Journal of Psychosomatic Research 76 (2014) 492–493
Contents lists available at ScienceDirect
Journal of Psychosomatic Research
Depression screening in pregnancy and postpartum: Who needs evidence? Brett D. Thombs a,b,c,d,e,f,g,⁎, Donna E. Stewart h,i,j,k,l,m,n a
Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada Department of Psychiatry, McGill University, Montreal, Quebec, Canada Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada d Department of Medicine, McGill University, Montreal, Quebec, Canada e Department of Educational and Counselling Psychology, McGill University, Montreal, Quebec, Canada f Department of Psychology, McGill University, Montreal, Quebec, Canada g School of Nursing, McGill University Montreal, Quebec, Canada h Women's Health Program, University Health Network, Toronto, Ontario, Canada i Department of Psychiatry, University of Toronto, Ontario, Canada j Department of Obstetrics and Gynaecology, University of Toronto, Ontario, Canada k Department of Family and Community Medicine, University of Toronto, Ontario, Canada l Department of Medicine, University of Toronto, Ontario, Canada m Department of Surgery, University of Toronto, Ontario, Canada n Department of Anesthesia, University of Toronto, Ontario, Canada b c
a r t i c l e
i n f o
Article history: Received 25 March 2014 accepted 25 March 2014
Depression in pregnancy and postpartum is associated with poor maternal and infant outcomes [1]. It is not clear, however, that depression screening would improve symptoms of depression or reduce the number of women with perinatal depression. In our recent systematic review [2], we did not find evidence from any well-conducted clinical trials that screening would benefit women in the perinatal period. In the absence of evidence of benefit, we concluded that existing guidelines and recommendations to screen should be reconsidered and that health care providers should provide good standard care by being alert to the possibility of depression, by paying attention to signs and risk factors, by asking about depression when appropriate, and by providing quality depression care when present. Additionally, we emphasized the need for appropriately designed clinical trials to test whether screening would improve depression outcomes for women in pregnancy and postpartum. Drs. Chaudron and Wisner [3] opine that there is some evidence that screening might be beneficial, argue that there is little reason to believe
DOI of original article: http://dx.doi.org/10.1016/j.jpsychores.2014.03.011. ⁎ Corresponding author at: Jewish General Hospital, 4333 Cote Ste Catherine Road, Montreal, Quebec H3T 1E4, Canada. Tel.: +1 514 340 8222x5112. E-mail address: [email protected] (B.D. Thombs).
http://dx.doi.org/10.1016/j.jpsychores.2014.03.102 0022-3999/© 2014 Elsevier Inc. All rights reserved.
that any harm could result from it, and suggest that whether or not depression screening improves depression outcomes is only a “small part” of factors that should be considered in evaluating whether or not to provide routine depression screening. They note that perinatal depression screening has been recommended by national organizations and that because screening recommendations “seek to improve health and do not have evidence to the contrary”, screening should proceed while more research is conducted. Drs. Chaudron and Wisner describe a number of criteria that should be met if screening is to be considered. Meeting some of those criteria, however, does not constitute evidence that screening would be effective. They cite a single, dramatically underpowered trial [4]. However, as described in our review, risk of bias was high in that trial, and there were reasons to doubt the results, including the unrealistically large magnitude of the effects and the switching of primary and secondary outcomes post-hoc to achieve statistical significance [2]. Drs. Chaudron and Wisner speculate that even if screening does not improve depression outcomes, there could be other potential benefits, such as uncovering anxiety, intimate partner violence, grief, or bipolar disorder. It would be surprising if depression screening would be effective and efficient for those purposes, and supporting evidence would be needed. There is a well-known maxim in health care decision-making: “All screening programmes do harm; some do good as well” [5]. Drs. Chaudron and Wisner suggest that there is little risk of harm. They argue that screening would always be followed by a competent mental health assessment and diagnosis and, thus, no unnecessary treatment would occur. However, in many non-mental health settings, treatment with antidepressants is initiated on the basis of positive screens [6,7]. Furthermore, some women who do meet criteria for a depression diagnosis, but have very mild symptoms, may be prescribed antidepressants, even though the effectiveness of antidepressants is limited in these patients [8–10]. Some of these women would not
