Perinatal Mental Health Screening Trial

Introduction

The perinatal period is a time of great change in a woman’s life. It is considered to be a time of joy and happiness, however during this period the woman is at increased risk of onset and relapse of mental health disorders.¹

One in five women experience a perinatal mental health disorder within the first year after the birth of their baby. However many of these women go undiagnosed.² Depression, stress and anxiety are among the most common mental health disorders experienced during pregnancy.³ Studies have shown that mild to moderate perinatal distress can result in various complications such as preterm birth, low birthweight, child developmental delay, impaired mother-child bonding, and poor child mental health.³

Therefore perinatal mental health services have been set up and are concerned with the prevention, detection and treatment of perinatal mental health problems that complicate pregnancy and the postpartum year. However, studies have shown that up to three quarters of the women meeting DSM criteria for depression and anxiety are not recognised and only one in ten women requiring mental health services receive it.¹

While health care system barriers are present which limit a woman’s accessibility to mental health services, there are other significant barriers to consider. These include stigma, lack of understanding of whether symptoms are abnormal or a typical pregnancy experience, lack of support persons who understand their concerns, and fear that disclosing symptoms may lead others to think that they are incompetent mothers.⁴

Materials and Methods

A trial for perinatal mental health screening at Mater Dei Hospital was set up in July 2018. This trial included all mothers under the care of four consultant obstetricians. All mothers involved in the trial were included in this prospective study, after obtaining appropriate ethics approval.

Screening was carried out by midwives during the booking visit by asking a series of five questions (including Whooley questions – questions 3 and 4):

1. Do you have a close family member (parent or sibling) with a history of bipolar disorder (manic depression) or any other serious mental illness?
2. Do you have a history of bipolar disorder (manic depression), puerperal psychosis, schizophrenia or other serious mental illness?
3. During the past month, have you often been bothered by feeling down, depressed or hopeless?
4. During the past month, have you often been bothered by having little interest or pleasure in doing things?
5. During the past month have you been feeling anxious or not being able to control worrying?

If the woman was found to be positive for one or more of these questions, the mother would be referred by the midwife for perinatal mental health services.

First a telephone consultation was carried out by the perinatal midwives discussing the perinatal mental health issues. An office consultation was always offered. During this office session the perinatal midwives would further evaluate her symptoms and score the EPDS (Edinburgh Postnatal Scale) and ANRQ (Antenatal Risk Questionnaire) scores. Based on this evaluation, the perinatal midwife would decide whether a referral to the psychiatric perinatal mental health clinic is necessary.

The psychiatric perinatal mental health clinic involves a collaboration of a multidisciplinary team involving the psychiatric firm of doctors, an obstetrician and the perinatal midwives. The consultation would involve a thorough history and examination and an appropriate diagnosis is obtained. The necessary investigations and appropriate management are provided to the mother, involving psychiatric medications, psychology referral, or social work support.

Results

A total of 283 mothers were screened from the 31st July to the 7th December. They had a mean age of 30.2 years and a mean gestation of 16 weeks.

From the 283 mothers, 105 were referred for perinatal mental health services. The majority of these mothers (46.67%) were referred due to anxiety. 43.80% were positive for the question regarding family psychiatric history; 34.28% were positive for personal psychiatric history; 29.52% were positive for low mood; and 20.95% were positive for anhedonia (refer to Figure 1).

Figure 1

Reason for Referral to Perinatal Mental Health Services

The 105 mothers requiring referral all received a telephone consultation from the perinatal midwives and 8 of these accepted to come for an office session with the midwives, while 9 mothers were seen in the perinatal mental health clinic. 88 mothers did not agree to attend (refer to Figure 2).

Figure 2

Results of total patients screened during trial

Of the 9 mothers seen at the perinatal mental health clinic, 2 were diagnosed with anxiety, 1 diagnosed with depression, 2 diagnosed with both anxiety and depression, 1 had a somatisation disorder, 1 had a past history of OCD, 1 had adjustment disorder and 1 had no psychiatric diagnosis.

