Introduction

The case for undertaking universal psychosocial assessment (including depression screening) of women during the ‘perinatal period’ has attracted much interest, and vigorous debate . The perinatal period (pregnancy and the first postnatal year) is a time of great adjustment for all parents, made more challenging by the presence of existing psychosocial risk factors (or morbidity). Key risk factors for poor perinatal emotional adjustment include a history of past or antenatal anxiety or major depression, other mental health disorder or substance misuse, lack of supports, issues in partner relationship, a history of trauma (including adverse childhood events and domestic violence), isolation (physical, mental, cultural), stressful life events, poverty, and personality vulnerabilities e.g., low self-esteem or high trait anxiety .

The presence of psychosocial morbidity (especially high levels of anxiety and stress) in pregnancy can adversely impact on fetal development with associated suboptimal cognitive, emotional and behavioural outcomes in the offspring as identified in a number of large prospective cohort studies . Postnatal depression may also impact on infant outcomes .

In many high income and developing countries, pregnancy and the postnatal period are opportunistic periods for health education due to the frequency of contact with health care providers. Expectant and new parents are often highly motivated to seek help in effecting change for the sake of their offspring and potential reduction in intergenerational family dysfunction. The perinatal period thus provides clinicians with a unique opportunity to address the psychological, social and physical health of their clients, and to consider universal psychosocial assessment as part of mainstream maternity and postnatal care. Early identification and treatment of psychosocial morbidity are especially important in relation to the functioning of the family unit and the critical parent-infant relationship with potential to positively impact on the health of the next generation. Equally important is the need to address adverse social circumstances (where possible) and history of current or past violence and trauma . With the research focus to date mainly on perinatal depression, interpersonal violence and past trauma have tended to be under-investigated as potential key risk and mediating factors.

Major depression – often accompanied by anxiety disorder and personality vulnerability – is the most common condition presenting in the postnatal period , and may be associated with negative outcomes for mother, partner, infant and family. Such episodes can be new in onset or the recurrence of a pre-existing condition. In high income countries, the prevalence of major depression in the nine month pregnancy interval is 12.7%; and 7.1% in the first 3 months postpartum .

Large population studies demonstrate an increased risk of new onset psychiatric episodes, especially major depression and puerperal psychoses, arising in the first few months postpartum , while risk of relapse of pre-existing mood disorder, often following the cessation of medication, increases significantly both in pregnancy and in the postnatal period , especially bipolar disorder . Maternal death associated with psychosocial morbidity (including substance misuse and interpersonal violence) has become one of the leading causes of maternal deaths in high income countries . There is a 70 fold increased risk of suicide in the first postnatal year after admission for a severe psychiatric episode compared to at other times in a woman’s life .

The evidence base for depression screening in the perinatal period has been extensively examined in the process of developing the 2007 British , 2012 Scottish and 2011 Australian Clinical Practice Guidelines which are all underpinned by systematic literature reviews (SLR). These three Guidelines vary in their degree of recommendation for or against the use of the Edinburgh Postnatal Depression Scale (EPDS, ), with the Australian Guidelines recommending for its universal use within an integrated screening program; while the Scottish (SIGN) and British (NICE) CPGLs suggest its use only as an adjunct to clinical practice. An AHRQ 2013 systematic review of screening for postnatal depression concludes that while current depression screening instruments are reasonably sensitive and specific in detecting postpartum depression, there is insufficient evidence to allow the benefits and harms of depression screening to be clearly balanced-or to ascertain whether the use of specific assessment tools/strategies would result in better outcomes.

While the Australian guidelines note the use of universal psychosocial assessment programs as a good practice point, in addition to the assessment of mother-infant dyads, neither of the SIGN or NICE Guidelines comment on the value of broader psychosocial assessment as defined in the current position statement. For more detail, the three sets of Clinical Practice Guidelines recommendations are summarised in Table 1 . It is important to note that recommendations carry a variable weight dependent on the quality of the evidence at the time of guideline development, hence the variation in degree of recommendation by different guidelines for the use of, for example, the EPDS.

Key Definitions and Concepts in Perinatal Mental Health

Before proceeding to articulate the debate, we need to define the terminology and concepts that have arisen over the last two decades in the field of perinatal mental health.

• 1.

  The ‘perinatal’ period : has been defined in different ways, but for the purposes of this document, it is defined as the period spanning pregnancy and the first postnatal yea r. The use of the term perinatal in the psychosocial setting underscores the importance of considering maternal and infant emotional wellbeing at a time when maternal risk of onset/relapse of mood disorder is highest, when maternal social and emotional vulnerabilities are often heightened, and at a critical time in the development of infant attachment. It also highlights the value of early intervention (ideally beginning in pregnancy) and the importance of detecting psychosocial issues which may impact adversely on maternal, obstetric, infant & family outcomes.

• 2.

  Psychosocial morbidity : for the purposes of this document, covers the spectrum of morbidity from diagnosable psychiatric disorders (e.g., major depression, psychosis, anxiety and bipolar disorder) to psychosocial risk factors (as described in the background section), but may also include substance misuse; personality vulnerability/disorder and poor adjustment to parenting.

• 3.

  Prevention : preventive health care aims to reduce the burden of chronic conditions by early identification of people with risk factors or symptoms and applying appropriate interventions. It is the key premise underlying the benefits of universal psychosocial assessment & depression screening.

• 4.

