Objectives Postpartum depression impacts 6.5–12.9% of U.S. women. Postpartum depression is associated with impaired bonding and development, marital discord, suicide, and infanticide. However, the current standard of care is to not screen women for postpartum depression. This study modeled the cost-effectiveness of physicians screening for and treating postpartum depression and psychosis in partnership with a psychiatrist. Methods This study follows a hypothetical cohort of 1000 pregnant women experiencing one live birth over a 2-year time horizon. We used a decision tree model to obtain the outcomes of screening for and treating postpartum depression and psychosis using the Edinburgh Postnatal Depression Scale. We use a Medicaid payer perspective because they cover approximately 50% of births in the U.S. The cost-effectiveness of the intervention is measured in cost per remission achieved and cost per quality-adjusted life-year (QALY) gained. We conducted both deterministic and probabilistic sensitivity analyses. Results Screening for and treating postpartum depression and psychosis produced 29 more healthy women at a cost of $943 per woman. The incremental cost-effectiveness ratios of the intervention branch compared to usual care were $13,857 per QALY gained (below the commonly accepted willingness to pay threshold of $50,000/QALY gained) and $10,182 per remission achieved. These results were robust in both the deterministic and probabilistic sensitivity analyses of input parameters. Conclusions for Practice Screening for and treating postpartum depression is a cost-effective intervention and should be considered as part of usual postnatal care, which aligns with the recently proposed recommendations from the U.S. Preventive Services Task Force.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Andrews, M. (2015). Prevention task force recommends depression screenings for pregnant women, new moms. Kaiser health news. Retrieved from http://khn.org/news/prevention-task-force-recommends-depression-screenings-for-pregnant-women-new-moms/.
Appleby, L., & Turnbull, G. (1995). Parasuicide in the first postnatal year. Psychological Medicine, 25(5), 1087–1090.
Appleby, L., Mortensen, P. B., & Faragher, E. B. (1998). Suicide and other causes of mortality after post-partum psychiatric admission. The British Journal of Psychiatry, 173(3), 209–211. doi:10.1192/bjp.173.3.209.
Bergink, V., Lambregtse-van den Berg, M. P., Koorengevel, K. M., Kupka, R., & Kushner, S. A. (2011). First-onset psychosis occurring in the postpartum period: A prospective cohort study. The Journal of Clinical Psychiatry, 72(11), 1531–1537. doi:10.4088/JCP.10m06648.
Briggs, A. H. (2000). Handling uncertainty in cost-effectivieness models. Pharmacoeconomics, 17(5), 479–500.
Briggs, A., Claxton, K., & Schulpher, M. (2006). Decision modeling for health economic evaluation. Oxford: Oxford University Press.
Briggs, A., O’Brien, B., & Blackhouse, G. (2002). Thinking outside the box: Recent advances in the analysis and presentation of uncertainty in cost-effectiveness studies. Annual Review of Public Health, 23, 377–401. doi:10.1146/annurev.publhealth.23.100901.140534.
Bureau of Labor Statistics. (2014). CPI detailed report. Retrieved from http://www.bls.gov/cpi/cpid1407.pdf.
Centers for Disease Control and Prevention. (2013). Depression among women of reproductive age. Retrieved from http://www.cdc.gov/reproductivehealth/depression/.
Centers for Medicare & Medicaid Services. (2015). Screening, brief intervention, and referral to treatment (SBIRT) services. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/SBIRT_Factsheet_ICN904084.pdf.
Cohen, L. S., Altshuler, L. L., Harlow, B. L., Newport, D. J., Viguera, A. C., Suri, R., et al. (2006). Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA: The Journal of the American Medical Association, 295(5), 499–508. doi:10.1001/jama.295.5.499.
Cox, J. L., Chapman, G., Murray, D., & Jones, P. (1996). Validation of the Edinburgh postnatal depression scale (EPDS) in non-postnatal women. Journal of Affective Disorders, 39, 185–189. doi:10.1016/0165-0327(96)00008-0.
Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782–786. doi:10.1192/bjp.150.6.782.
De Crescenzo, F., Perelli, F., Armando, M., & Vicari, S. (2014). Selective serotonin reuptake inhibitors (SSRIs) for post-partum depression (PPD): A systematic review of randomized clinical trials. Journal of Affective Disorders, 152–154, 39–44. doi:10.1016/j.jad.2013.09.019.
