Depression in pregnant and postpartum people is a serious problem. Rather than using a screening tool with a cut-off score to detect depression in every pregnant and postpartum patient, clinicians should ask patients about their well-being as part of usual care, recommends a new guideline from the Canadian Task Force on Preventive Health Care published in CMAJ (Canadian Medical Association Journal).
"Depression in pregnant and postpartum people is devastating, with a massive burden for families, and it's critical to detect it," says Dr. Eddy Lang, an emergency physician and professor at the Cumming School of Medicine, University of Calgary and chair of the task force's pregnancy and postpartum working group.
However, there is little evidence that universal screening for depression using a standard questionnaire and cut-off score improves longer-term outcomes for these patients, indicating more research is needed.
"We were disappointed to find insufficient evidence of benefit to universal screening with a questionnaire and cut-off score; rather, it's best for primary care clinicians to focus on asking patients about their well-being at visits," says Dr. Lang. "The emphasis is on an individualized rather than one-size-fits-all approach."
In creating the guideline, the task force engaged patients to understand their values and preferences around screening to inform recommendations. Participants felt strongly that a discussion about depression with their health care provider during pregnancy and the postpartum period is critical.
The guideline is aimed at health care providers in Canada, including physicians, nurses, midwives and other health care professionals who interface with pregnant and postpartum patients. It replaces the previous guideline from the task force, published in 2013.
The guideline applies to pregnant and postpartum people in the first year after delivery. It does not apply to pregnant or postpartum people with a history of depression or who are being assessed or treated for other mental disorders.
What Does This Mean for Clinicians?
- ask patients about their well-being as part of usual care,
- consider not using a standardized tool with a cut-off score to screen every patient,
- remain vigilant for depression, and
- use clinical judgment to decide on further steps.
"Given the health implications of depression during pregnancy and the postpartum period, it's essential to check in with people about how they're feeling," says task force member Dr. Emily McDonald, associate professor, McGill University and a physician at the McGill University Health Centre. "If clinicians are uncertain about how to start the conversation, they could refer to questionnaires for discussion prompts, which is different than formal screening that would use a cut-off score to determine next steps."
As the practice of screening varies in Canada, with several provinces and territories recommending screening using a standardized tool, updated guidance was needed.
"Jurisdictions that employ formal screening may wish to reconsider this practice given the very uncertain evidence of benefit," says task force member Dr. Brenda Wilson, a public health physician and professor at Memorial University, St. John's, Newfoundland, and task force co-chair. "What's essential is clinical vigilance for depression as part of usual care, as engaging in practices with no proven benefit can take away from other health issues."
The College of Family Physicians of Canada has endorsed the guideline.
View the full guideline and related tools here.
If people are feeling down or depressed, they should speak to their primary care clinician or access a depression resource, such as
- The Canada Suicide Prevention Service
- Quebec: 1.866.277.3553
- Postpartum Support International
- Your Life Counts
"As the authors of the new guideline take care to emphasize, abandoning screening doesn't mean primary care practitioners shouldn't ask patients about their mental health with a view to finding cases of treatable depression. They should," writes Dr. Kirsten Patrick, Editor-in-Chief, CMAJ, in a related editorial. "Moreover, they should bear in mind that those most likely to become cases may be the hardest to find. However, to support practitioners to do their job well, health systems will need to improve access to the primary care, mental health and social resources that can support better care for peripartum mental illness."