Perinatal anxiety is relatively common, affecting 15-20% of women during pregnancy and the postpartum period. Anxiety may reflect worries and fears about the pregnancy or caring for a new baby; however, anxiety symptoms may be more significant and may manifest as generalized anxiety disorder (GAD), panic disorder, phobias, social anxiety, obsessive-compulsive disorder, or post-traumatic stress disorder.

The impact of perinatal anxiety can be significant, potentially contributing to increased risk for pregnancy complications, including preterm birth, increased vulnerability to postpartum depression, and adverse neurodevelopmental outcomes in exposed children. Despite the prevalence of perinatal anxiety, there is a lack of consensus regarding the optimal timing for screening perinatal anxiety.

Insights from the MAP Study

The Methods of Assessing Perinatal Anxiety (MAP) study carried out in the United Kingdom used a variety of anxiety screening tools to determine the optimal time to screen for perinatal anxiety. This prospective longitudinal study included 2243 women who completed mental health questionnaires at four key time points: early pregnancy (11 weeks), mid-pregnancy (23 weeks), late pregnancy (32 weeks), and during the postpartum period (8 weeks).

Screening tools included the GAD-7, GAD-2, Stirling Antenatal Anxiety Scale (SAAS), Clinical Outcomes in Routine Evaluation (CORE-10), and the Whooley questions. Diagnostic interviews were conducted on a subsample of 403 participants using the MINI to confirm diagnosis of an anxiety disorder according to DSM-V criteria.

Early Pregnancy is the Optimal Screening Time

The researchers found that anxiety symptoms were the highest during the first trimester and tended to decrease as pregnancy progressed and during the postpartum period.

The study found that early pregnancy (at 11 weeks) is an optimal time to screen for perinatal anxiety. Screening at this time was the most accurate in predicting which women either had or would develop an anxiety disorder later in pregnancy. Screening at this time was also able to identify which women desired treatment for anxiety symptoms. This finding was consistent across all five anxiety and mental health questionnaires used to screen for anxiety, suggesting that early pregnancy screening is effective regardless of the specific tool employed.

Of interest is also the finding that screening positive for anxiety symptoms during early pregnancy did not as accurately predict treatment for an anxiety disorder. Instead the researchers observed that those who screened positive for anxiety during late pregnancy (32 weeks) or the postpartum period were more likely to receive treatment. What this suggests is that many women with anxiety symptoms early in pregnancy have an anxiety disorder yet do not receive treatment.

What Tools Should Be Used to Screen for Perinatal Anxiety?

The most recent guidelines on mental health screening during the perinatal period from the American College of Obstetricians and Gynecologists (ACOG) recommends screening for depression and anxiety at the initial prenatal visit, at least once later in pregnancy, and at postpartum visits, a recommendation that is consistent with the findings of the MAP study.

Another important finding of the MAP study is the consistency of its findings across different screening tools. This suggests that healthcare providers can use the screening tools they are already familiar with, without the need for standardization, as long as screening is conducted in early pregnancy. This flexibility can simplify the implementation of early screening in various healthcare settings.

While ACOG’s Perinatal Mental Health Toolkit points to the GAD-7 as the primary instrument to screen for anxiety, combined with the EPDS or PHQ-9 to screen for depression, this study suggests that a wider array of screening instruments can be used to detect anxiety. The priority should be that screening takes place during the first trimester.

This article discusses anxiety screening tools in greater detail.

Implications for Clinical Practice and Policy

The findings of the MAP study have significant implications for clinical practice and healthcare policy. Screening for perinatal anxiety in early pregnancy can facilitate early identification and intervention, potentially improving outcomes for both mothers and their infants. Given that early pregnancy coincides with routine maternity care appointments, integrating anxiety screening into these early visits could be a practical and effective approach.

Anxiety symptoms were the highest during the first trimester. This pattern aligns with the notion that early pregnancy is a particularly anxious period due to the physical and psychological adjustments women undergo, as well as concerns about miscarriage and other pregnancy-related issues. Although it is possible that this type of pregnancy-related anxiety could be transient, elevated anxiety symptoms observed during the first trimester most reliably predict women who have an anxiety disorder and those who would go on to have an anxiety disorder later in pregnancy.

Screening, however, is not a substitute for a diagnostic evaluation. In addition, women who screen positive for anxiety may not be referred for or may not receive treatment. This study indicates that the presence of anxiety symptoms during early pregnancy did not predict treatment. Exactly what this means is not clear. Are clinicians or patients considering anxiety to be a normal feature of early pregnancy and thus do not consider treatment? Are women with anxiety reluctant to pursue treatment? Given the prevalence of anxiety in the perinatal period and the association of anxiety with worse outcomes, it is essential that we understand why women with clinically significant symptoms do not pursue or receive treatment and to develop interventions to reduce anxiety that are acceptable and effective.

Ruta Nonacs, MD PhD

References

Ayers S, Sinesi A, Coates R, Cheyne H, Maxwell M, Best C, McNicol S, Williams LR, Uddin N, Shakespeare J, Alderdice F; MAP Study Team. When is the best time to screen for perinatal anxiety? A longitudinal cohort study. J Anxiety Disord. 2024 Apr; 103:102841.

Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 4. Obstet Gynecol. 2023 Jun 1;141(6):1232-1261.