Dias, C., & Figueiredo, B. (2015). Breastfeeding and depression: A systematic review of the literature. Journal of Affective Disorders, 171, 142–154. doi:10.1016/j.jad.2014.09.022.
Doubilet, P., Begg, C., Weinstein, M., Braun, P., & McNeil, B. (1985). Probabilistic sensitivity analysis using Monte Carlo simulation. Medical Decision Making: An International Journal of the Society for Medical Decision Making, 5(2), 157–177.
Doucet, S., Dennis, C. -L., Letourneau, N., & Blackmore, E. R. (2009). Differentiation and clinical implications of postpartum depression and postpartum psychosis. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 38(3), 269–279. doi:10.1111/j.1552-6909.2009.01019.x.
Drummond, M., Sculpher, M., Torrance, G., O’Brien, B., & Stoddart, G. (2005). Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press.
Earls, M. F. (2010). Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics, 126(5), 1032–1039. doi:10.1542/peds.2010-2348.
Field, T. (2008). Breastfeeding and antidepressants. Infant Behavior & Development, 31(3), 481–487. doi:10.1016/j.infbeh.2007.12.004.
Frayne, D., Rosener, S., & Brubach, J. (2015). The FMEC IMPLICIT network’s prescription for a healthy family: Improving birth outcomes through interconception care at well child visits. In 2015 annual state health director’s conference, Raleigh, NC.
Gaynes, B. N., Gavin, N., Meltzer-Brody, S., Lohr, K. N., Swinson, T., Gartlehner, G., et al. (2005). Perinatal depression: Prevalence, screening accuracy, and screening outcomes. Evidence report/technology assessment (Summary). Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15760246.
Gibson, J., McKenzie-McHarg, K., Shakespeare, J., Price, J., & Gray, R. (2009). A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women. Acta Psychiatrica Scandinavica, 119(5), 350–364. doi:10.1111/j.1600-0447.2009.01363.x.
Gold, M., Siegel, J., Russel, L., & Weinstein, M. (1996). Cost-effectiveness in health and medicine. New York: Oxford University Press.
Goodman, J., & Tyer-Viola, L. (2010). Detection, treatment, and referral of perinatal depression and anxiety by obstetrical providers. Journal of Women’s Health, 19(3), 477–490. doi:10.1089/jwh.2008.1352.
Grace, S. L., Evindar, A., & Stewart, D. E. (2003). The effect of postpartum depression on child cognitive development and behavior: A review and critical analysis of the literature. Archives of Women’s Mental Health, 6(4), 263–274. doi:10.1007/s00737-003-0024-6.
Guo, J., Keck, P., Li, H., & Patel, N. (2007). Bipolar-related and comorbidity treatment costs for patients with bipolar disorder in Medicaid. Psychiatric Services, 58, 1073–1078.
Haddix, A., Teutsch, S., & Corso, P. (2003). Prevention effectiveness: A guide to decision analysis and economic evaluation. Oxford: Oxford University Press.
Hervey, P. (2013). Agenda item 6.b. - provisionally licensed psychologist. Retrieved from http://www.hhsc.state.tx.us/news/meetings/past/2013/022813-HHSCC-docs/6b.pdf.
Hirth, R. A., Chernew, M. E., Miller, E., Fendrick, A. M., & Weissert, W. G. (2000). Willingness to pay for a quality-adjusted life year: In search of a standard. Medical Decision Making, 20(3), 332–342. doi:10.1177/0272989X0002000310.
Kaiser Family Foundation. (2010). Births financed by medicaid. Retrieved from http://kff.org/medicaid/state-indicator/births-financed-by-medicaid/.
Kaltenthaler, E., Shackley, P., Stevens, K., Beverley, C., Parry, G., & Chilcott, J. (2002). A systematic review and economic evaluation of computerised cognitive behaviour therapy for depression and anxiety. Health Technology Assessment, 6(22), 1–89.
Kelly, R., Zatzick, D., & Anders, T. (2001). The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in Obstetrics. The American Journal of Psychiatry, 158(2), 213–219. doi:10.1176/appi.ajp.158.2.213.
Kingston, D., Austin, M., Hegadoren, K., McDonald, S., Lasiuk, G., McDonald, S., et al. (2014). Study protocol for a randomized, controlled, superiority trial comparing the clinical and cost-effectiveness of integrated online mental health assessment-referral-care in pregnancy to usual prenatal care on prenatal and postnatal mental health and infant. Trials, 15(72). doi:10.1186/1745-6215-15-72.
