Mass General Hospital

Harvard Medical School

One in Four Pregnant Women Suffers from Psychiatric Illness: How Can We Identify and Support Them?

 

The title of the following article did not grab my attention; however, I discovered that this study, entitled Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and other mental disorders in early pregnancy published in the British Journal of Psychiatry, has some incredibly important findings.

First of all, this is the first study In the United Kingdom examining the prevalence of mental health problems in women during pregnancy using a structured diagnostic interview.   In this cross-sectional survey, women at their first obstetric visit in an inner-city maternity service in South-east London were screened using the Whooley Questions: ‘During the past month have you often been bothered by feeling down, depressed, or hopeless?’ and ‘During the past month have you often been bothered by having little interest or pleasure in doing things?  

A random sample of Whooley negative (W–) and all Whooley positive (W+)  women were invited to participate and were interviewed using the Structured Clinical Interview DSM-IV-TR (SCID) in order to determine psychiatric diagnoses in the participants.

Psychiatric Disorders Common Among Pregnant Women

Ultimately 287 W+ and 258 W- women were interviewed using the SCID.  A SCID-identified psychiatric disorder was found in 242 (45%) of the interviewed participants. Using weighted estimation, the population prevalence of any psychiatric disorder was calculated to be 27% (95% CI 22–32): depression (found in 11%), anxiety (15%), eating disorders (2%), obsessive-compulsive disorder (2%), PTSD (0.8%) and bipolar disorder (1%).

To my knowledge, this is the first study which has used the SCID to diagnose a spectrum of psychiatric disorders in a single cohort of pregnant women.  The prevalence of depression in this population is similar to that observed in previous studies which have used a variety of methods to identify depression, including evaluation of ICD codes in the medical record or screening for depression using the Center for Epidemiological Studies-Depression Scale (CES-D) and the Edinburgh Postnatal Depression Scale (EPDS).  At this point, we have less data on the prevalence of other psychiatric disorders during pregnancy.  

EPDS or Whooley Questions: What Should We Use to Screen Pregnant Women for Psychiatric Illness?

The Whooley questions are similar to those used in the 2-item Patient Health Questionnaire or PHQ-2 which has been used widely to screen for depression in primary care populations in the United States.  The PHQ-2 differs in terms of time frame (last 2 weeks vs. past month), response format (multiple choice vs. yes/no), and range of scores (0 to 6 vs. 0 to 2). As a result, the (yes/no) Whooley Questions are more sensitive, easier to administer and simpler to score than the (multiple choice) PHQ-2.  

In this study, the Whooley questions were administered face-to-face by a midwife at the time of the first visit.  For the Whooley questions, the weighted sensitivity for detecting depression was 0.41, the specificity was 0.95, and the negative predictive value or NPV was 0.93.  The ten-item EPDS (administered as a printed or digital questionnaire at the first visit) performed better, with a sensitivity of 0.77, a specificity 0.95, and a NPV of 0.97.

Previous studies using the Whooley questions to screen for depression in pregnant women have similarly shown that the Whooley questions did not identify about half of the cases (women with depression and/or anxiety) which were identified using the EPDS.  The researchers later interviewed a subset of the women participating in this study and found that under-disclosure was related to the context of the assessment and the perceived relevance of depression to maternity services. In other words, women were much less likely to reveal depressive symptoms if they believed that  this world negatively affect their care.

This is a big problem as we try to implement universal screening for depression in pregnant and postpartum women.  We can have women pee in a cup and can measure their blood pressure, and we can feel confident that we are screening for conditions that may negatively affect the pregnancy. However, when it comes to face-to-face screening for depression or other psychiatric disorders during pregnancy, even when using tools that have been validated in other primary care populations, we have about a 50-50 chance of getting a reliable reading.

While the EPDS does better, the authors note that administering and scoring a 10-item questionnaire in a busy obstetric setting is potentially burdensome. They observed, however, that using iPads to administer the EPDS did not reduce its effectiveness. Therefore, it is possible that the EPDS could be completed by women when they are in the waiting room without negatively impacting care.

While practical, I wonder if handing the patient a questionnaire or an iPad conveys the right message.  I have lost count of the number of patients I have seen for treatment who tell me they filled out “some questionnaire about depression” but that nobody followed up with them to discuss the results of the test.  On the other hand, when a health care provider – whether its an obstetrician, a midwife , or a nurse — asks a patient in a sensitive and non-judgmental manner about her mental health and is willing to discuss these issues with the patient, it sends an important message to the patient.  These sorts of questions can help to make the patient aware of the potential for mental health issues during pregnancy and the postpartum period and can establish the obstetric provider as an Important resource for women in need of additional information or treatment.

Ruta Nonacs, MD PhD

 

Darwin Z, McGowan L, Edozien LC. Identification of women at risk of depression in pregnancy: using women’s accounts to understand the poor specificity of the Whooley and Arroll case finding questions in clinical practice. Arch Womens Ment Health 2016; 19: 41–9

Howard LM, Ryan EG, Trevillion K, Anderson F, Bick D, Bye A, Byford S, O’Connor S, Sands P, Demilew J, Milgrom J, Pickles A.  Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and other mental disorders in early pregnancy.  Br J Psychiatry. 2018 Jan;212(1):50-56.

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