Perinatal Mood and Anxiety Screening: Recommendations and Controversies

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Perinatal anxiety and depression are associated with a wide range of adverse consequences for birth outcomes.
Perinatal anxiety and depression are associated with a wide range of adverse consequences for birth outcomes.

The high prevalence and significant clinical consequences of mood and anxiety disorders during pregnancy and postpartum have led to widespread enthusiasm for routine depression and anxiety screening in the obstetric and gynecologic setting.1-3 However, the call for routine screening has also engendered critique and controversy.4-7

Depression and anxiety frequently occur in women in the perinatal period. During pregnancy, between 12% and 22% of women have depression — double the rate seen in the general population of women.1 In the postpartum period, the rate of depression among new mothers in industrialized nations ranges between 10% and 15%.1 Although it has not engendered the same amount of attention from the public or from researchers, perinatal anxiety is also common, with an estimated prevalence of 4% to 39% during pregnancy and up to 16% postpartum.8 In addition to causing distress to the women who are directly affected, perinatal anxiety and depression are associated with a wide range of adverse consequences for birth outcomes (eg, pre-eclampsia, preterm birth, low birthweight, and small-for-gestational-age), fetal and child development (eg, behavioral and emotional disturbances and delayed cognitive and neuromotor development), and family relationships (eg, impaired mother-child attachment).1,9,10

In 2015, the American College of Obstetricians and Gynecologists issued a committee opinion recommending that “clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool.” Although noting the importance of screening for detection of depression, the opinion states that “screening by itself is insufficient to improve clinical outcomes and must be coupled with appropriate follow-up and treatment when indicated; clinical staff in obstetrics and gynecology practices should be prepared to initiate medical therapy, refer patients to appropriate behavioral health resources when indicated, or both.”11 The US Preventive Services Task Force (USPSTF) recommends screening for depression in the general adult population, including pregnant and postpartum women.12 However, both guidelines note that the evidence for such screening in the perinatal setting is limited.11,12 A more recent draft recommendation from the USPSTF on preventive interventions for perinatal depression states that “no accurate screening tool is available to identify women at risk of perinatal depression.”13 A systematic review by McGill University professor Brett Thombs, PhD, did not find evidence from any well-designed and well-conducted clinical trials that depression screening would benefit women in the pregnancy or postpartum setting. In the absence of evidence of benefit, Dr Thombs and colleagues concluded that existing guidelines and recommendations for depression screening in pregnancy or postpartum should be reconsidered. “Instead of screening, healthcare professionals working with women during pregnancy and postpartum should be encouraged to provide women, as well as their partners and families, with information about depression,” the authors wrote. “Healthcare professionals should also be alert to the possibility of depression among pregnant and postpartum women and should attend to symptoms that may suggest depression, such as low mood, anhedonia, insomnia, and suicidal thoughts, through assessment and, as appropriate, referral or management.”14

In a recent article published in Women's Reproductive Health,5 Akansha Vaswani, MS, and colleagues from the Department of Counselling and School Psychology at the University of Massachusetts in Boston, caution that the USPSTF recommendations are “likely to result in more harm than benefit by exposing women to unnecessary psychotropic drug treatment,” noting that when questionnaire scores meet the threshold, physicians are likely to consult the American Psychiatric Association's guideline for major depressive disorder, which recommends antidepressant medication as an initial treatment for mild to moderate symptoms.5,15

In an interview with Psychiatry Advisor, Ms Vaswani's coauthor Lisa Cosgrove, PhD, emphasized that the evidence does not demonstrate that perinatal depression screening improves outcomes. She also noted that by placing those who are screened in a diagnostic category, screening decontextualizes the stressors faced by pregnant and postpartum women. She pointed out that the widely used Edinburgh Postnatal Depression Scale does not include any questions about social support, financial or housing difficulties, help with childcare, or difficulty managing work and home responsibilities. “We want to be very clear that we are not advocating a ‘don't ask, don't tell' policy about depression in general or postpartum depression in particular. A clinical assessment – for which we advocate – is different than screening.” According to Dr Cosgrove, screening is a mechanized process by which the questionnaire determines the next steps, whereas clinical assessment involves the use of clinical skills to closely observe and ask thoughtful, appropriate questions about the patient's experience and current situation.