  Psychosocial assessment programs : these encompass both the evaluation of current and longstanding psychological, social, and cultural risk factors impacting on the mental health of women across the perinatal period . Such enquiry should cover the breadth of morbidity from the low prevalence serious mental health conditions (eg. schizophrenia, bipolar disorder, psychosis & personality disorders etc) through high prevalence conditions such as depression and anxiety disorders, to the presence of risk factors that will make adjustment to parenting more difficult. Unlike screening, psychosocial assessment does not set out to identify women with a possible diagnosis of a particular condition at the time of assessment. Rather it gives us a multidimensional picture of the woman’s psychosocial circumstances which can then be used to make decisions about best care options. Given its multidimensionality, it is essential that it be undertaken as part of an integrated care program (see definition below). Psychosocial assessment may be undertaken as part of clinical interview or using a structured tool.

• 5.

  Depression Screening : Screening for current depression is generally considered as one component of psychosocial assessment in the perinatal context, and should not be seen as the only aim of such assessment. Screening can be universal, i.e. done in all women. This is in contrast to targeted screening that is only undertaken in high risk groups (e.g. young, single, substance using mothers). Screening should only take place where a validated, acceptable & user-friendly screener is integrated with further diagnostic assessment and treatment (as appropriate), dependent on screen positive status . Screening tools are used for the detection of symptoms likely to be associated with a diagnosis, using an optimal cut-off score. Importantly, a screener is not a diagnostic tool. Diagnosis requires a full clinical assessment.

• 6.

  Integrated care : the use of this term in the perinatal setting highlights the importance of:

  • •

    Integration across health care disciplines and between primary and secondary/tertiary health care systems;

  • •

    Integration between components of a psychosocial assessment program: including the assessment itself (including depression screening); clinician training and supervision; clear clinician decision making guidelines round appropriate care planning and referral pathways;

  • •

    Integration across time periods (antenatal and postnatal) and service settings (e.g., hospital and community);

  • •

    Integration of psychosocial assessment with mainstream (physical) maternity and postnatal care.

Key Definitions and Concepts in Perinatal Mental Health

Before proceeding to articulate the debate, we need to define the terminology and concepts that have arisen over the last two decades in the field of perinatal mental health.

• 1.

  The ‘perinatal’ period : has been defined in different ways, but for the purposes of this document, it is defined as the period spanning pregnancy and the first postnatal yea r. The use of the term perinatal in the psychosocial setting underscores the importance of considering maternal and infant emotional wellbeing at a time when maternal risk of onset/relapse of mood disorder is highest, when maternal social and emotional vulnerabilities are often heightened, and at a critical time in the development of infant attachment. It also highlights the value of early intervention (ideally beginning in pregnancy) and the importance of detecting psychosocial issues which may impact adversely on maternal, obstetric, infant & family outcomes.

• 2.

  Psychosocial morbidity : for the purposes of this document, covers the spectrum of morbidity from diagnosable psychiatric disorders (e.g., major depression, psychosis, anxiety and bipolar disorder) to psychosocial risk factors (as described in the background section), but may also include substance misuse; personality vulnerability/disorder and poor adjustment to parenting.

• 3.

  Prevention : preventive health care aims to reduce the burden of chronic conditions by early identification of people with risk factors or symptoms and applying appropriate interventions. It is the key premise underlying the benefits of universal psychosocial assessment & depression screening.

• 4.

  Psychosocial assessment programs : these encompass both the evaluation of current and longstanding psychological, social, and cultural risk factors impacting on the mental health of women across the perinatal period . Such enquiry should cover the breadth of morbidity from the low prevalence serious mental health conditions (eg. schizophrenia, bipolar disorder, psychosis & personality disorders etc) through high prevalence conditions such as depression and anxiety disorders, to the presence of risk factors that will make adjustment to parenting more difficult. Unlike screening, psychosocial assessment does not set out to identify women with a possible diagnosis of a particular condition at the time of assessment. Rather it gives us a multidimensional picture of the woman’s psychosocial circumstances which can then be used to make decisions about best care options. Given its multidimensionality, it is essential that it be undertaken as part of an integrated care program (see definition below). Psychosocial assessment may be undertaken as part of clinical interview or using a structured tool.

• 5.

  Depression Screening : Screening for current depression is generally considered as one component of psychosocial assessment in the perinatal context, and should not be seen as the only aim of such assessment. Screening can be universal, i.e. done in all women. This is in contrast to targeted screening that is only undertaken in high risk groups (e.g. young, single, substance using mothers). Screening should only take place where a validated, acceptable & user-friendly screener is integrated with further diagnostic assessment and treatment (as appropriate), dependent on screen positive status . Screening tools are used for the detection of symptoms likely to be associated with a diagnosis, using an optimal cut-off score. Importantly, a screener is not a diagnostic tool. Diagnosis requires a full clinical assessment.

• 6.

  Integrated care : the use of this term in the perinatal setting highlights the importance of:

  • •

    Integration across health care disciplines and between primary and secondary/tertiary health care systems;

  • •

    Integration between components of a psychosocial assessment program: including the assessment itself (including depression screening); clinician training and supervision; clear clinician decision making guidelines round appropriate care planning and referral pathways;

  • •

    Integration across time periods (antenatal and postnatal) and service settings (e.g., hospital and community);

  • •

    Integration of psychosocial assessment with mainstream (physical) maternity and postnatal care.