Dwenda K. Gjerdingen

Postpartum Depression Screening: Importance, Methods, Barriers, and Recommendations for Practice

Background: Postpartum depression occurs in 10% to 20% of women who have recently given birth, but fewer than half of cases are recognized. The purpose of this review is to discuss the potential benefit of mass screening for improving postpartum depression recognition and outcomes. Methods: A review of the literature was conducted by searching MEDLINE, using the key words “depression,” “postpartum depression,” and “mass screening.” The Cochrane database was also searched for reviews on depression and postpartum depression. Results: Opportunities for routine postpartum depression screening include mothers’ postpartum office visits and their infants’ well-child visits. Although several depression screens have been used in postpartum women, additional studies using large representative samples are needed to identify the ideal screening tool. Depression screening plus “high-risk” feedback to providers improves the recognition of depression. However, for screening to positively impact clinical outcomes, it needs to be combined with systems-based enhanced depression care that provides accurate diagnoses, strong collaborative relationships between primary care and mental health providers, and longitudinal case management, to assure appropriate treatment and follow-up. Conclusions: Postpartum depression screening improves recognition of the disorder, but improvement in clinical outcomes requires enhanced care that ensures adequate treatment and follow-up.

Postpartum depression screening at well-child visits: validity of a 2-question screen and the PHQ-9.

PURPOSE Postpartum depression affects up to 22% of women who have recently given birth. Most mothers are not screened for this condition, and an ideal screening tool has not been identified. This study investigated (1) the validity of a 2-question screen and the 9-item Patient Health Questionnaire (PHQ-9) for identifying postpartum depression and (2) the feasibility of screening for postpartum depression during well-child visits. METHODS Study participants were English-literate mothers registering their 0- to 1-month-old infants for well-child visits at 7 family medicine or pediatric clinics. They were asked to complete questionnaires during well-child visits at 0 to 1, 2, 4, 6, and 9 months postpartum. Each questionnaire included 2 depression screens: the 2-question screen and the PHQ-9. The mothers also completed the depression component of the Structured Clinical Interview for DSM-IV (SCID) initially, and again at a subsequent interval if either screening result was positive for depression. RESULTS The response rate was 33%. Of the 506 women who participated, 45 (8.9%) had major depression (ie, they had a positive result on the SCID). The screen sensitivities/specificities over the course of the study were 100%/44% with the 2-question screen, 82%/84% with the PHQ-9 using simple scoring, and 67%/92% with the PHQ-9 using complex scoring. In addition, the corresponding values for the first 2 items of the PHQ-9 (ie, the 2-item Patient Health Questionnaire or PHQ-2) were 84%/79%. Some 38% of women completed their 2- to 6-month questionnaires during well-child visits; the rest completed them by mail (29%) or telephone (33%). CONCLUSIONS The 2-question screen was highly sensitive and the PHQ-9 was highly specific for identifying postpartum depression. These results suggest the value of a 2-stage procedure for screening for postpartum depression, whereby a 2-question screen that is positive for depression is followed by a PHQ-9. These screens can be easily administered in primary care clinics; feasibility of screening during well-child visits was moderate but may be better in clinics using a mass-screening approach.

Women's work roles and their impact on health, well-being, and career: comparisons between the United States, Sweden, and The Netherlands.

ABSTRACT As women have become more assimilated into the workforce over recent decades, they have realized considerable changes in their work roles which may contribute to health problems and other negative outcomes such as marital strain and diminished job status. The purpose of this review was threefold: (1) to synthesize data on the distribution of womens work efforts in the areas of paid employment, household chores, and childcare; (2) to outline research which addresses the impact of womens workload on their well-being and careers; and (3) to make international and gender comparisons regarding womens work responsibilities. Our findings showed that women from each of the three countries examined–the United States, Sweden, and The Netherlands–contribute more effort to household chores and childcare and less to the workplace than men do. As a result, their total workloads appear to be somewhat greater and more diffusely distributed than those of men. Heavy workloads may adversely affect womens health, especially in the presence of certain role characteristics (e.g., having a clerical, managerial, professional, or executive position, or caring for young children). Heavy work responsibilities may also undermine marital happiness, particularly if there is perceived inequity in the way partners share household work. Finally, womens total work responsibilities often impact their careers due to compensatory reductions in work commitment and job status. These observations point to the need for further research on womens workload and work roles, on the relationship of work to well-being, and on methods of preventing or alleviating adverse effects on overburdened workers.

