Identifying Perinatal Depression and Anxiety

Evidence-based Practice in Screening, Psychosocial Assessment and Management

Jeannette Milgrom, Alan W. Gemmill, Jeannette Milgrom, Alan W. Gemmill

• Publisher: Wiley-Blackwell
• Year: 2015
• Print ISBN:
  9781118509692
  9781118509654
• Edition: 1
• eBook ISBN:
  9781118509685
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Identifying Perinatal Depression and Anxiety brings together the very latest research and clinical practice on this topic from around the world in one valuable resource.

• Examines current screening and management models, particularly those in Australia, England and Wales, Scotland, and the United States
• Discusses the evidence, accuracy, and limitations of screening methods in the context of challenges, policy issues, and questions that require further research
• Up to date practical  guidance of how to screen, assess, diagnose and manage is provided.
• Considers the importance of screening processes that involve infants and fathers, additional training for health professionals, pathways to care following screening, and the economics of screening
• Offers forward-thinking synthesis and analysis of the current state of the field by leading international experts, with the goal of sketching out areas in need of future research

1
Is Population-Based Identification of Perinatal Depression and Anxiety Desirable?
A Public Health Perspective on the Perinatal Depression Care Continuum

Norma I. Gavin, Samantha Meltzer-Brody, Vivette Glover, and Bradley N. Gaynes

Introduction

The perinatal period is a profound time of transition for women and their families; a myriad of determinants—including social, psychological, behavioral, environmental, and biological forces—shape pregnancy and the postpartum course (Misra, Guyer, & Allston, 2003). Due to the complexity of this vulnerable time, psychiatric complications such as maternal depression and anxiety are common during the perinatal period (Wisner et al., 2013). The longitudinal course of depressive and anxiety disorders that manifest during pregnancy and the postpartum period and the management of the disorders are active areas of investigation. In particular, the study of whether systematic, population-level screening and case identification of perinatal depression and anxiety are desirable is an important area of controversy.

Although screening for current disorders has been widely promoted based on the serious adverse consequences of untreated maternal depression and anxiety, population-based screening has significant resource implications (Austin, Middleton, Reilly, & Highet, 2013; Henshaw & Elliott, 2005; National Institute for Health and Clinical Excellence [NICE], 2007; Shakespeare, 2005). In many settings, the successful implementation and maintenance of a population-based screening program would require additional provider training, increased provider workloads, and improved patient access to health services. Barriers to screening for existing disorders and the evidence base are covered in following chapters.

In this chapter, we investigate the case for population-based screening of perinatal depression and anxiety using a public health-care continuum model that takes the reader through the sequential steps from the identification and management of perinatal depression and anxiety to successful health outcomes. The conditions required for successful population-based screening are presented, and the current evidence in Western industrialized countries on each of these conditions is summarized.

Although we discuss both perinatal depression and anxiety, the literature on perinatal depression, and postnatal depression in particular, is more comprehensive and well developed than the literature on perinatal anxiety disorders. As a result, our discussion in this chapter, which primarily addresses perinatal depression but refers to perinatal anxiety where possible, reflects the current state of the literature. Moreover, because anxiety is often a common clinical symptom in women with perinatal mood disorders, it can be difficult to tease apart the difference between perinatal depression with anxious features and a completely separate perinatal anxiety disorder.

The chapter begins with a description of the clinical presentation of perinatal depression and anxiety followed by a description of the care continuum model and current evidence supporting each of the model’s components. We conclude with implications for policy and future research.

Clinical Presentation of Perinatal Depression and Anxiety

Perinatal depression and anxiety are clinical syndromes commonly described as the onset of a major depressive episode (MDE) or significant anxiety symptoms occurring during pregnancy and/or in the postpartum period (Gavin et al., 2005; O’Hara & Swain, 1996; Wisner et al., 2013). Symptom onset during pregnancy is often referred to as antenatal or prenatal depression or anxiety. Onset of symptoms in the postpartum period is usually described as postpartum/postnatal depression (PND) or postnatal anxiety.

PND has been the most widely studied perinatal psychiatric illness, although controversy exists regarding how best to define the onset of symptoms in the postpartum period (Elliott, 2000; Wisner, Moses-Kolko, & Sit, 2010). For example, the DSM-IV postpartum specifier strictly defined an MDE with onset of symptoms within 4 weeks after delivery (DSM-IV, 1994). DSM-5 instead provides a “peripartum” specifier expanded to include onset of symptoms during pregnancy (American Psychiatric Association, 2013). In ICD-10, postpartum onset is considered to be within 6 weeks after childbirth (Cox, 2004). A common broader definition of the term “perinatal depression” includes onset of mood and anxiety symptoms that occur during pregnancy and through one year postpartum (Gavin et al., 2005; Gaynes et al., 2005a). Subthreshold depressive symptoms are often considered important by clinicians and researchers. However, because more information is available on MDEs, our focus in this chapter is on major depression.

