In the last few years there has been a significant push to screen pregnant and postpartum women for symptoms of depression. In fact, in 2015 the American College of Obstetrics and Gynecologists (ACOG) recommended screening at least once during the perinatal period for symptoms of anxiety and depression using a clinically validated assessment tool such as the EDPS (Edinburgh Postnatal Depression Scale) or the PHQ-9 (Patient Health Questionnaire-9). Several states have followed suit in mandating depression screenings for perinatal populations.
This is clearly a step in the right direction. Indeed, a recent study out of the Kaiser Permanente healthcare system in California demonstrated that since implementation of a mandated screening program, the number of women screened for PMADs moved from less than 1% to nearly 98%. But here’s the problem, that study also found that despite being screened, the percentage of women who were then treated for perinatal mental health concerns remained low.
This is an enormous concern as we know that PMADS are the most common complication of childbirth and impact a large percentage of pregnant and postpartum women and families. Which is why in my opinion, universal screening for perinatal anxiety and depression is grossly insufficient.
Here are six reasons why:
- Screening just once during the perinatal period means that women whose symptoms develop after screening are missed. Because of this, PSI recommends screening women several times during their pregnancy, at their 6-week postpartum OB visit, and repeatedly during their first year postpartum at either the OB or Pediatricians office. This would not be difficult to implement given the frequency of perinatal and pediatric appointments.
- Because most doctors’ offices only flag women whose screening tests indicate symptoms above a specific threshold of severity, many women with milder or moderate symptoms are missed. This is reflected in the Kaiser study which showed an increase in treatment for the subset of women whose screening tests indicated more severe symptoms.
- Screening alone does not address the problems that come with stigma and lack of education around PMADS. Specifically, because of stigma associated with PMADS, which may be further activated by some of the questions on the screening test, women may not feel comfortable answering the questionnaires truthfully.
- The screening tools used do not address the full scope of perinatal mood and anxiety disorders. While anxiety and depression are the most common perinatal mood concerns, women who have symptoms of OCD, PTSD, bipolar disorder, or early signs of psychosis may be missed on screening.
- Screening is generally done in a very impersonal way. Most of the time a questionnaire is shoved into a stack of medical and administrative paperwork and is not reviewed or discussed during the appointment. This certainly does not foster communication, nor does it breed the personal connection required to established a trusting relationship between patient and provider. Its arguable that it even sends the message that the provider doesn’t feel comfortable talking about the screener which may lead women to feel uncomfortable disclosing how they are feeling.
- Not all providers feel equipped to handle referring their patients to therapy or other psychological treatment. Several of the medial providers I’ve spoken with have mentioned not knowing who to refer to, feeling too busy to manage the referral process, or feeling uncomfortable speaking with a woman about her symptoms.
Fortunately, there are a variety of simple ways providers can make sure they are taking better care of their perinatal patient’s emotional needs.
Here are my 6 suggestions:
- Ideally before pregnancy at the pre-conception visit, or at least at the first perinatal visit, medical providers should provide basic psychoeducation about PMADS. They should speak with women about their risk factors in the same way they would speak about other medical risk factors that are usually reviewed during these appointments.
- Women should be screened frequently during pregnancy and the postpartum period. PSI’s recommendations are fantastic and would not be very difficult to enforce.
- Doctors’ offices should use lower cut off scores on the screeners so that they are at least having a conversation about mental health and wellness with women with milder symptoms.
- Screening questionnaires should be reviewed during appointments, regardless of the score. This is a great way to facilitate discussion and communication, and sends the message that mental health is important.
- If possible, an in-house staff member who coordinates referrals can be helpful in easing the time burden on medical providers. This could be a nurse or administrative staffer whose job it is it maintain an active referral list of community mental health providers.
- Just ask. At each appointment, when you are asking about how a woman is feeling, sleeping, and eating, ask about her emotional health.