Postpartum Health of Employed Mothers 5 Weeks After Childbirth

PURPOSE Most new mothers return to work soon after childbirth. A need exists to reexamine the definition of postpartum health and evaluate employed women’s recovery from childbirth in association with such factors as delivery type and breastfeeding. METHODS Using a prospective cohort design, we recruited Minnesota women into the study while they were hospitalized for childbirth in 2001. Telephone interviews were conducted 5 weeks postpartum. Eligible women were 18 years or older, employed, and spoke English. Multivariate models using 2-stage least squares were used to estimate factors associated with physical and mental health and postpartum symptoms. RESULTS A total of 817 women were enrolled (71% response) in the study; 716 women completed interviews at 5 weeks postpartum. On average, women reported 6 postpartum symptoms, most frequently fatigue (64%), breast discomfort (60%), and decreased desire for sex (52%). Findings showed that cesarean (vs vaginal) deliveries were associated with significantly worse physical function, role limitations, and vitality. Multivariate findings showed that the effect of delivery type on physical health was moderately large (β = −5.96; P = <.01), and breastfeeding was associated with an increased frequency of postpartum symptoms (β = 4.63; P = .01). CONCLUSIONS These mothers experienced several childbirth-related symptoms at 5 weeks postpartum, indicating a need for ongoing rest and recovery. Health concerns were greater for women who were breastfeeding and for those whose babies were delivered by cesarean section, suggesting a need for greater support for these women and a reassessment by the medical community of the progressively growing practice of cesarean deliveries.

Mothers’ Health and Work-Related Factors at 11 Weeks Postpartum

PURPOSE Many new mothers return to work soon after childbirth. This study examines personal and work-related factors associated with the postpartum health of employed women 11 weeks after childbirth. METHODS Using a prospective cohort design, we recruited 817 Minnesota mothers into the study while they were hospitalized for childbirth in 2001. Telephone interviews were conducted at 5 and 11 weeks postpartum. Eligible women were 18 years or older, employed, and spoke English and gave birth to a singleton infant. Multivariate models using instrumental variables (2-stage least squares) were used to estimate personal and employment characteristics associated with women’s physical and mental health and postpartum symptoms. RESULTS At 11 weeks postpartum, 661 participants (81% of enrollees) completed a full interview, and 50% of participants had returned to work. On average, women reported 4.1 (SD 3.2) childbirth-related symptoms, most frequently fatigue (43%). Factors significantly associated with better health outcomes included better preconception health, the absence of prenatal mood problems, more control over work and home activities, more social support at work and home, and less job stress. CONCLUSIONS The findings suggest postpartum women need to be evaluated regarding their fatigue levels and mental and physical symptoms. Women whose fatigue or postpartum symptoms limit daily role function may find it helpful to have health care clinicians counsel them on strategies to decrease job stress, increase social support at work and home, and certify their use of intermittent family and medical leave to help them manage their symptoms.

The Determinants of Time off Work after Childbirth

Relatively little is known about the role that leave policies--family, parental, or maternity-leave policies--play in facilitating time off work after childbirth. Yet time off is a critical element of leave policies, as it facilitates the mothers recovery from childbirth and promotes maternal-infant attachment. Using data from Minnesota, the state with the highest rate of female labor force participation, we examine the extent to which policies, relative to personal, job, and workplace characteristics, determine the duration of womens childbirth-related leaves from work. A random sample of women identified from vital statistics records is used to estimate the relationship between leave policies and time off work after childbirth. Of our sample 85 percent had access to some paid leave benefits, although only 46 percent had paid maternity leave benefits. The difference in duration of leave between women with and without paid leave policies was approximately four weeks, a substantial difference for most women and their infants. Paid leave policies and spousal earnings as primary determinants of maternal time off work, suggest problems in the use of unpaid leave for economically vulnerable women.

Stepped Care Treatment of Postpartum Depression. A Primary Care-Based Management Model

BACKGROUND AND PURPOSE Postpartum depression (PPD), the most prevalent serious postpartum complication, is a devastating illness that negatively impacts not only the mother, but also her infant, other family members, and work performance. There is an extensive body of research addressing systems-based quality improvement efforts for treatment of depression in primary care populations; however, little of this research has been directed toward postpartum populations. This paper presents a health care systems-based quality improvement model for the treatment of PPD derived from research outcomes in general primary care populations. METHODS OVID/MEDLINE and PsychINFO searches were performed using the following terms: depression, postpartum depression, mass screening, collaborative care, stepped care, psychotherapy, cognitive-behavioral therapy, interpersonal therapy, and education as keywords. MAIN FINDINGS The PPD management model described herein includes screening and diagnosis, initiation of active treatment, and use of collaborative care, which includes primary care visits, case manager follow-up, and more intensive care, through specialty consultation or referral, for complicated or difficult cases. CONCLUSION Stepped care, a form of collaborative depression treatment, is proposed as a practical, cost-effective method for improving PPD diagnosis and clinical outcomes.

