INTERIM UPDATE ACOG COMMITTEE OPINION Number 757 (Replaes Committee Opinion No. 630, May 2015) Committee on Obstetri Pratie This Committee Opinion was developed by the and Gyneologists Committee on Obstetri Pratie. INTERIM UPDATE: This Committee Opinion is updated as highlighted to reflet a limited, foused hange in the language and supporting evidene regarding prevalene, benefits of sreening, and sreening tools. Sreening for Perinatal Depression ABSTRACT: Perinatal depression, whih inludes major and minor depressive episodes that our during pregnany or in the first 12 months after delivery, is one of the most ommon medial ompliations during pregnany and the postpartum period, affeting one in seven women. It is important to identify pregnant and postpartum women with depression beause untreated perinatal depression and other mood disorders an have devastating effets. Several sreening instruments have been validated for use during pregnany and the postpartum period. The and Gyneologists reommends that obstetriian gyneologists and other obstetri are providers sreen patients at least one during the perinatal period for depression and anxiety symptoms using a standardized, validated tool. It is reommended that all obstetriian gyneologists and other obstetri are providers omplete a full assessment of mood and emotional well-being (inluding sreening for postpartum depression and anxiety with a validated instrument) during the omprehensive postpartum visit for eah patient. If a patient is sreened for depression and anxiety during pregnany, additional sreening should then our during the omprehensive postpartum visit. There is evidene that sreening alone an have linial benefits, although initiation of treatment or referral to mental health are providers offers maximum benefit. Therefore, linial staff in obstetris and gyneology praties should be prepared to initiate medial therapy, refer patients to appropriate behavioral health resoures when indiated, or both. Reommendations and Conlusions The and Gyneologists (the College) makes the following reommendations and onlusions: The and Gyneologists (the College) reommends that obstetriian gyneologists and other obstetri are providers sreen patients at least one during the perinatal period for depression and anxiety symptoms using a standardized, validated tool. It is reommended that all obstetriian gyneologists and other obstetri are providers omplete a full assessment of mood and emotional well-being (inluding sreening for postpartum depression and anxiety with a validated instrument) during the omprehensive postpartum visit for eah patient. If a patient is sreened for depression and anxiety during pregnany, additional sreening should then our during the omprehensive postpartum visit. Women with urrent depression or anxiety, a history of perinatal mood disorders, risk fators for perinatal mood disorders, or suiidal thoughts warrant partiularly lose monitoring, evaluation, and assessment. There is evidene that sreening alone an have linial benefits, although initiation of treatment or referral to mental health are providers offers maximum benefit. Therefore, linial staff in obstetris and gyneology praties should be prepared to initiate medial therapy, refer patients to appropriate behavioral health resoures when indiated, or both. Systems should be in plae to ensure follow-up for diagnosis and treatment. e208 VOL. 132, NO. 5, NOVEMBER 2018 OBSTETRICS & GYNECOLOGY
Introdution The prevalene of perinatal depression is a signifiant ost to individuals, hildren, families, and the ommunity. In 2011, 9% of pregnant women and 10% of postpartum women met the riteria for major depressive disorders (1). It is important to identify pregnant and postpartum women with depression beause untreated perinatal depression and other mood disorders an have devastating effets. Regular ontat with the health are delivery system during the perinatal period should provide an ideal irumstane for women with depression to be identified and treated. The College reommends that obstetriian gyneologists and other obstetri are providers sreen patients at least one during the perinatal period for depression and anxiety symptoms using a standardized, validated tool. It is reommended that all obstetriian gyneologists and other obstetri are providers omplete a full assessment of mood and emotional well-being (inluding sreening for postpartum depression and anxiety with a validated instrument) during the omprehensive postpartum visit for eah patient (2). If a patient is sreened for depression and anxiety during pregnany, additional sreening should then our during the omprehensive postpartum visit. When indiated, obstetriian gyneologists and other obstetri are providers share a role in initiating