Implementing Perinatal Mental Health Screening

Who should be screened for perinatal mental health conditions?

ALL perinatal women should be screened for mental health conditions. ACOG’s Committee Opinions, #757, “Screening for Perinatal Depression1” recommends screening patients at least once during the perinatal period for depression and anxiety, and, if screening in pregnancy, it should be done again postpartum. Opinion #736, “Optimizing Postpartum Care,2” recommends a full assessment of physical, social, and psychological well-being within a comprehensive postpartum visit that occurs no later than 12 weeks after birth.

When should screening occur?

Wisner et al.3 (2013) suggests that among women who screen positive for depression in the postpartum period, the onset of depression occurs before delivery for the majority of women. Wisner et al. found that depression onset occurred prior to pregnancy among 27% of women, during pregnancy for 33%, and in the postpartum period for the remaining 40%. Screening at the following times may capture mental health conditions with onset at each time point:

• At the first obstetric visit to identify onset before pregnancy
• At 24-28 weeks gestation to identify onset during pregnancy
• At the comprehensive postpartum visit (4th trimester visit) to identify onset that occurs in late-pregnancy or early postpartum

Women with a history of depression or other mental health conditions, women who have previously taken psychiatric medications, or women who have screened positive in a pregnancy/postpartum episode often need more frequent monitoring. Re-administering screening tools can facilitate monitoring of symptoms and follow-up care with the goal of full symptom remission.

In addition, the American Academy of Pediatrics4 recommends screening for depression at well-child visits in the first postpartum year. Thus, additional screening should occur in the pediatric environment. Obstetric providers should expect women to be referred to them for care, if a positive screen is identified in the pediatric setting.

What screening tools should be used?

There are many validated tools available. ACOG does not endorse specific screening instruments. This toolkit includes screening instruments that are:
a. validated or accepted for use in pregnancy and the postpartum period;
b. routinely used;
c. free;
d. easy to administer and score; and,
e. available in numerous languages.

This Toolkit includes several commonly used screening instruments to provide a comprehensive assessment of perinatal women’s mental health.
To screen for Depression, the Toolkit includes the below, either of which can be used:

• Edinburgh Postnatal Depression Screen (EPDS), 10 questions
  or
• Patient Health Questionnaire-9 (PHQ-9), 9 questions

To screen for Anxiety, the Toolkit includes:

• General Anxiety Disorder 7 Screen (GAD-7), 7 questions

To screen for Posttraumatic Stress Disorder (PTSD), the Toolkit includes:

• PC-PTSD, 4 questions

To further screen for PTSD, the PCL-C is included in the appendix, 17 questions
To screen for Bipolar Disorder, the Toolkit includes:

• Mood Disorder Questionnaire (MDQ), 14 questions
  • 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.
  • We recommend screening all women for bipolar disorder. Minimally it needs to be done prior to initiating an antidepressant5 because 1 in 5 women who screen positive for depression may have bipolar disorder.3
  • 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.

Who hands out, scores, and responds to the screening tools?

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 and entered into the chart if not already done 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.

How do you talk about mental health conditions in a strength-based way?

Women are often reluctant to discuss mental health conditions for many reasons including stigma. As clinical support office staff are often the first to interact with women regarding screening for mental health, it is important that it is done with an inclusive, strength-based approach that emphasizes:

• They are common
• They are medical conditions, like diabetes, that need to be treated
• They are treatable
• That the practice screens every woman in pregnancy and the postpartum period
• The practice cares for the whole woman
• For more information, see How to Talk to your Patient About Their Mental Health

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 (see the Action Plan for Mood Changes During Pregnancy and After Giving Birth and Self-Care Plan, pages 29-30). 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.

When discussing treatment options, provide a balanced perspective of treated versus untreated illness and associated risks and benefits. Untreated illness has significant risk. Let women know that a healthy mother is critical to the health of the baby and it is important to prioritize a mother’s health, including mental health. Because of this, you will be checking in with her and her mental health regularly throughout her obstetric care.

Where can I find educational materials for patients and families?

Women and their families, or other members of her support system should be proactively provided with education so that they are aware of signs and symptoms of perinatal mood and anxiety disorders. Having these conversations early in the pregnancy and again in the early postpartum period, can decrease stigma, normalize screening and detection, and encourage women to discuss any mental health concerns. An environment with ample displays of, and access to, mental health-related information can help to reduce this stigma, and empower women and their families to seek help, while letting women know that they are not alone.

Recommendations for education:

• Provide educational materials to all new prenatal patients and again to patients at their postpartum visit.
• Place posters, pamphlets, and other materials throughout your offices.