depression; Acceptability of screening

1. Introduction Postnatal depression (PND) affects 13% of women who give birth (O'Hara and Swain, 1996), with potential long-term family mental health consequences (Murray and Cooper, 1997). A majority of women with PND do not seek treatment, because of factors such as stigma, and unrealistic perceptions of motherhood (McIntosh, 1993; Whitton et al., 1996). Studies have shown that detection ☆ This project was funded by beyondblue: the national depression initiative. ⁎ Corresponding author. Tel.: +61 3 94962940; fax: +61 3 94962360. E-mail address: [email protected] (A. Buist).

0165-0327/$ - see front matter © 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2006.02.019

of PND increases with routine use of a screening tool (Evins et al., 2000) and with training health professionals become aware of the issue and offer relevant management (Lumley, 2005; Seehusen et al., 2005). There is, however, an ongoing debate about the acceptability of routine screening (Shakespeare et al., 2003). The beyondblue Australian PND Program introduced routine antenatal screening across Australia, and in corresponding communities postnatally. This article reports on the acceptability of this screening. 2. Methods The screening program operated 2002–2005, with ethics approval received from 43 maternity hospitals/

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Table 1 Maternal demographics Sample characteristics (n = 507) Born in Australia Age (average) First child Married Income < $20,000 Income $20,001–40,000 Income $40,001–80,000 Income > $80,001 Mode of delivery – vaginal Mode of delivery – LUSC

National average (National Mental Health Survey, 2002) (n = 253,388)

81% (412) 31 years 55% (275) 62.7% (318) 8.2% (41) 21.1% (106) 48% (241) 16.7% (84) 63% (9% assisted)

77.9% 29.4 years 41.1% – – – – – 62.1% (10.8% assisted) 28% (12% elective, 27% 16% emergency)

area health services across Australia, (Buist et al., 2005). Part of an end evaluation is presented here. 2.1. Population and sample The beyondblue teams invited all maternity services in their region (six capital cities, and four major regional towns) as well as rural services in two States to participate; predominantly city and suburban public hospitals accepted, but with a repre-

sentation of rural, remote and private services (n = 43 services). Screening occurred both antenatally (16, 28 or 36 weeks depending on the ability to best access women; all women received an emotional health booklet) and at 6–8 weeks postnatally. Antenatally, midwives working in the hospitals conducted the screening at a majority of sites. Postnatally screening was conducted by the Maternal Child Health Nurses (MCHN). All English-speaking women attending the hospitals were invited to participate, and a sub-sample of non-English-speaking women. Coordinators worked with each service to implement screening, with training and support. Screening used the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987), a widely used 10-item questionnaire developed for screening for PND in the community, with robust reliability and validity, that has been validated for use in an Australian population (Milgrom et al., 2005). Women whose screening result identified them as being potentially depressed were recommended to see their GP, who was sent a letter with the screening result, and a guide to PND management. After three years of routine screening, a random sample of screened postnatal women, (n = 1460 from the total 12,033 screened) and of health professionals (n = 916), who had attended training and/or worked in the

Table 2 Use of the EPDS Women (n = 860)

GPs using the EPDS (n = 118)

MCHN using the EPDS (n = 230)

Midwives using the EPDS (n = 194)

χ2 test for group differences χ2 = 75.4 df = 3 p < 0.0001 χ2 = 59.0 df = 3 p < 0.0001 χ2 = 30.7 df = 3 p < 0.0001 χ2 = 32.86 df = 3 p < 0.0001 χ2 = 20.5 df = 2 p < 0.0001 χ2 = 6.7 df = 2 p = 0.034 χ2 = 3.2 df = 2 p = 0.206

Found the EPDS easy or fairly easy to complete (themselves or by their patients)

810 (93.4%)

84 (71%)

190 (83%)

147 (76%)

No discomfort in completing/explaining EPDS

735 (85%)

95 (80.5%)

196 (85%)

118 (61%)

Slight/somewhat uncomfortable completing/explaining EPDS

111 (13.1%)

20 (17%)

35 (15%)

Quite/very uncomfortable with EPDS

16 (1.9%)

3 (2.5%)

6 (2.5%)

19 (9.8%)

Usefulness of EPDS rated as “certainly/very”

N/A

65 (55%)

177 (75%)

112 (57%)

Usefulness of EPDS rated as “somewhat”

N/A

47 (40%)

35 (25%)

57 (30%)

Intent to keep using

N/A

114 (98%)

227 (99%)

57 (29.2%)

178 (97%) (n = 183)

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Table 3 Women's responses to being told they may have been depressed

3. Results

Response (one option only)

Women told they might be depressed (n = 154)

3.1. Postnatal women

Ignored assessment Little upset/upset Unsure Slightly relieved/relieved

26 (16%) 48 (29%) 44 (27%) 36 (23%)

Of the 1460 postnatal women surveyed, 860 women (59%) completed the experience of screening questionnaire, 507 women completing at least part of all questionnaires. Demographics are in Table 1. Almost all women (n = 830, 97.2%) reported receiving an explanation for the use of the EPDS; details are in Table 2. Overall, 47 women of the 709 women (6.6%) who completed an EPDS on the postal survey had an EPDS of ≥ 13. Whilst over 90% found it easy to complete, discomfort was significantly related to an EPDS ≥ 13; 87% women with an EPDS < 13 at this assessment experienced no discomfort compared to 64% of those with elevated scores (χ 2 = 31.9, df = 2, p < 0.0001). Of all women who were involved in the screening program both antenatally and postnatally (n = 12,033), 25–35% had an elevated score on the EPDS (lower if a more elevated cut off used); screening staff were using EPDS ≥ 13 as a definite discussion point and EPDS ≥ 9 as discretionary. Of women in the postal survey, 216 (25%) stated they were told they might have been depressed at screening, 82% of those completing the further questionnaire (n = 154), agreeing with this assessment (Table 3). Of the subgroup of 24 women who disagreed that they might have been depressed, 27% ignored it, 40% were at least a little upset, 18% were unsure and 14% relieved. Disagreement with the assessment did not have a significant relationship with reaction (χ2 = 6.34, df = 3, p = 0.096).

