The case for undertaking universal psychosocial assessment (including depression screening) of women during the ‘perinatal period’ has attracted much interest, and vigorous debate . The following position statement aims to articulate the arguments contributing to the debate and thus provide guidance to assist decision-making by clinicians, policy makers and health services.
Aims of the Position Statement
This document does not set out to make specific recommendations about psychosocial assessment and depression screening (as these will need to be devised locally depending on existing resources and models of care) nor does it attempt to summarise the vast evidence-base relevant to this debate.
The perinatal period (pregnancy and the first postnatal year) is a time of great adjustment for all parents, made more challenging by the presence of existing psychosocial risk factors (or morbidity). Key risk factors for poor perinatal emotional adjustment include a history of past or antenatal anxiety or major depression, other mental health disorder or substance misuse, lack of supports, issues in partner relationship, a history of trauma (including adverse childhood events and domestic violence), isolation (physical, mental, cultural), stressful life events, poverty, and personality vulnerabilities e.g., low self-esteem or high trait anxiety [2-5].
The presence of psychosocial morbidity (especially high levels of anxiety and stress) in pregnancy can adversely impact on fetal development with associated suboptimal cognitive, emotional and behavioural outcomes in the offspring as identified in a number of large prospective cohort studies . Postnatal depression may also impact on infant outcomes .
In many high income and developing countries, pregnancy and the postnatal period are opportunistic periods for health education due to the frequency of contact with health care providers. Expectant and new parents are often highly motivated to seek help in effecting change for the sake of their offspring and potential reduction in intergenerational family dysfunction. The perinatal period thus provides clinicians with a unique opportunity to address the psychological, social and physical health of their clients, and to consider universal psychosocial assessment as part of mainstream maternity and postnatal care. Early identification and treatment of psychosocial morbidity are especially important in relation to the functioning of the family unit and the critical parent-infant relationship with potential to positively impact on the health of the next generation. Equally important is the need to address adverse social circumstances (where possible) and history of current or past violence and trauma [8, 9]. With the research focus to date focussing mainly on perinatal depression, interpersonal violence and past trauma have tended to be under-investigated as potential key risk and mediating factors.
Major depression – often accompanied by anxiety disorder and personality vulnerability – is the most common condition presenting in the postnatal period [10, 11], and may be associated with negative outcomes for mother, partner, infant and family. Such episodes can be new in onset or the recurrence of a pre-existing condition. In high income countries, the prevalence of major depression in the nine month pregnancy interval is 12.7%; and 7.1% in the first 3 months postpartum .
Large population studies demonstrate an increased risk of new onset psychiatric episodes, especially major depression and puerperal psychoses, arising in the first few months postpartum , while risk of relapse of pre-existing mood disorder, often following the cessation of medication, increases significantly both in pregnancy and in the postnatal period [14-16], especially bipolar disorder . Maternal death associated with psychosocial morbidity (including substance misuse and interpersonal violence) has become one of the leading causes of maternal deaths in high income countries [18, 19]. There is a 70 fold increased risk of suicide in the first postnatal year after admission for a severe psychiatric episode compared to at other times in a woman’s life .
The evidence base for depression screening in the perinatal period has been extensively examined in the process of developing the 2007 British , 2012 Scottish  and 2011 Australian  Clinical Practice Guidelines which are all underpinned by systematic literature reviews (SLR). These three Guidelines vary in their degree of recommendation for or against the use of the Edinburgh Postnatal Depression Scale (EPDS, ), with the Australian Guidelines recommending for its universal use within an integrated screening program; while the Scottish (SIGN) and British (NICE) CPGLs suggest its use only as an adjunct to clinical practice. An AHRQ 2013 systematic review of screening for postnatal depression  concludes that while current depression screening instruments are reasonably sensitive and specific in detecting postpartum depression, there is insufficient evidence to allow the benefits and harms of depression screening to be clearly balanced-or to ascertain whether the use of specific assessment tools/strategies would result in better outcomes.
While the Australian guidelines note the use of universal psychosocial assessment programs as a good practice point, in addition to the assessment of mother-infant dyads, neither of the SIGN or NICE Guidelines comment on the value of broader psychosocial assessment as defined in the current position statement. For more detail, the three sets of Clinical Practice Guidelines recommendations are summarised in Appendix 1 and Table 1. It is important to note that recommendations carry a variable weight dependent on the quality of the evidence at the time of guideline development, hence the variation in degree of recommendation by different guidelines for the use of, for example, the EPDS.