B.D. Thombs, D.E. Stewart / Journal of Psychosomatic Research 76 (2014) 492–493
have sought treatment otherwise and will not benefit, but they and their fetuses may experience adverse medication effects. Potential harms have not been well-documented in depression screening, but if screening is done, some number of women who would not otherwise be exposed will experience harms, which, in addition to adverse medication effects, include the risk of labeling transient distress as a psychiatric illness, as well as nocebo effects from telling women who are not otherwise specifically concerned about their mental health that they have a psychiatric illness [11,12]. Drs. Chaudron and Wisner argue that screening is “low or no cost.” Having patients respond to questionnaires is not usually expensive. However, screening involves more, including follow-up assessments to determine which are true positives, and consultations to determine the best treatment option (including watchful waiting) [13]. Treatment and follow-up services are also part of a screening program [14]. Without evidence that it would improve depression outcomes, depression screening would consume scarce health care resources that might be better devoted to providing adequate depression treatment to women in pregnancy and the postpartum period who have marked psychopathology, but in many cases receive poor-quality care [11,12]. Drs. Chaudron and Wisner argue that until research proves that the harms of depression screening exceed benefits, women should be screened during pregnancy and postpartum. The idea that health care providers should offer any preventive care service that has not yet been fully disproved as long as the preventive care “seeks to improve health” opens the floodgates for any advocated preventive intervention that has not yet been entirely disproved, regardless of actual evidence. Decisions to implement preventive care services should be based on evidence of benefit, not solely the lack of strong evidence of failure. Drs. Chaudron and Wisner cite two “national medical organizations' guidelines” [15,16]. Neither was actually a guideline, and one specifically indicated that there was not any evidence to support a formal recommendation. Neither included a formal evidence review, even though guidelines should be based on systematic evidence review [17,18]. Too often guidance statements without evidence are based on preference-based judgments and call for more services, but do not result in better patient care [17,19]. Advocacy and evidence are not the same thing. Unlike decisions in a court of law, where guilt must be proven beyond a reasonable doubt, medical interventions that consume scarce resources and harm some people who would not otherwise be exposed should not be implemented until proved beyond doubt to be a bad idea. Rather, implementation of preventive health care programs, including depression screening, should be based on solid evidence of benefit and consideration of whether benefits would justify harms and resource costs. Until then, the best that we can do, responsibly, is to provide good, compassionate care that attends to signs and risk factors, assesses depression when appropriate, and provides guideline-consistent care for women with depression. Funding/support Dr. Thombs was supported by an Investigator Salary Award from the Arthritis Society (INS-13-001).
493
Conflicts of interest All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf. Dr. Thombs has no conflict of interest disclosures for the past 3-year reporting period. Dr. Stewart reports that she has received fees for depression scientific board membership from Cymbalta Pregnancy Registry Scientific Advisory Board of INC Research (a contract research organization for Eli Lilly), travel support from Ranbaxy Pharma, and royalties as an author of UpToDate®: Infants with antenatal exposure to selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs).
