‘Is it baby blues or perinatal depression?’ This might be a question asked by a lot of women during the perinatal period (from the start of pregnancy to a year after the birth of a child). According to the Diagnostic and Statistical Manual of Mental Disorders-5th edition (American Psychiatric Association, 2013), perinatal depression is defined as a major depressive episode with onset during pregnancy or within 4 weeks after delivery.
Perinatal depression is difficult to detect (Cox et al., 2016; El-Den et al., 2015). One reason is that common somatic or behavioural symptoms experienced by women during pregnancy and motherhood, such as fatigue, change in appetite and sleep patterns, make it difficult for clinicians or pregnant women to distinguish them from depressive symptoms (Yonkers et al., 2009). As a result, a significant number of women with perinatal depression go untreated. For instance, Cox et al., (2016) reported that 50 to 70% of women with perinatal depression were undetected and 85% were untreated in the United States.
Recently, more guidelines on perinatal depression screening have been developed and place the responsibility for screening perinatal depression on healthcare professionals (El-Den et al., 2015). However, research on guidelines for psychological and psychosocial assessment and intervention during the perinatal period, covered in this blog, has found that although key recommendations were consistent among guidelines, the quality of guidelines varied. Moreover, the implementation of clinical guidelines during the perinatal period in clinical practice still remains under-researched.
This review by Yang et al., (2024) aimed to evaluate the existing recommendations for perinatal depression screening and examine whether there are any discrepancies between guidelines’ recommendations and current research or clinical practice.
It is important to examine the gap between perinatal depression screening guidelines and what we’re actually doing in practice.
Methods
The protocol of this review was pre-registered and the study was conducted according to the PRISMA checklist. The reviewers conducted two searches covering publications in English and Chinese from 1 January 2010 to 19 December 2021.
First, the review searched 15 databases to identify observational studies that either i) focussed on perinatal depression or ii) investigated perinatal depression screening or iii) explored the prevalence of perinatal depression using validated measures. Studies that focused on specific groups of women or using methods for depression screening other than validated scales were excluded.
Second, relevant academic organisations’ websites, such as the Scottish Intercollegiate Guidelines Network, National Institute for Health and Care Excellence and World Health Organisation, were searched to identify guidelines, recommendations and reports related to perinatal depression screening.
Four reviewers conducted the title and abstract screening followed by examining the eligibility of the studies. The risk of bias of the included studies was then assessed following the relevant Joanna Briggs Institute (JBI) frameworks.
Results
Summary of guidelines
Forty-seven documents related to guidelines for perinatal depression screening were included in the review with the majority from high-income countries except one from China. Most guidelines (all but one) recommended routine screening and conducting screening at least once during the perinatal period. The majority of the guidelines also recommended using validated screening tools and encouraged healthcare referrals for those with positive screening results or a history of psychiatric illnesses.
However, there were significant variations in the guidelines. In terms of the timing of screening, for antenatal depression, recommendations ranged from first, second and third trimesters, whilst for postpartum depression, first screening recommendations ranged from 6 weeks to 6 months with subsequent screenings at 3, 6, 9, 12 months postpartum. There was little consensus on preferred screening modalities, screening personnel and screening settings with half of the guidelines not providing recommendations for screening modalities and settings.
Adherence to guidelines
103 original studies, including cross-sectional studies, cohort studies, case-control studies and prevalence studies, were examined with most conducted in upper-middle to high-income countries and 28 from low and middle-income countries. According to risk of bias assessment, the cross-sectional studies were mostly good quality whilst the prevalence studies had a relatively high risk of bias. The quality of the cohort studies and case-control studies could not be concluded due to limited sample sizes.
The review results showed that there were significant discrepancies between the implementation of guidelines and guidelines recommendations in terms of routine screening, referrals and timing and frequency of screenings.
First, regarding routine screening, although all guidelines except one recommended routine screenings, only 8.7% of the studies reviewed conducted routine screening. Moreover, the details of screening were poorly reported with only two studies reporting the screening and completion rates. With most studies focused on one-time screening, the result implies that there might be a lack of adoption of routine screening in clinical practice.
Second, a disparity was shown between guidelines and implementation regarding routine referrals with only 27.2% of the original studies providing referrals for mothers with positive screening results in addition to few studies referring mothers with a history of severe mental illness.
Third, most guidelines recommend having perinatal depression screening at their first perinatal visit. However, only 22.2% of studies reported conducting screening during the first trimester.
Despite guidelines recommending routine screening for perinatal depression, just under 9% of the studies included in this review showed evidence of this happening.
Conclusions
The authors noted there were variations regarding the timing and frequency of perinatal depression screening and a consensus of having routine screening and referrals in existing international perinatal depression guidelines. However, according to this review, routine screening and referrals were not widely adopted in clinical practice.
According to this review, routine screening and referrals for perinatal depression were not widely adopted in clinical practice.
Strength and limitations
The review provides a useful summary of perinatal depression screening across different countries. By examining guidelines and original studies in both English and Chinese, it allowed more studies conducted in non-Western countries to be included, hence, increasing the review’s cultural representativeness. However, given most guidelines were from high-income countries, it may be more suitable to examine the implementation of guidelines in low- to middle-income countries according to their own guidelines since their healthcare systems and economic situation may be different from those in high-income countries.