Key Definitions and Concepts in Perinatal Mental Health
Before proceeding to articulate the debate, we need to define the terminology and concepts that have arisen over the last two decades in the field of perinatal mental health.
1. The perinatal period: has been defined in different ways, but for the purposes of this document, it is defined as the period spanning pregnancy and the first postnatal year. The use of the term ‘perinatal’ in the psychosocial setting underscores the importance of considering maternal and infant emotional wellbeing at a time when maternal risk of onset/relapse of mood disorder is highest, when maternal social and emotional vulnerabilities are often heightened, and at a critical time in the development of infant attachment. It also highlights the value of early intervention (ideally beginning in pregnancy) and the importance of detecting psychosocial issues which may impact adversely on maternal, obstetric, infant & family outcomes.
2. ‘Psychosocial morbidity’: for the purposes of this document, covers the spectrum of morbidity from diagnosable psychiatric disorders (e.g., major depression, psychosis, anxiety and bipolar
Marcé International Society Position Statement 2013 disorder) to psychosocial risk factors (as described in the background section), but may also include substance misuse; personality vulnerability/disorder and poor adjustment to parenting.
3. Prevention: preventive health care aims to reduce the burden of chronic conditions by early identification of people with risk factors or symptoms and applying appropriate interventions. It is the key premise underlying the benefits of universal psychosocial assessment & depression screening.
4. Psychosocial assessment programs: these encompass both the evaluation of current and longstanding psychological, social, and cultural risk factors impacting on the mental health of women across the perinatal period . Such enquiry should cover the breadth of morbidity from the low prevalence serious mental health conditions (eg. schizophrenia, bipolar & personality disorders etc) through high prevalence conditions such as depression and anxiety disorders, to the presence of risk factors that will make adjustment to parenting more difficult. Unlike screening, psychosocial assessment does not set out to identify women with a possible diagnosis of a particular condition at the time of assessment. Rather it gives us a multidimensional picture of the woman’s psychosocial circumstances which can then be used to make decisions about best care options. Given its multidimensionality, it is essential that it be undertaken as part of an integrated care program (see definition below). Psychosocial assessment may be undertaken as part of clinical interview or using a structured tool.
5. Depression Screening: Screening for current depression is generally considered as one component of psychosocial assessment in the perinatal context, and should not be seen as the only aim of such assessment. Screening can be universal, i.e. done in all women. This is in contrast to targeted screening that is only undertaken in high risk groups (e.g. young, single, substance using mothers). Screening should only take place where a validated, acceptable & user-friendly screener is integrated with further diagnostic assessment and treatment (as appropriate), dependent on ‘screen positive’ status [24, 25]. Screening tools are used for the detection of symptoms likely to be associated with a diagnosis, using an optimal cut-off score. Importantly, a screener is not a diagnostic tool. Diagnosis requires a full clinical assessment.
6. ‘Integrated’ care: the use of this term in the perinatal setting highlights the importance of:
a) Integration across health care disciplines and between primary and secondary/tertiary health care systems;
b) Integration between components of a psychosocial assessment program: including the assessment itself (including depression screening); clinician training and supervision; clear clinician decision making guidelines round appropriate care planning and referral pathways;
c) Integration across time periods (antenatal and postnatal) and service settings (e.g., hospital and community);
d) Integration of psychosocial assessment with ‘mainstream’ (physical) maternity and postnatal care.
The current debate
Two key themes in current debate among perinatal clinicians, researchers, and policy-makers are: 1) the benefits (clinical and cost) vs. harms of a) universal psychosocial assessment and b) depression screening; and 2) undertaking such activity in resource-constrained settings.
1. The benefits vs. harms of universal psychosocial assessment and depression screening:
The debate in relation to universal depression screening encompasses a number of factors: the potential misuse of a screener as a diagnostic tool (leading to misdiagnosis and increased prevalence reporting); or inaccuracy as a result of lack of robustness in terms of the screener’s psychometric properties i.e., sensitivity, specificity, and positive predictive value (PPV i.e. the number of ‘positive screeners’ who actually have a diagnosis), and clinically optimal cut-off point. The most recent estimate of PPV is around 62% ; meaning that about 38% of women scoring >13 on the EPDS may be incorrectly diagnosed as having major depression if no further assessment is undertaken. This has led one author to highlight the potential risk for ‘overpathologising’ the presence of postnatal symptoms , with possible harm caused to the woman and in terms of cost to the system. . The other key concern is around availability of resources to support perinatal depression screening programs.
