Depression screening in the pregnant soldier wellness program.

Objectives: The purpose of this study was to determine the prevalence of depression among active-duty low-risk pregnant women using the Edinburgh Postnatal Depression Scale. Rates for depression have been reported to be as high as 13% during pregnancy and 12 to 22% postpartum, with postpartum suicidal ideation at nearly 7%.

Methods: From April 2002 through March 2003, 82 women receiving prenatal care at Madigan Army Medical Center completed screening questionnaires during pregnancy and/or postpartum visits.

Results: A total of 97 questionnaires were administered (71 antepartum and 26 postpartum). During pregnancy, 24% of individuals screened scored positive. During the postpartum, 19% scored positive. A total of 15 women were screened twice during the study period. One woman was screened twice during pregnancy and the remaining 14 were screened once antepartum and once postpartum. Suicidal ideation was present in 11% of those screened during pregnancy and in 15% postpartum.

Conclusions: Active-duty women appear to have a higher rate of depression and suicidal ideation compared with rates in nonmilitary populations; perhaps such screening should become a standard practice.

Key Words: active duty, depression, military women, postpartum, pregnancy

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Major depression is the most prevalent psychiatric disorder in the United States and costs an estimated $44 billion annually in the United States. (1,2) Depression is a serious disease and has a higher mortality rate than many other common chronic illnesses, with suicide occurring in 15% of untreated individuals. (2) Despite the frequency of depressive disorders, the proportion of those who actually obtain treatment by a mental health specialist is less than 50%. Depression is nearly twice as common in women compared with men, and nearly 20% of women have at least one episode of treatable depression. (2)

Postpartum depression occurs in as many as one in eight pregnancies in the United States, making it more common than gestational diabetes, preeclampsia, or preterm delivery, (3) yet recognition and treatment of depression in contemporary medical literature and in obstetric residency training programs has been very limited. (3) Depression is encountered frequently by obstetrician-gynecologists in clinical practice, but is still often unrecognized and untreated. (2,4,5) In a recent survey of 282 obstetricians-gynecologists regarding depression screening, most perceived it as difficult to carry out in everyday practice, and some questioned whether such screening could actually improve outcomes. (6)

In 2002, the American College of Obstetricians and Gynecologists and the Scottish Intercollegiate Guidelines Network recommended routine depression screening during pregnancy and in the postpartum period, using the Edinburgh Postnatal Depression Scale (EPDS). (2,7) The prevalence of postpartum depression in active-duty service women is unknown. A PubMed search (1966 to June 2003) using the terms "pregnancy, active-duty women, depression, postpartum depression, and EPDS," revealed no publications. The purpose of this investigation was to determine the prevalence of active duty pregnant and postpartum women at risk for major depression and compare that rate with reported rates in nonmilitary women.

Materials and Methods

Between April 2002 and January 2003, women receiving antepartum care at Fort Lewis, Tacoma, Washington, were screened for depression, using the EPDS. (8) Permission was obtained from the Institutional Review Board, Madigan Army Medical Center. The purpose of the screening program was to identify women who might benefit from additional care through Behavioral Health or Social Work Services at Madigan Army Medical Center, Tacoma, Washington. Women were screened at various times throughout pregnancy and at the postpartum visit.

The EPDS is a 10-item questionnaire, which has been validated for use during pregnancy and the postpartum period. (9,10) Scores range between 0 and 30. A score of 20 or greater has been shown to identify 88% of women with major depression and more than 63% of those with minor depression, with a specificity of 92% and a positive predictive value of 56%. (11) A score of 12 or greater was considered "positive" for referral and study purposes in this investigation. This was the score in which women were considered "high risk" under a screening program developed by a process improvement initiative at the National Naval Medical Center, Bethesda, Maryland, and was specific for active-duty women. With permission, we modeled our screening guidelines after this program.

Age of the women, gestational age at the time the EPDS was administered, total score, and the response to the suicidal ideation question were recorded. Demographic information and proportions of positive responses in each trimester of pregnancy and at the postpartum visit are reported using standard descriptive statistics.

The nurse coordinator of the clinic immediately scored the questionnaire after completion, before the patient was seen for her prenatal or postpartum visit. Each screen was then reviewed and discussed with the patient. In collaboration with the Department of Psychiatry and Maternal Child Social Work, a referral plan was agreed on and modeled after the scoring system currently in use at the National Naval Medical Center Depression Screening Program. Women scoring nine or less on the EPDS were considered "low risk" and were seen by a social worker on a routine basis. If the patient scored 12 or greater, they were considered "high risk" and were seen by a Behavioral Health provider within 1 week. If they scored greater than 20 or had a positive response to a suicidal ideation question, they were considered "emergent" and were referred for a same-day evaluation by both Behavioral Health and Social Work Departments.

Results

In this retrospective analytic study, 82 women participated by answering depression questionnaires between April 2002 and March 2003. The average age of the women who were screened was 23 years (range, 19 to 39 years). Twelve questionnaires were administered during the first trimester, 32 during the second trimester, 27 during the third trimester, and 26 after delivery (7 to 10 weeks postpartum). Positive scores on the EPDS questionnaire were found in 2 of 12 (16.6%) of 8- to 12-week surveys, 10 of 32 (32.2%) of second-trimester questionnaires, 5 of 27 (18.5%) of screens after 28 weeks, and in 5 of 26 (19%) of postpartum assessments. Overall, 24% of the study population had positive screens (a score of 12 or greater). Fifteen women were screened twice during the study period, one during the second and third trimesters, and 14 antepartum and postpartum. Of the 14 women screened before and after delivery, 4 scored positive in the antepartum period. Two of these women scored high on repeat screening at the postpartum visit and a third patient scored below the threshold but did report suicidal ideation. One individual who was screened twice during the pregnancy scored negatively both in the second and third trimesters and thus did not influence the reported rate of positive screens during pregnancy.

