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Screening Recommendations

There is no more vulnerable time for mothers, fathers, and children than during pregnancy and postpartum, when psychiatric admissions rise higher than any other time in a woman’s life. Postpartum depression is the most under-diagnosed obstetric complication in the U.S. (Earls, 2010) Because the burden of depression and other mental health distress is so high for mothers and their children, and because it is often overlooked, PSI believes that there is a tremendous need for universal screening of all pregnant and postpartum women. Emotional stress and perinatal mental health disorders, such as prenatal and postpartum depression and anxiety, are clinically defined, treatable, and amenable to support, education and intervention. Although there is increasing awareness of the rates of perinatal mental health disorders and the potential negative impact on mothers, babies, and families, perinatal mental health is far too often undiagnosed, under-treated or not treated at all.

Postpartum Support International (PSI) recommends universal screening for the presence of prenatal or postpartum mood and anxiety disorders, using an evidence-based tool such as the Edinburgh Postnatal Depression Screen (EPDS) or Patient Health Questionnaire (PHQ-9).

Both the EPDS and the PHQ-9 are validated for use in the perinatal population, and there is no fee. The benefits are that they are self-administered, translated into many languages, and easy to complete. The EPDS addresses the anxiety component of PMADs as well as depressive symptoms and suicidal thoughts. The PHQ-9 does not have the anxiety component but includes suicidal ideation. The PHQ-9 also incorporates the categories that define depression in the Diagnostic and Statistical Manual (DSM), which helps with diagnostic criteria. With anxiety being recognized as one of the presenting symptoms of PMADs it becomes important that it be assessed in the screening tool, making the EPDS the most widely used tool (“Screening for Perinatal Depression – ACOG,” 2015).

Understanding that healthcare settings are often very busy and providers feel pressured to complete appointments, we recommend that providers learn efficient ways to screen patients and work toward these ideal practices:

Timing:

  • First prenatal visit
  • At least once in second trimester
  • At least once in third trimester
  • Six-week postpartum obstetrical visit (or at first postpartum visit)
  • Repeated screening at 6 and/or 12 months in OB and primary care settings
  • 3, 9, and 12 month pediatric visits

Tools:

  • EPDS (Edinburgh Postnatal Depression Scale) and PHQ-9 (Patient Health Questionnaire-9)
  • The recommended cut-off score for a positive screen using either tool is 10.
  • The EPDS is a reliable and valid measure of mood in fathers. Screening for depression or anxiety disorders in fathers requires a two-point lower cut-off than screening for depression or anxiety in mothers, and we recommend this cut-off to be 5/6. (Matthey, 2001)

Setting:

PSI recommends universal screening in prenatal, postnatal, and pediatric settings. Settings for maternal mental health screening may include but are not limited to: health care providers (primary care, OB, midwifery, and pediatric), public health, addictions and mental health, community social services, and early childhood programs.

Administration:

Ideally, the self-report screening questionnaire should be provided in a private setting. It should be introduced and interpreted by a practitioner in a caring and informative manner that normalizes perinatal mental health needs. If possible, screening should be provided in the client’s native language.

System:

Screening must exist in a system of care that includes educated providers, social support for families, and a protocol to follow up with those who have screened above the cut-off score on an evidence-based screening tool, aligned with the ACOG and USPSTF recommendations. It is the goal of PSI to develop and nurture an integrated system of care that creates a safety net for parents and providers. All women should be screened routinely by their healthcare providers during and in the months following pregnancy, and ideally should have access to reproductive psychiatric specialists in their community who can treat and follow them, and coordinate care with OB providers, midwives, and pediatricians.

Resources:

Postpartum Support International exists to help families and providers become informed and find resources they need to adequately screen, assess, refer, and follow up. Contact PSI www.postpartum.net or 800-944-4PPD for up-to-date information, support, training, and resources.

Background:

Mandatory depression screening of pregnant and postpartum women is now recommended by an increasing number of professional organizations: the American College of Obstetrics and Gynecology (ACOG, 2015), the American Academy of Pediatrics (2010), and the American Medical Association, following the 2016 recommendation from the United States Preventive Services Task Force (2016).

In May 2015, ACOG recommended that screening for perinatal mood changes take place at least once during the perinatal period including pregnancy and 12 months postpartum. This was a shift for ACOG and speaks to the evolving research regarding perinatal mood disorders. In addition to screening with a validated tool, ACOG acknowledges that screening by itself does not improve outcomes. It is necessary to have a system in place that couples screening with appropriate follow-up and treatment. The recommendation included training front-line OB providers to recognize PMADs and be prepared to initiate treatment and referral to behavioral health providers.

Additionally, in January 2016, the U.S. Preventive Services Task Force (USPSTF, 2016) updated its 2009 recommendation related to screening for depression to include pregnant and postpartum women, adding to the consensus on screening in the perinatal period and the recommendation of PSI.

References:

Final Recommendation Statement: Depression in Adults: Screening – US Preventive Services
Task Force. (2016, October 29). https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening

Davidson JRT, Meltzer-Brody, SE: The under recognition and under treatment of depression: what is the breadth and depth of the problem? J Clin Psychiatr: 1999;60 (Suppl 7):24.

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(5):1032-9.

Flynn HA, Blow FC, Marcus SM: Rates and predictors of depression treatment among pregnant women in hospital-affiliated obstetrics practices. Gen Hosp Psychiatry: 2006;28:289-295.

Gavin NI, Gaynes BN. Perinatal depression A systematic review of prevalence and incidence. Obstetrics & Gynecology. 12/2005; 106(5 Pt 1): 1071-83.

Matthey, S., Barnett, B., Kavanagh, D. J., & Howie, P. Validation of the Edinburgh Postnatal Depression Scale for men, and comparison of item endorsement with their partners. Journal of affective disorders: 2001; 64(2), 175-184.

Screening for Perinatal Depression – ACOG. (2016, October 29). from https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Screening-for-Perinatal-Depression

Weissman MM, Pilowsky DJ, Wickramaratne PJ, et al: Remission in maternal depression and child psychopathology. L A Star*D-child report. JAMA 2006;295(12):1389-1398.

Wisner KL: Perinatal mental illness: definition, description and a etiology. Best Pract Res Clin Obstet Gynaecol:2014; 18(1):3-12.