Patient Screening

ACOG’s Clinical Practice Guideline 4: “Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum” recommends that …

Everyone receiving well-woman, prepregnancy, prenatal, and postpartum care be screened for depression and anxiety using standardized, validated instruments
Screening for perinatal depression and anxiety occur at the initial prenatal visit, later in pregnancy, and at postpartum visits
Mental health screening be implemented with systems in place to ensure timely access to assessment and diagnosis, effective treatment, and appropriate monitoring and follow-up, based on severity
Screening for bipolar disorder be done before initiating pharmacotherapy for anxiety or depression, if not previously done
When someone answers a self-harm or suicide question affirmatively, clinicians immediately assess for likelihood, acuity, and severity of risk of suicide attempt and then arrange for risk-tailored management
Clinicians provide immediate medical attention for postpartum psychosis

Please see Clinical Practice Guideline 4: “Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum” for additional information.

Talking to Your Patient About Mental Health and Screening

Patients are often reluctant to discuss mental health conditions for many reasons including stigma. It is important to use an inclusive, strength-based approach that emphasizes:

Mood changes are common during pregnancy and after giving birth
They are medical conditions, like diabetes, that need to be treated
They are treatable
The practice screens every woman in pregnancy and the postpartum period
The practice cares for the whole woman

Administering and Scoring the Screening Tools

ACOG recommends that obstetrician–gynecologists and other obstetric care providers screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool. If a patient is screened for depression and anxiety during pregnancy, additional screening should then occur during the comprehensive postpartum visit. While there are screening instruments which have been validated for use during pregnancy and the postpartum period, ACOG does not endorse specific screening instruments.

For ease of administration in obstetric practices, Lifeline for Moms created a composite screener, with separate screeners for both the Edinburgh Postnatal Depression Scale (EPDS) and Patient Health Questionnaire (PHQ-9). Both screeners also include the Mood Disorder Questionnaire (MDQ), General Anxiety Disorder (GAD-7), and Primary Care PTSD Screen for DSM-5 (PC-PTSD-5). Please note: The MDQ needs to be done only once in the perinatal period as it queries lifetime experience as compared to the other screening tools. These screeners are scored by clinical staff and providers using the accompanying scorers.

Every office is different, and the workflow for addressing perinatal mood and anxiety disorders needs to be tailored to each practice environment. Clinical support staff can often provide the screening tools to women at the time of check-in or appointment registration, or upon rooming. Women should be given time to complete it thoughtfully. Time in the waiting room or in the exam room while awaiting the provider can be used. Many electronic health records can be customized with templates for these screening tools.

After a woman completes the screening tools, they should be scored by clinical staff, entered into the chart, and included in an electronic medical record. Scoring is straightforward and can be done by any level of caregiver. It is imperative that they are scored before a woman leaves her appointment, so that a positive screen can be promptly addressed. The responsible licensed independent provider should be made aware of positive screening score(s), if they themselves did not administer the screening tools or did not do the scoring.

When screening for Bipolar Disorder, please note:

The MDQ needs to be done only once in the perinatal period as it queries lifetime experience as compared to the other screening tools which ask how a person has felt in the last 7 days to 1 month.
You may consider screening all women for bipolar disorder. Minimally it needs to be done prior to initiating an antidepressant¹ because 1 in 5 women who screen positive for depression may have bipolar disorder.²
Treatment of bipolar disorder with an antidepressant alone is contraindicated and is associated with worsening of mood symptoms which can increase risk of mania, psychosis, and suicide. If a patient has bipolar disorder, treatment with a mood stabilizer is generally indicated.
In general, if bipolar disorder is suspected, consultation with or referral to psychiatry for further assessment is indicated.

The first administration of perinatal mental health screening tools should be accompanied by the provision of educational materials for the patient and family that outline relevant symptoms and resources, including the Action Plan for Mood Changes During Pregnancy and After Giving Birth and Self-Care Plan. In addition, women, their families, and members of their support system should be encouraged to contact the practice if she or they are concerned about her mental health. Remind everyone that you are there to help and you want them to reach out to you or your colleagues at the practice.

¹ Kendig S, Keats JP, Hoffman MC, et al. Consensus Bundle on Maternal Mental Health: Perinatal Depression and Anxiety. Obstet Gynecol. 2017;129(3):422-430.

² Wisner KL, Sit DK, McShea MC, et al. Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry. 2013;70(5):490-498.

This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. This information does not represent ACOG clinical guidance. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications, toolkits and other resources regularly; however, this information may not reflect the most recent evidence. View ACOG's complete disclaimer.

Patient Screening