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Clinical Implications: The Effect of Postpartum Depression Screening on Identification of

Postpartum Depression

Nicole Jacobo

School of Nursing, Azusa Pacific University

GNRS 507: Scientific Writing

Professor Tracy Layne DNP, RN, MBA, CCRN-K, ECC, EBP-C

December 3, 2021

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The Effect of Postpartum Depression Screening on Identification of Postpartum

Depression: Literature Review

Postpartum depression (PPD) is a mental health issue that affects many mothers and their

infants. PPD is considered as any minor and major depressive episodes that affect women who

are pregnant or during the 12 months after delivery (ACOG, 2018). CDC research shows that

one in eight women suffers from postpartum depression symptoms (CDC, 2021). One of the

difficult aspects of PPD is that the exact causes are unknown (Ukatu et al., 2018). The signs and

symptoms are often thought to be related to normal post-pregnancy symptoms and can be easily

overlooked (ACOG, 2018). It is important to screen for PPD because this can initiate the

treatment process. The purpose of this paper is to present and review literature pertaining to PPD

screening to examine the current practice and its effect on identification of PPD. The literature

review will include methodology, sampling, results, and limitations.

Background

PPD is commonly seen in women during their pregnancy and during the months that

follow (Bauman et al., 2020). Some of the risk factors associated with PPD are a history of

depression or anxiety, history of sexual abuse, having a risky pregnancy, young age, and lack of

emotional and financial support (Ghaedrahmati et al., 2017). Age and race/ethnicity also play an

important role as risk factors for PPD (Ghaedrahmati et al., 2017). Some key signs and

symptoms include severe changes in sleeping patterns such as sleeping too much or not at all,

changes in eating patterns, and changes in activity (Patel et al., 2012). When a woman is

suffering from PPD some effects that can be seen include less breastfeeding initiation, poor

bonding between the mother and child, and possible developmental delays in the child (Bauman

et al., 2020). According to Bauman et al. (2020), one in five women are not asked about

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depression during their prenatal visits and one in eight women reported not being asked about

depression in their postpartum visit. These numbers also vary greatly, from 51% to 96%,

depending on the state where the woman is seeking care (Bauman et al., 2020).

The American College of Obstetrics and Gynecology published a recommendation for

screening of perinatal depression (ACOG, 2018). The ACOG recommends that providers use a

validated screening tool such as the Edinburgh Postnatal Depression Scale (EPDS), the Patient

Health Questionnaire 9 (PHQ-9), the Beck Depression Inventory, and the Center for

Epidemiologic Studies Depression Scale (ACOG, 2018). According to the ACOG

recommendation, the screenings should be done by an obstetrician-gynecologist or other

obstetric care provider and should be done at least once during the pregnancy and followed up

during the postpartum period (ACOG, 2018). Although the recommendations for depression

screening have been published, many women are not being screened for PPD and over half of

pregnant women who are identified to have depression are not being treated (Bauman et al.,

2020). The literature reviewed in this paper is focused on evidence that relates to the Population,

Intervention, Control, Outcome, Time (PICOT) question: in the postpartum patient, does

screening for postpartum depression (PPD), compared to no screening for PPD improve

identification of patients suffering from PPD in the 12 months after delivery?

Methodology

Methods

Out of eight studies that were analyzed for this paper, five were qualitative studies, one

was a quantitative study, one was a systematic review and one was a clinical practice guideline.

Logsdon et al. (2018), Premji et al. (2019), and Bhusal et al. (2016) conducted descriptive

studies. Lind et al. (2017) conducted an 18 month retrospective research analysis. Venkatesh et

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al. (2014) conducted a validation study. Ukatu et al. (2018) provided a non-research systematic

review of studies focusing on the accuracy of screening tools in identifying PPD. Yawn et al.

(2015) was the only study to present a quantitative analysis.