Discussion

The American College of Obstetricians and Gynecologists (ACOG) recommends psychosocial screening of pregnant women at least once during the perinatal period, but screening in routine care is uncommonly done.⁵

The most validated and widely used self-report screening tool for depression during the perinatal period, is the Edinburgh Postnatal Depression Scale (EPDS). EPDS removes items related to physical symptoms of depression that may be affected by the perinatal period rather than by mood. It is not a diagnostic tool but a screening tool that asks about depressive symptoms in the past 7 days.⁵ NICE guidelines recommend that healthcare professionals should ask the Whooley questions at a woman’s first contact with primary care, then again at her booking visit, and again postnatally (at 4-6 weeks and 3-4 months). The Whooley questions will act merely as case-finding questions, which are then later followed up with the use of self-report measures, such as EPDS, for further assessment or monitoring.⁶ During this trial a set of 5 questions were used as a case-finding measure (including the 2 Whooley questions). However the EPDS was only then carried out on those patients who agreed to an appointment with the perinatal midwives or at the clinic.

Perinatal mental health services were first set up at Mater Dei Hospital in November 2016. Data collected during 2017 states that 3% of all mothers delivering at Mater Dei Hospital were being referred and making use of the perinatal mental health service (although this data was never formally published). Once must also keep in mind that this percentage includes both antenatal and postnatal mothers. During this trial, the number of women making use of the service was 6% from the total mothers screened. Therefore a 3% increase was identified despite the fact that postnatal mothers were not included in the trial. This refers to a significant number of mothers who otherwise would have been suffering in the dark. This data proves the importance and impact of perinatal mental health screening.

However, screening alone is insufficient to improve clinical outcomes and must be coupled with appropriate follow-up and treatment, when indicated. Therefore the increase in pick-up rate noted in our study, points towards a requirement for the growth of the perinatal mental health service, referring to more human resources, more clinics, etc.

The scarcity of human resources poses a major deterrent to routine screening. E-screening has the potential to increase efficiency of mental healthcare by reallocating limited human resources where they are most needed - in-depth follow-up assessment, referral, and treatment. It is a low-resource option that can be embedded in current prenatal and postpartum care across various settings and thus increases access to routine screening.⁴

Postnatal depression occurs in over 11% of women who experience major or minor depression six weeks postnatally. There is now considerable evidence to show that postnatal depression has a substantial impact on the mother and her partner, the family, mother-baby interactions, and the longer term emotional and cognitive development of the baby, especially when depression occurs in the first year of life.⁶ Therefore a serious limitation of the trail was that screening was only carried out in the antenatal phase and therefore mental health disorders starting off in the postnatal stage were not picked up.

Another limitation of the study was that it was not identified why those 88 mothers who required referral to the service, refused to attend. Several factors may have come into play, including private psychiatric help, stigma, lack of social support and fear.

Conclusion

Our study proves that the perinatal mental heath screening trial was successful at recognising mothers suffering from perinatal mental health conditions, with an increased pick-up rate of 3%. We recommend that an established perinatal mental health screening program is set up for all mothers delivering at Mater Dei Hospital. Screening would be carried out first by the using the case finding questions (as used in the trial) during the booking visit, and again postnatally (at 4-6 weeks). We also recommend an increase in the human resources at the clinic as the above refers to a significant increase in workload. The possibility of e-screening should also be considered.

References

1. Centre of Perinatal Excellence. Mental Health Care in the Perinatal Period, Australian Clinical Practice Guideline, October 2017.
2. Johnson M, Schmeid V, Lupton SJ, Austin M-P, Matthey S.M, Kemp L, et al. Measuring perinatal mental health risk. Arch Womens Ment Health. 2012; 15(5): 375–386.
3. Kingston D, McDonald D, Tough S, Austin MP, Hegardoren K, Lasiuk G. 2014 Public views of acceptability of perinatal mental health screening and treatment preference: a population-based survey. BMC Pregnancy Childbirth. 2014; 14: 67.
4. Kingston D, McDonald S, Biringer A, Austin M-P, Hegadoren K, McDonald S, et al. 2014 Comparing the feasibility, acceptability, clinical- and cost-effectiveness of mental health e-screening to paper-based screening on the detection of depression, anxiety, and psychosocial risk in pregnancy women: a study protocol of a randomized, parallel-group, superiority trial. Trials. 2014; 15: 3.
5. Connelly CD, Baker-Ericzen MJ, Hazen AL, Landsverk J, McCue Horwitz S. 2010 A Model for Maternal Depression. J Womens Health (Larchmt). 2010 Sep; 19(9): 1747–1757.
6. Paulden M, Palmer S, Hewitt C, Gilbody S. 2009 Screening for postnatal depression in primary care: cost effectiveness analysis. BMJ 2009;339:b5203.

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