Sarah Kye Price, PhD, MSW, of the School of Social Work at Virginia Commonwealth University in Richmond told Psychiatry Advisor the most compelling reason for perinatal depression and anxiety screening is to begin authentic communication about a woman's comprehensive wellbeing, including her physical, mental, emotional, and behavioral health. “Screening leads to awareness; it opens patient-provider communication; it suggests ranges where studies have shown that further assessment and monitoring might be helpful. Screening is pointless if we cannot ensure access to services and interventions [that] support pregnant and postpartum women, irrespective of income or insurance status. We would not do that for breast cancer, diabetes, or heart disease. We screen so that we can promote health through a range of activities from lifestyle to medical intervention. Our healthcare system does not always afford women, particularly low-income women, the opportunity for preventive care of their physical or mental and emotional health. Pregnancy and the postpartum period offer that opportunity at a time when risk is magnified; therefore, it is incumbent upon us to address women's health comprehensively during this time,” she noted.

“When prescribing providers are in a ‘fix it' mindset, we miss opportunities to link women to support resources they need and deserve,” Dr Price explained. “Just this week, I heard from a postpartum woman who reported fatigue to her obstetric/gynecologic provider and rather than screening or conversation about her postpartum mental health and wellbeing was immediately prescribed a sedative and told to ‘get a good night's sleep.' Instead, during our brief conversation, she was linked with a local in-home support agency, a new mom's group, and information on nonpharmacologic self-care during pregnancy, all of which she was thrilled to receive. We have to move away from the quick-fix, prescribe-and-go mindset and into thinking about women's mental health holistically, especially at the critical time during and around pregnancy.”

References

  1. Accortt EE, Wong MS. It is time for routine screening for perinatal mood and anxiety disorders in obstetrics and gynecology settings. Obstet Gynecol Surv. 2017;72(9):553-568.
  2. El-Den S, O'Reilly CL, Chen TF. A systematic review on the acceptability of perinatal depression screening.J Affect Disord. 2015;188:284-303.
  3. Avalos LA, Raine-Bennett T, Chen H, Adams AS, Flanagan T. Improved perinatal depression screening, treatment, and outcomes with a universal obstetric program.Obstet Gynecol. 2016;127(5):917-925.
  4. Thombs BD, Stewart DE. Depression screening in pregnancy and postpartum: who needs evidence? J Psychosom Res. 2014;76(6):492-493.
  5. Vaswani A, Karter JM, Cosgrove L, Peters SM, Brodt M. Depression screening during pregnancy and the postpartum period: enhancing informed consent practices.Womens Reprod Health. 2018;5(1):1-12.
  6. Lobel M, Ibrahim SM. Emotions and mental health during pregnancy and postpartum. Womens Reprod Health. 2018;5(1):13-19.
  7. Dunkel Schetter C, Tanner L. Anxiety, depression and stress in pregnancy: implications for mothers, children, research, and practice.Curr Opin Psychiatry. 2012;25(2):141-148.
  8. Marchesi C, Ossola P, Amerio A, Daniel BD, Tonna M, De Panfilis C. Clinical management of perinatal anxiety disorders: a systematic review.J Affect Disord. 2016;190:543-550.
  9. Szegda K, Markenson G, Bertone-Johnson ER, Chasan-Taber L. Depression during pregnancy: a risk factor for adverse neonatal outcomes? A critical review of the literature.J Matern Fetal Neonatal Med. 2014;27(9):960-967.
  10. Davis EP, Sandman CA. The timing of prenatal exposure to maternal cortisol and psychosocial stress is associated with human infant cognitive development.Child Dev. 2010;81(1):131-148.
  11. Committee on Obstetric Practice. The American College of Obstetricians and Gynecologists Committee Opinion no. 630. Screening for perinatal depression.Obstet Gynecol. 2015;125(5):1268-1271.
  12. Siu AL, Bibbins-Domingo K, Grossman DC, et al; US Preventive Services Task Force (USPSTF). Screening for depression in adults: US Preventive Services Task Force Recommendation Statement.JAMA. 2016;315(4):380-387.
  13. Draft recommendation statement. perinatal depression: Preventive Interventions. US Preventive Services Task Force website.   https://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation-statement/perinatal-depression-preventive-interventions. Published August 2018. Accessed October 12, 2018.
  14. Thombs BD, Arthurs E, Coronado-Montoya S, et al. Depression screening and patient outcomes in pregnancy or postpartum: a systematic review. J Psychosom Res. 2014;76(6):433-446.
  15. Work Group on Major Depressive Disorders. Practice guideline for the treatment of patients with major depressive disorder. 3rd ed. Psychiatry Online website. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Accessed October 12, 2018.
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