Logsdon et al. (2018), Premji et al. (2019), and Yawn et al. (2015) focused on the

identification of PPD and the treatment that follows. Lind et al. (2017) focused on providing

PPD screening and treatment. Venkatesh et al. (2014) and Bhusal et al. (2016) analyzed the

effectiveness of the EPDS screening tool. All six research studies had the same dependent

variable which was the identification of PPD. They differed in how they defined identification of

PPD. Some studies defined PPD identification as having signs and symptoms, others defined it

as having a PPD diagnosis and other included having treatment for PPD. All studies used the

EPDS tool to identify PPD. Some studies focused on follow up care for up to four or six months

while others went up to the full twelve months postpartum. Ukatu et al. (2018) conducted a

review of the literature by using three different databases and only including articles from 2001-

2016. Ukatu et al. (2016) noted that out of 36 analyzed articles, twelve were qualitative studies

and 24 included quantitative synthesis.

Sampling

Two research studies had a sample size of about 100, two research studies had a sample

size of about 2,500, one research study had a sample size of about 350, and one study had the

largest sample size of about 4,900 participants. All studies used women who were new mothers

from a hospital or clinic setting. The women selected for the studies all were new mothers but

had different demographics. Some studies focused on having a variety of women while other

studies that were conducted in more rural areas did not have this luxury. Venkatesh et al. (2014)

and Bhusal et al. (2016) noted that their exclusion criteria included any woman who had a

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history of suffering from a mental health disorder. Venkatesh et al., Premji et al. (2019), and

Yawn et al. (2015) all used the data of participants who were involved in another trial. Venkatesh

et al. focused particularly on adolescent new mothers while the other research studies mostly

used new mothers above the age of 18.

All research studies obtained their data from the answers the new mothers provided when

being screened using the EPDS screening tool. Logsdon et al. (2018), Lind et al. (2017), and

Yawn et al. (2019) also noted that they obtained data from the electronic medical record of the

participants. Premji et al. and Yawn et al. also used a separate questionnaire apart from the EPDS

screening tool to collect data. All six research studies used the hospital or clinic staff to

administer the EPDS screening tool in person and Logsdon et al. also used telephone calls to ask

questions about follow up care. Ukatu et al. (2018) reported that sampling size between the 36

studies varied from the least being 95 participants to the most being 1,578 participants.

According to Ukata et al., all the studies used a type of screening tool questionnaire to obtain

their data. Ukatu et al. mentions that the geographical locations of the participants varied among

studies and that twelve studies were conducted in the United States and the remaining 24 studies

were conducted in other countries. Ukatu et al. found that the studies they analyzed used

participants that came from various socioeconomic, income, age, education, and marital

backgrounds.

Research Findings

Two out of the six research studies focused on whether PPD screening occurred during

the new mother’s visits to the hospital or clinic. Logsdon et al. (2018) found that only 43.6% of

new mothers were asked about PPD after discharge and 47.8% of those women said they were

asked by both an obstetrician and a pediatrician. Lind et al. (2017) stated that PPD screening

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occurred at 88% of eligible visits. Logsdon et al. and Lind et al. both reported screening data

from postpartum visits with obstetricians and pediatricians but their findings were somewhat

different. A possible explanation for this difference could be that Logsdon et al. focused their

research in a large hospital while Lind et al. used data from community-based clinics.

Premji et al. (2019) and Yawn et al. (2015) both reported that PPD screening can help

identify new mothers who are suffering from PPD. Premji et al. found that a total of 37% of

women who screened high-risk, 6% who screened low/moderate risk, and 12% of unscreened

women were diagnosed with PPD. Premji et al. also found that new mothers who were screened

high-risk were more likely to obtain a PPD diagnosis within a year compared to unscreened

women. Yawn et al. reported that out of 2,354 women, 1,432 women had a baseline screening

score of less than ten, which is considered negative for PPD. Twelve months later, out of those

1,432 women, 10.8% reported a now higher grade on the screening tool of 10 or greater which

suggests a high risk for PPD. Premji et al. was able to demonstrate that being screened for PPD

can lead to identification and treatment. Yawn et al. determined that continuation of PPD

screening throughout the 12 months postpartum can help further identify new mothers who begin

suffering from PPD at a later time.