References [1] Stewart DE. Clinical practice. Depression during pregnancy. N Engl J Med 2011;365:1605–11. [2] Thombs BD, Arthurs E, Coronado-Montoya S, Roseman M, Delisle VC, Leavens A, et al. Depression screening and patient outcomes in pregnancy or postpartum: a systematic review. J Psychosom Res 2014;76:433–46. [3] Chaudron L, Wisner KL. Perinatal depression screening: let's not throw the baby out with the bath water! J Psychosom Res 2014;76:491–3. [4] Leung SS, Leung C, Lam TH, Hung SF, Chan R, Yeung T, et al. Outcome of a postnatal depression screening programme using the Edinburgh Postnatal Depression Scale: a randomized controlled trial. J Public Health 2011;33:292–301. [5] Muir Gray JA. Evidence-based healthcare: how to make health policy and management decisions. London: Churchill Livingstone; 1997. [6] Kravitz RL, Franks P, Feldman MD, Tancredi DJ, Slee CA, Epstein RM. Patient engagement programs for recognition and initial treatment of depression in primary care: a randomized trial. JAMA 2013;310:1818–28. [7] Whooley MA. Depression and cardiovascular disease: healing the broken-hearted. JAMA 2006;295:2874–81. [8] Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med 2008;5:e45. [9] Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA 2010;303:47–53. [10] Barbui C, Cipriani A, Patel V, Ayuso-Mateos JL, van Ommeren M. Efficacy of antidepressants and benzodiazepines in minor depression: systematic review and meta-analysis. Br J Psychiatry 2011;198:11–6. [11] Gilbody S, Sheldon T, Wessely S. Should we screen for depression? BMJ 2006;332:1027–30. [12] Thombs BD, Coyne JC, Cuijpers P, de Jonge P, Gilbody S, Ioannidis JP, et al. Rethinking recommendations for screening for depression in primary care. CMAJ 2012;184:413–8. [13] National Collaborating Center for Mental Health. The NICE guideline on the management and treatment of depression in adults. Updated ed. UK: National Institute for Health and Clinical Excellence; 2010. [14] Raffle A, Gray M. Screening: evidence and practice. UK: Oxford University Press; 2007. [15] American College of Obstetricians and Gynecologists. Committee on Obstetric Practice. Committee opinion no. 453: Screening for depression during and after pregnancy. Obstet Gynecol 2010;115:394–5. [16] Earls MF. Committee on Psychosocial Aspects of Child and Family Health American Academy of Pediatrics. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics 2010;126:1032–9. [17] Institute of Medicine. Clinical practice guidelines we can trust. Washington, DC: National Academies Press; 2011. [18] AGREE Collaboration. Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project. Qual Saf Health Care 2003;12:18–23. [19] Shaneyfelt T. In guidelines we cannot trust. Arch Intern Med 2012;172:1633–4.
Contents lists available at ScienceDirect
Journal of Psychosomatic Research
Depression screening in pregnancy and postpartum: Who needs evidence? Brett D. Thombs a,b,c,d,e,f,g,⁎, Donna E. Stewart h,i,j,k,l,m,n a
Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada Department of Psychiatry, McGill University, Montreal, Quebec, Canada Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada d Department of Medicine, McGill University, Montreal, Quebec, Canada e Department of Educational and Counselling Psychology, McGill University, Montreal, Quebec, Canada f Department of Psychology, McGill University, Montreal, Quebec, Canada g School of Nursing, McGill University Montreal, Quebec, Canada h Women's Health Program, University Health Network, Toronto, Ontario, Canada i Department of Psychiatry, University of Toronto, Ontario, Canada j Department of Obstetrics and Gynaecology, University of Toronto, Ontario, Canada k Department of Family and Community Medicine, University of Toronto, Ontario, Canada l Department of Medicine, University of Toronto, Ontario, Canada m Department of Surgery, University of Toronto, Ontario, Canada n Department of Anesthesia, University of Toronto, Ontario, Canada b c
a r t i c l e
i n f o
Article history: Received 25 March 2014 accepted 25 March 2014
Depression in pregnancy and postpartum is associated with poor maternal and infant outcomes [1]. It is not clear, however, that depression screening would improve symptoms of depression or reduce the number of women with perinatal depression. In our recent systematic review [2], we did not find evidence from any well-conducted clinical trials that screening would benefit women in the perinatal period. In the absence of evidence of benefit, we concluded that existing guidelines and recommendations to screen should be reconsidered and that health care providers should provide good standard care by being alert to the possibility of depression, by paying attention to signs and risk factors, by asking about depression when appropriate, and by providing quality depression care when present. Additionally, we emphasized the need for appropriately designed clinical trials to test whether screening would improve depression outcomes for women in pregnancy and postpartum. Drs. Chaudron and Wisner [3] opine that there is some evidence that screening might be beneficial, argue that there is little reason to believe
DOI of original article: http://dx.doi.org/10.1016/j.jpsychores.2014.03.011. ⁎ Corresponding author at: Jewish General Hospital, 4333 Cote Ste Catherine Road, Montreal, Quebec H3T 1E4, Canada. Tel.: +1 514 340 8222x5112. E-mail address: [email protected] (B.D. Thombs).
