Not many studies have been done on the prevalence and identification of prenatal mental disorders such as depression and anxiety. The focus has tended to be more on testing screening methods for postpartum depression and maternal mental health disorders in the postpartum period which affects 10% to 20% of mothers, and even then, research is lacking, and screening rates for postpartum depression are less than 50%.
Depression affects about 10% of women at some point during their pregnancy in Canada and between 20% and 40% of women with a prior history of depression will suffer a relapse in the postpartum period. In the U.S., depression affects 13% of pregnant women.
As we’re learning that depression and other mental health disorders can occur or begin during pregnancy and the detrimental effects they can have on mother and child, the more we are starting to see research being done on how to effectively identify suffering women in order to provide them with safe and effective treatment.
To that end, in the first of its kind, a team of British researchers recently became the first in the world to study the accuracy of two screening methods for prenatal depression in early pregnancy. Their study titled, Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and other mental disorders in early pregnancy, was published in the British Journal of Psychiatry earlier this month.
The Whooley questions were developed by Pfizer in 1993 to help health care practitioners diagnose mental health disorders. They consist of two questions which are:
1. During the past month have you often been bothered by feeling down, depressed, or hopeless?; and
2. During the past month have you often been bothered by having little interest or pleasure in doing things?
The EPDS is a set of ten questions that was developed in Scotland in 1987 for health care practitioners to use to determine whether a woman is suffering from postpartum depression. The EPDS is usually self-administered and has been used in 23 countries. The questions look at how a woman has been feeling in the past seven days. If women score ten or higher, they are then referred for further assessment.
The Whooley questions and EPDS are screening methods used by some practitioners including midwives in Britain as well as family doctors, obstetricians and nurses in other jurisdictions around the world where prenatal screening is required or recommended. When the province of Ontario, Canada, recently updated their Antenatal Form in July 2017 to include mental health screening, they added the Whooley questions as a first stage screening method followed by the EPDS if women scored high enough to get to the next level. Australia requires prenatal depression screening and so do the states of New Jersey, Illinois, and West Virginia in the U.S. The U.K. also has screening strategies in place.
A total of 534 women from Southeast London participated in the British study which occurred between 2014 and 2016. Researchers found that though the EPDS method of screening was better able to identify major depression than the Whooley questions, there wasn’t much difference between the two. It’s the first time that the Whooley questions have been found to have a ‘lower sensitivity’ in identifying depression than what has been found in other studies that have examined the effectiveness of the Whooley questions. Researchers posit that may be perhaps in their study, the Whooley questions were administered face to face by a midwife, whereas in other studies, they were completed in written format or the variance in the training by staff administering the questions.
Though the EPDS was proven to be more effective in their study as identifying pregnant women suffering from depression, researchers point out that it may be “burdensome” in health care offices that are busier than others. They also point out that having women complete the EPDS on an iPad is just as effective as other means so they suggest that perhaps a solution to a busy environment is to have women can complete the EPDS questions on an iPad while waiting to see their health care practitioner in the waiting room. Researchers also found that older aged pregnant women were better able to answer the questions than younger aged pregnant women which they suggested may be due to older women understanding their conditions better as well as stigma in the younger generation or “self-perceived resilience”.
In addition to studying the effectiveness of the Whooley questions and EPDS in screening for prenatal depression, researchers also found that one in four pregnant women who participated in their study suffered from a mental health disorder. Eleven per cent suffered from depression, 15% from an anxiety disorder, 2% from obsessive-compulsive disorder and an eating disorder, nearly 1% from posttraumatic stress disorder, 0.7% from borderline personality disorder, and 0.3% from bipolar disorder. In all, 27% of pregnant women who participated in the study were found to be suffering from a mental health disorder.
At the end of the day, researchers conclude that both methods – the Whooley questions and the EPDS – are effective prenatal depression screening methods. They suggest the Whooley questions be administered by midwives and other health care practitioners in early pregnancy and that the EPDS be self-administered by pregnant women. If a woman scores positive on either test, she should then be referred for a complete psycho-social assessment to determine “the type and severity of mental disorder and related problems, and subsequent treatment to reduce maternal and fetal morbidity.”
Brett D. Thombs, Donna E. Stewart, (2014), Journal of Psychosomatic Research, Depression screening in pregnancy and postpartum: Who needs evidence?, https://www.ncbi.nlm.nih.gov/pubmed/24840148
Brett D. Thombs, Erin Arthurs, Stephanie Coronado-Montoya, Michelle Roseman, Vanessa C. Delisle, Allison Leavens, Brooke Levis, Laurent Azoulay, Cheri Smith, Luisa Ciofani, James C. Coyne, Nancy Feeley, Simon Gilbody, Joy Schinazi, Donna E. Stewart, Phyllis Zelkowitz, (2014), Journal of Psychosomatic Research, Depression screening and patient outcomes in pregnancy or postpartum: A systematic review, https://www.ncbi.nlm.nih.gov/pubmed/24840137
Julee Waldrop, Alasia Ledford, Leslie Chandler Perry, Linda S. Beeber, (2017), Journal of Pediatric Health Care, Developing a Postpartum Depression Screening and Referral Procedure in Pediatric Primary Care, https://www.sciencedirect.com/science/article/pii/S0891524517304595
Louise Michele Howard, Elizabeth G. Ryan, Kylee Trevillion, Fraser Anderson, Debra Bick, Amanda Bye, Sarah Byford, Sheila O’Connor, Polly Sands, Jill Demilew, Jeannette Milgrom and Andrew Pickles, (2018), Accuracy of the Whooley questions and the Edinburgh Postnatal Depression Scale in identifying depression and other mental disorders in early pregnancy, https://www.cambridge.org/core/services/aop-cambridge-core/content/view/A317DC7FBD645FB34FF8A1D2E2762A5F/S0007125017000095a.pdf/accuracy_of_the_whooley_questions_and_the_edinburgh_postnatal_depression_scale_in_identifying_depression_and_other_mental_disorders_in_early_pregnancy.pdf
Illinois Department of Healthcare and Family Services, Edinburgh Postpartum Depression Scale, https://www.illinois.gov/hfs/MedicalProviders/MaternalandChildHealth/Pages/Edinburgh.aspx
Office on Women's Health, U.S. Department of Health and Human Services, Depression During and After Pregnancy, https://www.womenshealth.gov/a-z-topics/depression-during-and-after-pregnancy
Government of Canada, Depression During Pregnancy, https://www.canada.ca/en/public-health/services/pregnancy/depression-during-pregnancy.html
Patricia Tomasi is a mom, maternal mental health advocate, journalist, and speaker. She writes regularly for the Huffington Post Canada, focusing primarily on maternal mental health after suffering from severe postpartum anxiety twice. You can find her Huffington Post biography here. Patricia is also a Patient Expert Advisor for the North American-based, Maternal Mental Health Research Collective and is the founder of the online peer support group - Facebook Postpartum Depression & Anxiety Support Group - with over 1500 members worldwide. Blog: www.patriciatomasiblog.wordpress.com