Venkatesh et al. (2014) and Bhusal et al. (2016) focused on evaluating the validity and

accuracy of the EPDS screening tool for PPD identification. Venkatesh et al. found that the

EPDS screening tool had an overall sensitivity of 80% and a specificity of 92% at detecting PPD

for adolescent women. Bhusal et al. reported that the sensitivity for the EPDS screening tool was

found to be 80-90% which means that the EPDS identified 80-90% of women who were

diagnosed with PPD through diagnostic interview. The EPDS’s specificity was 95% meaning

that it could identify mothers who were deemed non-depressed. Both research studies had similar

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findings and reported that they would support the use for the EPDS screening tool for PPD

identification. Ukatu et al. (2018) reported that out of the seven screening tools evaluated in

different studies, there was not one tool that was best at screening for PPD. Ukatu et al.

emphasized the importance of using any of the available tools to screen for PPD since they are

all adequate.

Study Limitations

The limitation of having a small sample size can be applied to three studies which had a

sample size of 101, 106 and 346 participants. A small sample size can affect the representability

of the general population (Polit & Beck, 2017). A major limitation that can be seen with all of

these studies due to using a questionnaire as their main form of data collection includes

discrepancies on how the providers present the questions in the screening tool. This limitation

affects the external validity of the results (Polit & Beck, 2017). Another limitation because of

this form of data collection includes how the participants chose to answer and whether or not

they were answering the questions with the truth. The studies who also used questionnaires to

follow up with their participants also faced the limitation of not being able to obtain a response

from all the women who had initially participated. Another limitation that can be seen in several

of these studies is that the amount of women who screened high-risk for PPD was not

representative of the average prevalence in the general population. The definitions and how PPD

was measured varied among the studies which can also be noted as a limitation.

A limitation for Venkatesh et al. (2014), Premji et al. (2019), and Yawn et al. (2015) is

that they all used data that was gathered from a previous study. The researchers have to rely on

the previous researchers to have accurately obtained the information that is being presented.

Finally, these researchers were limited to obtaining data from a certain time frame that the

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original researchers chose. Ukatu et al. (2018) mentioned that a major limitation found in their

literature review included the differences in the scoring methods for the different screening tools.

Having different scoring methods could impact the diagnosis and treatment decision. Ukatu et al.

also mentions that various screening tools have varied cut off scores which can make diagnosing

inconsistent.

Clinical Practice Guideline

The American College of Obstetricians and Gynecologists (ACOG) released a set of

recommendations for healthcare providers about screening for perinatal depression. These

recommendations aimed to increase the rate of early detection in combination with referrals for

treatment of perinatal depression. This clinical practice guideline recommended that all

obstetrician-gynecologists and other obstetric care providers screen their patient for PPD at least

once during the pregnancy using a validated tool. It also stated that the screening for depression

and anxiety should also be completed during a postpartum visit. The ACOG stated that there are

clinical benefits to screening but that it should also be supported with initiation of treatment or

referral to mental health providers to obtain the maximum benefit. This guideline recommended

the use of the EPDS tool due to its ease of access and inclusivity of different mental health

disorders. This guideline was created by various experts in the field of gynecology and obstetrics

which elevated the guideline’s validity.

Clinical Implications

The next focus of this paper will be the clinical implications that relate to the PICOT

question: in the postpartum patient, does screening for postpartum depression (PPD), compared

to no screening for PPD improve identification of patients suffering from PPD in the 12 months

after delivery? The literature previously presented will be used to identify key findings that will

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provide evidence for the use of screening tools for the identification of postpartum depression. A

plan will be presented that provides a guide on how this clinical practice change will be

implemented. The barriers and facilitators for implementation and the ethical and cultural

considerations will also be addressed.

