This June, the American College of Obstetrics and Gynecology (ACOG) recommended new screening guidelines for perinatal mental health conditions, including postpartum depression (PPD). The guidelines provide recommendations for PPD screening and diagnosis and offer ungraded “Good Practice Points” to help support physicians’ decision-making in cases with inadequate or no evidence.

American College of Obstetrics and Gynecology. Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum. June 2023.

 

For the most part, the guidelines are consistent with ACOG’s past recommendations; however, they emphasize the importance of screening during pregnancy as well as after giving birth. G. Thomas Ruiz, MD, the OB/GYN lead at MemorialCare Orange Coast Medical Center in Fountain Valley, CA, says that screening during pregnancy is typically recommended at 28 weeks into pregnancy. These early screens may have a profound impact on detecting PPD and give patients a “head start” on care, Dr. Ruiz adds.

 

What does ACOG recommend for PPD screening?

 

Among other things, ACOG’s new PPD screening guidelines recommend:

• Screening patients at their initial prenatal visit, later in pregnancy, and at postpartum visits.

  Patient screening.

   

   

• Screening patients for bipolar disorder before administering any pharmaceutical treatments for depression or anxiety.

• Asking immediate follow-up questions if a person expresses suicidality or self-harm intentions, including asking about likelihood, acuity, and severity of risk. After this, clinicians should arrange for risk-tailored management. 

• Providing immediate medical attention for people experiencing postpartum psychosis.

• Conducting screenings using standardized, validated tools. (ACOG does not endorse a specific tool so long as it is standardized and validated.)

• Offering educational materials for patients and families, action plan advice for dealing with mood changes, and self-care recommendations, such as those provided by the maternal mental health organization Lifeline for Moms.

 

Reframing PPD as perinatal depression

 

Because PPD symptoms can occur before and after giving birth, some researchers say that the condition may be more accurately referred to as perinatal depression.

Moore Simas TA, Whelan A, Byatt N. Postpartum Depression—New Screening Recommendations and Treatments. JAMA. Published online November 27, 2023. doi:10.1001/jama.2023.21311

 

In an article commenting on the new guidelines, researchers highlight studies showing that perinatal depression impacts one in seven perinatal individuals, with 27% of cases impacting people before pregnancy, 33% impacting people during pregnancy, and 40% impacting people in postpartum time frames. As a whole, perinatal mental health conditions like perinatal depression, depression, anxiety, bipolar disorder, acute postpartum psychosis, substance use disorders, and suicidality are the “leading cause of overall and preventable maternal mortality,” according to studies.

Moore Simas TA, Whelan A, Byatt N. Postpartum Depression—New Screening Recommendations and Treatments. JAMA. Published online November 27, 2023. doi:10.1001/jama.2023.21311

 

 

Delays in mental health care highlight the importance of early screening

 

Early PPD screening may be particularly impactful in states where laws prevent doctors from directly referring patients to mental health specialists or for new patients facing long waitlists, says Dr. Ruiz.

Dr. Ruiz works in California, where he says “mental health services are considered to be a carve-out” service.

“What that means is I can only suggest you see a mental health specialist or therapist,” Dr. Ruiz adds. “You actually have to call your health plan and get the name of an approved specialist and then call and make the appointment yourself—and right now it’s taking anywhere from four to six weeks for a patient to get into therapy.”

 

What makes a standardized, validated PPD screening tool?

 

Researchers have verified validated PPD screening tools as effective for detecting mental health conditions like depression. Some of these are the Edinburgh Postnatal Depression Scale (EPDS), a questionnaire that asks patients about mental health symptoms, some of which can be specific to pregnancy, and the PHQ-2/PHQ-9 scales, which ask more generally about mental health symptoms and are often used for non-pregnant patients as well.

J. L. Cox, J.M. Holden, R. Sagovsky. EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS). British Journal of Psychiatry (1987), 150, 782-786.

Gjerdingen D, Crow S, McGovern P, Miner M, Center B. Postpartum depression screening at well-child visits: validity of a 2-question screen and the phq-9. Ann Fam Med. 2009;7(1):63-70.

 

A 2019 survey conducted by the American Academy of Pediatrics (AAP) prior to the new recommendations found that only about half of pediatricians who responded (all of whom were members of AAP) conduct formal screening for maternal depression.

American Academy of Pediatrics. Primary Care Pediatricians’ Current Screening Practices for Developmental Delay, Maternal Depression, and Social Determinants of Health. May 20, 2020.

 

This is because hormonal changes in pregnancy can greatly impact a patient’s mental state, even those who do not have a history of mental health conditions. Hormones are neuromodulators, which influence how people’s neurotransmitter “communicates signals from nerve to nerve to get things done,” Dr. Ruiz explains. Rapid hormonal changes in and after pregnancy can impact this process, posing risks to anyone’s mental health, he adds. 

“Especially in the OB/GYN world, anyone can be susceptible to postpartum depression,” Dr. Ruiz says. “The screening questions in and of themselves can take less than 5 minutes to answer.”