According to a recent meta-analysis published in the Journal of Clinical Psychiatry, one in five pregnant women experience at least one type of anxiety disorder. While this may be surprising to some, anybody who works with pregnant and postpartum women is well aware that anxiety is very common in this population.
Because anxiety is so common and is often a very normal response to any sort of life transition, one of the challenges that faces women and the providers who care for them how to distinguish normal or appropriate anxiety in a given situation from something that requires further attention and/or treatment.
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, yet at the same time these screeners may yield many false positives.
But even if we had the perfect screening tool, we need to do more. While obstetric providers have stepped up to this challenge and increasing efforts to routinely screen women for depression and anxiety, we have also seen that screening alone does not necessarily lead to improved outcomes. Many women are identified as having depression or anxiety but they do not or are not able to receive appropriate care.
Noting that screening alone cannot improve clinical outcomes, the ACOG opinion statement says that it “must be coupled with appropriate follow-up and treatment when indicated,” and – most critically – adds that clinical staff in the practice “should be prepared to initiate medical therapy, refer patients to appropriate health resources when indicated, or both.” The latter recommendation is followed by the statement that “systems should be in place to ensure follow-up for diagnosis and treatment.”
While there are now more and more programs offering training to obstetricians, midwives, and nurses so that they can better identify, and even manage, perinatal mood and anxiety disorders, I suspect that many obstetric providers may feel uncomfortable assuming the care of this patient population. While screening is important, we must also make sure we tend to the ACOG recommendations regarding appropriate follow-up and treatment. Because the stigma continues to be significant with regard to mental health issues in mothers and mothers-to-be and because there are concerns regarding the use of medication in pregnant and nursing women, we must make sure that after screening, we help women to access appropriate resources and treaters who are familiar with treating women during pregnancy and the postpartum period.
Ruta Nonacs, MD PhD
Perinatal Mood and Anxiety Screening: Recommendations and Controversies (Psychiatry Advisor)
You’ve Heard of Postpartum Depression but Probably Not Postpartum Anxiety (Scientific American)