Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings

Abstract

Importance: The period prevalence of depression among women is 21.9% during the first postpartum year; however, questions remain about the value of screening for depression.

Objectives: To screen for depression in postpartum women and evaluate positive screen findings to determine the timing of episode onset, rate and intensity of self-harm ideation, and primary and secondary DSM-IV disorders to inform treatment and policy decisions.

Design: Sequential case series of women who recently gave birth.

Setting: Urban academic women's hospital.

Participants: During the maternity hospitalization, women were offered screening at 4 to 6 weeks post partum by telephone. Screen-positive women were invited to undergo psychiatric evaluations in their homes.

Main outcomes and measures: A positive screen finding was an Edinburgh Postnatal Depression Scale (EPDS) score of 10 or higher. Self-harm ideation was assessed on EPDS item 10: "The thought of harming myself has occurred to me" (yes, quite often; sometimes; hardly ever; never). Screen-positive women underwent evaluation with the Structured Clinical Interview for DSM-IV for Axis I primary and secondary diagnoses.

Results: Ten thousand mothers underwent screening, with positive findings in 1396 (14.0%); of these, 826 (59.2%) completed the home visits and 147 (10.5%) completed a telephone diagnostic interview. Screen-positive women were more likely to be younger, African American, publicly insured, single, and less well educated. More episodes began post partum (40.1%), followed by during pregnancy (33.4%) and before pregnancy (26.5%). In this population, 19.3% had self-harm ideation. All mothers with the highest intensity of self-harm ideation were identified with the EPDS score of 10 or higher. The most common primary diagnoses were unipolar depressive disorders (68.5%), and almost two-thirds had comorbid anxiety disorders. A striking 22.6% had bipolar disorders.

Conclusions and relevance: The most common diagnosis in screen-positive women was major depressive disorder with comorbid generalized anxiety disorder. Strategies to differentiate women with bipolar from unipolar disorders are needed.

Trial registration: clinicaltrials.gov Identifier: NCT00282776.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Wisner participated in an advisory board for Eli Lilly Company and received donated estradiol and placebo transdermal patches from Novartis for a National Institute of Mental Health-funded randomized trial, activities that do not involve the work described in this article. Dr Wisniewski has received compensation for consultation to Bristol-Myers Squibb Company (2007–2008), Organon (2007), Case Western Reserve University (2007), Singapore Clinical Research Institute (2009), Dey Pharmaceuticals (2010), and Venebio (2010) and received payment for his board membership for Cyberonic, Inc (2005–2009).

Figures

Figure 1

Subject flow. EPDS indicates Edinburgh Postnatal Depression Scale.

Figure 2

Frequency distribution of the Edinburgh Postnatal Depression Scale (EPDS) scores.

Figure 3

Responses to the Edinburgh Postnatal Depression Scale (EPDS) self-harm item for women with positive EPDS screen findings.