June 15, 2015
The American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice recently published a revised opinion on screening for perinatal depression, recommending that “clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standard, validated tool.” The statement adds that “women with current depression or anxiety, a history of perinatal mood disorders, or risk factors for perinatal mood disorders warrant particularly close monitoring, evaluation, and assessment.” A list of validated depression screening tools is included (Obstet. Gynecol. 2015;125:1268-71). In previous iterations, the committee had not recommended formal screening for perinatal depression (referred to as major or minor depressive episodes occurring during pregnancy or during the first 12 months after delivery) and left the utility of screening as an open question to the field.
Noting that screening alone cannot improve clinical outcomes, the ACOG opinion says that it “must be coupled with appropriate follow-up and treatment when indicated,” and – most critically – adds that clinical staff in the practice “should be prepared to initiate medical therapy, refer patients to appropriate health resources when indicated, or both.” The latter recommendation is followed by the statement that “systems should be in place to ensure follow-up for diagnosis and treatment.”
Many states have initiated programs for screening for perinatal depression, which is intuitive given the prevalence of mood and anxiety disorders in women of reproductive age. Unfortunately, to date, there are no data indicating whether screening results in improved outcomes, or what type of treatment women receive as a result of screening; the ACOG opinion notes that definitive evidence on the benefit of screening is “limited.”
In prevalence studies, maternal morbidity associated with untreated perinatal mood and anxiety disorders clearly exceeds the morbidity associated with hemorrhage and pregnancy-induced hypertension, with significant effects on families and children as well. Therefore, even in the absence of an evidence base, there is support for routine screening and for ob.gyns. to initiate treatment and to facilitate referrals to appropriate settings.
In Massachusetts, where I practice, screening is not mandatory but is becoming increasingly popular, and resources to manage those with positive screening results are being developed.
The MCPAP (Massachusetts Child Psychiatry Access Project) for Moms was established to enhance screening for perinatal depression and to provide screening and educational tools, as well as free telephone backup, consultation, and referral service for ob.gyn. practices. MCPAP for Moms is coupled with an extensive community-based perinatal mood and anxiety service network: mental health providers, including social workers; specialized nurses with expertise in perinatal mental health; and support groups for women suffering from perinatal mood and anxiety disorders. The program is new and has promise, although evidence supporting its effectiveness is not yet available.
Some argue that screening and treatment of perinatal depression by nonpsychiatric providers opens up a “Pandora’s box.” But should the box be opened nonetheless?
Obvious problems might include many women with positive screening results not being referred for appropriate treatment or, if referred, receiving incomplete treatment – all very valid concerns. But one could also argue that with a highly prevalent illness that presents during a discrete period of time, the opportunity to screen in the obstetric setting (or in the pediatric setting, a separate topic) is an opportunity to at least help mitigate some of the suffering associated with perinatal depression.
The clinician in the community who will screen these women will need to manage the substantial responsibility of initiating treatment for patients with perinatal depression or referring them for management. The main question following diagnosis of perinatal depression is really not necessarily how “best” to treat a patient with perinatal depression. An evidence base exists supporting efficacy for treatments, including medication and certain psychotherapies. Perhaps the greatest pitfall inherent in an opinion like the one from ACOG relates to the incomplete infrastructure and associated resources in many parts of the country – and in our health care system – needed to accommodate and effectively manage the increasing number of women who will be diagnosed with perinatal mood and anxiety disorders as a consequence of more widespread screening.
Whether community-based OB/GYNs will be comfortable with direct treatment of perinatal psychiatric illness or the extent to which they view this as part of their clinical responsibility remains to be seen. It is possible that they will follow suit, just as primary care physicians became increasingly comfortable prescribing antidepressants in the early 1990s as easy and safe antidepressant treatments became available, particularly for patients with relatively straightforward major depression.
This committee opinion is an incremental advance, compared with previous opinions, and most critically, puts the conversation back on the national scene at an important time, as population health management is becoming an increasingly proximate reality.
The opinion leaves many unanswered questions regarding implementation on a national level, which may be beyond the scope of the committee’s task. But the recommendations, if carried out, will increase the likelihood of mitigating at least some of the substantial suffering associated with a highly prevalent illness.
Dr. Cohen is the director of the Center for Women’s Mental Health at Massachusetts General Hospital in Boston, which provides information resources and conducts clinical care and research in reproductive mental health. He has been a consultant to manufacturers of psychiatric medications. To comment, e-mail him at firstname.lastname@example.org.