medial therapy or referring patients to appropriate behavioral health resoures, or both. Depression, the most ommon mood disorder in the general population, is approximately twie as ommon in women as in men, with its initial onset peaking during the reprodutive-age years (3). Therefore, it is not surprising that perinatal depression, whih inludes major and minor depressive episodes that our during pregnany or in the first 12 months after delivery, is one of the most ommon medial ompliations during pregnany and the postpartum period, affeting one in seven women (4). Perinatal depression and other mood disorders, suh as bipolar disorder and anxiety disorders (5), an have devastating effets on women, infants, and families; maternal suiide exeeds hemorrhage and hypertensive disorders as a ause of maternal mortality (6). Perinatal depression often goes unreognized beause hanges in sleep, appetite, and libido may be attributed to normal pregnany and postpartum hanges. In addition to health are providers not reognizing suh symptoms, women may be relutant to report hanges in their mood. In one small study, less than 20% of women in whom postpartum depression was diagnosed had reported their symptoms to a health are provider (7). Therefore, it is important for obstetriian gyneologists and other obstetri are providers to ask the pregnant or postpartum patient about her mood. Newborn are appointments also may be an opportunity to ask a mother about her mood. Obstetri providers should ollaborate with their pediatri olleagues to failitate treatment for women with mood disorders identified during newborn are (8). Anxiety is a prominent feature of perinatal mood disorders, as is insomnia. It may be helpful to ask a woman whether she is having intrusive or frightening thoughts or is unable to sleep even when her infant is sleeping. Women with urrent depression or anxiety, a history of perinatal mood disorders, risk fators for perinatal mood disorders (Box 1), or suiidal thoughts warrant partiularly lose monitoring, evaluation, and assessment. These women may benefit from evidene-based psyhologi and psyhosoial interventions and, in some ases, pharmaologi therapy to redue the inidene and burden of perinatal depression (9). If there is onern that the patient suffers from mania or bipolar disorder, she should be referred to a psyhiatrist before initiating medial therapy beause antidepressant monotherapy may trigger mania or psyhosis (10). Mania symptoms inlude inflated self-esteem or grandiosity, feeling restedafteronly3hoursofsleep,orengaginginrisky behaviors that worry her friends and family (5). Box 1. Risk Fators for Perinatal Depression Depression during pregnany: Maternal anxiety Life stress History of depression Lak of soial support Unintended pregnany Mediaid insurane Domesti violene Lower inome Lower eduation Smoking Single status Poor relationship quality Postpartum depression: Depression during pregnany Anxiety during pregnany Experiening stressful life events during pregnany or the early postpartum period Traumati birth experiene Preterm birth/infant admission to neonatal intensive are Low levels of soial support Previous history of depression Breastfeeding problems Data from Lanaster CA, Gold KJ, Flynn HA, Yoo H, Marus SM, Davis MM. Risk fators for depressive symptoms during pregnany: a systemati review. Am J Obstet Gyneol 2010;202:5 14 and Robertson E, Grae S, Wallington T, Stewart DE. Antenatal risk fators for postpartum depression: a synthesis of reent literature. Gen Hosp Psyhiatry 2004;26:289 95. VOL. 132, NO. 5, NOVEMBER 2018 Committee Opinion Perinatal Depression e209
In 2016, the U.S. Preventive Servies Task Fore hanged its reommendation for routine depression sreening to a B, endorsing depression sreening in the general adult population, inluding pregnant and postpartum women (11). Although there are no large randomized ontrolled trials that definitively prove the benefits of sreening alone without the neessary treatment, the task fore hanged its reommendation based on a large systemati review. This review ombined six randomized ontrolled trials that sreened pregnant or postpartum patients with or without additional are offered based on results of sreening. Most of the trials provided some type of treatment or support beyond sreening, suh as ounseling, treatment protools, or training to liniians and anillary staff. Thus, it is diffiult to distinguish the effet solely due to sreening or sreening ombined with some type of intervention. Nevertheless, follow-up of these patients several weeks to months later demonstrated an absolute risk redution in depression prevalene of as muh as 9% (12). Greater benefits were seen if linial support and training were offered to the staff that provided the