Evidence summary on the timing and frequency of screening for perinatal depression
Original Article

Evidence summary on the timing and frequency of screening for perinatal depression

Shafeng Jia1#, Mengwei Zhi2#, Jia Liu1, Jia Liu3, Ling Jiang3, Yueqin Zhu3

1Department of Obstetrics, Suzhou Municipal Hospital, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China; 2Department of Hepatobiliary Surgery, Suzhou Municipal Hospital, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China; 3Department of Nursing, Suzhou Municipal Hospital, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, China

Contributions: (I) Conception and design: J Liu, J Liu; (II) Administrative support: M Zhi; (III) Provision of study materials or patients: L Jiang; (IV) Collection and assembly of data: S Jia, Y Zhu; (V) Data analysis and interpretation: S Jia; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

#These authors contributed equally to this work.

Correspondence to: Jia Liu. Department of Obstetrics, Suzhou Municipal Hospital, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou 215000, China. Email: 2271634769@qq.com; Jia Liu. Department of Nursing, Suzhou Municipal Hospital, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou 215000, China. Email: liujia_sz@163.com.

Background: This study sought to search, evaluate, and summarize the best evidence about the time and frequency of screening for perinatal depression (PND).

Methods: The UpToDate, Scottish Intercollegiate Network, National Institute for Health and Care Excellence, National Guideline Clearinghouse, Guidelines International Network, BMJ Best Practice, Cochrane Library, Embase, Campbell Collaboration, CINAHL, Joanna Briggs Institute Library, Medline, CNKI, Wanfang, VIP, and CBM databases were searched to retrieve relevant articles.

Results: A total of 9 articles were included in the meta-analysis, comprising 2 guidelines, 1 expert consensus, 1 evidence summary, 3 systematic reviews, and 2 clinical decisions. A total of 11 articles of best evidence were collected. The evidence was mainly related to the two aspects of screening time and frequency.

Conclusions: There is abundant evidence on the best screening time for and frequency of PND; however, some evidence was from foreign evidence-based resources. Local clinical conditions need to be considered at the time of application.

Keywords: Perinatal depression (PND); screening time; screening frequency; evidence-based nursing

Submitted Aug 17, 2021. Accepted for publication Oct 22, 2021.

doi: 10.21037/apm-21-2675

Introduction

Perinatal depression (PND), which includes antenatal depression (AND) and postpartum depression (PPD), refers to mood disorders occurring from pregnancy to within 1 year postpartum for which the core symptoms are depression and anhedonia, accompanied by low interest, decreased attention, depression, and low self-evaluation symptoms (1). The incidence of PND worldwide is 12.4–38.8% (2). An Australia retrospective study shows the incidence of antenatal and postnatal depressive symptoms was 6.2% and 3.3%, respectively (3). In mainland China, the incidence of PND is 16.3%, among which, 19.7% is AND, and is 14.8% is PPD. PND has been on the rise in the past decade (4). Studies have shown that PND is not conducive to the physical and mental health of mothers and infants, affects family relationships, and sustained PND also causes short- and long-term adverse effects on infants’ cognitive, personality, emotion, and behavior development (5-7). In severe cases, patients’ may even commit suicide or infanticide (8-10), which places a heavy burden on families and society. PND interacts with pregnancy complications, smoking, social support, and other factors that jointly lead to adverse pregnancy outcomes. Thus, targeted preventive measures, such as specially trained health-care personnel, need to be implemented to provide appropriate help and guidance to women via timely screening and improve the mental health status of maternal women (11). According to the literature review, there is no uniform standard for the screening time of PND. Thus, best time for PND screening (e.g., prenatal or postpartum, or continuous multiple screenings) requires further study (12,13). Indeed, there is very little evidence on the best timing and frequency of PND screening. Thus, conclusions from a wider range of studies are important for clinical practice. This study sought to provide a scientific and effective decision basis for the time and frequency of PND screening through the retrieval, summary and analysis of domestic and foreign evidence.

Methods

Question identification

The question was identified using the Johns Hopkins’s evidence-based nursing practice problem development tool and the PICO principle. The formed initial question was as follows: P (population): adult maternal women; I (intervention): Timing and frequency of PND screening; C (comparison): Current time and frequency of routine screening for PND in adult maternal women; O (outcome): PND screening positive rate, screening positive referral rate, and Edinburgh postnatal depression scale (EPDS).