http://dx.doi.org/10.1016/j.jpsychores.2014.03.102 0022-3999/© 2014 Elsevier Inc. All rights reserved.
that any harm could result from it, and suggest that whether or not depression screening improves depression outcomes is only a “small part” of factors that should be considered in evaluating whether or not to provide routine depression screening. They note that perinatal depression screening has been recommended by national organizations and that because screening recommendations “seek to improve health and do not have evidence to the contrary”, screening should proceed while more research is conducted. Drs. Chaudron and Wisner describe a number of criteria that should be met if screening is to be considered. Meeting some of those criteria, however, does not constitute evidence that screening would be effective. They cite a single, dramatically underpowered trial [4]. However, as described in our review, risk of bias was high in that trial, and there were reasons to doubt the results, including the unrealistically large magnitude of the effects and the switching of primary and secondary outcomes post-hoc to achieve statistical significance [2]. Drs. Chaudron and Wisner speculate that even if screening does not improve depression outcomes, there could be other potential benefits, such as uncovering anxiety, intimate partner violence, grief, or bipolar disorder. It would be surprising if depression screening would be effective and efficient for those purposes, and supporting evidence would be needed. There is a well-known maxim in health care decision-making: “All screening programmes do harm; some do good as well” [5]. Drs. Chaudron and Wisner suggest that there is little risk of harm. They argue that screening would always be followed by a competent mental health assessment and diagnosis and, thus, no unnecessary treatment would occur. However, in many non-mental health settings, treatment with antidepressants is initiated on the basis of positive screens [6,7]. Furthermore, some women who do meet criteria for a depression diagnosis, but have very mild symptoms, may be prescribed antidepressants, even though the effectiveness of antidepressants is limited in these patients [8–10]. Some of these women would not
B.D. Thombs, D.E. Stewart / Journal of Psychosomatic Research 76 (2014) 492–493
have sought treatment otherwise and will not benefit, but they and their fetuses may experience adverse medication effects. Potential harms have not been well-documented in depression screening, but if screening is done, some number of women who would not otherwise be exposed will experience harms, which, in addition to adverse medication effects, include the risk of labeling transient distress as a psychiatric illness, as well as nocebo effects from telling women who are not otherwise specifically concerned about their mental health that they have a psychiatric illness [11,12]. Drs. Chaudron and Wisner argue that screening is “low or no cost.” Having patients respond to questionnaires is not usually expensive. However, screening involves more, including follow-up assessments to determine which are true positives, and consultations to determine the best treatment option (including watchful waiting) [13]. Treatment and follow-up services are also part of a screening program [14]. Without evidence that it would improve depression outcomes, depression screening would consume scarce health care resources that might be better devoted to providing adequate depression treatment to women in pregnancy and the postpartum period who have marked psychopathology, but in many cases receive poor-quality care [11,12]. Drs. Chaudron and Wisner argue that until research proves that the harms of depression screening exceed benefits, women should be screened during pregnancy and postpartum. The idea that health care providers should offer any preventive care service that has not yet been fully disproved as long as the preventive care “seeks to improve health” opens the floodgates for any advocated preventive intervention that has not yet been entirely disproved, regardless of actual evidence. Decisions to implement preventive care services should be based on evidence of benefit, not solely the lack of strong evidence of failure. Drs. Chaudron and Wisner cite two “national medical organizations' guidelines” [15,16]. Neither was actually a guideline, and one specifically indicated that there was not any evidence to support a formal recommendation. Neither included a formal evidence review, even though guidelines should be based on systematic evidence review [17,18]. Too often guidance statements without evidence are based on preference-based judgments and call for more services, but do not result in better patient care [17,19]. Advocacy and evidence are not the same thing. Unlike decisions in a court of law, where guilt must be proven beyond a reasonable doubt, medical interventions that consume scarce resources and harm some people who would not otherwise be exposed should not be implemented until proved beyond doubt to be a bad idea. Rather, implementation of preventive health care programs, including depression screening, should be based on solid evidence of benefit and consideration of whether benefits would justify harms and resource costs. Until then, the best that we can do, responsibly, is to provide good, compassionate care that attends to signs and risk factors, assesses depression when appropriate, and provides guideline-consistent care for women with depression. Funding/support Dr. Thombs was supported by an Investigator Salary Award from the Arthritis Society (INS-13-001).
