In this issue of the Journal, Lancaster and colleagues provide a broad and scholarly review of factors associated with possible clinical depression during pregnancy. This information may contribute to clinical screening efforts arising in the setting of obstetric recommendations favoring routine screening for perinatal depression. In contrast, a recent critical econometric analysis suggests generally unfavorable cost-benefit relationships in routine perinatal screening for depression. That analysis associated excess costs particularly with false-positive noncases identified by screening methods typically involving brief, patient-based questionnaires rather than clinical assessment. The potential importance of screening for prenatal major depression is encouraged by its cited prevalence of 12.5% during pregnancy. However, although somewhat greater than a 12-month risk, this rate is probably not greater than lifetime risk in the female general population.

The review by Lancaster et al does not consider patients with clinically verified diagnoses of major depression separately and does not report prevalences of depressive symptoms at various levels of severity and clinical significance. Such information might support testing of sensitivity and specificity of observed correlates and consideration of cost-benefit relationships involved. Since associations of potential risk factors were made with relatively generalized depressive symptoms, it may not be surprising that most identified factors involved life-situational stressors or other disadvantageous social circumstances of highly uncertain specificity in regard to severe clinical depression. Moreover, a particularly striking nonfinding was lack of strong association with a clinical history of major affective disorder, in large part owing to common lack of separate consideration of such cases in available reports. Very high risks of depression during pregnancy have been reported among pregnant women previously diagnosed with major depressive or bipolar disorders. Such women experienced mainly depressive or dysphoric-mixed manic-depressive recurrences at rates of 43–71% overall, particularly in the first several months of gestation, and the risks were far higher following discontinuation of antidepressant or mood-stabilizing treatments, as commonly occurs with pregnancy.

In conclusion, attention to the perinatal period as a time of relatively high risk of major affective illness should be encouraged, especially since highly cost-effective treatments are available, especially for relatively severe mood disorders. However, there is also a need for a critical and triage-oriented approach to this challenge, with better and earlier identification of women with potentially life-threatening and fetus-threatening major mood disorders as a first priority. It also seems appropriate to consider a cost-benefit perspective in such analyses as a guide to clinical policies and practice guidelines, especially in this era of intense concern about rational and optimal utilization of limited resources.