Stepped Care Treatment of Postpartum Depression: Impact on Treatment, Health, and Work Outcomes

Purpose: The purpose of this study was to pilot a stepped collaborative care intervention for women with postpartum depression and evaluate health differences between self-diagnosed depressed and nondepressed women. Methods: Five hundred six mothers of infants from 7 clinics completed surveys at 0 to 1, 2, 4, 6, and 9 months postpartum and a Structured Clinical Interview for DSM-IV (SCID). SCID-positive depressed women were randomized to stepped collaborative care or usual care. Nine-month treatment, health, and work outcomes were evaluated for stepped care women (n = 19) versus control depressed women (n = 20), and self-diagnosed depressed women (n = 122) versus nondepressed women (n = 344). Results: Forty-five women had SCID-positive depression whereas 122 had self-diagnosed depression. For SCID-positive depressed women, the stepped care intervention increased mothers’ awareness of their depression diagnosis (100% vs 61%; P = .008) and their receipt of treatment (94% vs 56%; P = .019). Self-diagnosed depressed women (vs nondepressed women) had more depressive symptoms and acute care visits, worse general and mental health, and greater impact of health problems on regular activities. Conclusions: The stepped care intervention improved womens knowledge of their postpartum depression diagnosis and their receipt of treatment. However, our formal diagnostic procedures missed many women whose depressed mood interfered with their health and function.

Hepatitis b status of hmong patients

Background: This study was conducted to determine the hepatitis B status, by age, of Hmong patients attending a St. Paul family practice residency clinic. Methods: The clinic records of 1585 Hmong patients 4 years of age and older were reviewed for information about hepatitis B status. Those without evidence of previous serologic testing or vaccination were invited to participate in the study by being tested for three hepatitis B virus (HBV) markers—hepatitis B surface antigen (HBsAg), antibody to HBsAg (anti-HBs), and hepatitis B core antibody (anti-HBc); those whose results were positive for HBsAg and anti-HBc were also tested for hepatitis B e antigen (HBeAg) and alanine aminotransferase (ALT). Patients whose results were positive for only anti-HBc had their serologic tests repeated after 3 or more months, and those patients whose results remained positive for only anti-HBc were offered the vaccine and further follow-up serologic tests. Results: Of the 434 total participants, 77 (18 percent) had acute or chronic infection (HBsAg present). The rate of infection was highest-28 percent—in the group of patients 15 to 19 years old. Of 66 patients with positive test results only for anti-HBc, 33 of 36 (92 percent) who had follow-up serologic tests after 3 or more months had the same result again in the absence of intervention. Six of 8 (75 percent) patients with results positive only for anti-HBc who received hepatitis B vaccine subsequently converted to an immune status (anti-HBs positive). For all age groups, the cost of pretesting patients with an unknown HBV status and vaccinating susceptible patients was less than the cost of vaccinating without pretesting. Conclusions: This study, which confirmed previous findings of a high occurrence of hepatitis B virus infection in Hmong refugee communities, found the highest rate of infection to be among adolescents. Prevaccination testing appeared to be a cost-saving procedure for patients whose hepatitis status was unknown.

Postpartum depression and health services expenditures among employed women

Objective: To investigate the association of postpartum depression with health services expenditures among employed women. Methods: Women, aged 18 years and older, were recruited from three community hospitals in Minnesota while hospitalized for childbirth in 2001. Using Andersens Behavioral Model, we regressed the natural log of the price-weighted sum of self-reported health services used from hospital discharge until 11 weeks postpartum on depression status at 5 weeks postpartum (Edinburgh Postnatal Depression Scale). Results: Five percent of the women met the depression threshold. Two-stage least squares analyses showed that depressed women incurred 90% higher health services expenditures than nondepressed women. Older age, poverty, non–public assistance insurance status, and increased maternal symptoms also were associated with higher expenditures. Conclusions: Higher health expenditures among postpartum depressed women highlight the importance of addressing mental health issues in the workplace.