Screening for Perinatal Depression

Perinatal depression is defined as major and minor depressive episodes that occur during pregnancy or in the first 12 months after delivery.  It is very common, affecting approximately 9% of women in pregnancy and 10% during the postpartum period.

Clinical Actions:

USPSTF (2019) recommends that

…clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions (Grade B Guidance)

Moderate net benefit

Note: Definition of Grade B Guidance

  • The USPSTF recommends the service | There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial
  • Suggestions for Practice: Offer or provide this service
  • Recommendation based on ‘convincing evidence’
    • Counseling interventions (e.g., cognitive behavioral therapy and interpersonal therapy) are effective in the prevention of perinatal depression

ACOG recommendations include the following

  • Perinatal period
    • ObGyns and other obstetric care providers should screen patients “at least once during the perinatal period for depression and anxiety symptoms”
  • Postpartum period
    • ObGyns and other OB providers should “complete a full assessment of mood and emotional well-being” during the comprehensive postpartum visit for every patient
    • Use a validated screening tool to identify the presence of depression or anxiety
  • Screening alone has potential for clinical benefit
    • In the context of a positive screening test, follow up with appropriate medical interventions and referrals provides maximal benefit
    • The USPSTF recommends routine depression screening in the general adult population, including pregnant and postpartum women (Grade B – The USPSTF recommends the service; there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial)
  • Gauge depression by paying attention to flat affect, noting unusual anxiety or tearfulness in addition to using a screening instrument

Antepartum Depression Risk Factors:

FACTOR STRENGTH OF ASSOCIATION
Maternal anxiety Medium – Large
Negative life events Medium – Large
Unintended pregnancy Medium
Medicaid (US) Medium
Poor relationship quality Medium
History of depression Medium
Domestic violence Small – Medium
Lack of social support Small – Medium
Smoking Small
Lower income Small
Lower education Small

Postpartum Depression Risk Factors:

  • Depression during pregnancy
  • Anxiety during pregnancy
  • Experiencing stressful life events during pregnancy or the early postpartum period
  • Traumatic birth experience
  • Preterm birth/infant admission to neonatal intensive care
  • Low levels of social support
  • Previous history of depression
  • Breastfeeding problems
  • Multiparity

Synopsis:

Left untreated, the results of depression can be devastating for both the child and the mother. Proactive screening is necessary because often depression can go unnoticed. Changes in libido, mood and sleep may incorrectly be attributed to the pregnancy or the birth of the child rather than underlying depression

Key Points:

  • Anxiety and insomnia can be significant indicators of depression
  • Women with a history or with common risk factors for depression are more likely to be affected by perinatal depression and extra caution is warranted
  • Management including evaluation and close follow up are required for women with
    • Current depression or anxiety
    • History of perinatal mood disorders
    • Risk factors for perinatal mood disorders
    • Suicidal ideation
  • The Edinburgh post-natal depression scale (EPDS) and the PHQ-9 screening tool (see ‘Learn More – Primary Sources’ below)
    • Are validated for use in the primary care setting
    • Take a relatively short time to complete
    • EPDS: Sensitivity 59-100% | Specificity 49-100%
    • PHQ-9: Sensitivity 75% | Specificity 90%
  • Other screening tools, unlike the EPDS, include constitutional symptoms
    • Constitutional symptoms such as altered sleep patterns are associated with pregnancy/postpartum period in general, and therefore can reduce screening specificity
  • Systems should be in place to ensure follow up, diagnosis and treatment

Learn More – Primary Sources:

ACOG Committee Opinion 757: Screening for Perinatal Depression

USPSTF Recommendation Statement (JAMA): Interventions to Prevent Perinatal Depression

USPSTF Perinatal Depression: Preventive Interventions (2019) 

Edinburgh Postnatal Depression Scale

PHQ-9 Screening Tool (University of Michigan)

Risk factors for depressive symptoms during pregnancy: a systematic review

Risk factors in pregnancy for post-traumatic stress and depression after childbirth

USPSTF: Final Recommendation Statement: Depression in Adults – Screening