Key Findings

Researchers found that women who were screened for PPD and were considered to be at

high-risk, were more likely to obtain a diagnosis for PPD which led to them getting a referral for

treatment and medications (Premji et al., 2019). Researchers also found that some women who

were not screened for PPD ended up being diagnosed with PPD (Premji et al.). Other findings

included the need to continue to screen for PPD during the twelve month postpartum period

(Yawn et al., 2015). Yawn et al. found that women could be considered to be at low or no risk

for PPD in their initial screening, however, further along the postpartum period could score in

the moderate to high risk category. Both Premji et al. and Yawn et al. found that screening for

PPD in the twelve months after giving birth could help identify women who are suffering from

PPD and result in treatment.

Another finding by researchers was that not all women were being screened for PPD in

their well visits for either themselves or pediatric well visits. One study found that less than half

of new mothers were being screened for PPD or asked about PPD during outpatient visits

(Logsdon et al., 2018). In order to obtain a diagnosis, PPD screening needs to be initiated and

continued throughout the postpartum period according to Logsdon et al., Premji et al. (2019),

Yawn et al. (2015), and Lind et al. (2017). The screening tools being used for the identification

of PPD were also tested for sensitivity and specificity. Researchers found that the most used

screening tool was the EPDS which showed to have a 95% specificity and a 80-90% sensitivity

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(Bhusal et al., 2016). This data reinforced the ability of this screening tool to both identify new

mothers suffering from PPD and those who were not. Researchers also found that there were no

major differences in the ability for various screening tools to identify PPD (Ukatu et al., 2018).

The researchers all supported the use of various available screening tools to identify new mothers

suffering from PPD (Bhusal et al.; Ukatu et al.). Other researchers also found that these

screening tools can be applied to new mothers of a young age and the sensitivity and specificity

remains in the 80-90% (Venkatesh et al., 2014).

Implementation Plan

Standardized PPD Screening in Clinical Facility. This will be a pre- post-

implementation EBP project. The project will focus on a hospital that does not use standardized

screening for PPD as part of their care. Implementation of standardized screening using the

Edinburgh Postpartum Depression Screening tool (EPDS) will be done. The choice to use the

EPDS tool came from its abundance of support that was found by various researchers (Bhusal et

al., 2016; Ukatu et al., 2018; Venkatesh et al., 2014; ACOG, 2018). The EDPS tool has also been

shown to have a sensitivity of 80-90% and a specificity of 95% which supports its reliability and

validity (Bhusal et al.). Data from before the implementation and data after the implementation

of the screening tool will be collected and compared. Implementation of the screening tool will

be done by educating the staff. The staff included in this teaching will be the labor and

delivery/postpartum nurses, the midwives, and the OBGYNs that care for the patients during

pregnancy, labor, and the postpartum periods.

A self-reporting questionnaire will be used to establish a baseline of the staff’s

knowledge. An in-service training will be held for all staff in regards to the screening tool. The

in-service will focus on teaching about PPD and the consequences of not identifying it, the EPDS

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tool, the importance of using the tool, how to use the tool, how to chart the information, and what

to do if someone scores high vs someone that scores low. The curriculum for the staff will

include the recommendations by the ACOG and their clinical practice guidelines which give

information about PPD, the EPDS tool, and the importance of referrals (ACOG, 2018). Each

staff member will receive a sample of the EPDS tool and will be taught how to ask and score

each question. The meaning of the scores will also be explained as well as the cutoff point.

Charting the information in their computer system will be taught. Finally, sample referral

paperwork will be given to the staff and they will be taught how to fill it out, who they can refer

the patients to, how to input it in the patient’s chart, and who to notify about the referral. Another

part of the curriculum will include how to teach the patient about PPD and what the treatment for

PPD looks like (therapy and/or medications). The in-service training will be available for a week

to reach all the staff. Once training is completed, an outline with steps and key points on what to

ask, how to chart, and what to report will be handed to every staff member and will be available

at the nurse’s station.

