Moving Backwards? Why Doesn’t the Canadian Task Force on Preventive Health Care Recommend Standardized Screening for Perinatal Depression?
In its latest recommendations, the Canadian Task Force on Preventive Health Care recommends against screening all individuals for depression during pregnancy and the postpartum period using standardized questionnaires. This decision is based on the fact that the evidence identified by the task force is unclear as to whether screening confers benefit above usual clinical care. This recommendation assumes that usual care during pregnancy and the postpartum period includes inquiry and attention to mental health and well-being of patients.
To be clear, the task force continues to recommend screening for perinatal depression; however, they are saying that screening using a standardized questionnaire does not appear to provide any benefit over usual care.
The task force found only one study demonstrating a benefit of routine depression screening in perinatal patients. This study was a randomized controlled trial carried out in Hong Kong in which 462 postpartum women were randomly assigned to receive screening using the Edinburgh Postnatal Depression Scale (EPDS) or no screening at two months postpartum. The women in the screening group were less likely than the no screening group to have an elevated EPDS score at six months postpartum (risk ratio: 0.59).
In an interview with Medscape, the lead author Dr. Eddy Lang also noted that this recommendation reflects womens’ preferences. He noted, “Although they told us they liked the idea of universal screening, they admitted to their family doctors that they actually preferred to be asked about their well-being, [to be asked] how things were going at home, and [to have] a discussion about their mental health and well-being, rather than a formal screening process. They felt a discussion about depression with a primary healthcare provider during the pregnancy and postpartum period is critical.”
While the Canadian Task Force on Preventive Health Care is correct — we do not have a clear signal to indicate that questionnaire-based screening improves outcomes — recommending against standardized screening seems short-sighted. We have ample evidence to indicate that usual obstetric care does not reliably identify women with perinatal depression and that standardized questionnaires outperform clinicians in terms of identifying women with depression during pregnancy and the postpartum period. Of course, most patients would like to have a more personal conversation about their mental health with their provider. The questionnaire is by no means a substitute for this discussion; using questionnaires helps clinicians to provide more individualized, targeted care. A standardized questionnaire is a relatively inexpensive and easy means of flagging women who need a more thorough mental evaluation and, based on that evaluation, might benefit from additional support or intervention.
I suspect that the reason we do not see better outcomes with screening for perinatal depression does not reflect a problem with screening but is more indicative of what happens when women screen positive for depression. Despite increasing awareness of and comfort with treating perinatal depression over the last few decades, there continue to be many barriers to obtaining care. We continue to hear about women who have not been able to access care in a timely fashion and those who have not been able to find treaters with expertise in the treatment of perinatal mood and anxiety disorders.
Perinatal depression is the most common complication of pregnancy and childbirth. Even if our mental health care system is not yet able to fully address the needs of this population, we need to continue to make maternal mental health a priority. This includes universal screening, the identification of women at high risk for perinatal mood and anxiety disorders, preventative interventions, and building a network of appropriate treatment referrals. We cannot afford to reverse directions with recommendations that imply that screening using standardized instruments is ineffective.
Ruta Nonacs, MD PhD
Lang E, Colquhoun H, LeBlanc JC, et al. Recommendation on instrument-based screening for depression during pregnancy and the postpartum period. CMAJ July 25, 2022 194 (28) E981-E989.
Guideline Advises Against Depression Screening in Pregnancy (Medscape)