Screening for Perinatal Depression Is Not Enough
Women, Babies, and Their Families Deserve Access to Adequate Treatment As Well
It is estimated that 1 in 7 women suffer from a depressive disorder during pregnancy or after childbirth. Untreated maternal mood disorders are associated with serious pregnancy complications and psychopathology in offspring. Maternal suicide is emerging as the leading cause of maternal mortality, exceeding deaths from hemorrhage or hypertensive disorders of pregnancy.
In recognition of this, the American College of Obstetricians and Gynecologists (ACOG) and the US Preventive Services Task Force both recommend that women be screened for depression during pregnancy and after giving birth.1 About 40 states have issued guidelines or mandates for postpartum depression screening. Such a bill is being debated here in California at present.
Sounds good so far, right? The logical endpoint of population-based screening is remission of depression in those who screen positive, however. Otherwise screening is just an empty endeavor. The extant limited data suggest that this may be the case at present.
A systematic review conducted in 2016 by Cox and colleagues2 analyzed 32 studies that included screening, referral, adequate treatment, or remission rates for antepartum and postpartum depression. Adequate treatment was defined as at least 6 weeks of psychotherapy or daily antidepressant therapy at the recommended dose; just 1 study out of the 32 examined this. The authors of the review report that only 8.6% of women who were diagnosed in pregnancy with a depressive illness received an “adequate” trial of treatment. Extrapolating from depression treatment rates in the general population and those for women with postpartum depression, they further estimate that only 6.3% of cases of depression diagnosed in the postpartum was adequately treated. I put the word “adequate” in quotes because I think most psychiatric providers would agree that a truly adequate trial of an antidepressant or psychotherapy spans at least 6 months. Data from the few studies that examined depression remission rates (variably defined), assuming the above treatment rates, suggest that only 4.8% of women with diagnosed depression in pregnancy and 3.2% of women diagnosed after birth achieved remission.
These data are now a few years old. Hopefully we have taken more strides toward alleviating the far-reaching suffering and cost of perinatal depression. Hopefully behavioral health is becoming increasingly integrated into maternity care, as ACOG recommends (albeit without specific actionable items), through local programs around the country.
Screening women who present for prenatal or postpartum care is pretty easy: hand the patient a copy of the 10-question Edinburgh Postnatal Depression Scale (EPDS), score it, and file it in her chart. No wonder state governments have gotten on the perinatal depression screening bandwagon: it is relatively simple, inexpensive, and makes officials appear responsive to the mental health needs of women and children.
Don’t get me wrong. Screening is absolutely necessary. According to ACOG, fewer than 20% of women disclose symptoms of perinatal mood disorders to a health care provider, and apparently only 7.2% to their psychiatrists.3 But where is the call for building integrative systems of care that actually address the devastating effects of untreated perinatal mood and anxiety disorders (PMADs)? Yes, these will cost money. However, the cost of untreated PMADs can also been monetized. Keeping in mind that 2 generations of patients are involved, Cox and colleagues estimate that $15 billion in health care dollars are lost because of untreated PMADs each year.
It is shockingly clear that much work remains to be done. Meeting the mental health needs of women during the peripartum cannot be done without psychiatric providers’ involvement. The need to integrate care is clear, but the way forward remains strewn with complexity.
Mousumi Mukerji is a certified nurse midwife who earned her master’s degree in nursing from Yale University, New Haven, Connecticut. She has provided prenatal, intrapartum, gynecological, and primary care to women throughout the United States and across the lifespan. Mukerji received a certificate in the assessment and management of perinatal mood disorders from Postpartum Support International in 2016. She completed the psychiatric-mental health nurse practitioner program at the University of California, San Francisco in March 2018 and is a board-certified PMHNP. She has research experience on the knowledge, attitudes, and beliefs about HIV/AIDS in India. Her future career interests lie in maternal mental health, trauma therapy, and psychotherapies.