Convenience sampling will be conducted by obtaining data from the labor and delivery

and the postpartum units of this facility. The patients eligible for this project will include any

pregnant women that had care within the last year before the implementation of the screening

tool. Also, any postpartum women that sought care in this facility within the year after

implementing the screening tool. The sample size will be 2,000 new mothers from the single

clinical facility. Data from the pre- and post- intervention periods will be analyzed using t-test

analysis to identify if there is a significant difference between the number of new mothers

diagnosed with PPD before and after the implementation of the EPDS tool. Data will be

collected for a year before the implementation of the intervention and again for a year after the

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implementation of the screening tool. Descriptive statistics will be used to describe the

knowledge of PPD screening from the staff before implementation and the demographic data of

the participants.

Barriers to Implementation

Possible challenges will include properly and efficiently educating the staff and them

understanding how to use the screening tool. Compliance from the staff to conduct the screening,

give the proper referrals/diagnosis, and chart the results. Another possible challenge will include

having all the staff members conduct the screening the same way especially if conducted by a

physician compared to a nurse. Another challenge might be obtaining accurate information from

the new mothers. Finally, a possible complication might involve having the skills to talk about

PPD with the patient which can be a difficult topic.

Some facilitators that could aid in the success of the evidence-based change would

include the research that supports screening for PPD to identify and diagnose new mothers.

Presenting the research and the recommendations from the ACOG will provide validity for this

change to the staff of the clinical facility. Another possible facilitator would be that the EPDS

tool is only ten questions long and its scoring is simple. The way the EPDS tool is formatted

allows for the ten questions to be answered with one of four choices which makes it easier to

conduct and score (Bhusal et al., 2016). Another facilitator would be that this intervention can be

conducted as part of the routine plan of care for the patient and does not involve any additional

equipment other than the EPDS tool which will be an addition to the charting process.

Ethical and Cultural Considerations

After researching and analyzing the literature that is available about PPD and PPD

screening it would be safe to say that implementing PPD screening for all new mothers is a

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beneficent and just act. Beauchamp & Childress (2019), defines beneficence as the moral

obligation to what is beneficial to others. Under this definition there are five rules which include

preventing harm from occurring to others, protecting and defending the rights of others, helping

people with disabilities, removing conditions that will cause harm to others, and rescuing people

who are in danger (Beauchamp & Childress). Justice can be thought of as the equitable

distribution of resources to maximize societal benefits (Beauchamp & Childress). Having a

standardized protocol for screening new mothers for PPD across healthcare facilities would

result in the benefit of PPD diagnosis and treatment.

Mental health is a part of healthcare that is not always easily discussed (Lind et al.,

2017). It is necessary to take the sensitivity of this topic into consideration when having

conversations with the patients. This is also a part of why the providers of care should be well

educated on the topic. Cultural components of the new mothers are important to consider when

assessing for PPD because not all cultures are as open to talking about mental health issues.

Having a background of the patient;s cultural norms can help gain the trust and rapport that is

needed to identify women suffering from PPD. Once the screening and identification is done, the

spiritual component should also be considered, especially for those who are identified as

suffering from PPD. Having the skill to talk to patients about PPD and knowing what resources

are available for them can help ease the transition to treatment.

Conclusion

All studies presented in this paper focus on screening for PPD. Some studies aimed to

evaluate the screening tool itself, others at the relationship between screening for PPD and

identifying/treating PPD, and sme studies evaluated whether or not PPD screening is being done.

Postpartum depression is a mental illness of which many new mothers suffer from (Lind et al.,

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2017). Identification can be challenging due to misdiagnosis or hesitance to report symptoms

because of fear of judgement (ACOG, 2018). Implementing screening for PPD can provide

benefits by identifying those at risk and initiating the conversation with women who might not

be willing to initiate it themselves (ACOG, 2018). The implementation plan presented would

help answer the PICOT question and provides a framework for future implementation projects.

More research still needs to be conducted on PPD screening and its direct effect on PPD

identification and treatment.

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