In the UK, universal depression screening using the EPDS (+/- the Whooley questions- see Appendix 1) is considered as potentially causing more harm than good  and not seen as cost-effective  on current available data. Interestingly, the US Prevention Task Force  recommends in favour of depression screening for the general population given good evidence of clinical benefit when it is undertaken in an enhanced care setting . Such an approach has not yet been assessed in the perinatal setting.
Psychosocial assessment, which entails enquiring about the woman’s overall psychosocial wellbeing (including past and current conditions as opposed to possible current depression), as part of maternity and postnatal care, clearly indicates to the woman that her clinician is interested in her overall wellbeing. There is a strong argument for considering such enquiry part of routine care – where physical and emotional care is integrated within the primary health care context. While some will disagree with the routine use of a depression screener (for the reasons outlined above) most clinicians would argue that psychosocial assessment has value in its own right (irrespective of availability of comprehensive psychosocial services) as a means of:
a) Opening up the conversation about psychosocial issues including those that impact the family more broadly (e.g., intimate partner violence, supports, help-seeking) and that can be addressed by non-mental health trained care providers.
b) Raising awareness and educating pregnant women/mothers and their carers about the fact that psychiatric and psychosocial conditions deserve to be treated; that difficulties in the parent-infant interaction may arise at this time; and that effective treatments and supports are available, should these problems arise.
The debate relating to universal psychosocial assessment is less contentious and tends to centre on the need to define methodologies and care models (e.g., use of structured questionnaires versus general unstructured enquiry, within an integrated care model) that are suited to local circumstances. Examples of structured psychosocial assessment tools include the ALPHA, ANRQ  and ARPA . Where psychosocial assessment programs are undertaken, primary care clinicians will need adequate psychosocial assessment skills training and ongoing clinical supervision from the mental health sector. Such integrated assessment care models, which must include a substantial training component, have begun to be implemented in Australia especially in maternity, and early childhood settings, but have yet to be evaluated [33-35].
Ultimately training and support for the primary health sector is likely to reduce the frequency of referrals to mental health services as these practitioners become more confident and skilled with managing women with milder psychosocial risk and depression or anxiety.
Of relevance to the debate, is the growing evidence that low intensity interventions (e.g., internet based programs), social support, peer support and self-help are effective in the management of milder mood or adjustment disorders [36-38], and may circumvent the perceived increased workload for the health care sector as a whole. Ultimately long-term follow up studies are needed to evaluate the benefits and costs for the wellbeing of mothers, infants and families and society.
2. Psychosocial assessment and depression screening in resource-constrained countries:
In most of the 112 low and lower-middle income countries (where the majority of the world’s women live) there are insufficient services for safe pregnancy and birth let alone recognition of psychosocial problems. In some settings the mental health services are limited to custodial institutions which provide poor quality and at times what would be considered, by world standards, abusive care. We must thus be cognisant of the context in which psychosocial assessment is undertaken while minimising its potential to worsen the woman’s predicament due to increased stigmatisation or even abuse .
Equally, identifying psychosocial risk factors (including those associated with poor antenatal attendance and nutrition) in resource-constrained countries has the potential to impact both the mental and physical health of women in pregnancy, thereby improving obstetric and offspring outcomes [40, 41]. In more economically advanced countries, much can now be undertaken by primary health care workers, both in regard to depression screening and broader psychosocial assessment.
Finally, we need to be mindful that depression screening instruments (mostly developed in Western settings) perform very differently in resource-constrained countries where there may be a very different understanding of concepts such as “depression”. In such situations women may have fewer words to describe their emotional experiences and needs. As their lives are chronically difficult, questions that assess whether they are feeling worse than usual are invariably answered ‘no’. The use of different cut-offs on screening tools will thus need to be evaluated in such settings . Development of local methods for screening based on the needs of, and acceptability to, that specific culture, are recommended.
In summary while there is no simple answer to the question of whether ‘there is a place for universal psychosocial assessment (including depression screening) without adequate referral services’, not undertaking such assessment because of the complexity of issues or a lack of mental health resources, overlooks the critical role of psychosocial wellbeing in maternal and infant outcomes.
There is now a growing, although not unanimous, view within the International Marcé Society in favour of undertaking universal psychosocial assessment in perinatal women, as long as it takes place within an integrated care model. It is generally recognised by clinicians that such assessment holds intrinsic value in terms of educating women and families and ‘starting the conversation’ about psychosocial issues. How exactly this takes place must be decided at a local health service level (see Box below for more detail).