Retrieval strategies

The following Chinese search terms were used: “gravida/puerpera/maternal/perinatal stage/antenatal/postpartum/puerperium”, “screening/assessment/management”, and “depression/Perinatal depression/anxiety/psychogeny/ Edingburgh postnatal depression scale”. The following English search terms were used: “pregnant woman/puerperal/perinatal/antepartum/postpartum/puerperium”, “screening/assessment/management”, and “depression/perinatal depression/anxiety/mood disorders/Edinburgh Postnatal depression scale”. The following databases were searched: UpToDate, Scottish Intercollegiate Network (SIGN), National Institute for Health and Care Excellence (NICE), National Guideline Clearinghouse (NGC), Guidelines International Network (GIN), BMJ Best Practice, Cochrane Library, Embase, Campbell Collaboration, CINAHL, JBI Library, Medline, China National Knowledge Infrastructure (CNKI), Wangfang, cqvip.com, and Chinese Biomedical Literature Database. Guidelines, expert consensuses, evidence summaries, clinical decision making articles, systematic reviews, and meta-analyses were included in this study.

Literature inclusion and exclusion criteria

To be eligible for inclusion in this study, the articles had to meet the following inclusion criteria: (I) the subjects comprised adult maternal women (≥18 years old); (II) the research examined the screening, assessment, or management of PND; (III) the article was published in the Chinese or English language; and (IV) the article was published between January 2016 and March 12, 2021. There were no restrictions in relation to the research environment. Articles were excluded from the study if they met any of the following exclusion criteria: (I) the article was a direct translation, or repeatedly included foreign guidelines or expert consensuses, such as guideline interpretations; (II) the article only comprised a published abstract; (III) the full text was not available; and/or (IV) the article failed to pass the literature quality evaluation.

Literature quality evaluation criteria

Clinical Guidelines were evaluated with Appraisal of Guidelines for Research and Evaluation, AGREE II (14). The scores of AGREE II ranges from 1–7, with 1 being “strongly disagree” and 7 being “strongly agree”. Guidelines were included or excluded based on the results of a standardized evaluation. The systematic review and expert consensus articles were evaluated using the evaluation criteria of the Australia JBI Evidence-based Health Care Center (15). CASE list was used to evaluate the evidence summary article (16). To evaluate the clinical decisions, they were traced back to the original literature based on the evidence, and corresponding evaluation criteria were selected according to the type of the original literature.

Literature quality evaluation process

Two researchers trained by the JBI Collaborating Center for Evidence-based Care at Fudan University independently evaluated the articles in accordance with the above criteria. The researchers discussed the evaluation results of each article together. If a dispute arose, the issue was discussed with a 3rd, researcher who decided whether to include or exclude the article. If there were any conflicts about the conclusions drawn for different sources of evidence, the principle of “evidence-based evidence first, high-quality evidence first, the latest published evidence first” was adopted.

Evidence extraction and summary

The data were extracted and cross-checked by the two researchers using a pre-developed “General information on the included literature” form. The extracted data included the author, the subject, evidence type, publication date, and source database.

Results

General characteristics of the included articles

Ultimately, a total of 9 articles were included, including 2 guidelines (17,18), 1 expert consensus (19), 1 evidence summary (20), 3 systematic reviews (21-23), and 2 clinical decisions (24,25). The literature screening flow chart is shown in Figure 1, and the general characteristics of the included articles are set out in Table 1.

Figure 1 Screening flow chart for articles.

Table 1

General information of included articles

Included article Topic Source Type of evidence Year
NICE (17) Pre- and postnatal mental health NICE Clinical guideline 2016
American College of Obstetricians and Gynecologists (18) PND screening ACOG Clinical guideline 2018
Psychosomatic Health Group of Chinese Preventive Medicine Association (19) Maternal mental health management CNKI Expert consensus 2019
Minooee et al. (20) Prenatal psychosocial assessment JBI Evidence summary 2020
O’Connor et al. (21) Preventive measures for PND Embase Systematic review 2019
Biaggi et al. (22) Diagnosis of prenatal anxiety and depression risk Embase Systematic review 2016
Martínez-Borba et al. (23) Application of information and communication technology in PND screening CINAHL Systematic review 2018
Viguera et al. (24) Evaluation of unipolar major depression after delivery UpToDate Clinical decision 2021
Lockwood et al. (25) Prenatal examination: mid-trimester and late pregnancy UpToDate Clinical decision 2020

PND, perinatal depression.

Quality evaluation results of the included articles

Results of quality evaluation of the guidelines

Two guidelines were included from the NICE (17) and the American College of Obstetricians and Gynecologists (18). AGREE II was used to evaluate the guidelines (Table 2).

Table 2

Quality of included guidelines

Guidelines Standardized scores in each area ≥60% field number (n) ≤30% field number (n)
Scope and purpose Involved personnel Preciseness of guideline development Clarity of presentation Applicability Independence of writing
NICE 100% 76.39% 88.10% 93.06% 88.89% 77.78% 6 0
ACOG 100% 65.28% 69.05% 94.44% 59.26% 80.56% 5 0

Quality evaluation results of expert consensus

One expert consensus was included (19). The evaluation results of the items were all “yes” except for the “Whether the points of view proposed are inconsistent with the previous literatures” item. The overall quality of the study was high; thus, it was included.

