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Last week, I met with a group of family physicians and obstetricians during grand rounds at a local community hospital. I was invited to give a presentation on perinatal mental health, especially during pregnancy.
Why?
Because while postpartum depression is often the focus of the medical community and the public alike, the fact is that up to 80% of women who struggle with postpartum depression had symptoms that could have been detected first in pregnancy. Early detection and treatment could save months of hardship for women and their families.
Do you know the signs of prenatal depression?
After the presentation, we had a long conversation about several frustrations these clinicians experienced, including:
- What screening tools used to detect anxiety or depression in pregnant women;
- How to help women who need and want help;
- Frustration with the lack of services in the community (of almost one million people!) and the intolerable wait time to get women into one of the only existing services in the city.
- This is not the first time I’ve heard these sentiments. This is the situation in North America for many primary care providers.
Let me provide some guidance surrounding these issues.
Detecting Anxiety and Depression in Pregnancy
Question: What screening tools should be used to detect anxiety or depression in pregnant women?
A major challenge in primary care is, as we all know, a lack of time. Our research shows that the majority of women don’t talk to their doctors about emotional health issues because there just isn’t enough time, and they’re not sure whether what they're experiencing is just a part of a “normal” pregnancy. Women have told us they want to be “good patients,” and so they don’t bring up concerns about anxiety, stress, or depression they have.
However, 97% of women also told us in a provincial survey that if their provider asked them first about emotional health, they would be pleased to respond and could be honest with them.
The NICE guidelines that were published in December 2014 presented (in my view) the best solution. They recommended two validated, but very brief, questionnaires that could be asked in any primary care setting in under five minutes. Remember: These are not diagnostic tools. They are screening questions that can efficiently identify women that are struggling and require a more in-depth follow-up.
For depression, they recommended the 2-question Patient Health Questionnaire (PHQ-2):
Over the past 2 weeks, how often have you been bothered by any of the following problems:
- Little interest or pleasure in doing things
- Feeling down, depressed or hopeless
For each question, answer: 0=Not at all; 1=several days; 2=more than half the days; 3=nearly every day
Notes: The score ranges from 0-6. If a woman scores 3 or more based on adding her score to question 1 and question 2, she should receive a follow-up appointment with a clinician who can conduct a more thorough assessment of her needs or be referred to a cognitive behaviour therapy program.
For anxiety, the NICE guidelines recommended the 2-question Generalized Anxiety Questionnaire (GAD-2):
Over the last 2 weeks, how often have you been bothered by the following problems:
- Feeling nervous, anxious, or on edge
- Not being able to stop or control worrying
For each question, answer: 0=Not at all; 1=several days; 2=more than half the days; 3=nearly every day
Notes: The score ranges from 0-6. If a woman scores 3 or more based on adding her score to question 1 and question 2, she should receive a follow-up appointment with a clinician who can conduct a more thorough assessment of her needs or be referred to a cognitive behaviour therapy program.
These tools are not perfect – none are! But, they are quite accurate and are brief enough to be used as a part of routine prenatal care. The best part is that our research shows that 99% of pregnant women who had not been screened for prenatal anxiety or depression wanted to be. In fact, in follow-up interviews, women told us they wanted to be routinely screened for emotional health — just like they had their blood pressure checked.
Check yourself for positive mental health here.
Help for Pregnant Women With Anxiety, Depression, or Stress
Question: What type of help can I offer pregnant women so that they can get timely assistance?
Research shows that 95% of pregnant women with emotional health concerns experience mild- or moderate-degree symptoms.
- That means that the vast majority of women can be effectively helped through online venues, which are cheaper, more available, and readily accessed than face-to-face sessions (which may not be an option in smaller communities).
- The NICE guidelines suggest that there is enough evidence to recommend cognitive behaviour therapy (CBT) to pregnant women with mild- or moderate- symptoms.
The last 5% of women who have more severe symptoms, and often co-existing challenges such as lack of support, interpersonal violence, or substance use, are best served by a combination of multidisciplinary services that may require coordination between a psychiatrist, family physician, psychologist, and/or social worker.
To find a therapist, visit the Psychology Today Therapy Directory.
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