There is a growing body of literature which indicates that anxiety symptoms are common during pregnancy and the postpartum period. Anxiety during pregnancy places the woman at greater risk for postpartum depression and may also affect pregnancy outcomes. The American College of Obstetricians and Gynecologists (ACOG) now recommends that clinicians screen women at least once during the perinatal period for depression and anxiety using a standardized, validated tool.
But what is the best tool to screen for anxiety symptoms in this setting? Certain items on the Edinburgh Postnatal Depression Scale (EPDS) may help to identify women with anxiety, but it is likely that this instrument does not identify all women with clinically relevant anxiety symptoms. In order to assess the accuracy of the most commonly used and/or recommended screening tools for perinatal anxiety disorders, researchers compared several different screening tools in a group of 310 Canadian women at three months postpartum.
Participants completed the Edinburgh Postnatal Depression Scale (EPDS) and its 3-item anxiety subscale (EPDS-3A), the Generalized Anxiety Disorder 2- and 7-item Scales (GAD-2 and GAD-7), and a clinically derived alternatieve, the Anxiety Disorder – 13 scale (AD-13). Those who scored at or above the cut-off score on one or more of the questionnaires completed a diagnostic interview for depression and all anxiety disorders(n?=?115).
Neither the EPDS-3A nor the GAD-2 performed well enough to be recommended for screening. Specifically, neither of these two measures achieved an area under the curve or AUC value of 0.8 or greater. (AUC measures the discrimination of a particular test, the ability of the test to correctly classify those with and without the disease. An AUC of 0.8 is considered good for a screening test.) Overall, the EPDS-3A performed better than the full version of the EPDS, whereas the GAD-7 outperformed the GAD-2.
The only self-report measure which performed well enough to be recommended for screening (having an AUC greater than 0.8) was the AD-13, regardless of whether all anxiety disorders were included or diagnoses were restricted to the five core anxiety disorders.
The authors note that the EPDS-3A asks only about feelings of anxiety, fear, panic and self-blame, and the GAD-2 asks only about feelings of anxiety and worry. The AD-13 was derived from other commonly used questionnaires used to identify the core symptoms of five types of anxiety disorders (generalized anxiety disorder, panic disorder, OCD, PTSD, and social anxiety disorder). Thus the AD-13 is much broader, covering panic attacks, social anxiety, obsessions, compulsions, intrusive thoughts, distressing memories, and hypervigilance. While they do not propose the AD-13 as a new screening tool, they do suggest that some of the questions used in this questionnaire may be useful for identifying a broader range of anxiety disorders in this setting. It is interesting to note that, given how frequently women with PPD and postpartum anxiety report obsessions and intrusive thoughts, the EPDS does not ask about these symptoms.
So What’s the Best Screening Tool for Perinatal Anxiety?
Based on the findings of this study, it looks as if none of the tools we commonly use in this setting, specifically the EPDS and the GAD-7, are great screening tools for perinatal anxiety. These two questionnaires focus mostly on generalized anxiety symptoms, so if we restrict ourselves to these screening tools, we might be missing women with OCD, PTSD, panic disorder, and social anxiety disorder. However, it is not so clear how many patients we would be missing if we only screened for generalized anxiety disorder. This study did not include data on the prevalence of specific anxiety disorders.
A while back, we wrote about the Perinatal Anxiety Screening Scale or PASS. Developed by researchers in Western Australia, PASS was developed to specifically screen for a broad range of anxiety symptoms during pregnancy and the postpartum period. This 31-item questionnaire is easy to complete and score, is sensitive to how anxiety presents in perinatal women, and may be used in a variety of settings. This scale assesses four categories of anxiety: (1) acute anxiety and adjustment, (2) general worry and specific fears, (3) perfectionism, control and trauma and (4) social anxiety. Although grouping slightly differently, PASS asks about the core symptoms of the five anxiety disorders listed above.
PASS identified 68 % of women with a diagnosed anxiety disorder, compared to the EPDS-3A subscale which detected 36 % of anxiety disorders. PASS can also be used to measure the severity of perinatal anxiety symptoms using the following cutoffs: minimal anxiety (PASS score of 0-20), mild-moderate anxiety (score of 21-41), and severe anxiety (score of 42-93).
If you take a look at the PASS questions, this survey seems to represent the symptoms we typically see in this population (downloadable version HERE), including intrusive thoughts, hypervigilance, and problems sleeping. Although my gut sense is that this would be a useful tool for screening for perinatal anxiety disorders, it has not been used extensively. As far as I can tell, PASS is not commonly used, and I did not find any studies using PASS as a screening tool other than the two from the original group in Western Australia.
Ruta Nonacs, MD PhD
Fairbrother N, Corbyn B, Thordarson DS, Ma A, Surm D. Screening for perinatal anxiety disorders: Room to grow. J Affect Disord. 2019 Mar 8;250:363-370.
Somerville S, Dedman K, Hagan R, et al. The Perinatal Anxiety Screening Scale: development and preliminary validation. Arch Womens Ment Health. 2014 Apr 4.
Somerville S, Byrne SL, et al. Detecting the severity of perinatal anxiety with the perinatal anxiety screening scale (PASS). J Affect Disord 2015
Here is a downloadable copy of the PASS from the Western Australia Department of Health.
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