sreening tool. Initiation of treatment or referral to mental health are providers offers maximum benefit. Clinial staff in obstetris and gyneology praties should be prepared to initiate medial therapy, refer patients to appropriate behavioral health resoures when indiated, or both. Reent evidene suggests that ollaborative are models implemented in obstetris and gyneology offies improve long-term patient outomes (13). For example, in one model of ollaborative are, a depression are manager, suh as a nurse or soial worker, an provide psyhotherapy and support under the supervision of a mental health speialist and a primary are provider. Systems should be in plae to ensure follow-up for diagnosis and treatment (9, 10). Sreening Tools Several sreening instruments have been validated for use during pregnany and the postpartum period to assist with systematially identifying patients with perinatal depression (Table 1). The Edinburgh Postnatal Depression Sale (EPDS) is most frequently used in the researh setting and linial pratie for several reasons. The sale, whih has been translated into 50 different languages, onsists of 10 self-reported questions that are health literay appropriate and take less than 5 minutes to omplete. The EPDS inludes anxiety symptoms, whih are a prominent feature of perinatal mood disorders, but exludes onstitutional symptoms of depression, suh as hanges in sleeping patterns, whih an be ommon in pregnany and the postpartum period. The inlusion of these onstitutional symptoms in other sreening instruments, suh as the Patient Health Questionnaire 9, the Bek Depression Inventory, and the Center for Epidemiologi Studies Depression Sale (Table 1), redues their speifiity for perinatal depression. In addition, with the exeption of the Patient Health Questionnaire 9 and the EPDS, other instruments have at least 20 questions and, thus, require more time to omplete and to sore. As with any sreening test, results should be interpreted within the linial ontext. A normal sore for a tearful patient with a flat affet does not exlude depression; an elevated sore in the ontext of an aute stressful event may resolve with lose follow-up. Table 1. Depression Sreening Tools Sreening Tool Number of Items Time to Complete (Minutes) Sensitivity and Speifiity Spanish Available Edinburgh Postnatal Depression Sale 10 Less than 5 Sensitivity 59 100% Yes Speifiity 49 100% Postpartum Depression Sreening Sale 35 5 10 Sensitivity 91 94% Yes Speifiity 72 98% Patient Health Questionnaire 9 9 Less than 5 Sensitivity 75% Yes Speifiity 90% Bek Depression Inventory 21 5 10 Sensitivity 47.6 82% Yes Speifiity 85.9 89% Bek Depression Inventory-II 21 5 10 Sensitivity 56 57% Yes Speifiity 97 100% Center for Epidemiologi Studies Depression Sale 20 5 10 Sensitivity 60% Yes Speifiity 92% Zung Self-Rating Depression Sale 20 5 10 Sensitivity 45 89% No Speifiity 77 88% e210 Committee Opinion Perinatal Depression OBSTETRICS & GYNECOLOGY
Conlusion Perinatal depression is a ommon ompliation of pregnany with potentially devastating onsequenes if it goes unreognized and untreated. There is evidene that sreening alone an have linial benefits, although initiation of treatment or referral to mental health are providers offers maximum benefit. Systems should be in plae to ensure follow-up for diagnosis and treatment. Therefore, the College reommends that obstetriian gyneologists and other obstetri are providers sreen patients at least one during the perinatal period for depression and anxiety symptoms using a standardized, validated tool. It is reommended that all obstetriian gyneologists and other obstetri are providers omplete a full assessment of mood and emotional well-being (inluding sreening for postpartum depression and anxiety with a validated instrument) during the omprehensive postpartum visit for eah patient. If a patient is sreened for depression and anxiety during pregnany, additional sreening should then our during the omprehensive postpartum visit. For More Information The and Gyneologists has identified additional resoures on topis related to this doument that may be helpful for ob gyns, other health are providers, and patients. You may view these resoures at www.aog.org/more-info/perinataldepression. These resoures are for information only and are not meant to be omprehensive. Referral to these resoures does not imply the and Gyneologists endorsement of the organization, the organization s website, or the ontent of the resoure. The resoures may hange without notie. Referenes 1. Centers for Disease Control and Prevention. PRAMStat System. Available at: https://www.d.gov/prams/prams-data/workdiretly-prams-data.html. Retrieved September 12, 2018. 2. Optimizing postpartum are. ACOG Committee Opinion No. 736. and Gyneologists. Obstet Gyneol 2018;131:e140 50. 