regions where screening occurred, were surveyed by post. Health professionals survey 1. Professional training, and experience, frequency seen and approach to depression. 2. Experience of depression screening. Survey of 8- to 12-week postnatal women 1. Basic demographics 2. Responses (Likert scale) on: ⋅ the usefulness of the educational material ⋅ comfort in completing the EPDS. 3. For women informed they had a high score, their reaction to this information. 4. The EPDS. 2.2. Analysis Participating States, as per required coding instructions, entered data on SPSS. The data was then checked in the National office before ANOVA analysis.

Table 4 Health professionals experience GPs (n = 229)

MCHNs (n = 267)

Midwives (n = 305)

Test for significance of group differences

Years of experience: mean (S.D.) Number within last 3 years working with women with perinatal depression

19.9 (8.5) 218 (94%)

18.5 (9.9) 265 (98.5%)

15.7 (9.2) 252 (80.8%)

Skills adequate or more than adequate as self reported

151 (67%)

160 (60%)

97 (32%)

78 (33%)

107 (40%)

208 (68%)

237 (89.1%)

204 (68.5%)

F(2,852) = 15.26, p < 0.0001 χ2 = 57.2 df = 2 p < 0.0001 χ2 = 75.6 df = 2 p < 0.0001 χ2 = 73.0 df = 2 p < 0.0001 χ2 = 73.8 df = 2 p < 0.0001

Need or benefit from more perinatal mood training

Currently using the EPDS

120 (54.3%)

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Table 5 Why the EPDS is not being used? GPs not MCHN not Midwives not using (n = 109) using (n = 37) using (n = 101) Too difficult 6 (0.5%) Unreliable 1 (0.1%) Not confident 4 (0.5%) Do not believe in 1 (0.1%) routine screening Would rather ask 30 (27.5%) about symptoms (i.e. take history) Not organizational 5 (4.6%) policy Other 15 (13.8%) Did not respond 47 (43.1%)

0 (0.0%) 2 (5.4%) 2 (5.4%) 0 (0.0%)

1 (1.0%) 3 (3.0%) 2 (2.0%) 1 (1.0%)

3 (8.1%)

5 (5.0%)

8 (21.6%)

28 (28.0%)

4 (10.8%) 18 (48.6%)

23 (23.0%) 38 (38.0%)

3.2. Health professionals GPs (n = 229), MCHNs (n = 267) and midwives (n = 305) returned some or all of the questionnaires. Response rates were: GPs 20%, MCHN 50% and midwives 29%. A summary of the health professionals' responses regarding ease of use of the EPDS is in Table 2 and experience in Table 4. Midwives had significantly less experience with mood disturbances than the other health professionals and rated their skills and comfort as less adequate. Midwives and GPs both perceived the tool as less useful than the MCHNs. Those responses of health professionals not using the EPDS are in Table 5.

screening is hardly surprising; although these numbers are low from a service point of view, it emphasizes the need for support of these women, and adequate training for the health professionals utilizing the EPDS. In this study, even with routine screening, 16% of women who recalled being told they had a high score ignored recommendations for follow-up. If screening is to be successful and potentially breakdown the barriers that may contribute to this response, it needs to be routine and universal so it does not stigmatize. Nursing staffs are in the ideal position to screen – midwives antenatally and MCHNs postnatally – as virtually all women see these health professionals. Many women will continue not to declare their mood symptoms when seeing their GP, so strengthening the links between these professional is essential. There are limitations to this study. All participating services had managerial support for screening. As common in GP surveys, response was low, suggesting a group of interested GPs is over represented. This may apply to postnatal women, with those women not seeking help under-represented. Generalization of these findings to all health professionals, or women as a whole, needs to be made cautiously. Never the less, our study included women who scored high and those who did not, as well as health professionals, and the numbers were significant and representative of a “routine” screening program. Given the possible sequelae of being inattentive to mood changes in perinatal women even this biased sample yields results that should not be ignored.

4. Discussion 5. Conclusions Most women involved in routine perinatal screening found the EPDS easy to complete (93%) and experienced no discomfort (85%), in keeping with the 90% reported by Matthey et al. (2005). Shakespeare et al. (2003) concluded based on a qualitative study of 39 women that the EPDS is unacceptable, because women wanted to talk about issues. The training of the health professionals in this sample emphasized this and might have improved the acceptability. Of those women who were distressed by the knowledge of their high score, or the discussion that ensued, this may not be related to screening per se or disagreement with the possible diagnosis, given this was not significantly correlated to distress, but rather the depression itself and what meaning the acknowledgement has for the woman. That women with higher scores were more likely to be distressed by

There have been many criticisms and calls for concern over routine perinatal depression screening. This sample, taken from an Australia wide screening program, suggests the following two outcomes: 1) That screening (antenatal and postnatal) is generally acceptable to both women and health professionals, providing there is appropriate support for women who screen positive. 2) The primary health care professionals providing screening need ongoing training and clinical supervision. References Buist, A., Bilszta, J., Barnett, B., Milgrom, J., Condon, J., Hayes, B., Brooks, J., 2005. Recognition and management of perinatal

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