Future Directions: building the evidence base
In order to inform clinicians looking for guidance & policy makers in setting funding priorities we need:
Guiding principles underpinning Universal Psychosocial Assessment & Depression Screening Programs – International Marcé Society Position Statement 2013
Where the provision of universal psychosocial assessment and care for perinatal women in the primary care setting is being considered, the following principles need to be considered:
The value of combining assessment of both the physical and emotional health and welfare of women in the perinatal period.
The impact of psychosocial morbidity on the transition to parenthood andinfant attachment and development.
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10. Austin, M.-P., et al., Depressive and anxiety disorders in the postpartum period: how prevalent are they and can we improve their detection? Archives of Women’s Mental Health, 2010. 13(5):395-401.
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17. Munk-Olsen, T., et al., Risks and predictors of readmission for a mental disorder during the postpartum period. Archives of General Psychiatry, 2009. 66(2): p. 189-195.
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19. Austin, M.P., et al, Maternal mortality and psychiatric morbidity in the perinatal period: challenges and opportunities for prevention in the Australian setting. Medical Journal of Australia, 2007. 186: 364-367.
20. Appleby, L., P.B. Mortensen, and E.B. Faragher, Suicide and other causes of mortality after post-partum psychiatric admission. British Journal of Psychiatry, 1998. 173: p. 209-211.
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23. Myers, E.R., et al., Efficacy and Safety of Screening for Postpartum Depression. Comparative Effectiveness Review 106., 2013, Agency for Healthcare Research and Quality: Rockville, MD.
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Psychosocial Assessment and Depression Screening in Perinatal Women
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34. Matthey, S., et al., Routine psychosocial assessment of women in the antenatal period: frequency of risk factors and implications for clinical services. Arch Womens Ment Health, 2004. 7(4): p. 223-9.
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Marie-Paule Austin (lead) St John of God Health Care Prof Perinatal & Women’s Mental Health, University NSW, Australia. Chair Australian (beyondblue) Guidelines Perinatal Depression & associated Disorders.
Gisele Apter Director Perinatal & Child Psychiatry Erasme Hospital, University Paris Diderot, France.
Bryanne Barnett, Perinatal Psychiatrist, St John of God Health Care & University NSW, Sydney, Australia.
Angela Bowen, Lead Maternal Mental Health & A/Professor Nursing, University of Saskatchewan, Canada.
Roch Cantwell, Perinatal Psychiatrist, Southern General Hospital; Glasgow Scotland; chair SIGN Guidelines.
Prabha Chandra, Professor Psychiatry, National Institute of Mental Health & Neurosciences, Bangalore, India.
Linda Chaudron, Professor, Psychiatry, Pediatrics, Ob/Gyn, University of Rochester, USA.
Jane Fisher Jean Hailes Professor Women’s Health, Monash University, Melbourne, Australia.
Jane Hanley, President International Marcé Society, College of Human and Health Sciences, Swansea University, Wales, Great Britain.
Nicole Highet, Executive Director Centre for Perinatal Excellence (COPE), Australia.
Jane Honikman, Founder Postpartum Support International, USA
Jeannette Milgrom Professor & Director Parent-Infant Research Institute, University Melbourne, Australia.
Anne-Laure Sutter-Dallay, Head Perinatal Psychiatry, University of Bordeaux, France
Katherine Wisner, Asher Professor of Psychiatry & Ob/Gyn, Northwestern University, USA.
Acknowledgements: We gratefully acknowledge the support of the International Marcé Society & St John of God Health Care in compiling the Advisory Committee’s comments.
Suggested reference: Marcé International Society Position Statement (2013). Psychosocial Assessment and Depression Screening for Women in the Perinatal Period.
Summary of National level Clinical Practice Guidelines for psychosocial assessment and Depression Screening (see also Table 1)
Over the last 10 years, three National level Clinical Practice Guidelines (CPGLs) have been developed. In addition, we have an extensive review of the use of the EPDS for depression screening perinatally from the US (AHRQ 2013 not summarised here). Each of these CPGLs is underpinned by a systematic literature review (SLR) and includes a number of graded evidence-based recommendations and good practice points. Each CPGL addresses two key domains:
1) Model of psychosocial care. Each of the Guidelines recommend similar approaches to this:
2) Focus and method of assessment. There are significant differences between the Guidelines with respect to this as follows:
Australian (NHMRC endorsed 2011)
English and Welsh Guidelines (NICE 2007; under review; next version due 2015)
Scottish Guidelines (SIGN 2012)