Kozhimannil, K. B., Adams, A. S., Soumerai, S. B., Busch, A. B., & Huskamp, H. a. (2011). New Jersey’s efforts to improve postpartum depression care did not change treatment patterns for women on Medicaid. Health Affairs, 30(2), 293–301. doi:10.1377/hlthaff.2009.1075.
Lindahl, V., Pearson, J. L., & Colpe, L. (2005). Prevalence of suicidality during pregnancy and the postpartum. Archives of Women’s Mental Health, 8(2), 77–87. doi:10.1007/s00737-005-0080-1.
Lucas, R. (1994). Puerperal psychosis: Vulnerability and aftermath. Psychoanalytic Psychotherapy, 8(3), 257–272. doi:10.1080/02668739400700251.
Marder, S. (2014). Postpartum psychosis: Epidemiology, clinical manifestations, assessment, and diagnosis. Retrieved from http://www.uptodate.com/contents/postpartum-psychosis-epidemiology-clinical-manifestations-assessment-and-diagnosis?source=search_result&search=postpartum+psychosis&selectedTitle=1~10.
Markus, A., Andres, E., West, K., Garro, N., & Pellegrini, C. (2013). Medicaid covered births, 2008 through 2010, in the context of the implementation of health reform. Women’s Health Issues, 23(5), 273–280. doi:10.1016/j.whi.2013.06.006.
McIntosh, J. (1993). Postpartum depression: Women’s help-seeking behaviour and perceptions of cause. Journal of Advanced Nursning, 18, 178–184. doi:10.1046/j.1365-2648.1993.18020178.x.
Medicaid. (2013). Pharmacy drug pricing. Retrieved from http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Prescription-Drugs/Pharmacy-Pricing.html.
Milgrom, J., Mendelsohn, J., & Gemmill, A. W. (2011). Does postnatal depression screening work? Throwing out the bathwater, keeping the baby. Journal of Affective Disorders, 132(3), 301–310. doi:10.1016/j.jad.2010.09.031.
Miniati, M., Callari, A., Calugi, S., Rucci, P., Savino, M., Mauri, M., & Dell’Osso, L. (2014). Interpersonal psychotherapy for postpartum depression: A systematic review. Archives of Women’s Mental Health, 17(4), 257–268. doi:10.1007/s00737-014-0442-7.
Montazeri, A., Torkan, B., & Omidvari, S. (2007). The Edinburgh Postnatal Depression Scale (EPDS): Translation and validation study of the Iranian version. BMC Psychiatry, 7, 11. doi:10.1186/1471-244X-7-11.
Muennig, P. (2008). Cost-effectiveness analysis in health: A practical approach (2nd ed.). San Francisco: Jossey-Bass.
Myers, E., Aubuchon-Endsley, N., Bastian, L., Gierisch, J., Kemper, A., Swamy, G., et al. (2013). Efficacy and safety of screening for postpartum depression. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.effectivehealthcare.ahrq.gov/reports/final.cfm.
North Carolina Department of Health and Human Services. (2012). Provisionally licensed clinicians billing incident to a physician. Retrieved from http://www.ncdhhs.gov/dma/fee/mhfee/mhfee_nonlicense_070112.pdf.
North Carolina Department of Health and Human Services. (2013). Licensed psychologist fee schedule, provider specialty 109. Retrieved from http://www.ncdhhs.gov/dma/fee/mhfee/psychologist-fee_012313.pdf.
North Carolina Department of Health and Human Services. (2014a). Physician fee schedule, provider specialty 001. Retrieved from http://www.ncdhhs.gov/dma/fee/phy_fee/phy_fee_sch100714.pdf.
North Carolina Department of Health and Human Services. (2014b). Who is eligible - Infants, children, and families. Retrieved February 3, 2015, from http://www.ncdhhs.gov/dma/medicaid/families.htm#pregnant.
Nylen, K., O’Hara, M., Brock, R., Moel, J., Gorman, L., & Stuart, S. (2010). Predictors of the longitudinal course of postpartum depression following interpersonal psychotherapy. Journal of Consulting and Clinical Psychology, 78(5), 757–763. doi:10.1037/a0020623.
