Given the well-documented impact of perinatal depression and anxiety on women and their families, national and international medical organizations have long supported the screening of all pregnant and postpartum women for mood and anxiety disorders. Many studies have documented the feasibility and acceptability of such screening programs; however, despite a significant increase in the number of programs incorporating screening as part of routine care, it is clear that many women with mood and anxiety disorders do not receive treatment. In addition, we must consider the ethical implications of a situation where screening programs are launched, but without the provision of treatment.
A mixed-methods systematic review and meta-analysis from Waqas and colleagues set out to answer one of the most important questions we must consider as we advocate for universal screening. For women during the perinatal period, do screening programs for perinatal depression and anxiety improve maternal mental health and infant outcomes compared to no screening?
Impact of Screening Program on Treatment and Outcomes
To help answer this question, researchers conducted a mixed-methods systematic review and meta-analysis, specifically examining whether screening programs for depression and anxiety in perinatal women improve maternal mental health and infant outcomes.
The researchers analyzed a total of 19 studies for qualitative synthesis and 9 studies for quantitative synthesis. Out of these 19 studies, randomized controlled trial findings were reported in 9 studies, cost-effectiveness in 2 studies, and acceptability of screening programs in 10 studies. All studies were conducted in high-income countries including the USA (n=2), the UK (n=2), and one each in Hong Kong, Netherlands, Australia, Sweden, and Norway.
Screening protocols varied across the studies and included nurses, nurses specializing in public health, midwives, health visitors, psychology students, and physicians. Six of the studies reported screening in the postpartum period and three in the antenatal period.
In terms of treatment offered, non-directive counseling, psychoeducation and pharmacological therapy were the most frequently cited strategies used in these trials. In some studies, treatment (counseling, psychoeducation) was offered within the context of the screening program; in other studies, women with depression were referred to their primary health care providers, outside mental health professionals, or specialized group treatment.
Do Screening Program Improve Treatment?
Given the heterogeneity of the screening programs examined, it is difficult to conduct a meaningful meta-analysis. Nonetheless, this article provides a good review of available screening programs. The meta-analysis conducted here shows that identifying women with perinatal depression and anxiety could potentially lead to direct health benefits for the women.
For example, Avalos and colleagues (2016) in their prospective evaluation of a screening program from the pre-implementation phase (n=122) to fully implemented stage (n=41,124), reported a corresponding increase in the diagnosis of new cases. Most importantly, the percentage of women receiving treatment increased from 5.9 to 81.9%.
On the other hand, other studies (Smith et al, 2009) reported that only a small proportion of their study sample remained in active treatment, citing the programs into primary healthcare settings.
Do Screening Programs Improve Maternal and Infant Outcomes?
Using a series of meta-analyses, the authors observed a reduction in perinatal depression and anxiety among perinatal women undergoing screening programs. For the outcome of depressive disorder, meta-analysis indicated a positive impact in favor of the intervention group (OR = 0.55).
Infant outcomes were reported in only three of the nine studies. A small improvement in child socio-emotional development was reported in one study. Another study reported improvements in parent-child interactions. No improvements were observed in terms of physical development of the infants or subsequent number of hospitalizations.
What Can We Do to Improve the Effectiveness of Screening?
While many of the screening programs take place most commonly in the context of obstetric visits, the authors note that screening could be beneficial when conducted at subsequent medical visits for the mother and child or in the community by allied health workers. Screening in these settings would help to improve the detection, diagnosis and referral of women to appropriate treatments.
The authors advocate for a more thoughtful integration of screening into primary care and/or maternal and child health services. This has many advantages, including more holistic health care, increased accessibility of mental health services, opportunities for reducing the stigma of mental health problems and lower costs.
However, this recommendation carries important ethical implications. All of the studies included in this analysis emphasize that the screening should only be carried out when there are adequate resources for screening, diagnosis, treatment and follow-up.
STEPS for PPD: Screening and Treatment Enhancement for Postpartum Depression
The Center for Women’s Mental Health at MGH recently launched a research study, funded by the Marriott Foundation, which aims to assess screening to treatment pathways in individuals with postpartum depression across the Mass General Brigham (MGB) hospital system: Screening and Treatment Enhancement Program For Postpartum Depression in the MGB System or STEPS for PPD. In collaboration with multiple obstetric clinics across MGB, the STEPS project will assess clinical and treatment outcomes of postpartum screening and explore barriers and facilitators to screening and treating PPD.
STEPS builds on previous research to investigate systems of PPD screening, referral, and treatment. Ultimately, we hope that findings from the project will ensure that patients are universally screened for postpartum depression and, if they do screen positive, are referred to receive adequate care and treatment of symptoms. The knowledge gained from this study will illuminate factors associated with utilization of treatment services for postpartum depression and can inform how best to increase access and uptake of services for future patients.
Ruta Nonacs, MD PhD
Waqas A, Koukab A, Meraj H, Dua T, Chowdhary N, Fatima B, Rahman A. Screening programs for common maternal mental health disorders among perinatal women: report of the systematic review of evidence. BMC Psychiatry. 2022 Jan 24;22(1):54. D