DEPRESSION SCREENING DURING PREGNANCY

Despite the overriding expectation of pregnancy and childbirth as joyous occasions, these are times of dynamic change that, for many women, are a catalyst for the new onset of depressive disorders or a precipitant for recurrent depression. Women who suffer from depression during the antepartum period are often overlooked and can invisibly suffer because of discomfort with disclosure and/or a health care system deficiency in routine screening. Depression is the leading cause of disease-related disability among women, and the incidence of depression in women is greatest during their reproductive years, occurring at a rate of 5% to 25%. Unfortunately, depression in pregnant women is usually diagnosed long after it has precipitated harm to the mother, child, and other individuals involved. Untreated depression in pregnancy can negatively impact perinatal outcomes, quality of life, relationship with the infant-child, and healthy family transitions. However, fewer than 50% of pregnant and postpartum women are routinely screened by their health care providers. Although there is more awareness about postpartum depression today than in the past, depression during pregnancy has received little attention from providers or the public. Recently, the Health Resources Service Administration issued state grants to launch intensive public education activities to promote better understanding of perinatal depression and the warning signs associated with it. In 2008, several noteworthy initiatives were designed to highlight the problems associated with perinatal depression. The American Public Health Association mission added the goal of making universal depression screening and treatment in pregnancy and the postpartum period a standard of care throughout the United States. Legislation in Illinois was enacted to increase awareness and promote early detection and treatment of perinatal depression. Illinois law now requires hospitals and providers of prenatal care to educate and screen all pregnant women for perinatal mental health disorders. Targeted screening for depression in early pregnancy while ruling out other health care problems is a first step to recognizing and reducing the impact of perinatal depression. Immediate and appropriate intervention is critical. Sufficient evidence demonstrates that depression left untreated can increase short-term and long-term health-related risks to mother and infant, including higher rates of miscarriage, premature birth, intrauterine growth restriction, and low birth weight infants; failure of maternal-infant bonding; delays in cognitive and language development; and behavioral issues with the growing child.

The purpose of this review is to aid practitioners in early identification of depression in the antepartum period to decrease postpartum depression and improve pregnancy outcomes. Providers should be familiar with the prevalence, risk factors, symptoms and diagnosis, screening tools, and interventions associated with this perinatal complication.

Despite the lack of validated screening tools for diagnosing depression during pregnancy, the Agency for Healthcare Research and Quality (AHRQ) conducted a systematic review of perinatal depression, including studies conducted throughout the antepartum period.The purpose of the AHRQ review was to evaluate the following 3 key questions regarding perinatal depression: 1) What are the incidence and prevalence of depression during pregnancy, postpartum, and non-childbearing periods? 2) What are the accuracies of screening tools for detecting depression during pregnancy and postpartum? and 3) Does prenatal or early postnatal screening, with subsequent intervention, lead to improved outcomes Thirty studies of moderate size met inclusion criteria that provided evidence of the percentage of the population experiencing depression during pregnancy. Point prevalence estimates for major depression ranged from 3.1% to 4.9% in the first, second, or third trimester of pregnancy. Combined prevalence rates for major and minor depression examined at different times in pregnancy demonstrated wider ranges (2.3% to 16.2%, 5.7% to 20.4%, and 4.9% to 15%, for the first, second, and third trimesters, respectively). The prevalence of depression during the antepartum period may be much higher than reported by the AHRQ review because the conclusions suggest that the findings were not representative of the racial and ethnic mix of the countries in which the studies were performed. Findings of research conducted in the United States alone suggest that 14.5% of pregnant women experience a new episode of depression (either minor or major) during pregnancy. In addition, 14.5% of mothers experience a new episode during the first 3 months postpartum. Bennett et al published a meta-analysis investigating the prevalence of depressive symptoms and depression in pregnancy. Combined results of 21 studies that included 19,284 women found depression during the first trimester at 7.4% (95% confidence interval [CI], 2.2%-12.6%), during the second trimester at 12.8% (95% CI, 10.7%-14.8%), and during the third trimester at 12% (95% CI, 7.4%-16.7%). To gain insight into the results of specific screening tools, these authors compared the Beck Depression Inventory (BDI), 17 Edinburgh Postnatal Depression Scale (EPDS)18 (both discussed in detail later in this article), and structured interviews. The prevalence of depression detected via structured interviews was similar to that detected via use of the EPDS, whereas the BDI found higher estimates of prevalence of depression.