Results of the quality evaluation of the evidence summary

One evidence summary was included (20). The evaluation result of the “Whether the reviewer or editor of the evidence summary is clear and transparent” item was “no”. The evaluation result of the “Whether the retrieval method is transparent and comprehensive”, and “Whether the summary of evidence avoids potential bias” items were “partly yes”. The evaluation results for all the other items were “yes”. The overall quality of the evidence summary was high; thus, it was included.

Quality evaluation results of the systematic reviews

Three systematic reviews were included. In the study of O’Connor et al. (21), the evaluation results of the items were all “yes” except that for the “Whether the database or resources of the retrieved literature are sufficient” item, which was “unclear”. In the study of Biaggi et al. (22), the evaluation results of the “Whether the literature quality evaluation criteria adopted are appropriate” and “Whether 2 or more reviewers independently completed the literature quality evaluation” items were “unclear”. The evaluation result of the “Whether the method of merging studies is appropriate” item was “no”. The evaluation results of all the other items were “yes”. In the study of Martínez-Borba et al. (23), the evaluation result of the “Whether the database or resources of the retrieved literature are sufficient” and “Whether the possibility of publication bias are assessed” items were “no”. The evaluation results of the “Whether the literature quality evaluation criteria adopted are appropriate”, “Whether 2 or more reviewers independently complete the literature quality evaluation”, and “Whether the method of merging studies is appropriate” items were “unclear”. The evaluation results of all the other items were “yes”. The overall quality of the systematic evaluations was high; thus, all articles were included.

Quality evaluation results of the clinical decisions

A total of two clinical decisions were included (24,25). One of the pieces of evidence was cited. Evidence came from a systematic review (26). The evaluation results for each item in the systematic evaluation were “yes”. The research designs were complete and the overall quality was high; thus, these articles were included.

Summary of evidence

In this paper, a total of 14 pieces of evidence about the time and frequency of PND screening were extracted from 9 included articles, and 11 pieces of evidence were included for grading after eliminating duplicates. The Australian JBI Evidence-based Health Care Centre Evidence Recommendation Level System (2014 edition) was used to grade the included evidence. According to the different types of research design, the evidence levels ranged from 1–5, and according to the reliability and rigor of the research design, the evidence levels were divided into A recommendation (strong recommendation) and B recommendation (weak recommendation) (see Table 3).

Table 3

Best evidence on the timing and frequency of screening for PND

Item Evidence description Source Evidence level Recommendation level
Screening time 1. Routine screening for depression is recommended throughout the perinatal period (23) CINAHL 1a A
2. Maternal mental health screening should be conducted at least in the 1st trimester (before 13+6 weeks), 2nd trimester (14–27+6 weeks), 3rd trimester (28 weeks and beyond) and 42 days after delivery (19) CNKI 5b A
3. It is recommended that depression screening begin in the 1st trimester and should end no later than 1 year postpartum (23) CINAHL 1c B
4. It is recommended that postpartum patients be screened at least once, and the ideal time for screening is 4–8 weeks after delivery (24) UpToDate 1a A
5. Of all contacts after the 1st primary care or appointment, health visitors and other health-care professionals who have regular contact with women during pregnancy and postpartum (the 1st year after delivery) should consider: asking 2 depression identification questions and administering the GAD-2 as part of a general discussion about their mental health and wellbeing, and using EPDS or PHQ-9 as part of the assessment (17) NICE 5b B
Screening frequency 6. Women should be assessed for symptoms of depression and anxiety at least once during pregnancy or postpartum, using proven screening tools (18) ACOG 5b B
7. For women with high-risk factors, the number of mental health assessments should be increased, as appropriate, during preparation and during pregnancy (18) CNKI 5b A
8. When women show anxiety or depression at 1 or 2 points in time, 1 screening is not enough (22) Embase 3e A
9. Conducting more evaluations during pregnancy and childbirth increases the accuracy of predicting the occurrence of PPD. If clinical manifestations are present, assessments can be repeated at any time during pregnancy and within the 1st year of delivery (19) CNKI 5b B
10. Repeated screening in the 1st year postpartum (e.g., 3 times) increased the number of women who screened positive for depression (24) UpToDate 3c A
11. When EPDS ≥13, a review of the EPDS is recommended after 2–4 weeks (20) JBI 3c A

PND, perinatal depression.

Screening time were recommended at least in the 1st trimester (before 13+6 weeks), 2nd trimester (14–27+6 weeks), 3rd trimester (28 weeks and beyond) and 42 days after delivery, and should end no later than 1 year postpartum.

Discussion

PND is an important disease affecting maternal physical and mental health. Although drugs and treatments are available to treat PND, early prevention and screening remain the best strategy. At present, there are different literatures on PND screening. Therefore, this study made a comprehensive summary and evaluation of relevant evidence, providing important evidence reference for clinical screening of PND and effective treatment.

