‘Screening for postnatal depression; not a simple task’1 is a well-titled paper and highlights some of the important difficulties in identifying and managing women with depression. I am concerned, however, about the authors’ conclusions and their misrepresentation of the recommendations of the beyondblue National Postnatal Depression Program.
The authors state that the screening program they reviewed (not one that was part of the beyondblue program) “did not meet the primary objective” of screening three times in the first 12 months. In the first instance, the methodology of this study is problematic, relying on retrospective case records. Second, this expectation may be quite unrealistic and not in itself a measure of failure. As the authors agree, identification is problematic without screening and, as Lumley et al.'s study2 highlights, just being sensitive to the woman, no matter how well trained, is also inadequate and does not increase the identification.
The beyondblue program screened more than 40,000 women, most done as part of routine care. For more than 17,000 of these, in New South Wales where screening is routine, all women participated so there was no dropout/refusal; while those who participated in the follow-up may have found it less problematic, this is a problem of all research participation. The authors state that women prefer to talk about their problems rather than complete a questionnaire. This is how the Edinburgh Postnatal Depression Scale (EPDS) should be used and how our program asked for it to be used – only as a talking point to ensure that depression is part of routine care just as blood pressure, urinary glucose and other physical care is. Some women will choose to not complete it accurately or deny their symptoms because of issues such as stigma. Our own qualitative study on why women don’t seek or delay seeking help3 shows that it is not screening that is the problem, but such things as societal pressures and lack of information. These women do get into help eventually, but by then much more long-term issues will have arisen with potential negative impact on child development. We know that not routinely asking does not work, but treatments do – we need to work to ensure they are identified as soon as possible. The argument should not be about whether screening should be universal or not (and other authors have concluded that it is effective4,5), but rather how we should be asking about emotional mental health in a routine, universal way that promotes decreasing stigma and accessing of services.
The beyondblue program did recommend routine screening. The current process, again funded by beyondblue, is looking at what this screening should entail – and maybe for everyone it will not include the EPDS, but routine emotional health questions. But the recommendation was also very clear that any routine ‘screening’ MUST include adequate support and training of staff AND adequate pathways to care. In other words, best evidence-based care for early identification and treatment.