In terms of methodology, the review was pre-registered in accordance with best practice and followed the gold standard – PRISMA guidelines. The study selection was clearly reported. Moreover, the quality assessment was conducted according to the Joanna Briggs Institute (JBI) framework and inter-rater reliability was reported. This strengthens the reliability of the findings of the included studies. However, given the questionable quality of the included prevalence studies, cohort studies and case-control studies, the interpretation of the included studies’ results requires caution. Moreover, the review did not state the authors of the included studies were contacted for unpublished studies, which makes the review more at risk of publication bias.
Additionally, the review has included 103 original studies that focus on perinatal depression screening or studying the prevalence of perinatal depression. However, the details of these studies are not reported in the review. For instance, there is a lack of methodological details such as whether the study was conducted in healthcare settings or whether it involved provider self-reports. Studies have found that most providers tend to overestimate their screening prevalence (Kim et al., 2009). It may be useful to examine whether the included studies were providers’ self-report or conducted in a healthcare setting in order to better understand the current clinical practice of perinatal depression screening.
The review examined guidelines and original studies in both English and Chinese.
Implications for practice
The lack of evidence base on clinical effectiveness of perinatal depression screening in addition to the cost required (Reily et al., 2020) may explain the lack of implementation of routine screening despite guidelines’ recommendations. In the UK, despite the National Institute for Health and Care Excellence (NICE) guidelines recommending detection and assessment of perinatal depression in the first contact with primary care or early in the postnatal period (NICE, 2023), the UK National Screening Committee (UKSNC) does not recommend postnatal depression screening due to a lack of accurate screening tools and unclear clinical effectiveness of postnatal depression screening (UKSNC, 2019). However, there is growing evidence supporting the acceptance of perinatal depression screenings (PDS) among healthcare professionals (El-Den et al., 2015) and the clinical effectiveness of PDS in improving access and engagement with mental health services (Reilly et al., 2020). This shows the need to develop the evidence base for the clinical effectiveness of screening and also the effectiveness of screening tools, such as the Edinburgh Postnatal Depression Scale, which can help guidelines to identify the most suitable screening tool based on the evidence base and help encourage routine screening to be carried out.
As a slight aside, previous research has also demonstrated that depression screening tools are not yet good enough to reliably detect postnatal depression in new Dads, as is demonstrated by this lived experience blog by the Mental Elf Founder André Tomlin.
In addition to routine screening, treatment of perinatal depression in a timely manner also relies on a systematic regular referral process and clear referral pathways to relevant services after perinatal depression screening (Reilly et al., 2020). However, this review noted that systematic referral processes have not been widely adopted in clinical practice. There is also a lack of clarity about the referral criteria, responsible healthcare professionals and services to be referred to. Policymakers in different countries need to set clear guidelines on referral criteria, such as positive screening results, and identify healthcare professionals and referral pathways according to the structure and needs of their healthcare system. This would facilitate the development of clear referral pathways in guidelines and in clinical practice.
More evidence supporting the validity and reliability of screening tools is needed for guidelines to recommend suitable screening tools.
Statement of interests
No conflicts of interest to declare.
Links
Primary paper
Yang, Y., Wang, T., Wang, D., Liu, M., Lun, S., Ma, S., & Yin, J. (2024). Gaps between current practice in perinatal depression screening and guideline recommendations: a systematic review. General Hospital Psychiatry. https://doi.org/10.1016/j.genhosppsych.2024.04.011
Other References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Cox, E. Q., Sowa, N. A., Meltzer-Brody, S. E., & Gaynes, B. N. (2016). The perinatal depression treatment cascade: baby steps toward improving outcomes. The Journal of clinical psychiatry, 77(9), 20901.
El-Den, S., O’Reilly, C. L., & Chen, T. F. (2015). A systematic review on the acceptability of perinatal depression screening. Journal of Affective Disorders, 188, 284-303. [PubMed abstract]
National Institute for Health and Care Excellence. (2020). How should I assess a women with depression in pregnancy or postnatally?. https://cks.nice.org.uk/topics/depression-antenatal-postnatal/diagnosis/assessment/#:~:text=NICE%20recommends%20a%20two%2Dstep,)%20%5BNICE%2C%202020%5D.
Purnell, L. (2024). A review of guidelines for perinatal mental health: psychological and psychosocial assessment and intervention. The Mental Elf, July 2024.
Reilly, N., Kingston, D., Loxton, D., Talcevska, K., & Austin, M. P. (2020). A narrative review of studies addressing the clinical effectiveness of perinatal depression screening programs. Women and Birth, 33(1), 51-59. [ScienceDirect abstract]
UK National Screening Committee. (2019, February 27). Screening for antenatal and postnatal mental health problems. https://view-health-screening-recommendations.service.gov.uk/postnatal-depression/
Woody, C. A., Ferrari, A. J., Siskind, D. J., Whiteford, H. A., & Harris, M. G. (2017). A systematic review and meta-regression of the prevalence and incidence of perinatal depression. Journal of affective disorders, 219, 86-92. [ScienceDirect abstract]
Yonkers, K. A., Smith, M. V., Gotman, N., & Belanger, K. (2009). Typical somatic symptoms of pregnancy and their impact on a diagnosis of major depressive disorder. General hospital psychiatry, 31(4), 327-333. [ScienceDirect abstract]
