We do appreciate the opportunity to discuss the important issue of recognition and support for Australian women who experience perinatal depression. Both the Armstrong and Small study (2007) and the beyondblue National Postnatal Depression Program (2001-05) have raised important issues.
Regarding unanswered questions, the beyondblue program was primarily a public health initiative and as such could not answer all questions. Indeed, in the National Steering Committee review cited in your letter numerous unanswered questions appear that are more than any project could answer.
Nevertheless, our program was highly successful in reaching many perinatal women and has the potential to answer many important questions. The preliminary overview is available on the beyondblue website; numerous publications are in preparation. Of particular relevance is one already published on acceptability and feasibility.1
The paper of Milgrom et al. (2005),2 which screened 4,148 women in Victoria and utilised 47 maternal and child health centres as opposed to 257 women in the Gippsland study, employed very similar methodology and had the advantage of added substantial initial training of nurses and represents a substantial study of routine screening.
It seems we all share similar concerns about these women. These should be the basis for looking closely at the processes that must precede, accompany and follow any assessment, including paper and pencil tests. This raises questions such as why in some areas, such as the Gippsland area surveyed, so many women are missed? Is it that inadequate protocols are in place, the need for further training, or the need for further resources?
We are not unaware of the realities of care provision after our experience over four years implementing screening protocols across Australia, involving many thousands of women. Of course some women will be missed. What was meant in our previous letter was that in New South Wales, screening for depression occurs as part of a broader routine psychosocial assessment. This preceded the beyondblue initiative and was already well established and integrated in routine care. While this does not necessarily access all women, some services report more than 90% uptake.
Screening with the Edinburgh Postnatal Depression Scale (EPDS) does not exist in a vacuum; it should always be part of the psychosocial assessment and care that midwives and child health nurses offer women, depending on their particular skills. The beyondblue study aimed to ensure this psychosocial assessment was more systematic and as much an integral part of antenatal and postnatal care as possible to ensure a broader, holistic approach to care. What we do know is that the EPDS identifies many women and these women and staff find the process very acceptable.
We welcome further constructive discussion around problems facing us all in identification of women with emotional health problems perinatally and the steps needed to improve pathways to care to achieve better social and emotional well-being of women in Australia.