December 30, 2025

Increased Awareness, But Still Low Rates of Screening for Perinatal Mood and Anxiety Disorders

Postpartum Psychiatric Disorders, Postpartum Psychiatric Disorders, Psychiatric Disorders During Pregnancy

Perinatal depression and anxiety remain underdiagnosed and undertreated despite ACOG guidelines recommending universal, repeated screening across pregnancy and postpartum visits.

Ruta Nonacs, MD PhD

The American College of Obstetricians and Gynecologists (ACOG) formally recommended routine screening of all pregnant and postpartum women for depression in 2010. Since then, ACOG has expanded these guidelines to support more frequent screening for perinatal depression and anxiety using validated tools across pregnancy and the postpartum period. Despite these recommendations, a recent study in a large urban medical center found that most pregnant and postpartum individuals did not receive any formal mental health screening.

How Often Are Perinatal Patients Screened for Depression and Anxiety?

This retrospective cohort study examined routine screening for perinatal depression and anxiety, as well as the severity and trajectories of symptoms, among pregnant and postpartum patients in an urban hospital system. Researchers reviewed electronic health records for 27,393 women who delivered in the New York-Presbyterian Hospital system between December 1, 2020, and February 1, 2024.

The investigators assessed how often patients completed three validated mental health questionnaires commonly used in obstetric practice:

Patient Health Questionnaire–9 (PHQ-9) for depression severity
Generalized Anxiety Disorder–7 (GAD-7) for anxiety severity
Edinburgh Postnatal Depression Scale (EPDS) for postpartum depression (and anxiety) symptoms

How Often Were Patients Screened?

In this cohort, most women were not screened for perinatal depression or anxiety at any time during pregnancy or the postpartum period. Of the 27,393 patients:

3,051 (11.1%) completed at least one of the screening instruments.
2,456 (9.0%) completed the EPDS.
723 (3.0%) completed the PHQ-9.
472 (2.0%) completed the GAD-7.

These low screening rates contrast sharply with ACOG’s recommendation that all perinatal patients be screened at least once for depression and anxiety, with repeat screening in pregnancy and again postpartum when feasible.

Impact of Mandatory Screening Protocols

On March 1, 2023, as part of a pilot program, three of eight obstetric clinics in the system (covering roughly 35% of deliveries) implemented mandatory EPDS screening. Screening with the EPDS was required at three time points: the initial prenatal visit, the 28-week prenatal visit, and the 6-week postpartum visit, with results automatically entered into the electronic health record.

After mandatory screening was implemented in these clinics, overall EPDS screening rates increased approximately fourteenfold, from about 1.0% before March 2023 to about 14.0% afterward. The authors note that early automation and workflow issues likely contributed to lower-than-expected rates during the first six months of implementation, suggesting that screening uptake may improve further as systems mature.

Prevalence of Clinically Meaningful Symptoms

Among the 3,051 women who completed at least one questionnaire, a substantial proportion had clinically meaningful symptoms of perinatal depression or anxiety. In this screened subgroup:

51.9% of those completing the GAD-7 had clinically meaningful anxiety symptoms.
21.3% of those completing the PHQ-9 had clinically meaningful depressive symptoms.
24.0% of those completing the EPDS had clinically meaningful depressive symptoms.

Rates of depression were similar before and after mandatory EPDS screening was introduced. The high proportion of elevated GAD-7 scores likely reflects selection bias, as the GAD-7 was typically administered when clinicians already suspected anxiety rather than as a universal screening tool. Because only a minority of patients were ever screened, the true burden of perinatal mood and anxiety disorders in this population is almost certainly higher.

Why Are Screening Rates Still So Low?

The current study indicates that, despite ACOG recommendations on routine screening for perinatal mood and anxiety disorders, most women did not receive a formal screening until mandatory screening was initiated. It is imperative to determine why, despite efforts to implement universal screening, actual rates of screening continue to be so low in many obstetric settings.

Multiple studies have addressed reasons for lack of screening, and have identified multiple barriers, including limited clinician time, insufficient staffing or behavioral health resources, inadequate training in using and interpreting screening tools, and lack of integrated referral pathways. Patient-level barriers, such as stigma, fear of judgment or loss of custody, and reluctance to disclose mental health symptoms, also reduce the likelihood that perinatal depression and anxiety will be identified and treated.

Moving Toward Universal and Effective Screening

Electronic health records (EHRs) can facilitate screening by automating questionnaire delivery, scoring, and documentation, and by embedding clinical decision support for follow-up care. At the same time, this study illustrates that EHR-based screening is not “plug-and-play”: early in the pilot period, automation and workflow issues limited the effectiveness of mandatory EPDS screening. The relatively short follow-up window after implementation means observed screening rates may underestimate what a fully optimized system could achieve over time.

Universal screening for perinatal depression and anxiety is a critical first step in improving maternal mental health outcomes. However, mandatory screening is not simply a matter of adding a form to the patient portal or handing out a paper questionnaire—it requires thoughtful integration into clinic workflows, clinician engagement, and ongoing quality improvement.

Equally important, positive screens must trigger timely evaluation, referral, and treatment. Embedding clear pathways to psychotherapy, pharmacotherapy, collaborative care, or other evidence-based interventions can help ensure that women with elevated perinatal depression and anxiety symptoms receive the care they need, rather than having screening operate as an endpoint.

– Ruta Nonacs, MD PhD