3. Weissman MM, Olfson M. Depression in women: impliations for health are researh. Siene 1995;269:799 801. 4. Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systemati review of prevalene and inidene. Obstet Gyneol 2005;106:1071 83. 5. Amerian Psyhiatri Assoiation. Diagnosti and statistial manual of mental disorders. 5th ed. Arlington (VA): APA; 2013. 6. Palladino CL, Singh V, Campbell J, Flynn H, Gold KJ. Homiide and suiide during the perinatal period: findings from the National Violent Death Reporting System. Obstet Gyneol 2011;118:1056 63. 7. Whitton A, Warner R, Appleby L. The pathway to are in post-natal depression: women s attitudes to post-natal depression and its treatment. Br J Gen Prat 1996;46: 427 8. 8. Earls MF. Inorporating reognition and management of perinatal and postpartum depression into pediatri pratie. Committee on Psyhosoial Aspets of Child and Family HealthAmerian Aademy of Pediatris. Pediatris 2010;126:1032 9. 9. Yonkers KA, Vigod S, Ross LE. Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women. Obstet Gyneol 2011;117:961 77. 10. Yonkers KA, Wisner KL, Stewart DE, Oberlander TF, Dell DL, Stotland N, et al. The management of depression during pregnany: a report from the Amerian Psyhiatri Assoiation and the and Gyneologists. Obstet Gyneol 2009;114:703 13. 11. Siu AL, Bibbins-Domingo K, Grossman DC, Baumann LC, Davidson KW, Ebell M, et al. Sreening for depression in adults: US Preventive Servies Task Fore Reommendation Statement. US Preventive Servies Task Fore (USPSTF). JAMA 2016;315:380 7. 12. O Connor E, Rossom RC, Henninger M, Groom HC, Burda BU. Primary are sreening for and treatment of depression in pregnant and postpartum women: evidene report and systemati review for the US Preventive Servies Task Fore. JAMA 2016;315:388 406. 13. Melville JL, Reed SD, Russo J, Croiu CA, Ludman E, LaRoo-Cokburn A, et al. Improving are for depression in obstetris and gyneology: a randomized ontrolled trial. Obstet Gyneol 2014;123:1237 46. Published online on Otober 24, 2018. Copyright 2018 by the and Gyneologists. All rights reserved. No part of this publiation may be reprodued, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, eletroni, mehanial, photoopying, reording, or otherwise, without prior written permission from the publisher. Requests for authorization to make photoopies should be direted to Copyright Clearane Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400. and Gyneologists 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920 Sreening for perinatal depression. ACOG Committee Opinion No. 757. and Gyneologists. Obstet Gyneol 2018;132:e208 12. VOL. 132, NO. 5, NOVEMBER 2018 Committee Opinion Perinatal Depression e211
This information is designed as an eduational resoure to aid liniians in providing obstetri and gyneologi are, and use of this information is voluntary. This information should not be onsidered as inlusive of all proper treatments or methods of are or as a statement of the standard of are. It is not intended to substitute for the independent professional judgment of the treating liniian. Variations in pratie may be warranted when, in the reasonable judgment of the treating liniian, suh ourse of ation is indiated by the ondition of the patient, limitations of available resoures, or advanes in knowledge or tehnology. The and Gyneologists reviews its publiations regularly; however, its publiations may not reflet the most reent evidene. Any updates to this doument an be found on www.aog.org or by alling the ACOG Resoure Center. While ACOG makes every effort to present aurate and reliable information, this publiation is provided as is without any warranty of auray, reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the produts or servies of any firm, organization, or person. Neither ACOG nor its offiers, diretors, members, employees, or agents will be liable for any loss, damage, or laim with respet to any liabilities, inluding diret, speial, indiret, or onsequential damages, inurred in onnetion with this publiation or reliane on the information presented. All ACOG ommittee members and authors have submitted a onflit of interest dislosure statement related to this published produt. Any potential onflits have been onsidered and managed in aordane with ACOG s Conflit of Interest Dislosure Poliy. The ACOG poliies an be found on aog. org. For produts jointly developed with other organizations, onflit of interest dislosures by representatives of the other organizations are addressed by those organizations. The and Gyneologists has neither soliited nor aepted any ommerial involvement in the development of the ontent of this published produt. e212 Committee Opinion Perinatal Depression OBSTETRICS & GYNECOLOGY