Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum

Abstract

PURPOSE:To review evidence on the current understanding of mental health conditions in pregnancy and postpartum, with a focus on mood and anxiety disorders, and to outline guidelines for screening and diagnosis that are consistent with best available scientific evidence. The conditions or symptoms reviewed include depression, anxiety and anxiety-related disorders, bipolar disorder, suicidality, and postpartum psychosis. For information on psychopharmacologic treatment and management, refer to American College of Obstetricians and Gynecologists (ACOG) Clinical Practice Guideline Number 5, “Treatment and Management of Mental Health Conditions During Pregnancy and Postpartum” (1).TARGET POPULATION:Pregnant or postpartum individuals with mental health conditions. Onset of these conditions may have predated the perinatal period or may have occurred for the first time in pregnancy or the first year postpartum or may have been exacerbated in that time.METHODS:This guideline was developed using an a priori protocol in conjunction with a writing team consisting of one specialist in obstetrics and gynecology and one maternal–fetal medicine subspecialist appointed by the ACOG Committee on Clinical Practice Guidelines–Obstetrics and two external subject matter experts. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.RECOMMENDATIONS:This Clinical Practice Guideline includes recommendations on the screening and diagnosis of perinatal mental health conditions including depression, anxiety, bipolar disorder, acute postpartum psychosis, and the symptom of suicidality. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

Postpartum Depression—New Screening Recommendations and Treatments

“…Two-thirds of individuals with perinatal depression have 1 or more comorbid psychiatric conditions, mainly anxiety disorders (83%), including generalized anxiety disorder (52%), panic disorder (14%), social phobia (12%), and obsessive-compulsive disorder (11%) . Untreated perinatal depression is associated with short- and long-term negative consequences for affected individuals and their offspring, partners, families, and society . Perinatal depression remains underdetected and undertreated; more than 75% of those who screen positive receive no treatment …”

“…In June 2023, the American College of Obstetricians and Gynecologists released new recommendations to minimally screen for depression at least twice in pregnancy (initial prenatal visit and later) and again at postpartum visits, using validated instruments . Additionally, depression screening is recommended at pediatric well-infant/child visits and well-woman visits.…”

“…Laboratory evaluation may include measuring hemoglobin or hematocrit, folate, vitamin B 12 , iron, and thyrotropin. Screening for comorbid substance use disorders via other screening instruments (eg, 4Ps or NIDA Quick Screen) is also recommended . Once a depression diagnosis is established, including for patients whose depression predates pregnancy, screening instruments such as the EPDS and PHQ-9 may be used for symptom monitoring.…”

“…Treating bipolar disorder with antidepressant monotherapy can precipitate mania, mixed states, rapid-cycling, or psychosis, which can increase suicide and infanticide risk. Given this, screening for bipolar disorder is recommended before initiating pharmacotherapy . Validated screening instruments for bipolar disorder include the Mood Disorder Questionnaire (MDQ) and the 3-question Composite International Diagnostic Interview (CIDI) …”

“…Given this, screening for bipolar disorder is recommended before initiating pharmacotherapy . Validated screening instruments for bipolar disorder include the Mood Disorder Questionnaire (MDQ) and the 3-question Composite International Diagnostic Interview (CIDI) …”