Findings from the AHRQ evidence report on perinatal depression suggest that the EPDS and the Center for Epidemiologic Studies Depression Scale (CES-D) provide the highest level of specificity and sensitivity for depression screening during pregnancy. Another systematic review conducted in 2003 evaluated 13 studies from 7 countries that administered antepartum screening tools to predict risk for postpartum depression. The purpose of the review was to describe screening properties of effective tools and to evaluate implications for screening. The majority of studies in this review developed a study-specific screening instrument for use in pregnancy rather than using a validated depression screening tool. The screening tools were evaluated to determine positive predictive value in classifying women in the prenatal period as having a risk or no risk for postpartum depression. Timing of antepartum screening varied from 10 to 12 weeks gestation to 36 weeks gestation. Outcomes of postpartum depression were calculated by use of the EPDS, standardized psychiatric interviews, or both.The prevalence of women depressed after birth ranged from 5.5% to 31.5%. The authors concluded that none of the screening methods met criteria for routine application in pregnancy because of poor sensitivity and low positive predictive values. Significant limitations to this systematic review include small sample sizes and poor controls for study variables, including variance in cut-off level for depression with the EPDS and inclusion of mothers with a history of depression, abuse, traumatic postnatal events, and personality disorders.

DEPRESSION SCREENING DURING PRENATAL CARE

In 2002, the American College of Nurse-Midwives (ACNM) reissued a position statement on depression screening, stating that certified nurse-midwives (CNMs)/certified midwives (CMs) have a critical role to play in the integration of prevention, screening, treatment, and/or referral for depression into the care they provide for women. Because the signs of pregnancy-related depression and somatic discomforts of pregnancy often overlap, differences between minor or major depression and normal discomforts can be difficult to diagnose. Recommendations include screening all women for pregnancy-related depression by using established, self-administered tools. A study assessing attitudes of obstetrics and gynecology practitioners in the state of Washington explored the frequency of screening for depression and found that although the majority of practitioners surveyed were concerned about depression, only 44% reported conducting depression screening in their offices, regardless of symptoms. Nearly 50% reported that they thought they did not have enough training to treat depression.

In 2004, a convenience sampling of ACNM members composed of CNMs/CMs attending the 2004 ACNM Annual Meeting & Exhibition yielded attendee surveys at a response rate of 42.6% (N = 378). Findings concluded that screening and management of depression is not fully integrated into primary care practice. Measures surveyed that were related to attitudes about depression screening in primary care included knowledge about diagnosis, treatment, screening practices, and incorporation into midwifery practice. Although only 25.1% of CNMs/CMs who participated in this survey reported that they always screen women for depression in primary care visits, 58.5% reported that they usually screen for depression. However, this survey did not examine screening and treatment for depression in pregnancy. If routine depression screening practices in primary care are not universally incorporated, it is likely that inadequate screening throughout antepartum care is common. The role of perinatal screening for depression by British midwives found similar challenges, both in the adequacy of training and frequency of formal screening (N = 182, response rate 86%). Results from this survey demonstrated that only 25% of midwives conducted formal antepartum screening to identify depression, whereas 94% asked women about previous or current psychological problems. Only 16% of midwives indicated that they received formal training in effectively screening for depression in women. Many reported difficulties with referral services, insufficient time for screening, and a deficiency in referral policies as compounding factors. Challenges CNMs/CMs face include perceived lack of qualified training and experience to correctly diagnose or treat depression, limited encounter time during antepartum visits for in-depth interviewing, and insufficient administration of depression screening tools.