Screening

Postnatal depression is an under-recognised disorder.[5] Randomised control trials (RCTs) on the benefits (and potential adverse effects) of screening for postnatal depression are currently lacking.[142]

One systematic review for the US Preventive Services Task Force has suggested that primary care screening for depression in pregnancy and the postnatal period is associated with improved health outcomes.[143] The review included only one trial on the potential harm of screening; this study was conducted on 462 Chinese women who were 2-months postnatal and found no adverse effects.[144]

The potential effectiveness of screening is related to the availability and effectiveness of services providing diagnosis and treatment; therefore, it is imperative that primary care practices offering screening for postnatal depression have effective systems in place that ensure positive screening results are being followed by accurate diagnosis, effective treatment, and careful follow-up.[92][115]​​

US screening recommendations

The American College of Obstetricians and Gynecologists (ACOG) recommends that everyone receiving well-woman, pre-pregnancy, antenatal, and postnatal care be screened for depression at multiple timepoints using the same standardised, validated screening instrument, such as the Edinburgh Postnatal Depression Scale (EPDS) or Patient Health Questionnaire (PHQ-9).[4]​ If treatment for depression is required, the same screening tool can be administered serially to help assess response to treatment and guide titration as needed.[4]

​The US Preventive Services Task Force recommends screening for depression in the general adult population, including pregnant and postnatal women.[92]​ 

The American Academy of Pediatrics (AAP) recommends routine screening of mothers at well-infants visits at 1, 2, 4, and 6 months, using a validated screening tool such as the EPDS.[145]

UK screening recommendations

In the UK (as in other countries, such as Canada), routine screening for postnatal depression is not currently recommended.[106]​ However, the UK National Institute for Health and Care Excellence recommends that healthcare professionals (including midwives, obstetricians, health visitors, and general practitioners) should consider asking two questions to identify possible depression, at the woman's first contact with primary care, at her booking visit (usually around week 10 of pregnancy), and postnatally (first year after childbirth):[5] 

  • During the past month, have you often been bothered by feeling down, depressed, or hopeless?

  • During the past month, have you often been bothered by having little interest or pleasure in doing things?

If the woman answers 'yes' to either of the initial questions, is at risk of developing a mental health problem, or there is clinical concern, consider:

  • Using the EPDS or

  • Using the PHQ-9 as part of a full assessment or

  • Referring the woman to her GP, or, if a severe mental health problem is suspected, to a mental health professional.[5]

It has been recommended that enquiry about depressive symptoms should be made, at a minimum, early in pregnancy (the ‘booking’ appointment) and postnatally (first year after childbirth). Women at high risk because of a prior or current history of severe depressive disorder should ideally be under the care of a specialist perinatal psychiatrist; clinicians should ask about depressive symptoms at each contact.​[5] 

Choice of screening tool

The Bromley Postnatal Depression Scale (BPDS), the EPDS, and the Postpartum Depression Screening Scale (PDSS) are self-reported measures specifically designed to screen for depression in the postnatal period.[107][108][109]​​ The EPDS has been most widely studied.[134]​ Sensitivity and specificity of cut-off points showed marked heterogeneity between different studies. Sensitivity results ranged from 34% to 100% and specificity from 44% to 100%.[110] The cut-off score of >12 has an overall positive predictive value of 57% and negative predictive value of 99%. Lower cut-off values (e.g., 10 or 11) may be used if the intention is to avoid false negatives.[4] Other tools such as the Beck Depression Inventory may have value but require further research.[112][113]​ Use these screening tools to identify women who need further clinical assessment. When using screening tools, take into account country-specific guideline recommendations as well as the cultural background of the woman.[114]

Electronic health (eHealth) is an emerging method of service delivery, which carries the potential to increase patient access to diagnosis and treatment by expanding opportunities for remote consultations. ACOG notes that web-based and tablet-based e-screening is acceptable to patients, as is text-message screening.[4]​ Telephone screening for postnatal depression has been studied and provisional data is encouraging, although there is currently limited RCT evidence on the effectiveness of this approach and more evidence is required.[146]

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