It is estimated that about 15% of women suffer from depression either during pregnancy or the postpartum period. Prior to the 1980s, most new mothers had never heard of postpartum depression.  Over the last few decades we have made considerable progress in educating women about their risk for psychiatric illness during this vulnerable time, and women now have a much more sophisticated understanding of depression as a real, but treatable, illness.

Still, most women who suffer from depression during pregnancy and the postpartum period  who do not receive adequate treatment.  In 2010, the American College of Obstetricians and Gynecologists (ACOG) recommended screening for depression in all pregnant and postpartum women. Many states have since drafted legislation supporting or mandating universal screening for perinatal depression. What we see now is an increasing number of health care professionals who feel comfortable talking about and screening for depression in this population. Sadly, it seems that this heightened vigilance has not necessarily translated into greater access to care for the women who need it most.

Multiple studies have demonstrated that various screening instruments may be effectively used to facilitate the identification of women with depression during pregnancy and the postpartum period.  But only a handful of studies have examined the outcomes of women who have been identified as depressed or at risk for depression using these screening techniques.  The results have been diappointing, indicating that, while we are able to identify women with depression during pregnancy and the postpartum period, most of these women do not or are not able to access mental health services.

In May of this year, ACOG revisited the issue of screening for depression in pregnant and postpartum women.  Compared to the recommendations made five years ago, this opinion paper is more prescriptive and acknowledges the importance of appropriate follow-up.

Recommendations

Although definitive evidence of benefit is limited, the American College of Obstetricians and Gynecologists (the College) recommends that clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool.

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.

Although screening is important for detecting perinatal depression, screening by itself is insufficient to improve clinical outcomes and must be coupled with appropriate follow-up and treatment when indicated; clinical staff in obstetrics and gynecology practices should be prepared to initiate medical therapy, refer patients to appropriate behavioral health resources when indicated, or both.

Systems should be in place to ensure follow-up for diagnosis and treatment.

This is certainly a big step in the right direction.  While there are now more and more programs offering training to obstetricians, midwives, and nurses so that they can better identify, and even manage, perinatal mood and anxiety disorders, I suspect that many obstetric providers may feel uncomfortable assuming the care of this patient population.  While screening is important, we must also make sure we tend to the ACOG recommendations regarding appropriate follow-up and treatment.   Because the stigma continues to be significant with regard to mental health issues in mothers and mothers-to-be and because there are concerns regarding the use of medication in pregnant and nursing women, we must make sure that after screening, we help women to access appropriate resources and treaters who are familiar with treating women during pregnancy and the postpartum period.

Ruta Nonacs, MD PhD

Committee Opinion No. 630: screening for perinatal depression.  Obstet Gynecol. 2015 May;125(5):1268-71.