Office of Rural Health and Community Care. (2014). North Carolina Telepsychiatry Program. Raleigh, NC: Office of Rural Health and Community Care. Retrieved from http://www.ncdhhs.gov/orhcc/2015_Profile/RHIT_TP_01-07-15.pdf.
Palladino, C., Singh, V., Campbell, J., Flynn, H., & Gold, K. (2011). Homicide and suicide during the perinatal period: Findings from the National Violent Death Reporting System. Obstetrics and Gynecology, 118(5), 1056–1063. doi:10.1097/AOG.0b013e31823294da.Homicide.
Paulden, M., Palmer, S., Hewitt, C., & Gilbody, S. (2009). Screening for postnatal depression in primary care: Cost effectiveness analysis. BMJ, 2210(340). doi:10.1136/bmj.b5203.
Petitti, D. (1999). Meta-analysis, decision analysis, and cost-effectiveness analysis: Methods for quantitative research in medicine. New York: Oxford University Press.
Qiu, Y., Christensen, D., Fu, A., & Liu, G. (2009). Cost analysis in a Medicaid program for patients with bipolar disorder who initiated atypical antipsychotic monotherapy. Current Medical Research and Opinion, 25(2), 351–361. doi:10.1185/03007990802634077.
Roy-Byrne, P. (2014). Postpartum blues and unipolar depression: Epidemiology, clinical features, assessment, and diagnosis. Retrieved from http://www.uptodate.com/contents/postpartum-blues-and-unipolar-depression-epidemiology-clinical-features-assessment-and-diagnosis.
Scholle, S. H., Haskett, R. F., Hanusa, B. H., Pincus, H. A., & Kupfer, D. J. (2003). Addressing depression in obstetrics/gynecology practice. General Hospital Psychiatry, 25, 83–90. doi:10.1016/S0163-8343(02)00006-9.
Sit, D., Rothschild, A., & Wisner, K. (2006). A review of postpartum psychosis. Journal of Women’s Health, 15(4), 352–368. doi:10.1089/jwh.2006.15.352.
Sullivan, P., Slejko, J., Sculpher, M., & Ghushchyan, V. (2011). Catalog of EQ-5D scores for the United Kingdom. Medical Decision Making. doi:10.1177/0272989X11401031.
Thomas, J. (2008). New breastfeeding and lactation coding column. American Academy of Pediatrics Section on Breastfeeding, (Winter). Retrieved from http://www2.aap.org/breastfeeding/files/pdf/Winter08Newsletter.pdf.
Thombs, B. D., Arthurs, E., Coronado-Montoya, S., Roseman, M., Delisle, V. C., Leavens, A., et al. (2014). Depression screening and patient outcomes in pregnancy or postpartum: A systematic review. Journal of Psychosomatic Research, 76(6), 433–446. doi:10.1016/j.jpsychores.2014.01.006.
Tufts Medical Center. (2013). Cost effectiveness analysis registry. Retrieved from https://research.tufts-nemc.org/cear4/.
U.S. Preventive Services Task Force. (2015). Draft recommendation statement: depression in adults: Screening. Retrieved from http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement115/depression-in-adults-screening1.
Weinstein, M., Siegel, J., Gold, M., Kamlet, M., & Russell, L. (1996). Recommendations of the panel on cost-effectiveness in health and medicine. JAMA: The Journal of the American Medical Association, 276(15), 1253–1258. doi:10.1001/jama.1996.03540150055031.
Whitton, A., Warner, R., & Appleby, L. (1996). The pathway to care in post-natal depression: Women’s attitudes to post-natal depression and its treatment. British Journal of General Practice, 46, 427–428.
The authors received assistance from a number of individuals in the course of this research; we would specifically like to thank Katie Wouk and Dr. Allison Stuebe for sharing their expertise. At the time of this research, AW was supported by a predoctoral Ruth L. Kirschtein National Research Service Award from the National Institute on Drug Abuse (F31 DA036961) and SL was supported by funding from the National MCH Workforce Development Center.
Electronic Supplementary Material
Below is the link to the electronic supplementary material.
About this article
Cite this article
Wilkinson, A., Anderson, S. & Wheeler, S.B. Screening for and Treating Postpartum Depression and Psychosis: A Cost-Effectiveness Analysis. Matern Child Health J 21, 903–914 (2017). https://doi.org/10.1007/s10995-016-2192-9