How to improve perinatal depression screening

Although perinatal depression is associated with several maternal risks and adverse outcome for offspring, it remains underdiagnosed and undertreated. A recent study in Obstetrics & Gynecology evaluated whether an institutional policy of universal perinatal depression screening is associated with increased screening frequency and treatment after a positive test result.

The retrospective cohort included women receiving prenatal care from a single academic medical center from 2008 to 2015. In January 2008, the state of Illinois enacted the Perinatal Mental Health Disorders Prevention and Treatment Act, which requires that obstetric providers: 1) provide education regarding perinatal depression during prenatal and postdelivery care and; 2) screen women for perinatal mental health disorders during prenatal and postnatal care. Following the mandate, an institutional policy of universal perinatal screening was disseminated with recommendations of screening twice antenatally and again postpartum.

To include women whose entire pregnancies occurred before or after the policy implementation, the study cohorts included women who delivered between January 1, 2008 and January 30, 2009 (pre-recommendation group) and women who delivered between December 1, 2009 and December 30, 2014 (post-recommendation group). Screening relied on the 9-item Patient Health Questionnaire (PHQ-9) at the first prenatal visit (28-32 weeks’ gestation) and at the postanal visit (6 weeks’ postpartum). Women who screened positive were given a diagnostic evaluation by the obstetrician, followed by initiation of a treatment plan.

Of the 5,127 women included in the study, 4,005 (78%) were in the post-recommendation group. In terms of demographics, women in the post-recommendation group were younger, more likely to belong to a racial-ethnic minority, have public insurance, have a medical comorbidity, multiparous, and had a higher prepregnancy BMI.

Frequency of depression screening completion in the first prenatal visit (0.1% vs 65.5%), in the third trimester (0.0% vs 42.7%), and the postpartum visit (69.5% vs 90.0%) all significantly increased after initiation of the policy (P < .001 for all). Even after controlling for potential confounders (maternal age, race-ethnicity, insurance, medical comorbidities, parity, and prepregnancy BMI), the improvement in postpartum depression screening completion persisted (adjusted odds ratio 5.3, 95% CI 4.4-6.5).

The authors also noted that following the initial increase in screening, the frequency of screening in the first and third semesters continued to rise over time (P < .001 for each) but the frequency remained stable for the postpartum visit (P = .29). However, the post-recommendation group was significantly more likely to have depression treatment recommended or provided by their obstetrician (64.7% vs 30.1%, P < .001).

The authors believe their findings indicate that an institutional policy of universal perinatal depression screening is effective for improving perinatal depression diagnosis and treatment. They also noted that their findings support recent guidelines from The American College of Obstetricians and Gynecologists (ACOG) and the U.S. Preventive Services Task Force (USPSTF), which have both recommended screening for perinatal depression antenatally and postpartum.