PND screening is recommended throughout the perinatal period

The level of evidence on the timing of PND screening is inconsistent. However, the results of the evidence summary highlight the importance of PND screening and suggest that screening should be performed throughout the perinatal period. Previous studies (27) have shown that the detection rates of PND fluctuates. Underwood et al. (28) found that 39% of women with prenatal depression showed PPD. On average, 47% of women with PPD also experience prenatal depression, which is associated with a 6.8 times increased risk of PPD (29). There is a correlation between prenatal depression and PPD. Previous depression or other psychological problems are the biggest risk factors for PND. Thus, it is necessary to strengthen the evaluation and management of the mental health status of perinatal women to achieve early detection and intervention.

Screening for depression should be done early in the prenatal period. The NICE has issued guidelines (17) suggesting that health-care providers should ask pregnant women on first primary care contact or at a doctor’s appointment about depression, and use EPDS or Patient Health Questionnaire-9 (PHQ-9) items as part of the assessment. Related studies (22) have shown that most women experience a brief bout of depression during pregnancy and within a year of giving birth, but recover to their previously good levels of mental health.

Sixty to eighty percent of women will have “Baby Blues” 1–3 days after delivery, which are manifested as sudden mood swings, crying, irritability, and other negative emotions. The duration is short, and usually requires only social support and health education, and no medication (29,30). Screening for depression at this time would cause a large number of false positives, and as depression symptoms tend to stabilize 6 weeks after delivery, it would be reasonable to screen for PPD 6 weeks after delivery (27). More than 1/3 of the articles included in this systematic review focused on PPD screening at 7–12 months (31). These studies suggest that the risk of PPD far exceeds the 4–6 weeks postpartum range suggested in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This is important for the future development of PND screening strategies and specific treatment approaches.

For high-risk maternal women, PND should be properly reassessed

There are some risk factors in PND, like mental health problem, anxiety during pregnancy, life stresses, family and social supports, and socioeconomic factors (32-34). There is a lack of high-level evidence on the frequency of PND screening. According to the recommendations of the American College of Obstetricians and Gynecologists, proven screening tools should be used, and a depression screening should be performed at least once during pregnancy or postpartum (18). For women with high-risk factors, the frequency of psychological evaluations during pregnancy preparation and pregnancy should be increased as appropriate (19). Research has shown that risk factors for PND include a history of adverse pregnancy, pregnancy comorbidities, a history of depression, irregular antenatal visits, low income, domestic violence, being unmarried, and low social support (35). Prenatal and PPD risk factors are not the same. Thus, continuous attention and evaluations are necessary. When maternal women present with clinical symptoms, such as anxiety and depression, referral or a clinical interview is recommended for diagnosis, and repeat evaluations for PND should be performed. The JBI evidence summary indicates that when EPDS is ≥13, reevaluations with the EPDS should be conducted after 2–4 weeks (20).

For depression screening to be suitable in clinical practice, it must be simple and clear, with an acceptable risk of false positives and false negatives (36). Women are very concerned about the results of PND screenings, which may be related to the stigma associated with a diagnosis of depression, the referrals that a positive result may lead to, and the separation of mother and child. When the false positive rate of screening is high, this can also lead to expensive referral fees, unnecessary diagnostic evaluations and the possibility of misdiagnosed women being placed on antidepressants (24). Thus, the Lancet suggests that high-quality randomized controlled trials be conducted to undertake a comprehensive assessment of any potential adverse effects before the large-scale screening of depression is introduced (37).

Although medicines are not recommended during pregnancy, there is some evidence that they are effective. Brexanolone is proved to improve symptoms in three RCT. Further, Sertraline has also been reported to exert benefit role in reducing anxiety (38). Besides drugs, psychotherapy and social support therapy are also feasible methods to treat PND (36).

Conclusions

This study summarized the best evidence on the timing and frequency of screening for PND, and provided an evidence-based basis for determining the timing and frequency of PND screening. However, most of the articles included in this study were foreign, and consideration must be given to the different concepts and cultures in different regions and the different development levels of different countries. The application of the evidence should consider to combine the clinical conditions. Health-care professionals should fully consider the promotion and obstacles of applied evidence, patients’ wishes, and other factors to develop personalized and local PND screening programs to improve the quality of maternal mental health care.

Acknowledgments

Funding: Science and Technology Development Funding of Nanjing Medical University (NMUB2019331).

Footnote

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/apm-21-2675). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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(English Language Editor: L. Huleatt)

Cite this article as: Jia S, Zhi M, Liu J, Liu J, Jiang L, Zhu Y. Evidence summary on the timing and frequency of screening for perinatal depression. Ann Palliat Med 2021;10(10):10896-10903. doi: 10.21037/apm-21-2675

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