493
Conflicts of interest All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf. Dr. Thombs has no conflict of interest disclosures for the past 3-year reporting period. Dr. Stewart reports that she has received fees for depression scientific board membership from Cymbalta Pregnancy Registry Scientific Advisory Board of INC Research (a contract research organization for Eli Lilly), travel support from Ranbaxy Pharma, and royalties as an author of UpToDate®: Infants with antenatal exposure to selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs).
References [1] Stewart DE. Clinical practice. Depression during pregnancy. N Engl J Med 2011;365:1605–11. [2] Thombs BD, Arthurs E, Coronado-Montoya S, Roseman M, Delisle VC, Leavens A, et al. Depression screening and patient outcomes in pregnancy or postpartum: a systematic review. J Psychosom Res 2014;76:433–46. [3] Chaudron L, Wisner KL. Perinatal depression screening: let's not throw the baby out with the bath water! J Psychosom Res 2014;76:491–3. [4] Leung SS, Leung C, Lam TH, Hung SF, Chan R, Yeung T, et al. Outcome of a postnatal depression screening programme using the Edinburgh Postnatal Depression Scale: a randomized controlled trial. J Public Health 2011;33:292–301. [5] Muir Gray JA. Evidence-based healthcare: how to make health policy and management decisions. London: Churchill Livingstone; 1997. [6] Kravitz RL, Franks P, Feldman MD, Tancredi DJ, Slee CA, Epstein RM. Patient engagement programs for recognition and initial treatment of depression in primary care: a randomized trial. JAMA 2013;310:1818–28. [7] Whooley MA. Depression and cardiovascular disease: healing the broken-hearted. JAMA 2006;295:2874–81. [8] Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med 2008;5:e45. [9] Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA 2010;303:47–53. [10] Barbui C, Cipriani A, Patel V, Ayuso-Mateos JL, van Ommeren M. Efficacy of antidepressants and benzodiazepines in minor depression: systematic review and meta-analysis. Br J Psychiatry 2011;198:11–6. [11] Gilbody S, Sheldon T, Wessely S. Should we screen for depression? BMJ 2006;332:1027–30. [12] Thombs BD, Coyne JC, Cuijpers P, de Jonge P, Gilbody S, Ioannidis JP, et al. Rethinking recommendations for screening for depression in primary care. CMAJ 2012;184:413–8. [13] National Collaborating Center for Mental Health. The NICE guideline on the management and treatment of depression in adults. Updated ed. UK: National Institute for Health and Clinical Excellence; 2010. [14] Raffle A, Gray M. Screening: evidence and practice. UK: Oxford University Press; 2007. [15] American College of Obstetricians and Gynecologists. Committee on Obstetric Practice. Committee opinion no. 453: Screening for depression during and after pregnancy. Obstet Gynecol 2010;115:394–5. [16] Earls MF. Committee on Psychosocial Aspects of Child and Family Health American Academy of Pediatrics. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics 2010;126:1032–9. [17] Institute of Medicine. Clinical practice guidelines we can trust. Washington, DC: National Academies Press; 2011. [18] AGREE Collaboration. Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project. Qual Saf Health Care 2003;12:18–23. [19] Shaneyfelt T. In guidelines we cannot trust. Arch Intern Med 2012;172:1633–4.
