Screening for Maternal Depression

Screening women for maternal depression can improve outcomes for women and infants. The earlier a woman is identified with maternal depression, the earlier she can receive treatment. Currently, there are no national evidence-based guidelines regarding the recommended intervals (i.e., timing or frequency) for prenatal or postpartum depression screening, and the optimal settings, tools and targets (i.e., major vs. minor depression) for screening have not been identified. There is good evidence that maternal depression can be accurately identified using brief standardized depression screening instruments, and that treatment improves the prognosis for the woman and her family.

The NYS Medicaid program will provide reimbursement for postpartum maternal depression screening and referral for diagnosis and treatment, as appropriate. Please click here for more information.

The table below summarizes the current recommendations for maternal depression screening by several professional organizations.

Recommendations for Maternal Depression Screening

Organization Recommendations
U.S. Preventive Services Task Force (USPSTF) Recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. *
American Congress of Obstetrician and Gynecologist Committee on Obstetric Practice (ACOG) Recommends clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool. Screening should be coupled with appropriate follow-up and treatment when indicated.
American Academy of Pediatrics Bright Futures and Mental Health Task Force The primary care pediatrician, by virtue of having a longitudinal relationship with families, has a unique opportunity to identify maternal depression and help prevent untoward developmental and mental health outcomes for the infant and family. Screening can be integrated, into the well-child care schedule and included in the prenatal visit. This screening has proven successful in practice in several initiatives and locations and is a best practice for PCPs caring for infants and their families. Intervention and referral are optimized by collaborative relationships with community resources and/or by co-located/integrated primary care and mental health practices.
AAP/ACOG Guidelines for Perinatal Care Prior to delivery, patients should be informed about psychosocial issues that may occur during pregnancy and in the postpartum period. A woman experiencing negative feelings about her pregnancy should receive additional support from the health care team. All patients should be monitored for symptoms of severe postpartum depression and offered culturally appropriate treatment or referral to community resources. Specifically, the psychosocial status of the mother and newborn should be subject to ongoing assessment after hospital discharge. Women with postpartum blues should be monitored for the onset of continuing or worsening symptoms because these women are at high risk for the onset of a more serious condition. The postpartum visit approximately 4-6 weeks after delivery should include a review of symptoms for clinically significant depression to determine if intervention is needed.
  • * A USPSTF Grade "B" recommendation means that the USPSTF recommends that practices offer or provide this service, based on findings that there is high certainty that the net benefit is moderate or that there is moderate certainty that the net benefit is moderate to substantial.
  • American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 6th ed. Elk Grove Village, Ill.: American Academy of Pediatrics, and Washington, D.C.: American College of Obstetricians and Gynecologists, 2007.

Despite widespread recognition of the problem of maternal depression and the potential benefits of screening, studies suggest that screening for maternal depression is not standard. In a survey of OB/GYNs, less than half of providers reported that they often or always screen their patients for depression or use validated screening tools. A study assessing screening rates among pediatricians found that only 8% of pediatricians routinely ask their patients' mothers about depressive symptoms, and none reported using standardized screening questionnaires. These studies suggest that there are significant missed opportunities to identify women at risk for maternal depression. Since one half of postpartum depression begins during pregnancy, and women with a personal or family history of depression are at increased risk, the prenatal period is an ideal time for screening and prevention, which may be done easily with maternal depression screening instruments. Women who have had previous postpartum depression may wish to take medication immediately after delivery to prevent recurrence, or choose to be monitored closely for symptoms.

New York State specific data from the Medicaid Perinatal Care Study showed that 63% of women were assessed for depression at the initial visit assessment, but among these, only 7% of records documented using standardized screening tools. In addition, 51.4% of women with a documented postpartum visit were assessed for depression.

Screening Tools

A number of validated screening tools are available, including both provider- and patient-administered instruments, and tools designed for screening a general adult population as well as those developed specifically for maternal depression. At this time, no single screening tool is recommended by U.S. professional organizations. A 2005 review by Gaynes et al found that various tools can accurately identify maternal depression, and that the Edinburgh Postpartum Depression Scale (EPDS) and the Postpartum Depression Screening Scale (PDSS)may be more accurate than others. The USPSTF and ACOG have endorsed the use of a two-question screen, such as those included in the Patient Health Questionnaire-2 (PHQ-2), and a 2007 study by Gjerdingen et al suggested using the PHQ-2 as an initial screening test, followed by the PHQ-9 to confirm a diagnosis for women who screen positive on the PHQ-2.

Screening tools can help providers introduce the subject of depression and differentiate depression from "normal" symptoms of pregnancy and postpartum adjustment. Screening can be incorporated in routine prenatal, postpartum and well-baby visits. It is important to remember that screening does not replace a diagnostic work up, but can help to identify women at risk for depression and in need of further follow-up evaluation and treatment.

The table below summarizes available screening tools for depression in adults, including tools specific for maternal depression.

Selected Screening Tools for Maternal Depression

Screening Tools Description Cost
BDI®-FastScreen for Medical Patients (previously known as the Beck Depression Inventory-Primary Care version/BDI-PC)
  • Used to detect depressive symptoms
  • Completed by patient
  • Seven items
  • Takes less than five minutes to complete
Cost to purchase complete kit (manual and record forms); price varies by format
Center for Epidemiologic Study Depression Scale (CES-D
  • Measures depressive feelings and behaviors over the past week
  • Completed by patient
  • 20 questions
  • Takes about five minutes to complete
Free
Edinburgh Postnatal Depression Scale (EPDS)
  • Created specifically to identify patients at risk for postpartum depression
  • Assesses symptoms of depression and anxiety
  • Completed by patient
  • Ten questions, takes five to ten minutes to complete
  • Most widely used screening tool among pregnant and postpartum women
Free
Hamilton Rating Scale for Depression (HAM-D)
  • Determines patient's level of depression before, during and after treatment
  • Administered by clinician
  • 21 items but scoring is based on first 17 questions
  • Takes 15-20 minutes to complete interview and score results
Free. Requires free membership registration
Montgomery-Asberg Depression Rating Scale (MADRS)
  • Used in patients with major depressive disorder to measure the degree of severity of depressive symptoms and the change in symptom severity during treatment.
  • Administered by clinician
  • Ten-item checklist
  • Takes about 15 minutes to complete
Free
Patient Health Questionnaire-2 (PHQ-2)
  • Asks two simple questions about mood: 1) Over the past two weeks, have you ever felt down, depressed, or hopeless? 2) Over the past two weeks, have you felt little interest or pleasure in doing things?
  • Completed by patient or administered by clinician
  • Takes less than one minute to complete
  • Positive scores should be followed up with a more comprehensive screening tool
  • Endorsed by ACOG and USPSTF
Free
Patient Health Questionnaire-9 (PHQ-9)
  • Screens for depression and can be used to monitor symptom severity during treatment
  • Completed by patient
  • Nine-item questionnaire, takes about five to 10 minutes to complete and then can be quickly scored by staff or self-scored by patient
Free
Postpartum Depression Screening Scale (PDSS)
  • Used to identify women at high risk for postpartum depression
  • Completed by patient
  • 35-item questionnaire
  • Can be completed in five to 10 minutes
Cost to purchase complete kit (25 AutoScore test forms and scoring manual)
RAND 3-Question Screen
  • Three-item adaptation of an eight-item depression screener
  • Completed by patient
  • Takes less than a minute to complete
Free

Source: National Institute for Health Care Management, 2010.