Commonly Used Screening Tools May Not Identify Women with Perinatal Anxiety Disorders
In 2015, the American College of Obstetricians and Gynecologists issued a committee opinion recommending that clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms. Most obstetric clinics use questionnaires, like the Edinburgh Postnatal Depression Scale, to screen for depression. While this screening tool was specifically designed to screen for depression, it does include some questions about anxiety and can identify women with anxiety disorders. But it appears that most of the tools we commonly used in this setting may fail to identify many women with anxiety disorders, specifically PTSD.
A new study takes a look at how screening for perinatal anxiety in an obstetric setting would impact the identification of patients who could benefit from mental health services during pregnancy and the postpartum period.
In obstetric clinics at the Montefiore Medical Center/Albert Einstein College of Medicine in the Bronx, patients are currently being screened for depression using the Patient Health Questionnaire-2 (PHQ2) at all prenatal visits.
Women screened with the PHQ-2 were prospectively tracked for 3 months in women presenting for visits between 24 and 28 weeks (PHQ2-only group). A second group of women were screened with the Generalized Anxiety Disorder 2-item (GAD2) questionnaire in addition to the PHQ-2 (PHQ2+GAD2 group).
A total of 100 women were eligible to be screened during the PHQ2-only period, and 125 during the PHQ2+GAD2 period. In the PHQ2-only group, 51 out of 100 women were screened, and two women reported positive depression screens. In the PHQ2 + GAD2 group, 40 out of 125 women were screened, yielding 5 positive screens for depression and 4 for anxiety. Three anxiety positive patients had been negative via depression screening. Thus, we could hypothesize that if we do not screen for anxiety, we are missing about a third of the women who might benefit from some type of mental health intervention.
Referral rates in the two groups of women were similar, although women in the PHQ2+GAD2 with prior history of mental health diagnosis (OR 14.9, CI 5.6-39.7) or substance abuse (OR 26.7, CI 4.6-155.0) were more likely to be referred for mental health services.
The Bottom Line
This is an extremely small study, and thus its findings should be cautiously interpreted. It is somewhat surprising that the PHQ2, when used alone, identified only 2/51 or 3.9% of women with depression. More women in the PHQ2+GAD2 group had positive screens for depression (12.5%). Other studies using different diagnostic tools indicate that 10%-15% of women screen positive for depression during pregnancy.
What the findings do suggest, and we have seen this in other studies, is that different tools may yield different results. For example, certain items on the Edinburgh Postnatal Depression Scale (EPDS) can identify women with anxiety disorders. Previous studies have shown that the GAD2 is not adequate for screening for perinatal anxiety; however, the GAD7 performs somewhat better.
Furthermore, screening tools like the EPDS, GAD2, and GAD7 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.
While many (or most) women with perinatal depression may have comorbid anxiety disorders, we must ensure that we identify women who present only with anxiety during pregnancy and the postpartum period. These women may also benefit from interventions to decrease anxiety.
Ruta Nonacs, MD PhD
Lieb K, et al. Adding Perinatal Anxiety Screening to Depression Screening: Is It Worth It? Am J Obstet Gynecol MFM, March 2020.