In addition to PND, the development of a new-onset anxiety disorder in the postpartum period or exacerbation of an existing anxiety disorder have been documented in the literature including, but not limited to, generalized anxiety disorder (GAD) (Prenoveau et al., 2013) and postpartum obsessive–compulsive disorder (PP-OCD) (Abramowitz et al., 2010; Fairbrother & Abramowitz, 2007; Prenoveau et al., 2013). GAD is characterized by excessive worry that interferes in multiple domains of the person’s life. Because symptoms must be present for 6 months before a diagnosis can be made, criteria for new-onset GAD are unlikely to be met during the 9 months of pregnancy or the early postpartum period (Ross & McLean, 2006). In contrast to ruminating symptoms, PP-OCD is characterized by persistent, and unwanted, obsessional thoughts and the implementation of compulsive rituals and behaviors aimed at neutralizing or managing the intrusive thoughts (Abramowitz et al., 2010; DSM-IV, 1994). The literature documents an increased incidence of both obsessive–compulsive symptoms and a clinical diagnosis of OCD in postpartum women, although controversy exists in the field regarding whether PP-OCD is a distinct clinical entity (Abramowitz et al., 2010; Altemus et al., 2012; McGuinness, Blissett, & Jones, 2011; Uguz, Akman, Kaya, & Cilli, 2007). Postpartum posttraumatic stress disorder (PP-PTSD) also occurs (Cohen, Ansara, Schei, Stuckless, & Stewart, 2004; Olde, van der Hart, Kleber, & van Son, 2006: but note that PTSD is no longer listed as an anxiety disorder in DSM-5).The primary trigger for the development of PP-PTSD is the women’s subjective experience of a negative or traumatic birth (Garthus-Niegel, von Soest, Vollrath, & Eberhard-Gran, 2013). A history of sexual trauma and a preexisting anxiety sensitivity have also been associated as risk factors for developing PTSD after childbirth (Verreault et al., 2012).

Depressive symptoms occur on a continuum of severity, and not all women will meet diagnostic categories. The clinical presentation of perinatal depression is often characterized by mood symptoms that cause significant distress to the perinatal woman (Bernstein et al., 2008; Cooper & Murray, 1997). Sadness, weepiness, low mood, irritability, impaired concentration, and feeling overwhelmed are commonly reported symptoms (Hendrick, Altshuler, Strouse, & Grosser, 2000). Moreover, anxiety or agitation is often a distinguishing feature of perinatal depression and can take the form of ruminating and obsessional thoughts, often about the pregnancy or the infant (Abramowitz et al., 2010; Bernstein et al., 2008). In the postpartum period, women with PND can demonstrate severe hypervigilance about the baby and will be unable to sleep at night, even when the baby is sleeping, due to concerns about the infant’s well-being (Leckman et al., 1999; Wisner, Peindl, Gigliotti, & Hanusa, 1999). Alternatively, some women will report feeling detached from the infant and/or will exhibit a lack of interest in holding, interacting, or caring for their baby. Importantly, most women with perinatal mood symptoms report feelings of guilt that they are not able to enjoy the baby (Beck, 1996b; Yonkers, Vigod, & Ross, 2011). Diagnostic criteria for MDEs and other specified depressive disorders are covered in Chapter 7.

Care Continuum

Strategies for screening and case identification (including standardized perinatal depression screens) have been promoted but remain controversial (Austin et al., 2013; Henshaw & Elliott, 2005; National Institute for Health and Clinical Excellence [NICE], 2007; Shakespeare, 2005), with arguments against screening including that the potential additional costs of managing women falsely identified as depressed or anxious are not cost-effective (Paulden, Palmer, Hewitt, & Gilbody, 2009).

To determine whether population-based identification of perinatal depression and anxiety is desirable, we consider a model that assesses whether a strategy of screening ultimately leads to improved outcome. In the model, the identification and management of perinatal depression follow along a “treatment cascade” or “care continuum,” which involves multiple sequential steps that can lead to a successful outcome (Figure 1.1) (Gardner, McLees, Steiner, Del Rio, & Burman, 2011; Pence, O’Donnell, & Gaynes, 2012). The model posits that to achieve successful treatment, both patient and her clinician must be aware of the diagnosis; effective care must be available and accessible; and the patient must be engaged in care, remain in care, and adhere to treatment (Mugavero, Norton, & Saag, 2011). This model requires active participation by both the patient and the provider. Attrition of the population at any of these steps may worsen health outcomes for both the patient and the child.

Figure 1.1 Care continuum for perinatal depression and anxiety.

At any point along the care continuum, strategies can be developed and applied to strengthen the likelihood of remission. For example, clinical recognition can be increased with population-based screening and both clinical and patient education efforts, and the likelihood that providers adhere to treatment guidelines and patients comply with treatment recommendations can be increased through education and various patient support systems.

Within this framework, a number of conditions are necessary to make population-based identification desirable:

1. The condition must be common. Enough women must suffer from perinatal depression or anxiety that general screening among a population of pregnant and postpartum women would yield enough cases to make screening worthwhile.
2. The condition must have bad consequences. The harmful effects on the woman and her child of unrecognized and untreated perinatal depression and anxiety must be significant enough to outweigh the costs of screening and treatment....

Table of contents

• Cover
• Title page
• Table of Contents
• About the Editors
• About the Contributors
• Foreword
• Introduction: Current Issues in Identifying Perinatal Depression
• 1 Is Population-Based Identification of Perinatal Depression and Anxiety Desirable?
• 2 When Screening Is Policy, How Do We Make It Work?
• 3 Acceptability, Attitudes, and Overcoming Stigma
• 4 How to Use the EPDS and Maximize Its Usefulness in the Consultation Process
• 5 Screening Tools and Methods of Identifying Perinatal Depression
• 6 Identifying Perinatal Anxiety
• 7 Diagnostic Assessment of Depression, Anxiety, and Related Disorders
• 8 Psychosocial Assessment and Integrated Perinatal Care
• 9 Postnatal Depression, Mother–Infant Interactions, and Child Development
• 10 Fathers’ Perinatal Mental Health
• 11 Evidence-Based Treatments and Pathways to Care
• 12 International Approaches to Perinatal Mental Health Screening as a Public Health Priority
• 13 Training Health-Care Professionals for the Assessment and Management of Perinatal Depression and Anxiety
• 14 An Overview of Health Economic Aspects of Perinatal Depression
• 15 The Future of Perinatal Depression Identification
• 16 Conclusion
• Index
• End User License Agreement