The level of urgency in positive EPDS screens as well as suicidal ideations were also addressed. Of the 22 positive EPDS screens, 36% were considered "emergent," based on a score of 20 or greater or a positive response regarding suicidal ideation. Suicidal thoughts were present in 11% of the entire study population and in 15.4% of women at the post-partum visit. Only one (1.3%) of the 75 negative EPDS screens administered was positive for suicidal ideation. As previously mentioned, this patient had initially screened positively in the third trimester, then scored below the threshold when screened postpartum.

Discussion

Although having a baby is one of the most joyous times in a woman's life, it is estimated that 70 to 80% of postpartum women will feel weak, upset, and alone (baby blues) after giving birth. (12) In a smaller subset of these women, postpartum depression is present and for optimal outcomes treatment must be initiated promptly.

Risk factors for depression identified from previous studies using the EPDS during and after pregnancy include single status, unemployment of the mother or head of household, unplanned pregnancy, non-breastfeeding, age less than 19 years, and being divorced or separated. (13-15) Untreated depression during pregnancy may result in adverse prenatal fetal development including low birth weight, intrauterine growth restriction, and preterm delivery. (2) Untreated depression during pregnancy may also increase the rate of postpartum depression, which has been linked with poor mother-infant bonding and in the most extreme cases with infanticide and/or suicide. (1) The prevalence and severity of postpartum depression may be related to the first appearance of the depression antepartum. (6)

Interestingly, a recent longitudinal cohort study found that mean scores on the EPDS were higher during pregnancy than postpartum and recommended that an emphasis also be placed on the screening and treatment of depression before delivery. (16) Our findings are in agreement, as the highest rate of positive questionnaires was observed during the second trimester of pregnancy with 31% of screens scoring positively.

Several studies in nonmilitary populations have used the EPDS during pregnancy and postpartum to screen for depression. (13-16) Evans et al (16) reported the rate of depression scores greater than 12 at 18 to 32 weeks' gestation, as well as at 8 weeks and 8 months postpartum. In this study, eleven (8%) women at 18 weeks, 13.5% of women at 32 weeks, 9.1% at 8 weeks postpartum, and 8.1% at 8 months postpartum were positive. They also found that more women scored above 12 between 18 and 32 weeks, than between 32 weeks and 8 weeks postpartum. Only two screens had scores of 12 in our study, and both of these were in the second trimester. Recalculating our rates based on a threshold of greater than 12, as in the study by Evans et al, (16) would only reduce the overall rate of positive screens in the antepartum period from 23.9 to 21.1% and in the second trimester the rate would change from 31.2 to 25%.

Positive screens for depression during pregnancy have been reported as high as 13.5%. In the postpartum period, the rate of positive screens (12 or greater) was 11.4%, with suicidal ideation in 5.3% of women at 6 weeks postpartum. (15) In the present study, the rate for positive depression screening was nearly twice the rate reported in nonmilitary populations, both antepartum and postpartum, and the rate of suicidal ideation in the postpartum period was triple that observed in one study. Several stressors unique to this population may have contributed to the increased rate of positive screens observed in this study. First, during the time frame in which the surveys were administered, a large number of soldiers at Fort Lewis were actively being assigned to operational tours in response to the September 11, 2001 attacks. Second, although marital status or military rank was not specifically addressed, the majority of participants were young, single, and unmarried. They therefore had the added stress of a limited salary, were far from family with little significant social support, and were often tasked with finding affordable housing outside of the barracks before their delivery.

There are several limitations of this investigation. It is a retrospective study that incorporated new guidelines based on National Naval Medical Center Perinatal Depression Program. In addition, this study evaluated a highly selected population during a unique period of time, wartime; therefore our findings are difficult to generalize or compare with other patient populations. Moreover, antepartum and postpartum comparisons are available in only 14 women; therefore, it is not possible to draw any conclusions whether antepartum screening is useful or indicated in this population. Despite these obvious limitations, the rate of positive scores in this relatively small study is alarming, and it is important to identify and treat these women.

Conclusion

Our findings suggest a significantly higher rate of depression and suicidal ideation both during pregnancy and postpartum for active-duty women. As screening for depression may not be routinely performed in all clinics, our findings suggest that a formal screening program is feasible and should be implemented in all active-duty service health care facilities providing obstetric care, with emphasis placed on recognizing and treating depression during pregnancy, particularly in our young active-duty population.

Accepted October 20, 2004.

References

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RELATED ARTICLE: Key Points

* Postpartum depression occurs in as many as one in eight pregnancies in the United States, is linked with poor mother-infant bonding, and in the most extreme cases is linked with infanticide and/or suicide.

* The rate of positive screening for depression in this military population was twice that reported for nonmilitary populations.

* The rate of suicidal ideation in the postpartum military population is also much higher than that observed in the nonmilitary population.

Amy L. O'Boyle, MD, Everett F. Magann, MD, Robert E. Ricks, Jr, MD, Michael Doyle, MD, and John C. Morrison, MD

From the Departments of Obstetrics and Gynecology at the Naval Medical Center Portsmouth, Portsmouth, VA; Operational Medicine Clinical Services Division, USAMEDCOM, Fort Sam Houston, TX; Madigan Army Hospital, Tacoma WA; and the University of Mississippi Medical Center, Jackson, MS.

The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. The authors are military service members; this work was prepared as part of official duties.

Correspondence to Dr. John C. Morrison, Department of Obstetrics and Gynecology, University of Mississippi Medical Center, 2500 North State St., Jackson, MS 39216-4505. Email: [e-mail]