Tackling postnatal depression in primary care
Postnatal depression affects around 10% of women in the early weeks postpartum.
Those affected suffer from the additional burden of guilt arising from the negative impact of their illness on their child. The quality of mother-infant interactions is impaired which can have long-term detrimental effects on the child's behaviour and cognitive development.1
Effective management of postnatal depression is bedevilled by confusion regarding the respective roles of GPs and health visitors. A prospective cluster trial has produced new evidence that health visitors can provide clinically effective psychological interventions.2
The Trent study identified 595 women with an Edinburgh postnatal depression scale (EPDS) score ?12 at six weeks postpartum. A total of 404 were randomised to the intervention group and 191 to the control group. Women from the intervention group completed a further EPDS face to face with the health visitor at eight weeks postpartum. Those who still had a score ? 12 were offered up to eight hour-long sessions of psychological therapy each week.
In all, 70% of the women were followed up at six months postpartum, of whom 34% (93/271) in the intervention group and 46% (67/147) in the control group still had an EPDS score ? 2. This represents a significant 40% reduction in the odds. The absolute risk reduction of 12% indicates an NNT of 9.
One of two psychological interventions was provided, according to the cluster randomisation. These were based on cognitive behavioural and person-centred principles respectively. The two interventions were equally effective in accordance with the equivalence paradox: the quality of the therapeutic relationship may be more important than the specific therapy used.3
Traditionally, health visitors have provided screening for postnatal depression. However, the reduction in health visitors means they are often unable to provide one-to-one support for low-risk mothers.4 I believe that the responsibility for screening should now lie with the GP and in our practice we have begun sending out the two-question screen with our postnatal check invitations. To improve the positive predictive value and hence the value of the screen, we ask patients who have said 'yes' to either question to complete an EPDS.
In the Trent study, the minority of control health visitors who were using EPDS screening would typically refer patients to their GP for treatment. However, a qualitative study found that many health visitors were reluctant to involve GPs as they felt that the only treatment available would be antidepressants.4 I believe a strong case can be made for referral from GP to health visitor: we should provide screening and diagnosis, and the health visitor should provide treatment. However, is this cost effective? Of the 271 patients from the intervention group, 124 were offered therapy and 77 (28%) accepted. Based on the median number of sessions (four), I calculate nine hours of health visitor time to treat one patient successfully.
A more cost-effective strategy might be the use of peer support to help prevent vulnerable women from becoming depressed. The lack of effective support from spouse, family or friends is a major risk factor for postnatal depression.1 An RCT from Canada has found that provision of telephone-based peer support to high-risk women significantly reduced the number with an EPDS score > 12 at 12 weeks postpartum (odds reduced by 53%, NNT = 8.8).5 High risk was defined as an EPDS score > 9 within the first two weeks postpartum; telephone support was provided by trained volunteers who had experienced and recovered from postnatal depression.
Postnatal depression is common and has potentially devastating consequences for mother and child. GPs and health visitors have a shared responsibility for providing effective diagnosis and management, and need to work together to clarify their respective roles.Author
Dr Phillip Bland
BA BM BCh MRCGP DRCOG
GPs and health visitors have a shared responsibility for providing effective diagnosis and management